Fluoroscopy-guided (C-arm X-ray) blocks are the standard technique for deep spinal procedures where millimetre precision is critical for safety and efficacy. We use them where structures are too deep for ultrasound (e.g. intervertebral foramina, epidural space), or where confirmation of medication distribution with iodine contrast is required.

Full Range of Fluoroscopy-Guided Blocks at Neurolocus Warsaw

  • Sphenopalatine ganglion block
  • Facet joints (cervical/thoracic/lumbosacral) – 1 side
  • Facet joints (cervical/thoracic/lumbosacral) – bilateral
  • Perineural/epidural block – 1–2 nerve roots
  • Perineural/epidural block – 3–4 nerve roots
  • Perineural/epidural block – 5–6 nerve roots
  • Interlaminar epidural block (C6/7, C7/Th1, Th1/Th2 or lumbar segment)
  • Transforaminal nerve root neuroplasty (hydrodecompression + hyaluronidase + steroid)
  • Caudal epidural block (via sacral hiatus)
  • Sacroiliac joint block – 1 joint
  • Sacroiliac joint block – 2 joints
  • Ganglion Impar block (Walter’s ganglion)
  • Thermolesion with alcohol neurolysis of Walter’s ganglion under X-ray guidance

Why Must Some Blocks Be Performed Under X-Ray Rather Than Ultrasound?

  • DEEP AND BONY STRUCTURES – fluoroscopic X-ray ideally shows bones and allows precise needle introduction into intervertebral foramina, between vertebral laminae, into the epidural space and to Walter’s ganglion. Ultrasound does not penetrate bone
  • EPIDUROGRAPHY WITH CONTRAST – only fluoroscopy allows iodine contrast injection and real-time observation of its distribution, confirming correct medication placement and excluding intravascular injection (critical in spinal blocks)
  • DOCUMENTATION – fluoroscopic images are part of the medical record and can be archived
  • PRECISION IN VARIANT ANATOMY – in patients after spinal surgery with advanced degenerative changes, anatomy is distorted; X-ray provides a full overview of bony structures

Most Important Categories of Fluoroscopy-Guided Blocks

  • Facet Joint Blocks

    Indicated for axial spinal pain originating from facet joints (approximately 15–45% of chronic low back pain, 40–60% of neck pain). The block may be diagnostic (confirming the pain source before RFA thermolesion) or therapeutic (steroid + local anaesthetic into the joint or medial branches). Performed in: cervical (C2–C7), thoracic (Th1–Th12) and lumbosacral (L1–S1) segments.

  • Perineural and Epidural Blocks (transforaminal/interlaminar ESI)

    Gold standard for treating sciatica and cervicobrachial neuralgia in disc herniation. Under fluoroscopic guidance, steroid + local anaesthetic is administered to the intervertebral foramen where the compressed nerve root is located. Efficacy in 70% of patients (effect lasting 3 to 12 months).

    Performed in three variants:

    • TRANSFORAMINAL – typically for 1–2 nerve roots, the most common and most precise approach
    • INTERLAMINAR – general injection into the epidural space, used e.g. in cervical ESI or multilevel changes – most commonly at levels: C6/7, C7/Th1, Th1/Th2
    • additionally the entire thoracic and lumbar segment

  • Sacroiliac Joint Block

    Used for pain originating from the sacroiliac joint (10–25% of chronic low back pain). Under fluoroscopic guidance, steroid + lignocaine is administered into the joint. Serves a diagnostic role (confirming pain source before thermolesion or cryolesion) and a therapeutic role.

  • Autonomic Ganglion Blocks

    • Sphenopalatine ganglion – migraine, cluster headaches, facial neuralgias
    • Ganglion Impar (Walter’s ganglion) – perineal pain, coccygodynia, pelvic cancer pain
    • Celiac plexus – upper abdominal pain (pancreatic cancer) – see neurolysis

  • Advanced Procedures

    • Transforaminal neuroplasty – nerve root hydrodecompression + hyaluronidase + steroid
    • Caudal epidural block – injection via the sacral hiatus

Procedure Sequence (using L5 perineural block as an example)

  • Qualifying consultation with MRI review – confirmation of specific nerve root compression.
  • Patient in the prone position on the table with fluoroscope.
  • Under fluoroscopic guidance, after adjusting endplate alignment, the precise puncture site is localised in oblique projection through the so-called Kambin’s Triangle.
  • Local skin anaesthesia. Under fluoroscopic guidance, a fine 22–25G needle is introduced into the L5/S1 intervertebral foramen.
  • After confirming correct position (aspiration test) – injection of 1–2 ml iodine contrast (Omnipaque). We observe the ‘neurogram’ on fluoroscopy – the outline of the nerve root and spread of contrast in the epidural space, confirming correct administration. Intravascular needle placement is excluded.
  • Administration of 1 ml steroid (depo-medrol 40 mg or triamcinolone) + 0.5–1 ml 0.5% bupivacaine.
  • Brief monitoring for adverse reactions. Same-day discharge.

Preparation

  • Current spinal MRI/CT (no older than 6 months)
  • Discontinuation of anticoagulants per ASRA protocol (NOACs – 48–72h, warfarin – INR <1.5)
  • No need to fast
  • Inform of allergies (especially to iodine contrast)
  • Return transport
  • In diabetics – blood glucose monitoring (steroid may cause transient hyperglycaemia) and temporary blood pressure rise

Effects

  • First relief (anaesthetic effect): immediately after the procedure, lasting 4–8 hours
  • Steroid effect: develops over 7–21 days
  • Full effect: 1–2 weeks
  • Duration of effect: typically 6–12 weeks, in some patients up to 6 months
  • The procedure can be repeated up to 3–4 times per year
  • Best results achieved in combination with physiotherapy
  • Block efficacy is approximately 70–80%

Possible Side Effects

  • Transient pain at the puncture site (1–7 days)
  • Transient pain intensification in the first 24–48h (depo-steroid effect)
  • Minor haematoma
  • In diabetics: transient hyperglycaemia after steroid (1–7 days)
  • Facial flushing, insomnia, restlessness – short-term steroid effects
  • Blood pressure rise in hypertensive patients for a few days
  • Very rarely (<0.1%): infection, epidural haematoma, allergic reaction to contrast, intravascular steroid injection (prevented by aspiration test and contrast)
  • Occasionally: absence of satisfactory relief (usually correlates with advanced structural changes)

FAQ

Are fluoroscopy-guided blocks safe? What about radiation exposure?

Yes – the radiation dose in a single procedure is small and comparable to a few X-ray images. The benefits (precise access to deep structures, procedural safety) far outweigh the risk associated with minimal radiation exposure. We use dose minimisation techniques (collimation, pulsed mode).

Will a steroid block 'cure' my disc herniation?

It will not cure the structural problem, but it can extinguish the inflammation around the compressed nerve root, allow time for spontaneous disc herniation regression (which naturally occurs in 60–70% of patients within 6–12 months) and enable return to normal activity and physiotherapy. In many patients, a block allows surgery to be avoided.

How many epidural blocks can I have in a year?

Standard practice is up to 3 steroid blocks within 6–12 months. The decision to repeat depends on the efficacy of the previous procedure and the clinical picture. Lack of improvement after 2 blocks may suggest that further blocks will not be effective and a different strategy is needed (PRF, neuroplasty, surgery).