The introduction of blunt needles and the presence of pathologies that are not suitable for traditional spinal injections makes it possible to consider unusual approaches to the spine. 

  In a private practice setting, the author has used the techniques below in over 1200 patients with a retrospective review of 50 charts demonstrating no new motor or sensory deficits and with excellent pain relief.  Lateral recess blocks incorporate a far lateral approach with a 20 gauge blunt needle inserted through a 16ga angiocath at a 15-40 degree angle to the coronal plane.  The tip of the needle may be guided directly to the pathology in the anterior epidural space paracentral disc herniation or into the lateral recess for foraminal stenosis when transforaminal blocks do not demonstrate contrast ingress.  The blunt needle does not pith a nerve as would a sharp needle.   

The second approach to the lateral recess involves entry of the same needle set through the sacrococcygeal ligament with advancement along the anterior epidural space using a blunt needle with a double convex curve.  Navigation to the level of the pedicle of L5 on either side, the central disc of L5S1, or as high as the pedicle of L4 is possible by remaining closely adherent to the posterior vertebral periosteum.  This approach is particularly useful for L5S1 central disc herniations or paracentral disc herniations when contrast will not rise to the superior level of the L5S1 disc.

Finally, for zygapophyseal synovial cysts, a cross spine technique may be useful with a needle introduced parallel to the the contralateral ligamentum flavum angling towards the posterior-lateral epidural space at the site of the cyst for drainage purposes.  With the needle tip in the posterior ˝ of the spinal canal, the nerve root will not be exposed to the needle tip.

.