Spinal Injections

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Section 5 Spinal Injections

Spinal injection guidelines

We strongly recommend that clinicians wishing to give spinal injections attend recognized training courses and undergo a period of supervised practice with an experienced colleague before attempting them on their own.

Overview

Low back pain without disc herniation is the most common problem among chronic pain disorders, but a patho-anatomical cause can be established in only 15 % of all cases.¹ Treatments to relieve this affliction have been many, among them spinal injections – engendering much controversy in the literature; opinions about efficacy, safety and relevance have differed greatly since their inception in the 1920s, with many studies considered poor quality.²^–¹⁷

Although epidural injections are one of the most commonly used invasive interventions in the treatment of low back pain, with or without radicular pain, there is currently little consensus about this technique and wide variation in practice.²¹ There is also no agreement on the most effective approach for lumbar epidural injection, whether to use steroid, local anaesthetic, saline or a combination, or the exact volume required. Depot steroids are not licensed for spinal use^18,¹⁹ but orthopaedic and pain specialists, rheumatologists and others use these injections extensively.²⁰ The caudal route of administration may require a larger volume but is least likely to cause dural puncture.^22,²³

A paucity of well designed, randomized controlled studies, and a lack of statistically significant results in the existing literature mean that a solid foundation for the effectiveness of spinal injection therapy is lacking.⁹ NICE, the UK National Institute for Health and Clinical Excellence, recommended that patients with persistent non-specific low back pain should not be offered injections of therapeutic substances,²⁴ but what impact this has had on clinical practice is uncertain.

A Cochrane Review found minor side-effects such as headache, dizziness, transient local pain, tingling, numbness and nausea reported in a small number of patients in only half the trials reviewed. The review concluded that there is no strong evidence for or against the use of any type of injection therapy for individuals with subacute or chronic low-back pain.¹⁰

Safety

All the contraindications listed in Section 2 apply, but particularly:

• anticoagulant therapy with warfarin is an absolute contraindication.

The incidence of intravascular uptake during lumbar spinal injection procedures is approximately 8.5%; it is greater in patients over 50, and if the caudal route is used rises to 11%. Absence of flashback of blood on pre-injection aspiration does not predict extravascular needle placement.³¹ Epidural steroid injection is safe in patients receiving aspirin-like antiplatelet medications, with no excess risk of serious haemorrhagic complications, i.e. spinal haematoma. Increased age, large needle gauge, needle approach, insertion at multiple interspaces, number of needle passes, large volume of injectant and accidental dural puncture are all relative risk factors for minor haemorrhagic complications.³²

Safety precautions and strict aseptic techniques are the same as for all injections. An additional hazard is the rare possibility of an intrathecal injection of local anaesthetic which may be avoided by using corticosteroid alone. The rationale is that the benefit of the brief relief of pain and the diagnostic information obtained from using an anaesthetic does not outweigh the potential risks. Normal saline can be added or Adcortyl used instead of Kenalog if additional volume is required.

New neurological symptoms or worsening of pre-existing complaints that persist for more than 24 hours (median duration of symptoms 3 days, range 1–20 days) might occur after epidural injection,³² but in the authors’ experience this is rare.

The British Society for Rheumatology and the Royal College of Anaesthetists produce guidelines for the use of epidural injections. We commend them to all practitioners who give these injections. They can be found at:

• www.rheumatology.org.uk

• www.rcoa.ac.uk

Accuracy

Performing spinal injections under imaging can ensure correct placement but requires specialized training and is expensive to perform, especially if done in theatre; many doctors perform these techniques ‘blind’ and obtain satisfactory results.

Accuracy of blind caudal epidural injections compared with targeted placement has been assessed in a few studies. In one, successful placement on the first attempt occurred in three out of four subjects. Results were improved when anatomical landmarks were identified easily (88%) and no air was palpable subcutaneously over the sacrum when injected through the needle (83%). The combination of these two signs predicted a successful injection in 91% of attempts. In another study blind injections were correctly placed in only two out of three attempts, even when the operator was confident of accurate placement. When the operator was less certain, the success rate was less than half and if the patient was obese the success rate reduced even further. In a third prospective randomized, double-blind trial, the results showed no advantage of spinal endoscopic placement compared with the more traditional caudal approach.26–29,^34,³⁹

Efficacy

Lumber epidurals: a systematic review of epidural corticosteroids for back pain found at least 75% pain relief in the short term (1–60 days) with the number needed to treat (NNT) of 7 (7–16) and at least 50% pain relief in the long term (3–12 months) with NNT of 13 (7–314).³ A randomized, double-blind, controlled trial concluded that lumbar interlaminar epidural of local anaesthetic with steroid was effective in 86% of patients, and without steroid in 74%.³¹

A systematic review indicated positive evidence (Level II-2) for short-term relief of pain from disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections; there was less strong evidence for long-term pain relief for these conditions and for the short- and long-term relief of pain from spinal stenosis and from discogenic pain without radiculitis or disc herniation.²⁵ Another review of both caudal and lumbar epidurals also concluded that the best studies showed inconsistent results and benefits were of short duration only.⁶ Yet another showed strong evidence for epidurals in the management of nerve root pain due to disc prolapse, but limited evidence in spinal stenosis.²² A multicentre randomized controlled trial of epidurals for sciatica reported significant relief at 3 weeks but no long-term benefit.¹⁴

In the past, large volumes have been injected into the epidural space;³³ however, a total injection volume of 8 ml is sufficient for a caudal epidural injection to reach the L4/5 level.³⁴

Selective guided nerve-root injections of corticosteroids are significantly more effective than those of bupivacaine alone in obviating the need for operative decompression for 13–28 months following the injections in operative candidates. This finding suggests that patients who have lumbar radicular pain at one or two levels should be considered for treatment with selective nerve-root injections of corticosteroids prior to operative intervention. A significantly greater proportion of patients treated with transforaminal injection of steroid achieve relief of pain compared with those treated by transforaminal injection of local anesthetic or saline or intramuscular steroids.³⁰ When symptoms have been present for more than 12 months, local anaesthetic alone may be just as effective as steroid and local anaesthetic together.

When conservative measures fail, nerve-root injections are effective in reducing radicular pain in patients with osteoporotic vertebral fractures and no evidence of nerve root palsy. These patients may be considered for this treatment before percutaneous vertebroplasty or operative intervention is attempted.^35,^36,³⁸

Injection of the sacroiliac joints for painful sacroiliitis appears to be safe and effective. It can be considered in patients with contraindications or complications with NSAIDs, or if other medical treatment is ineffective,³⁷ though often manipulative techniques can obviate the need for an injection. However, accurate placement of the drug without the use of fluoroscopy is estimated to be successful in only 12 % of patients.⁴⁰

Indications for spinal injection

The techniques described here include caudal epidural, nerve root, facet joint, sacroiliac joint and sacrococcygeal joint injections and the far less common technique for cervical nerve root pain. The choice between giving a caudal or nerve root injection can be aided by the site of pain; if this is clearly unilateral in the lumbar area, or radiating down one leg, a nerve root injection may be effective. If the pain is bilateral or central in the lumbar spine, a caudal epidural may be a better choice; however, this guide is not an absolute.

The following are the main indications for caudal and nerve root injections:

• Acute back and/or leg pain where pain makes manipulation impossible to perform

• Chronic back and/or leg pain where conservative treatment has failed

• Prior to considering surgery.

Older patients with chronic back pain and stiffness increased on active extension may benefit from facet joint injections. A retrospective study of patients with spinal stenosis found that 35 % of patients had at least 50 % improvement; those with spondylolisthesis, single level stenosis and older than 73 had better outcomes.²⁸ Less commonly, injections for coccydinia or sacroiliac joint pain can be attempted in cases of acute traumatic or post-natal pain.

Summary

There is a wide variation of opinion about the efficacy of spinal injections for back pain; adverse effects are generally minor and it cannot be ruled out that specific subgroups of patients may respond to a specific type of injection therapy. A cost-effective intervention which may be performed safely as an outpatient procedure and rapidly relieve pain, even in the short term, is worth considering for carefully selected patients with both acute and chronic low back pain provided that, as with all injection techniques, resuscitation facilities are available and the guidelines on aseptic technique are strictly followed.

Examination of the spine

The capsular pattern is a set pattern of loss of motion for each joint. It indicates that there is some degree of joint capsulitis caused by degeneration, inflammation or trauma. There may be a hard end feel in advanced capsulitis.

Caudal epidural

Acute or chronic low back pain or sciatica

Causes and findings

• Disc lesion, acute nerve entrapment

• Central or bilateral pain in low back with or without sciatica or root signs

• Painful: flexion and usually side flexion away from pain with nerve root tension signs

Equipment

Anatomy

The spinal cord ends at the level of L1 and the thecal sac ends at S2 in most individuals. The aim of this injection is to pass a disinflaming solution through the sacral hiatus and up the canal so that it bathes the posterior aspect of the intervertebral disc, anterior aspect of the dura mater and any affected nerve roots centrally. The sacral cornua are two prominences that can be palpated at the apex of an equilateral triangle drawn from the posterior superior spines on the ileum to the coccyx. There is a thick ligament at the entrance to the canal. The angle of the curve of the canal varies widely and the placement of the needle reflects this.

Technique

• Patient lies prone over small pillow

• Identify sacral cornua at base of imaginary triangle with thumb

• Insert needle between cornua and pass horizontally through ligament

• Pass needle a short distance up canal adjusting angle to curve of sacrum

• Aspirate to ensure needle has not penetrated thecal sac or blood vessel

• Slowly inject solution into epidural space

• Keep hand on sacrum to palpate for swelling caused by suprasacral injection

Comments

Occasionally the canal is difficult to enter. This might be because of a bifid or very small canal or because the angle of the sacrum is very concave. If this is encountered, a small amount of local anaesthetic can be injected into the ligament to make penetration more comfortable and reangulation of the needle might be necessary. If clear fluid or blood is aspirated at any point the procedure is abandoned and attempted a few days later.

Alternative approach

If the affected level is higher than the common L5/S1 level or the patient is large, more volume may be required to reach these levels. In this case we recommend the addition of up to 10 ml of normal saline, depending on the level of the lesion and the size of the patient.³⁹

Aftercare

The patient is advised to keep active within pain limits and is reassessed about 10 days later. If the injection has only partially helped it can be repeated as long as improvement continues. The causes of the back pain should then be addressed – weight, posture, work positions, lifting techniques, exercise, abdominal control, etc.

Lumbar facet joint

Chronic capsulitis

Causes and findings

• Osteoarthritis, traumatic capsulitis, ankylosing spondylitis, spondylolysis

• Uni- or bilateral low back pain, sometimes with dull vague aching down leg/s

• Painful: capsular pattern limitation, in spondylolysthesis combined extension with side flexion to the painful side may be the most painful movement.

Equipment

Anatomy

The lower lumbar facet or zygaphophyseal joints lie lateral to the spinous processes – approximately one finger width at L3, one and a half at L4 and two fingers’ width at L5. They cannot be palpated but are located by marking a vertical line along the centre of the spinous processes and horizontal lines across between each process. The posterior capsule of the joint is found by inserting the needle the correct distance for that level laterally on the horizontal line.

Technique

• Patient lies prone on small pillow to aid localization of spinous interspace

• Identify and mark one or more tender levels

• Insert needle at first selected level vertically

• Angle needle slightly cephalad and medially and pass slowly down to bone

• Aspirate to ensure needle point is not intrathecal or in blood vessel

• Deposit solution into and around capsule

• Withdraw needle and repeat at different levels if necessary

Comments

Sometimes it is impossible to enter the joint, but controlled studies have shown that depositing the solution into the capsule can be therapeutically effective ¹¹.

Alternative approach

These injections are often performed under imaging but this is less cost effective.

Aftercare

Patient avoids excessive movement while maintaining activity. Abdominal strengthening and mobilizing exercises should be performed regularly. Occasional mobilization and hamstring stretching will help to maintain flexibility. A lumbar support may be used during activities.

Lumbar nerve root

Nerve root inflammation

Causes and findings

• Spinal stenosis, nerve-root entrapment

• Acute or chronic sciatica with or without root signs

• Painful: flexion and usually side flexion away from pain plus nerve root tension signs

Equipment

Anatomy

The lumbar nerve roots emerge obliquely from the vertebral canals between the transverse processes at the level of the spinous process. Draw a vertical line along the centre of the spinous processes and horizontal lines at each spinous level. A thumb’s width laterally along the horizontal line marks entry site for the needle.

Technique

• Patient lies prone over small pillow to aid localization of spinous processes

• Identify spinous process at painful level and mark spot along horizontal line

• Insert needle and pass perpendicularly to depth of about 3“ (7 cm)

• Aspirate to ensure needle point is not intrathecal

• Inject solution as a bolus around nerve root

Comments

This injection can be especially effective when the patient is in severe pain and conservative manual therapy techniques are impossible to administer. It can also be given when caudal epidural has proved unsuccessful – the caudal is technically an easier procedure but the solution might not reach the affected part of the nerve root. The needle must be repositioned if it encounters bone at a distance of about 2“ (5 cm) as this means it is touching the lamina or facet joint. Equally, repositioning is necessary if the patient complains of sharp ‘electric shock’ sensation because the needle will be in the nerve root. If clear fluid is aspirated the needle is intrathecal and the procedure must be abandoned, although it can be attempted a few days later. Two levels can be infiltrated at a time. A large patient may require a longer needle.

If the first level injected does not relieve the symptoms, a level above or below can be tried. This is well worth trying before considering surgery.

Aftercare

Patient keeps mobile within pain limits and is reassessed 10 days later. Repeat as necessary.

Sacrococcygeal joint

Coccydynia – strain of coccygeal ligaments, subluxation

Causes and findings

• Postnatal, trauma e.g. fall onto buttock or prolonged sitting on hard surface

• Pain localized over sacrococcygeal joint

• Pain on sitting or bearing down

• Tender on joint line, coccyx might be subluxed

Equipment

Anatomy

The ligaments at the sacrococcygeal joint line are usually very tender and can be palpated both on the dorsal and ventral surfaces. The gloved finger palpates the angle of the coccyx rectally to check for subluxation of the bone.

Technique

• Patient lies prone over small pillow

• Identify and mark tender site on dorsum of coccyx at joint line

• Insert needle down to touch bone

• Pepper solution around into tender ligaments

Comments

Pain in this area can be symptomatic of psychological or psychosexual distress, in which case the appropriate treatment/advice is required. With somatic pain the protocol above appears to work either well or not at all. Surgery is not usually indicated or particularly successful.

Aftercare

Advise patient to avoid sitting on hard surfaces and to use a ring cushion. At follow-up 10 days later, manipulation of the coccyx might be necessary to correct any subluxation; the anti-inflammatory effect of the steroid enables this to be performed with less discomfort. The gloved finger is inserted into the rectum and a firm anteroposterior movement applied. Sometimes an audible click can be heard and some days later the relief of pain is apparent.

Sacroiliac joint

Acute or chronic sprain or capsulitis

Causes and findings

• Acute sacroiliitis, ankylosing spondylitis

• Chronic ligamentous pain after successful manipulation

• Usually female – often pre- or post-partum or traumatic incident such as fall onto buttocks

• Pain over buttock, groin or occasionally down posterior thigh to calf

• Pain after rest, or long periods of sitting or standing

• Painful: stressing posterior ligaments in hip flexion, oblique and transverse adduction, and anterior ligaments in hip flexion, abduction and external rotation

Equipment

Anatomy

The sacroiliac joint surfaces are angled obliquely posteroanteriorly, with the angle being more acute in the female. The dimples at the top of the buttocks indicate the position of the posterior superior iliac spines. The easiest entry point is usually found in a dip just below and slightly medial to the spines.

Technique

• Patient lies prone over small pillow

• Identify and mark posterior superior iliac spine on affected side

• Insert needle a thumb’s width medial and just below this bony landmark at level of second sacral spinous process

• Angle needle obliquely anterolaterally at an angle of about 45°

• Pass needle between sacrum and ilium until a ligamentous resistance is felt

• Inject solution as a bolus within joint if possible, or pepper posterior capsule

Comments

This is not a very common injection; usually manipulation, mobilization and exercise techniques clear the majority of chronic sacroiliac joint symptoms.

The needle often comes up against bone when attempting this injection and then has to be manoeuvred around to allow for the variations in bony shape before entering the joint space. It is unusual to have to repeat this injection and the joint can often be successfully manipulated a week later if necessary.

Aftercare

Movement within the pain-free range is encouraged – a lunging motion with the foot up on a chair can help relieve pain, as can moderate walking. The patient should avoid hip abduction positions and sit with back supported. A temporary belt is worn if the joint is unstable, and sclerosing injections can be given to increase ligamentous stability.

Cervical facet joint

Acute or chronic capsulitis

Causes and findings

• Osteoarthritis, rheumatoid arthritis or traumatic capsulitis

• Pain in posterior neck, up to head, into scapula or to point of shoulder

• Increased by sleeping in awkward positions and end-of-range movement

• Painful capsular pattern limitation, tender over one or more facet joints

Equipment

Anatomy

The facet or zygaphophyseal joints in the cervical spine are plane joints lying at angles of approximately 30–45° to the vertical. They can be palpated by identifying the spinous process and moving a finger’s width laterally, and are felt as a flat pillar.

Comments

This an uncommon injection and, although it appears alarming, it is perfectly safe provided great care is taken that the needle always lies parallel to the spinous process and never angles medially, and that the point touches bone before depositing the solution. The results in the osteoarthritic neck can be good for several months, provided the patient does not strain the neck and maintains mobility and good posture as above.

Alternative approach

This injection can also be done under imaging which ensures correct placement but is less cost effective.

Aftercare

Patient maintains gentle movement, continues correct posture and is careful to sleep with a suitable number of supporting pillows to maintain the head in a neutral position. Prone lying should be avoided. Manual traction, mobilizing and sustained stretching techniques together with friction massage to the joint capsule helps maintain comfortable movement.

Summary of suggested spinal dosages

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2. Watts R.W., Silagy C.A. A meta-analysis on the efficacy of epidural corticosteroids in the treatment of sciatica. Anaesth Intensive Care. 1995;23:564-569.

3. McQuay H.J., Moore R.A. Epidural steroids for sciatica. Anaesth Intensive Care. 1996;24:284-285. (letter)

4. Samanta A., Beardsley J. Sciatica: which intervention? Br Med J. 1999;319:302-303.

5. Bush K., Hillier S. A controlled study of caudal epidural injections of triamcinolone plus procaine for the management of intractable sciatica. Spine. 1991;16(5):572-575.

6. Koes B., Scholten R., Mens J., et al. Efficacy of epidural steroid injections for low back pain and sciatica: a systematic review of randomised clinical trials. Pain. 1995;63:279-288.

7. Carette S., Leclaire R., Marcoux S., et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med. 1997;336(23):1634-1640.

8. Slosar P., White A.H. Controversy – the use of selective nerve root blocks: diagnostic, therapeutic or placebo? Spine. 1998;20:2253-2256.

9. Riew K.D., Yin Y., Gilula L., et al. The effect of nerve root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomised, controlled, double blind study. J Bone Joint Surg Am. 2000;82:1589-1593.

10. Staal J.B., de Bie R., de Vet H.C.W., et al. Injection therapy for subacute and chronic low-back pain. Cochrane Database Syst Rev. (3):2008. Art. No.: CD001824. DOI:10.1002/14651858.CD001824.pub3

11. Carette S., Marcoux S., Truchon R., et al. A controlled trial of corticosteroid injections into facet joints for chronic low back pain. N Engl J Med. 1991;325(14):1002-1007.

12. Jackson D.W., Rettig A.C., Wiltse L.L. Epidural cortisone injections in the young athletic adult. Am J Sports Med. 1980;8(4):239-243.

13. Valat J.-P., Giraudeau B., Rozenburg S., et al. Epidural corticosteroid injections for sciatica: a randomised, double blind, controlled clinical trial. Ann Rheum Dis. 2003;62:639-643.

14. Arden N.K., Price C., Reading I., et al. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study. Rheumatology. 2005;44(11):1399-1406.

15. Buttermann G.R. Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy; a prospective, randomized study. J Bone Joint Surg Am. 2004;86:670-679.

16. van Tulder M., Koes B. Low back pain and sciatica (acute and chronic). London: BMJ Books. 2004:286-291. Clinical Evidence Concise No. 11

17. Samanta A., Samanta J. Is epidural injection of steroids effective for low back pain? Br Med J. 2004;328:1509-1510.

18. Ferner R.E. Prescribing licensed medicines for unlicensed indications. Prescribers J. 1996;36(2):73-78.

19. Wildsmith J.A. Routes of drug administration: 6. Intrathecal and epidural injection. Prescribers J. 1996;36(2):110-115.

20. Fanciullo G.J., Hanscom B., Seville J., et al. An observational study of the frequency and pattern of use of epidural steroid injection in 25,479 patients with spinal and radicular pain. Reg Anesth Pain Med. 2001;26(1):5-11.

21. Cluff R., Mehio A.K., Cohen S.P., et al. The technical aspects of epidural steroid injections: a national survey. Anesth Analg. 2002;95:403-408.

22. Abi S., Datt S., Lucas L. Role of epidural steroids in management of chronic spinal pain: Systematic review of effectiveness and complications. Pain Physician. 2005;8(1):127-143.

23. Snarr J. Risks, benefits and complications of epidural steroid injections: case report. AANA J. 2007;75(3):183-188.

24. National Collaborating Centre for Primary Care. Low back pain: early management of persistent non-specific low back pain. 2009. (NICE Guideline CG88). May 2009

25. Conn A., Buenaventura R.M., Datta S., et al. Systematic review of caudal epidural injections in the management of chronic low back pain. Pain Physician. 2009;12:109-135.

26. Price C.M., Roger P.D., Prosser A.S.J., et al. Comparison of the caudal and lumbar approaches to the epidural space. Ann Rheum Dis. 2000;59(11):879-882.

27. Stitz M.Y., Sommer H.M. Accuracy of blind versus fluoroscopically guided caudal epidural injection. Spine. 1999;24(13):1371.

28. Barre L., Lutz G.E., Southern D., et al. Fluoroscopically guided caudal epidurals for lumbar/spinal stenosis. Pain Physician. 2004;7(2):187-193.

29. Botwin K., Brown L.A., Fishman M., et al. Fluoroscopically guided caudal epidural injections in degenerative lumbar spinal stenosis. Pain Physician. 2007;10(4):547-548.

30. Ghahreman A., Ferch R., Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med. 2010;11(8):1149-1168.

31. Manchikanti M., Singh V., Falco F.J.E., et al. Evaluation of effectiveness of lumbar interlaminar epidural injections in managing chronic pain of lumbar disc herniation of radiculitis: a randomized double-blind controlled trial. Pain Physician. 2010;13:343-355.

32. Horlocker T., Zahid H., Bajwa Z.H., et al. Risk assessment of hemorrhagic complications associated with non-steroidal anti-inflammatory medications in ambulatory pain clinic patients undergoing epidural steroid injection. Anesth Analg. 2002;95:1691-1697.

33. Cyriax J. Epidural injection. Textbook of Orthopaedic Medicine, 2. London: Bailliére Tindall. 1984:178.

34. Bryan B.M., Lutz C., Lutz G.E. Fluoroscopic assessment of epidural contrast spread after caudal injection. Journal of Orthopaedic Medicine. 2000;22(2):38-41.

35. Riew K., Yuming Y., Gilula L., et al. Effect of nerve root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomised, controlled, double blind study. J Bone Joint Surg Am. 2000;82:1589-1593.

36. Ng L.C., Sell P. Outcomes of a prospective cohort study on peri-radicular infiltration for radicular pain in patients with lumbar disc herniation and spinal stenosis. Eur Spine J. 2004;13(4):325-329.

37. Maugars Y., et al. Assessment of the efficacy of sacroiliac corticosteroid injections in spondylarthropathies: a double-blind study. Br J Rheumatol. 1996;35:767-770.

38. Kim D., Yun Y., Wang J. Nerve-root injections for the relief of pain in patients with osteoporotic vertebral fractures. J Bone Joint Surg Br. 2003;85(2):250-254.

39. Dashfield K., Taylor M., Clekven J., et al. Comparison of caudal steroid epidural with targeted steroid placement during spinal endoscopy for chronic sciatica; a prospective randomized, double-blind trial. Br J Anaesth. 2005;94(4):514-516.

40. Hansen H. Is fluoroscopy necessary for sacroiliac injections? Pain Physician. 2003;6:155-158.

41. Jones D.S., Chattopadhyay C. Suprascapular nerve block for the treatment of frozen shoulder in primary case: a randomised trial. Br J Gen Pract. 1999;49:39-41.

42. Jackson D., Evans N., Thomas B. Accuracy of needle placement in the intra-articular space of the knee. J Bone Joint Surg Am. 2002;84:1522-1527.

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