Technique of L5 transforaminal and L5-S1 facet joint steroid injection in high iliac crest

Today, I will share a clinical practice of transforaminal injection with ipsilateral facet joint injection in case of right L5 foraminal stenosis in patients with a high iliac crest.
Wait a second. What is it? It is my secret of protection.
It is my hand-made lead shield that protects me from x-ray radiation.
I will share my experiments about this shield soon.
I cover the sterile surgical drape after the lead shield.
After draping, I will prepare solutions for the procedure while my technician is preparing the C-arm setting.
Let's begin from the C-arm AP view.
I try not to skip this step because I can figure out the whole picture of the spine and plan the trajectory.
then, I let my C-arm turn to an ipsilateral oblique position.
He said his right buttock pain disturbs him most. And I expressed to him I understood.

It is the sequential image of the oblique sagittal scan of the right L5-S1 foraminal area.
There is foraminal stenosis of L5-S1 with compression of L5 dorsal root ganglion.

I think he has a high iliac crest that can obstruct the needle trajectory.
so, I lessen the degree of rotation to avoid the needle touch to the iliac bone
I clean the surgical site one more. Secondary infection is the worst scenario of the interventional procedure.
let's begin puncture the skin under oblique C-arm guidance.
I always protect my hand with lead gloves and placenta-long forceps.
At first, the needle will move dramatically, but once the needle takes its tract tightly,
I can manipulate the needle with my bare hand.

I turn to AP view. And then more advance the needle on AP view.
I am steering the needle by controlling the bent needle tip.


then turn to the contralateral oblique image for fine-tuning.
Let me describe the C-arm anatomy.
It is the tangential view of the spinous process.
It is the contour of the vertebral bodies.
It is the contour of the transverse process.
It is the outer margin of the pedicle.
I advanced the needle under the pedicle,
but I am not satisfied with this image because the inferior border is not clear at this angle.

so I adjusted the C- arm angle to visualize the inferior border of the pedicle.
I said, "please tell me if you have any discomfort."

then, I administered contrast media on contralateral oblique image guidance.
Again, make sure your hand is out of the field of the x-ray radiation
observe the contrast pattern on the contralateral oblique image and AP image.
after confirming the transforaminal epidural space,
I gently administer the steroid mixture and listen to the patient's response.
A high concentration of dextrose makes you feel stiff when you push the pump.

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