Ultrasound-guided selective nerve root block versus fluoroscopy-guided transforaminal block for the treatment of radicular pain in the lower cervical spine: a randomized, blinded, controlled study

Epidural Contrast Patterns and Clinical Implications: An Educational Review

PURPOSE OF REVIEW

The purpose of this educational review is to describe the contrast spread patterns that indicate accurate needle placement in the epidural space and spread patterns associated with erroneous needle insertion.

RECENT FINDINGS

Epidural injections are minimally invasive and commonly used for patients with acute and chronic back pain that does not respond to conservative management. Imaging with contrast is frequently used during this procedure to improve accuracy and reduce adverse events. Contrast spread patterns are an important tool that can help identify where the needle is placed and whether the placement is accurate. Despite this, there may be discrepancies in the interpretation of spread patterns which ultimately reduce the utility of contrast. Inaccurate needle placement may result in intrathecal/subarachnoid, subdural, fascial, or retrodural space of Okada injections. The correct interpretation of contrast spread patterns on imaging is crucial for confirming accurate epidural needle placement. Furthermore, understanding contrast patterns of improper needle placement can prevent adverse events that result from injection outside of the epidural space.

Evaluation of the efficacy of ultrasound-guided selective cervical nerve root pulsed radiofrequency treatment in patients with chronic cervical radicular pain

PURPOSE

Management of cervical radicular pain is complex and may be resistant to conservative treatment. The primary aim of this study was to evaluate the efficacy of ultrasound-guided selective cervical nerve root pulsed radiofrequency (US-SCNR PRF) treatment in patients with radicular neck pain due to cervical disc herniation who did not respond to conservative treatment. The secondary aim was to determine the efficacy of the treatment in terms of functionality, neuropathic pain, and treatment-related adverse events.

METHODS

This study included 62 patients with chronic cervical radicular pain who underwent US-SCNR PRF treatment. Pain intensity was assessed using the Numerical Rating Scale before treatment and at 1, 3, and 6 months after treatment. The Neck Disability Index and Douleur Neuropathique 4 Questions were used to assess functionality and neuropathic pain before and 6 months after treatment. Significant pain relief was defined as ≥ 50% reduction in the pain score compared with the pre-treatment score.

RESULTS

Cervical radicular pain was significantly reduced at 1, 3, and 6 months after pulsed radiofrequency compared to pre-treatment (P < 0.001). Successful pain relief was achieved in 59.6% of the patients at 6 month. However, there was no significant difference between the mean pain scores in the 1st month, 3rd month and 6th month. In addition, the functionality and neuropathic pain scores were significantly reduced at 6 month.

CONCLUSIONS

These results suggest that US-SCNR PRF treatment is effective for cervical radicular pain, functionality, and neuropathic pain for at least six months in the majority of patients with refractory cervical radicular pain, and is considered a safer and preferable treatment modality due to real-time visualization of the cervical nerve roots and adjacent neurovascular structures and no radiation exposure.

Selective ultrasound-guided nerve root block improves outcomes for discectomy in patients with cervical disc disease: a randomized, controlled, single-blinded study

BACKGROUND

We hypothesized that ultrasound-guided selective nerve root block could play a role in the prediction of clinical outcomes in patients with multilevel cervical disease following selective anterior cervical discectomy and fusion.

METHODS

Patients were randomized to receive ultrasound-guided selected nerve root block as a diagnostic tool (study group) or not (control group), but both groups had surgery. Pain evaluation for arm and neck pain was recorded. The Visual Analog Scale (VAS) pain scores, Neck Disability Index, and MRI results were compared between groups. They were assessed every two weeks for three months, postoperatively. The percentage of patients who showed ≥ 50% reduction in their pain levels and a VAS rating of ≤2 was deemed an acceptable surgical outcome.

RESULTS

Patients in the study group had significantly lower VAS scores for pain intensity than control patients at nearly all periods. This baseline pain improved significantly in the study group. A more significant proportion of patients in the study group showed a ≥50% reduction in their pain scores from baseline at weeks four, eight, and 12, and this difference was significantly lower than in the control group (P<0.05). The study group improved significantly over baseline in Neck Disability Index scores compared to control patients. Patients were highly satisfied with no significant adverse events in the study group.

CONCLUSIONS

In patients with multilevel cervical disease, ultrasound-guided selective nerve root block is an excellent, safe, non-radiating, and reliable test to determine the appropriate level for operation.

Genicular nerve radiofrequency ablation practice patterns: A survey study of the International Pain and Spine Interventional Society

Introduction

Chronic knee pain often results from degenerative conditions such as knee osteoarthritis (OA) and can worsen after surgical interventions like total knee arthroplasty (TKA). Knee OA affects approximately 86 million individuals globally, leading to decreased function, mobility limitations, and disability. While TKA is a common surgical treatment for refractory knee OA, though up to 20 % of patients experience chronic post-operative knee pain worse than their pre-operative pain. Genicular nerve radiofrequency ablation (GnRFA) has emerged as a promising intervention for knee OA pain unresponsive to conservative management and for chronic post-TKA pain. GnRFA is an evidence-based technique supported by multiple prospective cohort studies and randomized controlled trials (RCTs). However, practice patterns and GnRFA techniques vary, and no peer-reviewed publication has yet quantified these variations in real-world clinical practice.

Objective

This study aims to understand the practice patterns of interventional pain physicians regarding patient selection, use of prognostic blocks, imaging, nerve targets, GnRFA types, and GnRFA techniques in treating knee pain secondary to OA or persistent post-TKA pain.

Methods

An anonymous 29-question survey was distributed via electronic mail to members of the International Pain and Spine Intervention Society (IPSIS) from January 16, 2024, to February 29, 2024. The survey assessed practice patterns related to patient selection, prognostic block use, and GnRFA techniques. Data were collected and stored using REDCap software, with descriptive statistics calculated.

Results

A total of 150 completed surveys were analyzed, representing a completion rate of 2.0 % of surveys sent, 3.5 % of emails opened, and 56.8 % of those who clicked on the survey link. Respondents generally use common selection protocols regarding OA grade (Kelgren-Lawrence 3 and 4), duration of failed conservative care (3-6 months), a single anesthetic block paradigm, and use of fluoroscopic guidance for the GnRFA procedure. More variability was reported between respondents regarding the volume of anesthetic used during prognostic blocks, the threshold to consider a prognostic block "positive," the technology used, and nerves targeted during the GnRFA procedure.

Conclusion

The study provides valuable insights into the current practice patterns of GnRFA among interventional pain physicians. While there is consensus on some aspects of patient selection and procedural techniques, significant variability exists in prognostic block protocols and nerve targets for GnRFA. These findings highlight the need for further research to explore the long-term efficacy and safety of GnRFA and to standardize techniques and protocols across different practice settings, ultimately improving patient outcomes and quality of life. The low response rate may limit generalizability, and the survey did not include data on active tip sizes used for ablation or whether other procedures should be exhausted before resorting to GnRFA. Additionally, a survey to IPSIS membership only may not fully represent a diverse cohort of pain management specialists, potentially introducing sampling bias. Future studies should include members from a broader range of professional organizations to enhance representativeness.

Sciatica-like pain caused by cervical spondylotic myelopathy: four case reports and systematic review

Objective

This study aimed to demonstrate and characterize a rare cervical spondylotic myelopathy (CSM) with sciatica-like pain as the main clinical manifestation through case presentation and systematic review.

Methods

Four cases of CSM with sciatica-like pain as the main clinical manifestation were retrospectively studied. A systematic review of electronic databases such as PubMed, Embase, and Web of Science was conducted to explore the clinical characteristics of CSM with sciatica.

Results

All four cases of CSM symptomatic of sciatica-like pain were initially diagnosed with lumbar degenerative conditions. However, due to the presence of neurological signs such as hyperactive tendon reflexes, a positive Babinski sign, or a Hoffmann sign, they underwent further cervical MRI scans. Eventually, all four cases were diagnosed with CSM and experienced relief from sciatica after cervical decompression surgery. The systematic review analyzed a total of four studies with a combined sample size of 10 cases, all of whom experienced a reduction in sciatica-like pain following cervical decompression surgery.

Conclusion

CSM symptomized by sciatica-like pain can often be misdiagnosed as lumbar degenerative disease. Preoperative abnormal neurological signs associated with CSM may aid in diagnosing this condition. In addition, the clinical presentation of hyperextension of the cervical spine resulting in worsening lower limb pain may serve as diagnostic indicators for this disease.

Radicular Pain Management Using Ultrasound-Guided Versus Fluoroscopy-Guided Epidural Steroid Injections: A Systematic Scoping Review of Comparative Studies

Back pain is the leading cause of disability globally and results in a substantial medical and economic burden. Epidural steroid injections (ESIs) have been widely used as a treatment for back pain with radiculopathy of various etiologies. Ultrasound guidance (UG) for delivering ESIs can reduce costs and facilitate the procedure in resource-limited settings compared to the current standard technique of using fluoroscopic guidance (FG). This scoping review aimed to compare the clinical outcomes between UG and FG ESIs in the treatment of radicular pain. Systematic searches of Embase, Ovid Medline, Scopus, CENTRAL (Cochrane Central Register of Controlled Trials), CDSR (Cochrane Database of Systematic Reviews), and ClinicalTrials.gov were conducted in accordance with PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews) guidelines. Randomized controlled trials (RCTs) and comparative observational studies investigating the outcomes between UG and FG ESIs in the treatment of radicular pain were included. The risk of bias for included RCTs was assessed using the Cochrane Collaboration risk-of-bias tool. From 1,659 potentially relevant publications, eight studies (five RCTs and three retrospective comparative studies) were included. Five of the studies were conducted in the Republic of Korea, one in China, one in India, and one in Egypt. All studies reported no significant difference between UG and FG ESIs in success rate, pain index, and postoperative disability (p > 0.05). One study reported increased intravascular injections in the FG group, but this did not reach statistical significance (p > 0.05). One study reported decreased needle-placement time in the UG group (p < 0.001). One study reported decreased total operation time in the UG group (p < 0.05). Overall, treatment outcomes and adverse events profile are comparable between UG and FG ESIs for radicular pain. UG ESIs reduce costs, minimize radiation exposure, facilitate vessel identification, prevent injury, and potentially save intraoperative time while offering the same benefits as FG injections. Future studies should focus on long-term outcomes, cost-effectiveness, and the impact of UG ESIs on patient satisfaction and quality of life.

Ultrasound-Guided Cervical Selective Nerve Root Block versus Fluoroscopy-Guided Interlaminar Epidural Injection for Cervical Radicular Pain: A Randomized, Prospective, Controlled Study

Ultrasound (US)-guided cervical selective nerve root block (CSNRB) procedures are increasingly being performed as an alternative to conventional fluoroscopy (FL)-guided epidural injections for the treatment of cervical radicular pain. The aim of this study was to compare the effectiveness of US-guided CSNRB versus FL-guided interlaminar cervical epidural steroid injection (IL-CESI) for cervical radicular pain. A total of 60 patients with cervical radicular pain due to a single-level disc herniation were randomized into either the FL or US group. The numeric rating scale, Short Form-36, and neck disability index were evaluated before treatment at months 1, 3, and 6 after treatment. Procedure time, complications, pain medication consumption, and patient satisfaction were also recorded. Patients experienced significant improvement in pain, disability, and quality of life scores up to 6 months after the procedure (p < 0.001). Treatment success rate was achieved in 56.6% of the IL-CESI group and 50% of the CSNRB group without any significant difference between the study arms (p = 0.617). US-guided CSNRB was shown to be as effective as the FL-guided IL-CESI in the treatment of cervical radicular pain, in addition to the absence of radiation exposure and requiring less procedure time.

Therapeutic Efficacy of Ultrasound-Guided Selective Nerve Block on Chronic Cervical Radiculopathy

Background and Objectives: Cervical radiculopathy (CR) manifests as pain and sensorimotor disturbances in the upper extremities, often resulting from nerve root compression due to intervertebral disc herniation, degenerative changes, or trauma. While conservative treatments are initially preferred, persistent or severe cases may require surgical intervention. Ultrasound-guided selective nerve root block (SNRB) has emerged as a promising intervention for alleviating symptoms and potentially obviating the need for surgery. This study evaluates the therapeutic efficacy of ultrasound-guided SNRB in managing chronic CR, aiming to determine its potential in symptom relief and delaying or avoiding surgical procedures. Materials and Methods: A retrospective analysis was conducted on 720 outpatients treated for CR between October 2019 and March 2022. After excluding patients with traumatic CR, previous surgeries, malignancies, progressive neurological symptoms requiring immediate surgery, or inadequate conservative treatment, 92 patients who had experienced cervical radicular pain for more than three months and had failed to improve after more than six weeks of conservative treatment with VAS scores ≥ 5 were included. The patients underwent single or multiple ultrasound-guided SNRB procedures, involving the injection of dexamethasone and lidocaine under real-time ultrasound guidance. Symptom severity was assessed at the baseline, and at 4, 8, and 12 weeks post-procedure using the Visual Analog Scale (VAS). The data collected included age, sex, presence of neck and/or radicular pain, physical examination findings, recurrence of symptoms, improvement in symptoms, and whether surgical intervention was ultimately required. Statistical analyses were performed to identify the factors associated with symptom improvement or recurrence. Results: Significant symptom improvement was observed in 69 (75.0%) participants post-SNRB, with 55 (79.7%) showing improvement at 4 weeks, 11 (15.9%) at 8 weeks, and 3 (4.4%) at 12 weeks. Symptom recurrence, defined by an increase in VAS score accompanied by a pain flare lasting at least 24 h after a pain-free interval of at least one month, was noted in 48 (52.2%) patients. The presence of combined neck and radicular pain was a significant predictor of recurrence (p = 0.008). No significant associations were found between symptom relief and factors such as age, gender, initial pain severity, or MRI findings. Conclusions: Ultrasound-guided SNRB effectively manages chronic CR, providing substantial symptom relief and potentially reducing the need for surgical intervention. This technique offers a promising conservative treatment option, especially given its real-time visualization advantages and minimal radiation exposure.

Ultrasound-guided versus fluoroscopy-guided lumbar selective nerve root block: a retrospective comparative study

The purpose of this study is to compare the accuracy and effectiveness of ultrasound-guided and fluoroscopy-guided lumbar selective nerve root block (SNRB), and to explore the feasibility of ultrasound-guided methods. This retrospective study included patients with lumbar radicular pain who underwent ultrasound-guided and fluoroscopy-guided selective nerve root block at Honghui Hospital Affiliated to Xi'an Jiaotong University from August 2020 to August 2022. Patients were divided into U-SNRB group and F-SNRB group according to ultrasound-guided or fluoroscopy-guided selective nerve root block. There were 43 patients in U-SNRB group and 20 patients in F-SNRB group. The pain visual analogue scale (VAS) scores, Japanese Orthopaedic Association (JOA) scores, related indexes and complications were recorded and compared between the two groups before, 30 min, 1 month and 6 months after block. To evaluate the feasibility, accuracy and effectiveness of ultrasound-guided selective nerve root block. There were no complications in the process of selective nerve root block in both groups. The operating time and the times of closing needle angle adjustment in U-SNRB group were better than those in F-SNRB group, and the difference was statistically significant (P < 0.05). The VAS score and JOA score of patients in the two groups were significantly improved 30 min after block, 1 month and 6 months after block, and the difference was statistically significant (P < 0.05). There was no significant difference between the two groups (P > 0.05). The accuracy of ultrasound-guided selective nerve root block and the degree of pain relief of patients were similar to those of fluoroscopy guidance, but the operation time and needle angle adjustment times were significantly less than that of fluoroscopy, and could effectively reduce radiation exposure. Therefore, it can be used as a better way to guide for choice.

Benefit of pain and function after cervical transforaminal epidural steroid injections, an observational study

Objective

To evaluate the improvement of pain and function after cervical transforaminal epidural steroid injections (CTFESI) for radicular pain.

Design

This is a retrospective observational study of patients receiving fluoroscopically-guided cervical transforaminal epidural steroid injections under a single provider at a tertiary referral center from December 2013 to December 2020. Primary outcome measures were Numeric Rating Scale (NRS), patient reported percent of pain relief, the Patient Health Questionnaire, the Patient Reported Outcome Measurement Information System (PROMIS) Global Health Physical and Mental Health score, and the Pain Disability Questionnaire.

Results

A total of 219 individual patients underwent 261 CTFESI and were included in the analyses. The average subject age was 51.9 years (SD = 11.3) and 50.9 % were male. Following the intervention, average pain relief by NRS at 3 months, 6 months, 1 year, and 2 years was -4.07, -3.82, -4.20, and -4.45, respectively. The average functional improvement with PROMIS-GH physical at 3-months, 6-months, 1- year, and 2-years was 2.23, 2.35, 3.15, and 3.29, respectively.

Conclusions

Our results suggest that patients with cervical radiculopathy report significant pain relief and functional improvement following CTFESI. They can also report clinically important improvement in their health-related quality of life.

Ultrasound-Guided Versus Conventional Fluoroscopy-Guided Epidural Injection for Radiculopathy. A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Radiculopathy, a painful condition due to the irritation of a spinal nerve root, is a common neurosurgical presentation. Apart from its conventional treatment with pain killers and surgical management, it can also be managed with epidural steroid injections (ESIs). The objective of this study is to compare ultrasonography (USG) guidance with conventional fluoroscopy (FL) guidance for ESIs to treat radiculopathy.

METHODS

PubMed, Embase, Clinicaltrials.gov, and Cochrane were systematically searched and randomized controlled trials comparing USG with conventional FL for ESIs in the case of radiculopathy were included. Web Revman was used for data analysis.

RESULTS

The Literature search resulted in 640 studies, of which 7 studies were included in this meta-analysis after extensive screening. There was no statistically significant difference in pain reduction between USG and FL groups especially in the case of lumbosacral spinal level at 1 month [mean difference -0.12 (-0.47-0.23)] and at 3 months [mean difference 0.73 (-1.49, 2.96)]. Similarly, functional improvement after ESIs was comparable between the 2 groups. The Risk of inadvertent vascular puncture in USG-guided ESIs was lower as compared to conventional FL-guided ESIs [odds ratio 0.21 (0.07, 0.64)]. Furthermore, the procedure time in the USG group was also significantly lower as compared to FL group.

CONCLUSION

USG-guided ESIs are not only comparable to conventional FL-guided ESIs in terms of pain control and functional improvement, particularly evident at the lumbosacral spinal level, but also have a lower risk of inadvertent vascular puncture.

Comparative efficacy of ultrasound guidance and fluoroscopy or computed tomography guidance in spinal nerve injections: a systematic review and meta-analysis

PURPOSE

Spinal nerve injections have traditionally been performed under fluoroscopic (FL) and computed tomography (CT) guidance. Recently, ultrasound (US)-guided procedures have provided an alternative guidance approach that does not expose the patient and operator to radiation. The aim of this study was to compare the efficacy and safety of US-guided spinal nerve injections compared with FL- or CT-guided spinal nerve injections.

METHODS

MEDLINE, Cochrane Library, EMBASE, international clinical trials registry platform (ICTRP) and ClinicalTrials.gov database searches for inclusion until February 2023 were independently performed by two authors using predefined criteria. Randomized controlled trials (RCTs) were included. Primary outcomes were change in pain score (numeric rating scale or visual analogue scale) and major adverse events. Secondary outcomes were procedure time, change in functional disability score and minor adverse events. Meta-analysis was performed using random-effect model. We evaluated the certainty of evidence based on the Grading of Recommendations, Assessment and Development (GRADE) approach.

RESULTS

Eight RCTs involving 962 patients were included. There might be little to no difference in the mean score of the pain change between the US-guided methods and the FL- or CT-guided injections (standard mean difference -0.06; 95% confidence interval [CI] -0.26 to 0.15). US guidance probably reduced major adverse events (0.7% [3/433] and 6.5% [28/433], respectively), reduced procedure time (mean difference -4.19 min; 95% CI -5.09 to -3.30), and probably reduced minor adverse events (2.1% [9/433] and 4.2% [18/433], respectively) compared with FL or CT guidance. There was probably little to no difference in the change in functional disability score with either method.

CONCLUSION

US-guided spinal nerve injections remained effective and reduced adverse events compared with conventional FL- or CT-guided spinal nerve injections. Further RCTs are required to verify our results.

STUDY REGISTRATION

Open Science Forum (Available from: https://osf.io/vt92w/ ).

Ultrasound-Guided vs. Fluoroscopy-Guided Interventions for Back Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The objective of this study was to compare the outcomes of the ultrasound- and fluoroscopy-guided techniques in the management of back pain. Using PubMed, Scopus, and the Cochrane Library, we searched randomized controlled trials (RCTs) published before May 2023, which reported relevant data on the topic. The effectiveness of the ultrasound-guided (US-guided) and fluoroscopy-guided (FL-guided) approaches for back pain management was compared in terms of postoperative pain intensity, postoperative functional outcomes, and postoperative complications. Subgroup analyses were conducted for different postoperative periods. Eight studies were included in the analysis. There was no significant difference in post-procedural pain relief at one week, two weeks, one month, two months, and three months between the US-guided and FL-guided interventions for back pain management (SMD with 95% CI is -0.01 [-0.11, 0.10]), p = 0.91, I2 = 0%). In terms of the postoperative functional outcomes assessed by the "Oswestry Disability Index" (ODI) functionality score, the model tends to favor the FL-guided injections over the US-guided injections (SMD with 95% CI: 0.13 [-0.00, 0.25], p = 0.05, I2 = 0). Finally, the US-guided and FL-guided injections did not show significantly different results in terms of postoperative complications (RR with 95% CI is 0.99 [0.49, 1.99], p = 0.97, I2 = 0). The subgroup analysis also did not demonstrate differences between the US-guided and FL-guided techniques in the following outcomes: vasovagal reaction, transient headache, and facial flushing. There was no significant difference between the US-guided and FL-guided injections for treating back pain in terms of postoperative pain intensity and complications. Still, the model tends to favor the FL-guided injections over the US-guided injections in terms of functionality.

Proposal of a Route Map for Cervical Spinal Ultrasonography: A Simple and Clear Learning Tool for Beginners

Spinal ultrasonography has increasingly been used to image axial structures from the cervical to sacral region in recent years. In this work, we propose a comprehensive, systematic cervical scanning protocol that we refined as a route map, especially for beginners, to facilitate teaching, learning, diagnosis, and treatment in clinical pain practice. As a simple and clear tool to demonstrate the scanning protocol, the route map is delineated with rectangles, lines, and arrows. The rectangles represent the positions of the transducer, the arrows indicate route directions, and the lines show the routes of transducer movement. In this article, we describe cervical spinal ultrasonography to illustrate the route map interpretation, scanning protocol and target anatomical structures in detail. We believe that this comprehensive, clear, systematic, and portable route map will be beneficial for inexperienced pain clinicians and ultrasound beginners.

Ultrasound-guided nerve hydrodissection of cervical nerve roots for cervical radicular pain in patients with mild and moderate to severe stenosis: a retrospective cohort study

Because fascial entrapment neuropathy can occur in multiple locations, ultrasound-guided nerve hydrodissection has become a key component of the treatment of cervical radicular pain. In this paper, we propose a combination of injectates used for nerve hydrodissection of the cervical nerve roots and compare the clinical outcomes of this treatment among patients with different severities of stenosis. This is a retrospective cohort study designed to compare outcomes between patients with mild stenosis and moderate to severe stenosis. Forty-four patients with mild cervical stenosis and 30 patients with moderate to severe cervical stenosis were consecutively enrolled into two groups. A 10-mL mixture in a single level consisting of 5% in Dextrose, 0.2% lidocaine (Xylocaine), and 4 mg betamethasone (Rinderon) was used for nerve roots hydrodissection. The two groups were compared with regard to their numeric rating scales (NRS) of pain, proportion of patients who exhibited a favorable outcome (a reduction of pain ≥ 50%), duration of patient exhibited a favorable outcome, and occurrence of serious complications and minor side effects. The follow-up period ranged from 3 to 20 months. The NRS of both groups improved significantly by 1 week, 1 month, 3 months, and final follow-up after the initial injection. Differences in the groups' NRS, proportion of patients who exhibited a favorable outcome, duration of patient exhibited a favorable outcome, and occurrence of serious complications and minor side effects were nonsignificant. There were 4 patients (5.4%) experienced dizziness in that resolved without further treatment. Ultrasound-guided nerve hydrodissection of cervical nerve roots is a safe procedure that reduces pain associated with cervical radicular pain, even in patients with moderate to severe stenosis.

Ultrasound-guided Versus Computed Tomography Fluoroscopy-assisted Cervical Transforaminal Steroid Injection for the Treatment of Radicular Pain in the Lower Cervical Spine: A Randomized Single-blind Controlled Noninferiority Study

OBJECT

To estimate the contrast dispersion short-term clinical efficacy and safety of ultrasound (US)-guided transforaminal steroid injection (TFSI) compared with computed tomography (CT) guidance for the treatment of cervical radicular pain.

METHOD

A total of 430 patients with cervical radicular pain from cervical herniated disk or cervical spondylosis were recruited in the randomized, single-blind, controlled, noninferiority trial. The patients were randomly assigned to receive either the US-guided or CT-guided TFSI for 1 affected cervical nerve. The dispersion pattern of contrast was monitored at the time of TFSI in both groups, using CT. Patients were assessed for pain intensity by numeric rating scale (NrS) and functional disability by Neck Disability Index (NDI) at baseline, 1 and 3 months after the intervention. Complications were also recorded.

RESULTS

The satisfactory rate of contrast distribution was respectively 92.1% in US group and 95.8% in CT group. Pain reduction and functional improvement were showed in both groups during follow-up. Statistical difference was not observed in the decrease in NRS pain scores and NDI scores between 2 groups with F =1.050, P =0.306 at 1 month and F =0.103, P =0.749 at 3 months after intervention. No permanent and severe complications were observed.

CONCLUSIONS

This study demonstrated that US provided a noninferior injectate spread pattern and similar improvement of radicular pain and functional status when compared with CT-guided TFSI. US may be advantageous during this procedure because it allows visualization of critical vessels and avoids radiation exposure.

Efficacy of the lumbar sympathetic ganglion block in lower limb pain and its application prospects during the perioperative period

The sympathetic nervous system is involved in the physiological pathogenesis of many different types of chronic pain. Sympathetic blocks can interrupt the reflex control system by intercepting the noxious afferent fibers accompanying autonomic nerves, resulting in changes in peripheral or central sensory processing. A lumbar sympathetic ganglion block (LSGB), as a treatment method, refers to the injection of nerve blockers into the corresponding lumbar sympathetic nerve segments, usually requiring imaging assistance (CT, X-ray, ultrasound) to guide. At present, LSGB has been widely used in the clinical treatment of lower limb pain, such as neuropathic pain, lower limb ischemic pain, and so on. Its mechanism of action may be through inhibiting sympathetic nerve activity and dilating blood vessels, thereby alleviating pain and inhibiting stress response. However, there are few reports of LSGB during the perioperative period, especially in postoperative pain and gastrointestinal function. Therefore, by studying the literature about LSGB-related studies, this article reviews the anatomy of the lumbar sympathetic nerve (LSN), with its clinical application and possible mechanism. We reviewed the analgesic effect of LSGB in patients with lower limb pain and postoperative pain and the potential application prospects in the recovery of gastrointestinal function, finally providing a reference for its clinical application.

Ultrasound-guided cervical selective nerve block: A case series

BACKGROUND

Cervical radiculopathy is characterized by pain, numbness, tingling, and weakness, mostly in an affected extremity, reflecting compression of a nerve in the neck is compressed or irritated where it emerges from the spinal cord. Diagnosis requires a detailed anamnesis, physical examination, and imaging. Physical therapy, exercise, medical therapy, and injections are the preferred treatments, but injections into the cervical region are only indicated if conservative treatment is ineffective.

OBJECTIVE

This study explored the utility of selective cervical nerve root blocks (SNRBs) performed at various levels under ultrasound guidance (USG).

METHODS

We evaluated patients diagnosed with cervical radiculopathy via physical examination and magnetic resonance imaging from November 2019 to March 2020. We included those who did not respond to conservative treatment and therefore received SNRBs at various levels. Sixty-three patients were evaluated over 6 months in terms of pain, functional status, and complications.

RESULTS

We retrospectively evaluated patients with cervical herniated discs who received SNRBs at various levels between C4-7 under USG. Pain and functional status improved in month 1 and was maintained until at least month 6.

CONCLUSION

SNRB injections performed under USG effectively treated pain and poor functional status in selected patients. The procedure is safe (especially) for patients who do not respond to conservative treatment.

Lumbar nerve root blocks using MRI - the effectiveness and safety of ultrasound/MRI fusion image guidance

OBJECTIVE

To compare the outcome of nerve root injection guided by ultrasound/MRI fusion with radiofrequency needle tracking (eTRAX^©) and the same procedure undertaken by fluoroscopic guidance.

METHODS

This is a retrospective audit of anonymised clinical records from before and after a change in the imaging technique used to perform nerve root blocks.We studied 181 consecutive patients who had undergone a nerve root block, the first 124 guided by fluoroscopic technique and the next 57 guided by ultrasound/MRI fusion with radiofrequency needle guidance.Using pain diaries, we reviewed the outcome scores at 24 h and 2 weeks. We recorded the use of analgesia, the patient's satisfaction, complications and the duration of the procedures.

RESULTS

Completed pain diaries were returned by 61% in the fluoroscopy group and 67% in the fusion imaging group.The visual analogue pain score was reduced at 24 h by 3.29 [standard deviation (SD) 2.35] for the fluoroscopy group and by 3.69 (SD 2.58) in the fusion group (p 0.399).At two weeks the pain reduction was 3.27 (SD 2.57) for the fluoroscopic group and 4.21 (SD 2.95) for the fusion group (p 0.083). There was no statistically significant difference between the groups.The patient's satisfaction scores were similar for both groups.The procedure by the two guidance methods took a similar time to perform.There were no serious complications in either group. One patient in the fusion-guided nerve root block group experienced paraesthesia in the nerve distribution for 2 h.

CONCLUSION

Ultrasound/MRI fusion imaging with needle tracking is an effective alternative to fluoroscopic image-guided injection.

ADVANCES IN KNOWLEDGE

Fusion imaging guidance provides the same outcome as fluoroscopic guidance.Fusion imaging guidance avoids the need for ionising radiation.

Diagnosis and Treatment of Cervical Spondylotic Radiculopathy Using Selective Nerve Root Block (SNRB): Where are We Now?

Cervical spondylotic radiculopathy (CSR) is one of the most common degenerative diseases of the spine that is commonly treated with surgery. The primary goal of surgery is to relieve symptoms through decompression or relieving pressure on compressed cervical nerves. Nevertheless, cutaneous pain distribution is not always predictable, making accurate diagnosis challenging and increasing the likelihood of inadequate surgical outcomes. With the widespread application of minimally invasive surgical techniques, the requirement for precise preoperative localization of the affected segments has become critical, especially when treating patients with multi-segmental CSR. Recently, the preoperative use of a selective nerve root block (SNRB) to localize the specific nerve roots involved in CSR has increased. However, few reviews discuss the currently used block approaches, risk factors, and other aspects of concern voiced by surgeons carrying out SNRB. This review summarized the main cervical SNRB approaches currently used clinically and the relevant technical details. Methods that can be used to decrease risk during cervical SNRB procedures, including choice of steroids, vessel avoidance, guidance with radiographs or ultra-sound, contrast agent usage, and other concerns, also are discussed. We concluded that a comprehensive understanding of the current techniques used for cervical SNRB would allow surgeons to perform cervical SNRB more safely.

The Role of Diagnostic Injections in Spinal Disorders: A Narrative Review

Neck and back pain is increasingly prevalent, and has increased exponentially in recent years. As more resources are dedicated to the diagnosis of pain conditions, it is increasingly important that the diagnostic techniques used are as precise and accurate as possible. Traditional diagnostic methods rely heavily upon patient history and physical examination to determine the most appropriate treatments and/or imaging studies. Though traditional means of diagnosis remain a necessity, in many cases, correlation with positive or negative responses to injections may further enhance diagnostic specificity, and improve outcomes by preventing unnecessary treatments or surgeries. This narrative review aims to present the most recent literature describing the diagnostic validity of precision injections, as well as their impact on surgical planning and outcomes. Diagnostic injections are discussed in terms of facet arthropathy, lumbar radiculopathy, discogenic pain and discography, and sacroiliac joint dysfunction. There is a growing body of evidence supporting the use of diagnostic local anesthetic injections or nerve blocks to aid in diagnosis. Spinal injections add valuable objective information that can potentially improve diagnostic precision, guide treatment strategies, and aid in patient selection for invasive surgical interventions.

US-Guided Transforaminal Cervical Nerve Root Block: A Novel Lateral in-Plane Approach

OBJECTIVE

The aim of the present study was to investigate the effectiveness and safety of a novel lateral in-plane approach for ultrasound-guided transforaminal cervical nerve root block (US-guided TF-CNRB) in the treatment of cervical radiculopathic pain.

DESIGN

The design of the present study consisted of an institutional, retrospective case series.

SETTING

The present study was conducted at a university hospital.

SUBJECTS

Thirty-two patients with cervical radiculopathy who were resistant to conservative therapies and regular US-guided CNRB were included as participants.

METHODS

The included patients were treated with US-guided TF-CNRB. During the treatments, using real-time fluoroscopy, we monitored the spreading patterns of a contrast medium and double confirmed the positions of needle tips. Pain numeric rating scales (NRS) and symptom relief grades were determined via telephone interviews at one, four, and 12 weeks after the procedures.

RESULTS

US-guided TF-CNRB was performed at the C5 level in six patients, the C6 level in 18 patients, and the C7 level in eight patients. Compared with NRS at baseline, pain scores decreased throughout the observation period. Symptom relief rates of US-guided TF-CNRB at one, four, and 12 weeks were 72%, 69%, and 63%, respectively. Venous blood was aspirated during the procedures in two patients, and the needle tips were corrected. No intravascular injections or neurologic injuries were observed.

CONCLUSION

US-guided TF-CNRB produced circumferential spreading around the involved cervical nerve root and showed significant clinical effectiveness in patients resistant to regular US-guided CNRB.

New Simple Ultrasound-Guided Transforaminal Injection in Patients With Radiculopathy in the Lower Cervical Spine: A Computed Tomography-Controlled Study

OBJECTIVES

To evaluate the feasibility of a new simple ultrasound-guided transforaminal injection in patients with cervical radiculopathy.

METHODS

Ultrasound scans of the neck in a plastic model and in 5 unaffected participants were first performed to identify the intervertebral foramen. Then ultrasound-guided transforaminal injections were performed in 20 patients with radiculopathy in the lower cervical spine, and computed tomography was used to verify the accuracy. Complications, the visual analog score, and the neck disability index were assessed at 1 and 3 months after the injection.

RESULTS

Computed tomography confirmed that the needle tip was correctly placed in the intervertebral foramen in 88.5% (23 of 26) of injections. No immediate or short-term complications were observed in all patients. The visual analog score and neck disability index at 1 and 3 months were significantly lower than those before the injection (both P < .0001).

CONCLUSIONS

Ultrasound may be a feasible and accurate method to guide cervical transforaminal injection.

Risk Analysis of Needle Injury to the Long Thoracic Nerve during Ultrasound-Guided C7 Selective Nerve Root Block

Background and Objectives: Ultrasound (US)-guided cervical selective nerve root block (SNRB) is a widely used treatment for upper limb radicular pain. The long thoracic nerve (LTN) passes through the middle scalene muscle (MSM) at the C7 level. The needle trajectory of US-guided C7 SNRB pierces the MSM, therefore indicating a high probability of injury to the LTN. We aimed to identify the LTN and to investigate the risk of needle injury to the nerve during US-guided C7 SNRB. Materials and Methods: This retrospective observational study included 30 patients who underwent US-guided SNRB at the C7 level in a university hospital. We measured the maximal cross-sectional diameter (MCSD) of the LTN and cross-sectional area (CSA) of the C7 nerve root and assessed the injury risk of LTN during US-guided C7 SNRB by simulating the trajectory of the needle in the ultrasound image. Results: The LTN was detectable in all the cases, located inside and outside the MSM in 19 (63.3%) and 11 (36.7%) of cases, respectively. The LTN's mean MCSD was 2.10 mm (SD 0.13), and the C7 root's CSA was 10.78 mm2 (SD 1.05). The LTN location was within the simulated risk zone in 86.7% (26/30) of cases. Conclusion: Our findings suggest a high potential for LTN injury during US-guided C7 SNRB. The clear visualization of LTNs in the US images implies that US guidance may help avoid nerve damage and make the procedure safer. When performing US-guided C7 SNRB, physicians should take into consideration the location of the LTN.

Ultrasound-guided paravertebral perineural glucocorticoid injection for signs of refractory cervical pain associated with foraminal intervertebral disk protrusion in four dogs

CASE DESCRIPTION

4 dogs, 7.5 to 10 years of age, were presented for evaluation of signs of chronic cervical pain and forelimb lameness secondary to cervical foraminal intervertebral disk protrusion (IVDP). All dogs were refractory to ≥ 2 weeks of conservative management including strict rest and pain management with anti-inflammatory drugs, methocarbamol, and gabapentin.

CLINICAL FINDINGS

The MRI findings included left foraminal IVDP at C2-3 causing mild C3 nerve root compression (dog 1), multifocal degenerative disk disease with mild focal left-sided disk protrusion at C6-7 without associated spinal cord or nerve root compression (dog 2), left foraminal C6-7 IVDP with suspected focal spinal cord atrophy or mild compression (dog 3), and right foraminal C6-7 IVDP and multifocal cervical intervertebral disk degeneration with annulus fibrosus protrusion (dog 4).

TREATMENT AND OUTCOME

Ultrasound-guided paravertebral perineural injections with methylprednisolone acetate (1 mg/kg [0.45 mg/lb]) at the C3 nerve root in dog 1 and at the C7 nerve root in the other 3 dogs were performed. Injections were repeated at intervals of 4 weeks to 3 months on the basis of clinical response. None of the dogs had any complications from the procedures. For dogs 1 and 4, there was complete resolution of lameness and signs of cervical pain following perineural injections, and for dog 3, there was complete resolution of lameness and only minimal residual cervical pain. Dog 2 did not have long-lasting improvement.

CLINICAL RELEVANCE

Findings indicated that ultrasound-guided paravertebral perineural injection can be an effective treatment of cervical foraminal IVDP for some dogs. Additional studies to determine appropriate case selection and better assess the overall success rate and risks associated with this technique are warranted.

Ultrasound-guided cervical selective nerve root injections: a narrative review of literature

BACKGROUND/IMPORTANCE

Ultrasound (US)-guided cervical selective nerve root injections (CSNRI) have been proposed as an alternative to fluoroscopic (FL) -guided injections. When choosing US guidance, the proceduralist should be aware of potential issues confirming vertebral level, be clear regarding terminology, and up to date regarding the advantages and disadvantages of US-guided CSNRI.

OBJECTIVE

Review the accuracy and effectiveness of US guidance in avoiding vascular puncture (VP) and/or intravascular injection (IVI) during CSNRI.

EVIDENCE REVIEW

Queries included PubMed, CINAHL and Embase databases from 2005 to 2019. Three authors reviewed references for eligibility, abstracted data, and appraised quality.

FINDINGS

The literature demonstrates distinct safety considerations and limited evidence of the effectiveness of US guidance in detecting VP and/or IVI. As vascular flow and desired injectate spread cannot be visualized with US, the use of real-time fluoroscopy, and if needed digitial subraction imaging, is indicated in cervical transforaminal epidural injections (CTFEIs). Given the risk of VP and/or IVI, the ability to perform and to retain FL images to document that the procedure was safely conducted is valuable in CTFEIs.

CONCLUSION

US guidance remains to be proven as a non-inferior alternative to FL guidance or other imaging modalities in the prevention of VP and/or IVI with CTFEIs or cervical selective nerve root blocks. There is a paucity of adequately powered clinical studies evaluating the accuracy and effectiveness of US guidance in avoiding VP and/or IVI. US-guided procedures to treat cervical radicular pain has limitations in visualization of anatomy, and currently with the evidence available is best used in a combined approach with FL guidance.

Ultrasound-Guided Neuraxial Anesthesia

PURPOSE OF REVIEW

There has been a recent surge of interest in clinical applications of ultrasound, which has revolutionized acute pain management. This review is to summarize the current status of ultrasound utilization in neuraxial anesthesia, the most common type of regional anesthesia.

RECENT FINDINGS

Ultrasound-assisted and ultrasound-guided neuraxial anesthesia has improved clinical accuracy and patient safety through landmark identification including proper vertebral level and midline, as well as via measurements on neuraxial space. Direct needle or catheter visualization during the entire procedure has not yet been achieved consistently. The recent introduction of ultrasound into neural anesthesia has clinical performance benefits and patient safety implications, with documented improvement on overall efficacy with higher first attempt success rate as well as less needle pass. More controlled studies are needed for the overall impact of ultrasonography in neuraxial anesthesia in obstetric and non-obstetric patients.

Ultrasound-Guided Selective Nerve Root Block versus Fluoroscopy-Guided Interlaminar Epidural Block versus Fluoroscopy-Guided Transforaminal Epidural Block for the Treatment of Radicular Pain in the Lower Cervical Spine: A Retrospective Comparative Study

Background

Recently, ultrasound- (US-) guided selective nerve root block (SNRB) has been reported to have similar effects compared to fluoroscopy- (FL-) guided cervical epidural steroid injection (CESI). There is no published study comparing the therapeutic efficacy and safety of interlaminar- (IL-) CESI and transforaminal- (TF-) CESI with US-guided SNRB. Our retrospective study aimed to compare the mid-term effects and advantages of the US-guided SNRB, FL-guided IL-CESI, and TF-CESI for radicular pain in the lower cervical spine through assessment of pain relief and functional improvement.

Methods

Patients with radicular pain in the lower cervical spine who received guided SNRB (n = 44) or FL-guided IL (n = 41) or TF-CESI (n = 37) were included in this retrospective study. All procedures were performed using a FL or US. The complication frequencies during the procedures, adverse event, treatment effects, and functional improvement were compared at 1, 3, and 6 months after the last injection.

Results

Both the Neck Disability Index (NDI) and Verbal Numeric Scale (VNS) scores showed improvements at 1, 3, and 6 months after the last injection in all groups, with no significant differences between groups (P < 0.05). Furthermore, the treatment success rate at all time points was not significantly different between groups. Logistic regression analysis revealed that the injection method (US- or FL-guided), cause, sex, age, number of injections, and pain duration were not independent predictors of treatment success. Blood was aspirated before injection in 7% (n = 3), 14% (n = 6), and 0% patients in the FL-guided IL, TF, and US-guided groups, respectively. In 2 patients of FL-guided IL and 7 of FL-guided TF group, intravascular contrast spread was noted during injection.

Conclusions

Our results suggest that, compared with FL-guided IL and TF-CESI, US-guided SNRB has a low intravascular injection rate; it is unlikely that serious complications will occur. Also, US-guided SNRB requires a shorter administration duration while providing similar pain relief and functional improvements. Therefore, for the treatment of patients with lower cervical radicular pain, US-guided SNRB should be considered as a prior epidural steroid injection.

Extraforaminal Cervical Selective Nerve Root Block-Description of a Posterolateral Approach With Cone Beam-Based CT Guidance

BACKGROUND

Cervical selective nerve root blocks (C-SNRBs) maintain utility for presurgical planning in patients with cervical radiculopathy. Traditional fluoroscopic or stationary computed tomography (CT)-guided methods have been associated with complications, including catastrophic neurologic insults, while ultrasound guidance has been investigated based on its theoretical advantages. Maximizing patient safety by obtaining superior anatomic and procedural details promotes the exploration for better alternative guidance.

METHODS

We describe a novel approach of posterolateral (PL) extraforaminal (EF) C4 SNRB using cone beam-based CT (CBCT)/fluoroscopy, which was performed on 3 separate occasions for 1 patient with suspected right C4 radiculopathy for presurgical evaluation. CBCT/fluoroscopy uniquely provides the function of both CT and fluoroscopy using a C-arm machine. It allows precise 3-dimensional needle planning and sophisticated 2-dimensional needle guidance, while ensuring tight needle control and detailed monitoring of contrast spread.

RESULTS

A successful right C4 SNRB was repeatedly achieved, as evidenced by postprocedural paresthesias over the C4 dermatomal distribution and periradicular contrast spread. Additionally, the patient reported symptomatic relief (with regard to pain scores and neck range of motion), leading to cancelation of his surgical plan.

CONCLUSION

We propose the PL-EF approach as the safest protocol for C-SNRBs. When compared with fluoroscopy or CT, CBCT/fluoroscopy is an advanced imaging system that provides superior anatomic neurovascular detail, while offering precise needle control, contrast media monitoring, and easy operation in an office setting. These advanced features support it as the ideal guidance method for maximizing both the safety and efficiency of the PL-EF C-SNRB approach. However, the claimed advantages cannot be concluded without increasing its accessibility to pain specialists and conducting a prospective study with a large sample size.

Ultrasonography-Guided Perineural Injection of the Ramus ventralis of the 7 and 8th Cervical Nerves in Horses: A Cadaveric Descriptive Pilot Study

Objective: To describe the feasibility and dye diffusion of selective perineural injection of the 7 and 8th cervical nerve (C7 and C8) ramus ventralis under ultrasonographic guidance in horses. Study design: Prospective experimental pilot cadaver study. Animals: Four equine cadavers of similar body weight (420-480 kg) and neck conformation. Methods: Five C7 and five C8 rami were perineurally injected with a dye solution. Anatomic dissections including vertebral canal opening were conducted to confirm nerve dye staining and describe the extent of color diffusion. Results: The ramus ventralis of the spinal cervical nerves was visualized in all cadavers. All the injections were successful in staining a portion of the nerve trunk. Eight rami had a uniform transversal staining of the nerve trunk that longitudinally covered a distance >2 cm. One C7 and one C8 nerve trunk showed incomplete transversal staining with a more concentrated color on its half cranial aspect and a longitudinal coverage of <2 cm. Five injections resulted in dye extending proximally and medially into the epidural space. Volume had no appreciable effect on the extent of nerve staining. A greater proportion of epidural diffusion was found with injections done within less than one cm distally to the articular processes. All injections were considered to be selective for the targeted nerve. Conclusion and clinical relevance: Ultrasonography-guided perineural injection of C7 and C8 ramus ventralis is a feasible technique that may have multiple applications in multimodal analgesia in horses. Further clinical study will be necessary to determine the appropriate drug, dosage, and volume to inject and to confirm its usefulness.

Ultrasound practice for chronic pain procedures: A comprehensive review

Chronic pain management techniques have evolved in recent years. With regard to this, ultrasound (US) technology has become a standard for most acute pain procedures and essential for postsurgical pain relief and enhanced recovery after surgery protocols. This manuscript summarizes clinical studies evaluating US use for chronic pain management and compares efficacy with standard techniques including fluoroscopy (FL). US possesses several unique benefits when compared with FL, including elimination of radiation exposure while providing similar clinical outcomes. In summary, US use for chronic pain procedures is emerging as a viable, safe, and effective modality. Additional studies are needed to best appreciate US and its role in chronic pain management.

Vascular Evaluation around the Cervical Nerve Roots during Ultrasound-Guided Cervical Nerve Root Block

Introduction

To carry out ultrasound-guided cervical nerve root block (CNRB) safely, we investigated the frequency of risky blood vessels around the target nerve root and within the imaginary needle pathway in the actual injecting position.

Methods

30 patients (20 men, 10 women) with cervical radiculopathy who received ultrasound-guided CNRB were included in this study. We defined a risky blood vessel as an artery existing within 4 mm from the center of the target nerve root or located in the range of 2 mm above or below the imaginary needle pathway.

Results

Using the color Doppler method, the frequency of a risky blood vessel existing around 4 mm from the center of the C5 nerve root was 3.3% (1/30), whereas it was 3.3% (1/30) for the C6 nerve root and 23.3% (7/30) for the C7 nerve root. Hence, the C7 level had more blood vessels close to the target nerve root compared to the C5 and C6 levels, but there was no significant difference (p = 0.0523). On the other hand, the frequency of a risky blood vessel existing within 2 mm above and below the imaginary needle pathway was 3.3% (1/30) for the C5 nerve root, whereas it was 3.3% (1/30) for the C6 nerve root and 10.0% (3/30) for the C7 nerve root. The C7 level had more blood vessels within the needle pathway compared to the C5 and C6 levels, but there was no significant difference (p = 0.301).

Conclusions

To reduce the risk of unintended intravascular injections, more careful checking for the presence or absence of blood vessels at the C7 level using color Doppler is necessary.

The Effectiveness of Fluoroscopically Guided Cervical Transforaminal Epidural Steroid Injection for the Treatment of Radicular Pain; a Systematic Review and Meta-analysis

Objective

Determine the effectiveness of fluoroscopically guided cervical transforaminal epidural steroid injection (CTFESI) for the treatment of radicular pain.

Design

Systematic review and meta-analysis.

Subjects

Persons aged ≥18 years with cervical radicular pain due to disc herniation or degenerative spondylosis.

Comparison

Sham, placebo procedure, or active standard of care treatment, excluding alternative versions of epidural steroid injection.

Outcomes

The primary outcome measure was patient-reported improvement in pain of at least 50% from baseline, assessed four or more weeks after the treatment intervention. Secondary outcomes included validated functional assessment tools and avoidance of spinal surgery.

Methods

Randomized or nonrandomized comparative studies and nonrandomized studies without internal control were included. Three reviewers independently assessed publications in the Medline, PubMed, and Cochrane databases up to July 2018. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system was used to evaluate risk of bias and overall quality of evidence. A meta-analysis was conducted for comparative measures of effect and for within-group response rates if applicable.

Results

There were no studies with an internal comparison group (control group) meeting the review’s definition of comparison group. Therefore, comparative measures of effect were not calculated. In cohort studies, pooled response rates were 48% (95% confidence interval [CI] = 34–61%) at one month and 55% (95% CI = 45–64%) at three months.

Conclusions

Approximately 50% of patients experience ≥50% pain reduction at short- and intermediate-term follow-up after CTFESI. However, the literature is very low quality according the GRADE criteria, primarily due to a lack of studies with placebo/sham or active standard of care control comparison groups.

An unusual complication of sacral nerve root injury following bone marrow harvesting: a case report

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) remains an important therapeutic option for many hematologic malignancies. Bone marrow harvesting from an appropriate donor must be conducted for hematopoietic stem cell transplantation (HSCT). Many previous studies show complications of the recipient after hematopoietic stem cell transplantation (HSCT). However, complications of the donor after bone marrow harvesting are rare. We here report a unique case of a patient who developed sacral nerve root injury after bone marrow harvesting.

CASE PRESENTATION

A 26-year-old man was admitted to our medical center complaining of acute onset painful burning and tingling sensation at the left posterior thigh and calf. He was a bone marrow donor for his brother's bone marrow transplantation. He had underwent a bone marrow harvesting procedure two days before admission as a bone marrow donor, using both posterior superior iliac spine (PSIS) as the puncture site. Pelvic magnetic resonance image (MRI) showed enhancement around the left S2 nerve root in T1 and T2-weighted images. Nerve conduction studies (NCS) revealed normal conduction velocity and amplitude on both lower extremities. Electromyography (EMG) presented abnormal spontaneous activity and neurogenic motor unit potentials on the S2-innervated intrinsic foot muscle and gastrocnemius, soleus muscle on the left. The patient was treated with pregabalin for pain control. The patient was followed up after 3, 6, and 12 months. Neuropathic pain improved to Visual Analogue Scale (VAS) 1, and recovery state was confirmed by re-innervation patterns of motor unit potentials in electromyography.

CONCLUSION

Bone marrow harvesting is a relatively safe procedure. However, variable complications may occur. Accurate anatomical knowledge and carefulness are required to avoid sacral nerve root injury when performing the bone marrow harvesting procedure.

Safety of CT-guided cervical nerve root corticosteroid injections

INTRODUCTION

Computed tomography-guided cervical nerve root corticosteroid injections are a commonly performed procedure for cervical radiculopathy. There have been major complications such as spinal cord infarction and posterior circulation stroke reported mostly with X-ray fluoroscopic-guided methods, however, there is relatively little data on the safety of newer CT-guided methods. The purpose of this study was to identify any major complications and evaluate the rate of minor complications from CT-guided cervical nerve root corticosteroid injections performed in a tertiary public hospital.

METHODS

Four hundred and three CT-guided cervical nerve root injection procedures were identified over a period from July 2015 to January 2018 using the radiology information system (RIS) and data collected about the technique and any immediate complications. Patient follow-up and delayed complications were then reviewed, either via outpatient clinic records or telephone consultation.

RESULTS

Two hundred and eighty-six procedures were performed by radiology registrars or fellows, and 117 by radiologists, most commonly via an anterolateral approach and injecting 4 mg (in 1 mL) of dexamethasone. Follow-up data were obtained for all 403 procedures and identified 16 minor complications, but no major neurovascular complications.

CONCLUSION

The overall recorded rate of minor complications with CT-guided nerve root injection was 4.0% with no major neurovascular complications, suggesting that CT-guided transforaminal cervical corticosteroid injection is a safe procedure.

The effectiveness of ultrasound-guided cervical transforaminal epidural steroid injections in cervical radiculopathy: a prospective pilot study

Background

Cervical transforaminal epidural steroid injection (CTFESI) is used to provide pain relief and restore function in patients with cervical radiculopathy. Traditionally, it is performed under the guidance of fluoroscopy or computed tomography. Here, we introduce a novel technique - ultrasound-guided CTFESI - with which operators can easily distinguish the close soft tissue (nerve, vessels) around the cervical foramina to avoid intravascular injection during the procedure.

Objective

To present the immediate and long-term effectiveness of ultrasound-guided CTFESI in patients with cervical radiculopathy in an academic pain-management center with prospective clinic experiments.

Methods

Fifteen patients with cervical radiculopathy who were resistant to conservative therapies and ultrasound-guided selective cervical spinal nerve-root injections, were treated with ultrasound-guided CTFESI. During the injection procedures, the needle tips were reconfirmed by real-time fluoroscopy. Pain numeric rating-scale and neck-disability-index scores were assessed from onset to six months after the procedures.

Results

During the procedures, based on real-time fluoroscopic confirmation, the injection solution outlined the spinal nerve root and spread into the epidural space in most cases (14 of 15). All patients reported pain relief within 10 minutes after the injection. The majority of patients (eleven of 15) experienced pain relief and neck-disability index-score improvement throughout the 6-month study period. No patient experienced any complication.

Conclusion

We suggest that ultrasound-guided CTFESI is an effective, safe, and simple procedure free of radiation or magnetization and provides sustained pain relief in patients with cervical radiculopathy who have failed previous conservation therapies.

Ultrasound-guided selective nerve root block versus fluoroscopy-guided interlaminar epidural block for the treatment of radicular pain in the lower cervical spine: a retrospective comparative study

PURPOSE

Recent studies have compared the therapeutic efficacy and safety of the procedure using ultrasound and fluoroscopy. However, there are no published studies comparing the therapeutic efficacy and safety of fluoroscopy (FL)-guided cervical interlaminar epidural steroid injection (CIESI) with that of ultrasound (US)-guided selective nerve root block (SNRB). This study aimed to compare the mid-term effects and advantages of US-guided SNRB with FL-guided CIESI for radicular pain in the lower cervical spine through assessment of pain relief and functional improvement.

METHODS

Patients with radicular pain in the lower cervical spine who received US-guided SNRB (n = 51) or FL-guided CIESI (n = 61) were included in this retrospective study. All procedures were performed using FL or US. The complication frequencies during the procedures, adverse events, treatment effects, and functional improvement were compared at intervals of 1, 3, and 6 months after the last injection.

RESULTS

Both the neck disability index and verbal numeric scale showed improvements at 1, 3, and 6 months after the last injection in both groups, with no significant differences between groups (p < 0.05). Furthermore, the treatment success rate at all time points was not significantly different between groups. Logistic regression analysis revealed that the injection method (US- or FL-guided), sex, analgesic use, pain duration, number of injections, and age were not independent predictors of treatment success. Blood was aspirated before injection in 8% (n = 5) and 0% of patients in the FL-guided and US-guided groups, respectively. In seven patients of the FL-guided group, intravascular contrast spread was noted during injection.

CONCLUSIONS

Our results suggest that, compared with FL-guided CIESI, US-guided SNRB requires a shorter administration duration while providing similar pain relief and functional improvements.

Ultrasound diagnosis and therapeutic intervention in the spine

Spine pathology afflicts people across the globe and is responsible for a large portion of physician visits and healthcare costs. Imaging such as plain radiographs, CT, MRI, and ultrasound is vital to assess structure, function, and stability of the spine and also provide guidance in therapeutic interventions. Ultrasound utilization in spine conditions is less ubiquitous, but provides benefits in low costs, portability, and dynamic imaging. This study assesses ultrasound efficacy in diagnosis and therapeutic interventions for spine pathology. A systematic review conducted via PubMed, MEDLINE, and Google Scholar identified 3,630 papers with eventual inclusion of 73 papers with an additional 21 papers supplemental papers subsequently added. Findings highlighted ultrasound utilization for different structural elements of the spine such as muscle, bone, disc, ligament, canal, and joints are presented and compared with radiographs, CT, and MRI imaging where relevant. Spinal curvature and mobility are similarly presented. Ultrasound efficacy for guided therapeutics about the spine is presented and assessed against other modalities. Ultrasound is a widely used and efficacious modality to guide injections about the spine. Diagnostic utility is less well studied, but shows promise in assessing fractures, posterior ligamentous stability, and intra-operative hardware placement. The low cost, portability, and dynamic imaging ability make it an attractive modality particularly for developing health systems and resource limited environments such as combat settings and the International Space Station. Further study is recommended before broad adoption in diagnostics.

Image Guidance Technologies for Interventional Pain Procedures: Ultrasound, Fluoroscopy, and CT

Chronic pain is a common medical condition. Patients who suffer uncontrolled chronic pain may require interventions including spinal injections and various nerve blocks. Interventional procedures have evolved and improved over time since epidural injection was first introduced for low back pain and sciatica in 1901. One of the major contributors in the improvement of these interventions is the advancement of imaging guidance technologies. The utilization of image guidance has dramatically improved the accuracy and safety of these interventions. The first image guidance technology adopted by pain specialists was fluoroscopy. This was followed by CT and ultrasound. Fluoroscopy can be used to visualize bony structures of the spine. It is still the most commonly used guidance technology in spinal injections. In the recent years, ultrasound guidance has been increasingly adopted by interventionists to perform various injections. Because its ability to visualize soft tissue, vessels, and nerves, this guidance technology appears to be a better option than fluoroscopy for interventions including SGB and celiac plexus blocks, when visualization of the vessels may prevent intravascular injection. The current evidence indicates the efficacies of these interventions are similar between ultrasound guidance and fluoroscopy guidance for SGB and celiac plexus blocks. For facet injections and interlaminar epidural steroid injections, it is important to visualize bony structures in order to perform these procedures accurately and safely. It is worth noting that facet joint injections can be done under ultrasound guidance with equivalent efficacy to fluoroscopic guidance. However, obese patients may present challenge for ultrasound guidance due to its poor visualization of deep anatomical structures. Regarding transforaminal epidural steroid injections, there are limited evidence to support that ultrasound guidance technology has equivalent efficacy and less complications comparing to fluoroscopy. However, further studies are required to prove the efficacy of ultrasound-guided transforaminal epidural injections. SI joint is unique due to its multiplanar orientation, irregular joint gap, partial ankylosis, and thick dorsal and interosseous ligament. Therefore, it can be difficult to access the joint space with fluoroscopic guidance and ultrasound guidance. CT scan, with its cross-sectional images, can identify posterior joint gap, is most likely the best guidance technology for this intervention. Intercostal nerves lie in the subcostal grove close to the plural space. Significant risk of pneumothorax is associated with intercostal blocks. Ultrasound can provide visualization of ribs and pleura. Therefore, it may improve the accuracy of the injection and reduce the risk of pneumothorax. At present time, most pain specialists are familiar with fluoroscopic guidance techniques, and fluoroscopic machines are readily available in the pain clinics. In the contrast, CT guidance can only be performed in specially equipped facilities. Ultrasound machine is generally portable and inexpensive in comparison to CT scanner and fluoroscopic machine. As pain specialists continue to improve their patient care, ultrasound and CT guidance will undoubtedly be incorporated more into the pain management practice. This review is based on a paucity of clinical evidence to compare these guidance technologies; clearly, more clinical studies is needed to further elucidate the pro and cons of each guidance method for various pain management interventions.

Cervical vertebroplasty under sedoanalgesia using combined ultrasonography and fluoroscopy guidance: a novel technique

PURPOSE

The aim of this report was to describe a case using combined USG and fluoroscopy for cervical VP via a percutaneous route under sedoanalgesia.

METHODS

A 70-year-old male patient had severe neck pain for 6 weeks because of metastatic mass lesions in C6. After the decision to VP, the patient was placed on the operating table and 2 mg midazolam and 75 µg fentanyl were administered for conscious sedation. Localisation of the carotid artery, internal jugular vein, and trachea had been determined with USG. 3 mL of 2% lidocaine was infiltrated after proceeding a needle from the axis of the trochar to the C6 vertebra corpus. The trochar entered into the vertebra corpus between the carotid artery and trachea right-antero-laterally under C-arm and USG guidance. 6 mL of PMMA was injected into this field. Then C6 VP procedure had been completed without complications.

RESULTS

This case has three differences from studies in the literature. First, cervical VP was conducted under sedoanalgesia. The second important feature of this case is that cervical VP was performed via a percutaneous route. A third important feature of this case is that it was performed under USG guidance for the first time in the literature.

CONCLUSION

We consider that the combined use of C-arm fluoroscopy and USG should improve success rates and prevent vascular and neural injuries and dura perforation.

Ultrasonography Evaluation of Vulnerable Vessels Around Cervical Nerve Roots During Selective Cervical Nerve Root Block

Objective

To evaluate the prevalence of vulnerable blood vessels around cervical nerve roots before cervical nerve root block in the clinical setting.

Methods

This retrospective study included 74 patients with cervical radiculopathy who received an ultrasonography-guided nerve block at an outpatient clinic from July 2012 to July 2014. Before actual injection of the steroid was performed, we evaluated the vulnerable blood vessels around each C5, C6, and C7 nerve root of each patient's painful side, with Doppler ultrasound.

Results

Out of 74 cases, the C5 level had 2 blood vessels (2.7%), the C6 level had 4 blood vessels (5.45%), and the C7 level had 6 blood vessels (8.11%) close to each targeted nerve root. Moreover, the C5 level had 2 blood vessels (2.7%), the C6 level 5 blood vessels (6.75%), and the C7 level had 4 blood vessels (5.45%) at the site of an imaginary needle's projected pathway to the targeted nerve root, as revealed by axial transverse ultrasound imaging with color Doppler imaging. In total, the C5 level had 4 blood vessels (5.45%), the C6 level 9 blood vessels (12.16%), and the C7 level 10 had blood vessels (13.51%) either at the targeted nerve root or at the site of the imaginary needle's projected pathway to the targeted nerve root. There was an unneglectable prevalence of vulnerable blood vessels either at the targeted nerve root or at the site of the needle' projected pathway to the nerve root. Also, it shows a higher prevalence of vulnerable blood vessels either at the targeted nerve root or at the site of an imaginary needle's projected pathway to the nerve root as the spinal nerve root level gets lower.

Conclusion

To prevent unexpected critical complications involving vulnerable blood vessel injury during cervical nerve root block, it is recommended to routinely evaluate for the presence of vulnerable blood vessels around each cervical nerve root using Doppler ultrasound imaging before the cervical nerve root block, especially for the lower cervical nerve root level.

The Impact of Body Mass Index on Fluoroscopy Time During Lumbar Epidural Steroid Injection; A Multicenter Cohort Study

Objective

This study aimed to assess the relationship between BMI and fluoroscopy time during lumbar epidural steroid injections (LESIs) performed for lumbosacral radicular pain.

Design

Multicenter retrospective cohort study.

Setting

Three academic, outpatient pain treatment centers.

Subjects

Patients who underwent fluoroscopically guided LESI.

Methods

Mean and standard deviation (SD) fluoroscopy time were compared between patients with normal (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2) BMI. Statistical significance was set at P=0.01 due to multiple comparisons.

Results

A total of 2,930 procedure encounters were included, consisting of 598 interlaminar LESIs and 2,332 transforaminal LESIs. Fluoroscopy time was significantly longer in the obese patients compared to normal and overweight patients during interlaminar LESI (P < 0.01). Fluoroscopy time was significantly longer with each increasing BMI category in during transforaminal LESI (P < 0.01). These relationships remained when a trainee was involved (P < 0.01; P<0.01), during repeat injections (P < 0.01; P < 0.01), and during bilateral transforaminal LESIs (P < 0.01). While longer fluoroscopy times were required in high BMI categories during L5-S1 transforaminal LESI (P < 0.01), there was no relationship between fluoroscopy time and BMI during L4-L5 and S1 transforaminal LESI (P = 0.02; P = 0.13). Fluoroscopy time during interlaminar LESI compared to transforaminal LESI was significantly lower within all BMI categories (all P<0.01).

Conclusions

The findings of this study indicate that fluoroscopy time is increased during interlaminar LESIs and during L5-S1 transforaminal LESIs in patients who are obese. These relationships are not affected by injection number, performance of bilateral injections, or trainee involvement. Further study is needed to determine if this increase in fluoroscopy time is indicative of a clinically significant associated increase in radiation dose.

A brief report on a technical description of ultrasound-guided lumbar sympathetic block

The lumbar sympathetic ganglion block (LSGB) is widely used for diagnosing and treating sympathetically maintained pain disorders. The LSGB has been conventionally carried out under fluoroscopy or computed tomography guidance. However, as ultrasound technology improved, ultrasound-guided interventions have been expanding their territory to deeper structures. Ultrasound guidance provides many benefits including protecting vascular injection, shortening procedure time in some cases, and reducing the emission of radiation. In this report, we describe a successful case of a US-guided LSGB without major complications. We expect that US-guided LSGBs can be implemented and furnished in the daily outpatient clinical setting by highly trained pain physicians.

Localized cervical pain: advantages and limits of ultrasound evaluation

PURPOSE

Cervical pain is very frequent in the general population. In clinical practice, plain X-ray and, in selected cases, computed tomography or magnetic resonance imaging, are performed. However, the feasibility and utility of ultrasound examination have been poorly investigated. Aim of the present study was to evaluate whether ultrasound could be useful in the diagnosis of localized cervical pain.

METHODS

Subjects suffering from posterior cervical pain without irradiation to surrounding tissues were enrolled. After clinical and functional evaluation (demographic and anthropometric data, VAS at rest and during neck movements, symptoms duration, and characteristics of pain onset [atraumatic or traumatic]), an ultrasound exam of the cervical spine was performed according to standard protocols.

RESULTS

The anatomic structures of the neck district were visualized in 124/127 enrolled patients and pathological features were observed in 58. Significant ultrasound differences were registered between the patients with traumatic and atraumatic onset of neck pain. In the first group, articular effusion, capsular bulging, disalignment and avulsion of the articular apex were observed, whereas in the latter cortical irregularities, osteophytosis, and articular ankylosis were prevalent.

CONCLUSIONS

Ultrasound examination can be used as diagnostic tool in the evaluation of selected patients suffering from localized cervical pain, particularly in cases of pain due to traumatic injuries.

Update in Musculoskeletal Ultrasound Research

CONTEXT

Musculoskeletal ultrasound (US) research is expanding due to increased clinical utility of sonography.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Ultrasound is widely applied in musculoskeletal imaging and sports medicine. The real-time capabilities and favorable cost profile of US make it ideal for use in diagnosis of musculoskeletal conditions. The enthusiasm for the use of US in musculoskeletal imaging has led to an increase in US research to broaden its applications.

CONCLUSION

Several recent advances have been made in conventional and novel US imaging techniques, quantitative US imaging, and US-guided interventions.

STRENGTH OF RECOMMENDATIONS TAXONOMY SORT

C.

Ultrasound indications for chronic pain management: an update on the most recent evidence

PURPOSE OF REVIEW

The ability of ultrasound to provide detailed anatomic visualization while avoiding radiation exposure continues to make it an appealing tool for many practitioners of chronic pain management. This review will present the most recent evidence regarding the use of ultrasound-guidance for the performance of interventional procedures in the treatment of chronic pain.

RECENT FINDINGS

For a variety of different procedures, studies continue to compare ultrasound-guided techniques to commonly used fluoroscopic or landmark-based techniques. Small, randomized controlled trials are beginning to demonstrate that ultrasound-guided approaches to interventional pain procedures can be as well tolerated and effective as the traditionally used techniques, while providing some potential advantages in terms of decreased radiation exposure, avoidance of vascular structures, and in some cases, improved efficiency and decreased rates of adverse effects.

SUMMARY

Despite continued interest in ultrasound-guided techniques for chronic pain management procedures, the evidence is still limited mainly to small, randomized trials and case series. For some procedures, such as stellate ganglion block and peripheral joint injections, recent evidence appears to be tilting in favor of ultrasound-guidance as the preferred technique, though fluoroscopy continues to be a much more reliable method for detection of intravascular uptake of injectate.

Ultrasound versus fluoroscopy-guided caudal epidural steroid injection for the treatment of chronic low back pain with radiculopathy: A randomised, controlled clinical trial

Background and Aims:

Caudal epidural steroid administration is an effective treatment for chronic low back pain (LBP). Fluoroscopy guidance is the gold standard for pain procedures. Ultrasound guidance is recently being used in pain clinic procedures. We compared the fluoroscopy guidance and ultrasound guidance for caudal epidural steroid injection with respect to the time needed for correct placement of the needle and clinical effectiveness in patients with chronic LBP.

Methods:

Fifty patients with chronic LBP with radiculopathy, not responding to conventional medical management, were randomly allocated to receive injection depot methyl prednisolone (40 mg) through caudal route either using ultrasound guidance (Group U, n = 25) or fluoroscopy guidance (Group F, n = 25). Pre-procedural visual analogue scale (VAS) score and Oswestry Disability Index (ODI) were noted. During the procedure, the time needed for correct placement of needle was observed. Adverse events, if any, were also noted. All patients were followed up for next 2 months to evaluate Visual Analogue Scale (VAS) score and ODI at the 2^nd week and again at the end of 1^st and 2^nd month.

Results:

The needle-placement time was less using ultrasound guidance as compared to fluoroscopy guidance (119 ± 7.66 vs. 222.28 ± 29.65 s, respectively, P < 0.001). Significant reduction in VAS score and ODI (clinical improvement) was noted in the follow-up time points and comparable between the groups at all time points.

Conclusion:

Ultrasound guidance can be a safe alternative tool for achieving faster needle placement in caudal epidural space. Clinical effectiveness (reduction of VAS and ODI scores) remains comparable between both the techniques.