Fluoroscopy (Current Procedural Terminology [CPT™] code 76005 [Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction] ) is one of the many services rendered by interventional pain medicine physicians in the diagnosis and treatment of pain. Since being introduced into the CPT in 2000, 76005 has engendered controversy.

Many argue that fluoroscopic guidance should be used whenever possible in order to enhance and ensure the precise position of needles or catheters. Others argue that for many procedures, fluoroscopic guidance offers no significant improvement in precision and should be used only in specific situations where the benefits of X-ray outweigh the added expenses associated with its application.

Code 76005 has become especially contentious when pain medicine physicians perform epidural injections. Interventional pain medicine physicians have developed several approaches for epidural injections. Anesthesiologists commonly perform lumbar, thoracic and cervical translaminar epidural procedures prior to surgery without fluoroscopic guidance. Clinical experience in achieving safe and effective regional local anesthetic blocks is often cited as validation for the clinical precision of blind epidural approaches performed by physicians skilled in their placement. Similarly, the caudal approach to the epidural space has been utilized for surgical and obstetric care without the benefit of fluoroscopic guidance.

Recently selective nerve root injection techniques have been used to deliver drugs to nerve roots. Transforaminal techniques represent the latest addition to the epidural family. Many believe that these procedures provide short-term relief of nerve root irritation. Epidural steroids have been advocated for nerve root pain associated with:

• disc herniations
• postlaminectomy pain
• spinal stenosis
• herpetic neuralgia
• compression fractures
• scoliosis
• facet or synovial cyst
• trauma

Fluoroscopy and radiographic contrast dye studies offer pain medicine physicians confirmation of the location of drug delivery. Many believe that the clinical response to epidural steroid injection (ESI) can be influenced by the addition of fluoroscopy as well as other technical factors such as the quantity of the steroid instilled, the volume of injectate and targeting to underlying pathophysiology.

A recent report by Baker et al. underscores the potential for spinal cord injury as a complication of cervical transforaminal injections.¹ Baker and coworkers demonstrated that it is possible to instill contrast medium into a cervical radicular artery during the performance of a transforaminal injection. The authors suggest that digital subtraction capability may enhance the identification vascular uptake, reducing the possibility of arterial embolization of repository drugs with the potential for cord infection. Since the location of radicular arteries are poorly understood and the potential for spinal cord infarction following transforminal infections catastrophic, the findings of this case study are very compelling.

Modern portable imaging technology may warn interventionists of intravascular or intrathecal localization. Appropriate use of fluoroscopic guidance can potentially reduce catastrophic complications.

On the other hand, the standard loss of resistance technique has been demonstrated to be a reliable indicator of the epidural space identification in patients who have not had previous spinal surgery. Fredman and colleagues reported that loss of resistance reliably indicates epidural space penetration. However, instilled solutions reached the predetermined target level only 26 percent of the time when performed on patients who had previous laminectomies.²

Based on an examination of publications by nonanesthesiology pain interventionists, it is clear that fluoroscopic guidance is deeply entrenched in the culture of physical medicine and radiology-trained pain practitioners. Anesthesiologists are skilled in needling techniques using local anesthetic indicators of spread; the pain literature, both scientific and public, is espousing the importance of fluoroscopic guidance for enhanced precision. It is easy to argue that blind translaminar epidurals remain a clinically appropriate therapeutic option.³ For many pain interventions, the use of X-ray is appropriate for confirmation of needle location and safety. Contrast dye studies can assist in identification of the spread of the anti-inflammatory mixtures. In this author’s practice, X-ray is used for all transforaminal and sacroiliac joint injections. Translaminar ESI injections are often performed without the benefit of fluoroscopic guidance. X-ray confirmation of needle location is commonly required when patients have undergone previous spine surgery or when surface topography is judged to be problematic.

Hugh C. Gilbert, M.D., is Associate Professor, Northwestern University, Evanston, Illinois.