Absolute: unwilling patient, localized infection over procedure area, current anticoagulant use (see current america society of regional anesthesia (ASRA) and pain medicine guidelines on anticoagulants), increased intracranial pressure (ICP), bleeding diathesis, and patient that cannot remain still during the procedure.

Relative: allergy to medications that will be injected (contrast, local anesthetic, steroid) pregnancy, immunosuppression, systemic infection, and anatomic changes that would prevent a safe procedure (congenital or surgical).

Because of the risks associated with this procedure, only physicians who have training and experience in using fluoroscopy as well as precise injection techniques should perform this procedure. All patients should be fully monitored, and equipment to handle airway, local anesthetic toxicity, and cardiovascular emergencies should be readily available.

Although physicians may have different techniques, the primary aspects of all must include proper positioning of the patient in order to optimize visualization of the anatomy of the cervical spine at the target level(s). After discussing risks and benefits, answering questions, and obtaining written informed consent, an intravenous line is placed (for sedation or for emergency access). The patient is taken into the procedure suite and can be placed in the supine, oblique, or lateral position depending on physician preference. The area of the neck is prepped and draped in a sterile manner. The fluoroscopy beam is then adjusted to visualize the intervertebral foramen at its maximum diameter, usually an anterior oblique view. The anterior surface of the superior articular process of the inferior vertebrae (posterior aspect of foramen) is identified, and the entry point is marked. The skin and subcutaneous tissues are anesthetized with 1 % lidocaine. A 25-gauge needle is then directed toward the anterior portion of the superior articular process. It should always be directed toward this bony landmark, as going directly toward the foramen could result in a needle being placed too deep and into the spinal cord. Once the superior articular process is contacted, the depth of the needle should be noted. Repositioning of the needle should never exceed this noted depth by more than a few millimeters. The needle is then carefully adjusted so that it passes into the intervertebral foramen. The needle should always remain slightly anterior to the superior articular process. It should never be in the anterior portion of the intervertebral foramen as this may risk injection into the vertebral artery.

Once the needle is in the correct position, the fluoroscope is repositioned for a true anteroposterior (AP) view. This will allow the physician to see the depth of the needle. The correct depth is when the tip of the needle lies opposite the sagittal midline of the silhouettes of the articular pillars. If the needle contacts the existing nerve root, the patient will feel radicular pain. At this point, the needle should be slightly withdrawn and the procedure halted until the sensation disappears. If the sensation does disappear, the needle can be redirected back to its intended position, but avoiding the exact spot that caused the radicular pain. Fluoroscopy should be used to check in an oblique direction as well as an AP view to confirm needle position and depth. Only after this is done should anything be injected.

After negative aspiration is confirmed, less than 1 ml of contrast solution is injected under live fluoroscopy. It should enter the intervertebral foramen and outline the spinal nerve. It is of utmost importance to be sure there is no intra-arterial injection of contrast. Although this location of needle placement usually will not contain a radicular or a vertebral artery, these arteries can be atypically located. In case of an intra-arterial injection, the contrast will move and disappear during live fluoroscopy. If this is the case, one can redirect the needle until contrast is not seen entering an artery. However, it may be more prudent, given the severity of possible intra-articular injection through the punctured site, to abort the procedure. If contrast injection leads to rapid dilution of the contrast material, it may imply that there has been subarachnoid needle placement. In this case, abort the procedure and give enough time for the puncture to heal as injection even into another location may lead to entrance of medication into the subarachnoid space through the puncture hole created.

Once it has been confirmed by AP and oblique views that there has been correct needle placement, contrast injection has been negative for intra-arterial and subarachnoid injection, the contrast appropriately outlines the spinal nerve, and injection of contrast is negative for pain or paresthesia, the local anesthetic and steroid can be given. How much steroid depends on whether the pain is monoradicular or multiradicular. If monoradicular, betamethasone (3–6 mg), triamcinolone (20–40 mg), or dexamethasone (7.5–10 mg) can be used. If multiradicular, betamethasone (12 mg), triamcinolone (80 mg), or dexamethasone (15 mg) can be used.

Once the medication has been injected, the needle is removed with a saline or local anesthetic flush to clear the needle and track of steroid. The area that was prepped should be cleansed and a bandage placed over site of needle insertion. The patient should then be taken to a recovery area where they should be monitored for complications resulting from conscious sedation as well as complications from the procedure itself.

This procedure can be performed by either a loss of resistance technique or a hanging drop technique. One technique has not been shown to be better than the other; thus, the choice of technique is based on physician preference.

This procedure is becoming more common in the chronic pain management arena. Similar to the cervical epidural procedure, the spinal cord can be injured during this procedure. It must also be remembered that the artery of Adamkiewicz can be located anywhere in the lower thoracic levels.