X-ray Guidance
Why Prolotherapy injections under x-ray guidance (fluoroscopy) are generally not needed. Most folks may not realize that in the early/mid 90’s I was medical director of a pain clinic at a local hospital. The hospital was on the west side of Chicago and serviced a lot of folks on public aide. This was one of the things that drew me to this hospital, as they really were trying to help the poor. While director of this pain center I used fluoroscopic guidance for nearly every Prolotherapy case. Of course, it helped me see directly where the needle was going and I took neat pictures and studied them. What shocked me the most, however, was the fact that the charges by the hospital were often 2-3 times my charge for the actual Prolotherapy procedure. What should have been a $500 procedure in the office became a $1500-$1700 procedure. AND this was in the mid 1990s I can only imagine what it would cost now!
 In reviewing a billing statement from a local well respected rehabilitation center of one of my patients, I was shocked to see a single cortisone injection under x-ray to the hip was billed out at $2600! Compare this to the price for a comprehensive Hackett-Hemwall Prolotherapy hip procedure, which may include up to 60 injections! $375. In my opinion the comprehensive Prolotherapy treatment has the greatest potential to heal this person’s condition versus one cortisone shot. Don’t be fooled with technology. I might add that a person receiving shots under x-ray has a less likely chance to be healed compared to someone injecting “blindly,” (except in very rare situations which I will explain). In other words, you hear Dr. Hauser saying that if you are receiving Prolotherapy under x-ray, I believe that in general you will have a less likely chance to heal than if you went to someone doing it “blindly.” I performed injections under x-ray and the bottom line is - it didn’t help patient outcome. I also feel that the way x-ray guided injections are performed now actually hurts healing, and does not help it.
Chronic pain is a diffuse problem, not a localized one. Anyone with chronic pain will tell you that the problem is diffuse and very seldom localized. Doctors doing procedures like Prolotherapy under x-ray guidance are trying to hit one specific area and somehow this is miraculously going to get rid of all of the patient’s chronic pain. It doesn’t happen. It can’t happen. When someone has chronic pain, while their initial injury may have been localized, after 6 years of pain, seeing 10 different specialists and spending 10’s of thousands of dollars, it is no longer a simple problem. It is complicated and diffuse. This is why the patient needs comprehensive Hackett Hemwall Prolotherapy. This means for a lower back treatment, the patient may need 80-100 injections. Even for a knee or shoulder, most often 20-40 injections are required. The patients are not going to heal with one injection given under x-ray. If a person with a diffuse chronic painful condition goes to a doctor and receives Prolotherapy under x-ray, you can bet that this patient will get one to three shots, spend thousands of dollars and it won’t work. The extra money spent on x-ray guidance is not worth it.
The more skilled the doctor, the less technology is needed. There are doctors that do basically all of their procedures under x-ray. Wouldn’t there be a time where the doctor knows where the hip joint or vertebral joint is located without using x-ray? It became clear to me pretty quickly that it was unethical for me to be using x-ray guidance for Prolotherapy unless it was going to help the patient. For Hackett-Hemwall Prolotherapy, I just did not need x-ray guidance in the vast majority of cases. Also over the years I have seen a myriad of patients and receive emails at least weekly (most of the time daily) from clients who have received Prolotherapy under x-ray guidance and are asking, “Why didn’t it work?” The usual questions we ask is this, “How many shots did you receive?” The normal answer is “one or two”, sometimes up to five, but the bottom line is the person spent a whole bunch of money (generally around $3000) and the Prolotherapy treatment was not thorough enough. As we try to explain in our materials, it is best to get Comprehensive Prolotherapy using Hackett-Hemwall Prolotherapy to the injured area, and most of the time no x-ray guidance is needed.
Injections under x-ray have not been proven to provide better results than blind injections. If we want to be scientific about it, there is no study in the world that I know about, that shows injections under x-ray guidance give better results than blind injections. If you know of such a study, please send it to me. I did find one study that showed that x-ray guidance made no difference , so in essence it was a waste of money, but again if you know of a study send it to me.(1) Bottom line is for most patients who need Prolotherapy, make sure the Prolotherapy is comprehensive, strong, thorough, and completely covers the painful areas. Remember Prolotherapy is a treatment that stimulates the body to repair injured musculoskeletal tissues, such as ligaments, tendons, joints, cartilage, meniscus, labrum, by the induced proliferation of cells. What it means is that all the structures that are associated with the pain need to be treated with enough solution, that causes the body enough of a reaction that healing occurs. So will one or two shots done under x-ray do this? In my opinion, the answer is clearly “no.”
Radiographs lead doctors astray. What about those who say you need to see the degenerated structure and where the solution is going? My answer is “what about all the false positives and false negatives on MRIs?” What I am trying to say is often patients get into trouble because all of their medical care is based on MRI results and not the patient. I’ll give you an example that is happening every day in the United States. A person has an MRI that shows a hip labral tear. The person then goes to get PRP under x-ray guidance (whether ultrasound or x-ray) because the doctor wants to “make sure” the shot goes into the hip joint. Well this all sounds good except the patient has hip instability caused not only from the labrum tear but by stretching of the iliofemoral and ischiofemoral ligaments of the hip. The person receives an expensive PRP treatment under x-ray and gets 20% improvement. While the 20% improvement is great, was it worth all the expense? What they needed was comprehensive Hackett-Hemwall Prolotherapy, but this was not given, because the ligaments don’t show up on radiographs, so they weren’t treated. I believe most chronic pain has a joint instability component, and since x-rays, ultrasound, and MRI’s don’t show ligaments well (a few show up like the anterior cruciate ligament), the ligaments are not treated when a person gets one shot of Prolotherapy under x-ray.
 When does Dr. Hauser use Fluoroscopy for his Prolotherapy procedures? One of my main areas of interest in Prolotherapy is neck instability. I have treated a lot of patients with cervical instability, Barre-Lieou Syndrome, and C1-C2 instability. Anyone familiar with neck injections knows that treating C1 and C2 takes a certain amount of expertise. Because I have done a lot of these procedures early in my career under x-ray, the vast majority of C1-C2 cases I can do in the office blindly, but on occasion I use fluoroscopy to treat C1-C2 instability. The image in the photograph to the right illustrates that it is easy to see the needle going to the various locations including C1 and C2. So yes, I do on occasion do Prolotherapy under fluoroscopy, but 99.9% of the time it is not necessary. So don’t spend the money on it!
I have no problem with someone saying that injections under x-ray show you exactly where the needle is going and are more accurate than blind injections. But my question back to them would be “yes but has it ever been shown to help the patient?”
Radiculopathy: For folks with cervical or lumbar radiculopathy I do nerve injections without x-ray guidance in the office. I have had good success, but on occasion I will refer someone for a transforaminal nerve block under x-ray. Sometimes this is needed, but it is rare. Epidurals? I do them blindly, but very rarely. I would rather put the solution directly where it is needed, so if someone has a true radiculopathy I would rather put the solution close the nerve.
If you have any questions about Prolotherapy or Prolotherapy under fluoroscopy feel free to email us your questions.
1. Cohen SP, Strassel SA, Foster L. Comparison of fluoroscopically guided and blind corticosteroid injections for greater trochanter pain syndrome: multicentre randomized controlled trial. British Medical Journal. 2009;338:b1088
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