Presented at the 2013 AAPM Annual Meeting « Back

Ultrasound-Assisted S1 Transforaminal Epidural Steroid Injection

Mark-Friedrich Hurdle, MD, hurdle.markfriedrich@mayo.edu¹, Shawn A. Candler, MD¹, Salim M. Ghazi, MD¹, (1) Mayo Clinic, Jacksonville, Florida

Introduction/Statement of Problem: An 83-year-old female was referred for S1 epidural steroid injection. Although fluoroscopy offers excellent visualization of the sacrum, in patients with severe osteoporosis, degenerative changes, sacroplasty, or a recent bowel preparation, this view can be compromised. Conversely, with ultrasound-guidance, the posterior foramen of the sacrum are clearly visualized. Materials and Methods: A 12-5 MHz linear probe was placed on the skin directly over the PSIS. Scanning from lateral to medial in the axial plane, the probe was positioned medially until the S1 foramina were visualized. Ultimately, correct placement by visualizing the L5-sacral junction, and the S1 and S2 foramina, in a sagittal view was achieved. After sterile preparation and administration of local anesthesia, a 22-gauge 3-1/2 inch spinal needle was atraumatically advanced under direct visualization in the cephalad to caudal plane until the dorsum of the sacrum was palpated adjacent to the foramina. Then, the needle was advanced into the epidural space. Epidural spread was confirmed with fluoroscopy intermittently using iohexol (Omnipaque) 300 mg/cc. Results: Our attempt to view the S1 region with the use of ultrasound was well thought-out and the method proved successful. Furthermore, verification was performed by intermediately using fluoroscopy during the procedure. Conclusions: Ultrasound-guided spine transforaminal epidural injections (1,2) and the accuracy of ultrasound-guided spinal interventions (3-7) have been previously described in detail . Ultrasound-assisted, fluoroscopically confirmed sacral transforaminal epidural steroid injections could be considered an additional imaging modality for accurately locating and advancing into the sacral foramina, thus potentially limiting radiation exposure. References: 1) Narouze, SN. Ultrasound-Guided Cervical Spine Injections: Ultrasound “prevents” wheras contrast fluoroscoply “detects” intravascular injections. Reg Anesth Pain Med. 2012;37(2):127-30 2) Gofeld M, Bristow JS, Chiu SC, McQueen CK, Bollaq L. Ultrasound-guide lumbar transforaminal injections. Spine. 2012;37(9):808-12 3) Stulc SM, Hurdle MF, Pingree MJ, Brault JS, Porter CA. Ultrasound-Guided Thoracic Facet Injections. J Ultrasound Med. 2011;30(3):357-62 4) Chen CP, Wong AM, Hsu CC, Tsai WC, Chang CN, Lin SC, Huang YC, Chang CH, Tang SF. Ultrasound as a screening tool for proceeding with caudal epidural injections. Arch Phys Med Rehabil. 2010;91(3):358-63 5) Siegenthaler A, Curatolo M. Ulrasound Guided Spinal Procedures. European Journal of Pain Supplements. 2011;5(S2):495-7. 6) Galiano K, Obwegeser AA, Bodner G, Freund M, Maurer H, Kamelger FS, Schatzer R, ploner F. Ultrasound Guidance for Facet Joint Injections in the Lumbar Spine: A Computed Tomography-Controlled Feasibility Study. Anesth Analg. 2005;101(2):579-83 7) Shim JK, Moon JC, Yoon KB, Kim WO, Yoon DM. Ultrasound-Guided Lumbar Medial-Branch Block: A Clinical Study with Fluoroscopy Control. Reg Anesth Pain Med. 2006;31:451-4.

Funding: None

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