Sacral Selective Epidural Injection

Sacral selective injection is indicated for patients with sciatic radicular pain who have impingement of the S1 nerve root (typically a paracentral disc herniation at L5-S1). This is readily performed fluoroscopically by identifying and distinguishing the dorsal and ventral S1 foramina and tilting the X-ray beam craniocaudally in the anteroposterior projection to attain optimal visualization (Fig. 3). The ventral foramen (broad, ovoid, and sharply defined) is more easily visualized than the dorsal foramen, which is round and often poorly seen. To target the dorsal foramen, it is best to use L5 as a guide: tilt the beam so that the L5 pedicle is seen en face,

FIGURE 3 Sacral selective epidural injection. (A) Fluoroscopic image showing optimal obliquity for needle placement. Note vertebral pedicle at L5 (number "5") and Si (number "1"). The S1/S2 dorsal foramen is outlined by arrowheads. Note ventral foramen (letter "V"). Needle (a/row) is in place. (B) Lateral view confirms needle tip (arrow) in sacral canal. (C) Nonionic contrast injection shows opacification of the exiting Si nerve root sheath (arrows). After confirmation of optimal positioning, medication is injected.

FIGURE 3 Sacral selective epidural injection. (A) Fluoroscopic image showing optimal obliquity for needle placement. Note vertebral pedicle at L5 (number "5") and Si (number "1"). The S1/S2 dorsal foramen is outlined by arrowheads. Note ventral foramen (letter "V"). Needle (a/row) is in place. (B) Lateral view confirms needle tip (arrow) in sacral canal. (C) Nonionic contrast injection shows opacification of the exiting Si nerve root sheath (arrows). After confirmation of optimal positioning, medication is injected.

approximately half way between the superior and inferior end plate. More inferiorly, the pedicle of the S1 vertebra will then be in view. Rotate the beam slightly lateral so that the needle will track medially. Advance a 22-gauge needle just inferior to the S1 pedicle until bone is reached or radicular pain is generated. A lateral projection can confirm proper positioning within the foramen. After injection of contrast documents optimal positioning, injection of medication is performed.

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