Sharp needles are not recommended for most advanced interventional procedures. Placing blunt needles through the skin to the target is virtually impossible, therefore a two-needle technique using an introducer and procedure needle is necessary. Clinicians use the blunt needle for atraumatic access to nerve blocks, sleeve blocks, deep muscle blocks, hypogastric, paravertebral blocks, joint blocks, facets, selective nerve root, lumbar sympathetic, thoracic sympathetic, splanchnic, and celiac plexus blocks.
Below is an outline of the techniques on placing a blunt needle close to the target by taking a safe path to the final placement area.
Fluoroscopic guidance is critical for performing interventional pain procedures safely and effectively. Procedures should not be attempted until optimal fluoroscopic images are obtained by the combination of patient positioning, C-arm positioning, and radiological technique. A skilled professional technician and a modern C-arm are needed for proper interventional pain practices.
The three most common C-arm positions for correct visualization and needle placement. (a) A/P view. (b) 30 degree oblique. (c) lateral view.
Fluoroscopic Positioning
Rotate the C-arm to an oblique view (sideways) until the spinous process moves to the other side of the superior articular process (SAP). It is very difficult to get a Coudé® Blunt Needle close to the target without an introducer. The target position for the introducer is at the tip of the superior articular process (SAP), also known as the “Scottie Dog’s“ ear. This will establish a safe bony target which is behind the nerve root.
Remove the metal needle of the introducer. Advance the Coudé® Blunt Needle through the blue hub with the arrows of the hub facing medially until it touches the tip of the “Scottie Dog’s” ear (SAP).
(A) Once bony contact is made with the “Scottie Dog’s” ear (SAP), rotate the arrow on the needle hub 180° laterally while (B) advancing the Coudé® Blunt Needle beyond the SAP.
(A) Anterior to the “Scottie Dog’s” ear (SAP), rotate the needle hub 180° medially. (B) Advance through the intertransverse ligament until you feel a “pop”, then rotate the C-arm to a lateral view.
The needle tip will enter the neural foramen with enhanced safety as the Coudé® Blunt Needle is less likely to penetrate blood vessels. Now the needle tip now has access to any part of the neural foramen. Confirm the needle position with A/P and lateral fluoroscopic visualization. Inject contrast to verify the spread followed by injection of local anesthetic and steroids. The most commonly chosen target site is all the way to the ventral lateral epidural space until bony contact is made.
The Coudé® Blunt Needle tip can be steered to the ventral lateral bony structure of the neural foramen. Confirm the needle position with A/P & lateral fluoroscopic views. Contrast injection is recommended in the lateral view to identify venous spread. Accumulation of contrast can be seen in the vena cava as a thin line interior and parallel to the vertebrae. Most larger veins are located at the interior neural foramen (disc) area. If venous spread is present, redirect the blunt needle and verify there is no vascular (venous) spread. If there is no spread, continue with injection of choice.
*Please refer to current literature for volumes and medications used for injections.
Remove the metal needle of the introducer. Advance the Coudé® Blunt Needle through the blue hub with the arrows of the hub facing medially until it touches the tip of the “Scottie Dog’s” ear (SAP).
(A) Once bony contact is made with the “Scottie Dog’s” ear (SAP), rotate the arrow on the needle hub 180° laterally while (B) advancing the Coudé® Blunt Needle beyond the SAP.
(A) Anterior to the “Scottie Dog’s” ear (SAP), rotate the needle hub 180° medially. (B) Advance through the intertransverse ligament until you feel a “pop”, then rotate the C-arm to a lateral view.
The needle tip will enter the neural foramen with enhanced safety as the Coudé® Blunt Needle is less likely to penetrate blood vessels. Now the needle tip now has access to any part of the neural foramen. Confirm the needle position with A/P and lateral fluoroscopic visualization. Inject contrast to verify the spread followed by injection of local anesthetic and steroids. The most commonly chosen target site is all the way to the ventral lateral epidural space until bony contact is made.
The Coudé® Blunt Needle tip can be steered to the ventral lateral bony structure of the neural foramen. Confirm the needle position with A/P & lateral fluoroscopic views. Contrast injection is recommended in the lateral view to identify venous spread. Accumulation of contrast can be seen in the vena cava as a thin line interior and parallel to the vertebrae. Most larger veins are located at the interior neural foramen (disc) area. If venous spread is present, redirect the blunt needle and verify there is no vascular (venous) spread. If there is no spread, continue with injection of choice.
*Please refer to current literature for volumes and medications used for injections.
Place the patient in the supine position. Palpate the posterior lateral border of the cervical spine. Using a marking pen, mark the posterior border of the transverse process.
Under fluoroscopy, find the target neural foramen using a 30° oblique fluoroscopic view and place a pointer over the target site. Mark the level on the previously placed line, outlining the posterior border of the transverse process which will be the entry site for the introducer cannula.
After infiltration of local anesthetic at the needle entry site, place the C-arm in an A/P position. Advance the introducer needle to the target site at the lateral (arrow) border of the transverse process until bony contact is encountered.
Remove the metal needle of the introducer. Maintain an A/P C-arm position and introduce the Coudé® Blunt needle through the blue hub with the arrows of the needle tip facing posterior. Advance the blunt needle until you experience bony contact on the lateral border of the transverse process.
(A) Rotate the C-arm to the 30° oblique view from horizontal. Rotate the Coudé® Blunt needle 180° to the anterior position, having the arrows of the hub readily visible. (B) Advance the needle tip until it is visible in the neural foramen.
(A) Rotate the Coudé® Blunt needle back to 180° to a posterior direction and advance allowing for the needle to slide on a bone behind the nerve root. Rotate the C-arm to the A/P position. (B) On the A/P view, advance the needle to mid facet position. First aspirate, then inject contrast to verify the absence on the intravascular injection. Once this has been verified, the local/steroid of choice is injected.
*Please refer to current literature for volumes and medications used for injections.
Under fluoroscopy, find the target neural foramen using a 30° oblique fluoroscopic view and place a pointer over the target site. Mark the level on the previously placed line, outlining the posterior border of the transverse process which will be the entry site for the introducer cannula.
After infiltration of local anesthetic at the needle entry site, place the C-arm in an A/P position. Advance the introducer needle to the target site at the lateral (arrow) border of the transverse process until bony contact is encountered.
Remove the metal needle of the introducer. Maintain an A/P C-arm position and introduce the Coudé® Blunt needle through the blue hub with the arrows of the needle tip facing posterior. Advance the blunt needle until you experience bony contact on the lateral border of the transverse process.
(A) Rotate the C-arm to the 30° oblique view from horizontal. Rotate the Coudé® Blunt needle 180° to the anterior position, having the arrows of the hub readily visible. (B) Advance the needle tip until it is visible in the neural foramen.
(A) Rotate the Coudé® Blunt needle back to 180° to a posterior direction and advance allowing for the needle to slide on a bone behind the nerve root. Rotate the C-arm to the A/P position. (B) On the A/P view, advance the needle to mid facet position. First aspirate, then inject contrast to verify the absence on the intravascular injection. Once this has been verified, the local/steroid of choice is injected.
*Please refer to current literature for volumes and medications used for injections.
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