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How Imaging Procedures Assist in the Alleviation of Back Pain:
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Epidural Injection via the Sacral Hiatus
By William J. Vanarthos, M.D.
3821 Merton Drive
Raleigh, NC 27609
fax 919.787.9154
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Raleigh, NC 27609
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Garner, NC 27529
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Chapel Hill, NC 27514
fax 919.933.9925
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• Imaging-guided percutaneous techniques confirm
needle placement, thereby increasing precision and
reducing complications
SCANNINGS is a quarterly publication
of Wake Radiology, Wake Radiology
Oncology Services and Raleigh MRI
• Pain can be treated safely and effectively with local
injections of anesthetic and/or long-acting steroids
William J. Vanarthos, MD
• Injection of the epidural space through the sacral
hiatus is a safe and quick procedure, maximizing
exposure to the sacral roots and relieving most low
back, pelvic, and hip pain
Robert E. Schaaf, MD
William H. Johnson
Figure 1. The sacral hiatus.
3700 Barrett Drive, Suite #200
Raleigh, NC 27609
• How Imaging Procedures Assist in
the Alleviation of Back Pain
• May is National Osteoporosis
US Postage
Permit #1
Raleigh, NC
• Village Radiology is now
Wake Radiology
• New Apex Office Open
• New Oncology Web Site
3700 Barrett Drive, Suite 200
Raleigh, NC 27609
• Dr. Posillico Joins Wake Radiology
• New Garner Location
• New Clinical Editor for Scannings
• Managed Care Update
Local back pain and radiculopathy are prevalent
Numbers 2 and 7 depict the extent of the
sacral hiatus. Taken from the Color Atlas
conditions that debilitate millions of Americans
of Anatomy by Rohen and Yokochi, p.353.
annually resulting in an enormous number of lost
man-hours of work. The prevalence of these
conditions is at least 5% annually (1,2,3). Most cases are treated conservatively with rest, non-steroidal
anti-inflammatory drugs, or physical therapy. A small percentage of cases require surgery. Unfortunately,
since imaging abnormalities do not correlate with symptoms in most cases (4), a specific diagnosis
cannot be made, yet patients have continued pain.
Percutaneous injection techniques have been utilized for back pain management for many years, but
historically have been performed without imaging guidance (1). More recently, minimally invasive
imaging-guided percutaneous techniques utilizing primarily fluoroscopy and computed tomography
have been employed to confirm needle placement, thereby increasing precision. In most cases,
better results and reduced complication rates have made these procedures grow in popularity (1).
Cervical, thoracic, lumbosacral, and sacroiliac pain can be treated safely and effectively with local
injections of anesthetic and/or long-acting steroids into facet joints, sacroiliac joints, selective nerve roots,
spondylolytic regions, and the epidural space (1). The purpose of this article is to highlight one
approach to the epidural space through the sacral hiatus (Figure 1) using c-arm fluoroscopy.
With the patient in a prone position (to enhance comfort and virtually eliminate movement), c-arm
fluoroscopy is used to identify the sacral hiatus in the lateral projection. Using sterile technique and
local anesthesia, a 5-inch, 22-gauge spinal needle is directed into the sacral hiatus and advanced until its
tip reaches the level of S3. This level maximizes exposure of the sacral roots (Figure 2) to the injected
solution, yet is caudal enough to minimize the risk of dural puncture (Figure 3). An injection of < 5-ml.
of nonionic myelography-approved iodinated contrast confirms needle placement with an “upside-down
Christmas tree” configuration, but is typically unnecessary since the c-arm affords excellent visualization
of the needle in two planes. For patients with ipsilateral pain, the needle bevel is directed to the
symptomatic side (1). A solution of 5 ml. (40 mg./ml.) of Triamcinolone Acetonide Injectable
Suspension (Kenalog-40), 4-5 ml. (5 mg./ml.) of 0.5% Bupivicaine HCL Injection (Sensorcaine-MPF),
(continued on page 2)
(Epidural injection continued from page 1)
and 1 ml. of 1% Lidocaine HCL Injection (10mg./ml.) is injected to achieve
immediate pain relief and long-term anti-inflammatory therapy. Lidocaine
reduces any pain the patient may experience from the pressure of the
injection, however it can be eliminated.
From start to finish, the procedure takes less than 5 minutes in experienced
hands, especially if the patient is consented and prepared by the
technologist prior to the arrival of the radiologist. Generally, the patient
experiences immediate and often complete pain relief, which lasts
3-4 months on average.
Figure 3. Line drawing of midsagittal sacrum demonstrates the
needle path during the injection.
Dr. Louis F. Posillico
Joins Wake Radiology
Wake Radiology
Diagnostic Imaging
welcomes Dr. Louis F.
Posillico to its staff.
Previously, Dr. Posillico
served as a staff
radiologist with Staff
Care in Irving, TX,
Precision Health Imaging
in Modesto, CA along
with a number of other
Dr. Posillico earned his
MD from Georgetown
University and served
his internship and
radiology residency
at the University of
Pittsburgh Medical Center. He was a Nuclear Medicine
Fellow at Duke University Medical Center. He is currently certified
by the American Board of Radiology and the American Board
of Nuclear Medicine.
1. Silbergleit R, Mehta BA, Sanders WP, Talati SJ. Imaging-guided injection
techniques with fluoroscopy and CT for spinal pain management.
Radiographics 2001; 21:927-939.
Figure 2. Sagittal and coronal illustrations of the
lumbosacral plexus. The sacral and pudendal plexi
(depicted by #s 11 and 12) are most susceptible
to the sacral hiatus injection. Taken from the
Color Atlas of Anatomy by Rohen and Yokochi, p. 383.
2. El-Khoury GY, Renfrew DL. Percutaneous procedures for the diagnosis and
treatment of lower back pain: discography, facet joint injection, and epidural
injection. AJR 1991; 157:685-691.
3. Frymoyer JW. Back pain and sciatica. N Engl J Med 1988; 318:291-300.
Wake Radiology offers an informative brochure on
osteoporosis and important screenings to detect
bone density. Call today for your copy. (919) 788-7907.
Wake Radiology Garner Office to
Move, Expand in Late Summer
Village Radiology in Chapel Hill
becomes Wake Radiology
Wake Radiology Diagnostic Imaging will expand its facilities and
move the Garner office to a new location in late summer 2004,
according to Bill Johnson, Wake Radiology Practice Administrator.
Village Radiology Consultants in Chapel Hill will soon undergo a
name change to Wake Radiology Diagnostic Imaging.
The new office will be located at the Health Park at Timber Drive,
adjacent to the new Rex Wellness Center. Physician offices in the
Garner area will be notified well in advance of the move in order
to facilitate an easy transition and to assist patients in finding the
new imaging facility.
The office will keep its same phone number, (919) 662-9500,
and fax number, (919) 662-2244.
Village Radiology Consultants, Inc. at 110 South Estes Drive in
Chapel Hill has been serving the local medical community since
1993 when Wake Radiology Diagnostic Imaging, Inc. in Raleigh
purchased the practice.
Wake Radiology Managing Partner Dr. Robert Schaaf explains,
"We believe one name will simplify the scheduling and reporting
process, a seamless approach across the entire practice."
The morning breakfasts at Wake Radiology North Hills, West
Raleigh, Cary and Chapel Hill offices have concluded with
the holiday fare served in December. The breakfasts,
initiated in celebration of the practice’s 50th anniversary,
greeted a variety of staff from practices nearby to the
four locations.
“Sharing our anniversary with so many new friends was
really satisfying to us all,” said Ceily Davis, Wake Radiology
Marketing Administrator.
Please note changes: Wake Radiology Diagnostic Imaging
and Village Radiology Consultants no longer participate with
CCN and TRICARE (except for TRICARE for Life).
Wake Radiology Diagnostic Imaging, Village Radiology
Consultants, Raleigh MRI Center and Wake Radiology
Oncology Services participate with the following plans:
• Aetna - (all plans)
New Clinical Editor Named for Scannings
William J. Vanarthos Named
Health Care Editor
4. Haldeman S. Failure of pathology to predict back pain. Spine 1990; 15:718-724.
May is National Osteoporosis Month.
“Wake Up With Wake Radiology”
Hibernates In Winter
We welcome William J. Vanarthos, MD as Scannings’ new Medical
Editor. Dr. Vanarthos joined Wake Radiology in 1999. He received
his medical degree from New York Medical College in Valhalla,
New York. He completed a combined internship and residency
in Diagnostic Radiology at Jackson Memorial Hospital as part of
the University of Miami School of Medicine Program in Miami,
Florida. Dr. Vanarthos further completed a Musculoskeletal
Radiology fellowship at North Carolina Baptist Hospital as part of
the Bowman Gray School of
Medicine program in WinstonSalem. Dr. Vanarthos is board
certified in diagnostic
radiology by the American
Board of Radiology. Prior to
coming to North Carolina,
Dr. Vanarthos was an
assistant professor of
Diagnostic Radiology,
Chief of Orthopedic and
Emergency Radiology,
and Clinical Director for
Medical Services at the
University of Kentucky
Medical Center in
Lexington, Kentucky.
• AHA (American Healthcare Alliance they use MedCost’s network)
• Alliance PPO (a MAMSI product)
• Blue Cross and Blue Shield - (all plans)
• CIGNA - (all plans)
• DukeHealth Direct
• Health Care Savings
• MAMSI Life & Health PPO
• MedCost - (all plans)
• Medicare
• Medicaid
• Optimum Choice of the Carolinas Inc.
(OCCI - a MAMSI product)
• PARTNERS National Health Plans of North Carolina, Inc.
(not Medicare Choice)
• TRICARE for Life (secondary to Medicare)
• UnitedHealthcare of North Carolina, Inc.
• UnitedHealthcare Insurance Company
• United Medicare+Choice
• ***Wake Radiology Oncology Services only:
WellPath/Coventry, TRICARE (regular)
Note: Patients who are in a plan with which we do not
participate with can be seen on an out-of-network basis.
A patient can choose this option with a higher deductible
and/or higher co-insurance. We will be glad to contact the
insurer to get eligibility and benefit coverage if requested.
Wake Radiology continues to align its managed care
contracts with those of its referring physicians. If there are
additional plans that we should consider, please call
Michele Jackson at (919) 788-7904, fax to (919) 789-4461,
or e-mail [email protected]
Additionally, later this summer, the Chapel Hill office location
MR service offerings will be upgraded with a new range of
procedures on a new state of the art instrument and daily hours
of operation will be extended, providing service 7 days per week.