A Randomized Comparison Between Ultrasound- and Fluoroscopy-Guided Sacral Lateral Branch Blocks:

The effectiveness of sacral lateral branch radiofrequency neurotomy for posterior sacroiliac joint complex pain in patients selected by dual sacral lateral branch blocks; A real-world cohort study

Background

Previous study of spinal neurotomy procedures indicates that stringent block selection improves outcomes. However, this pattern is not established for sacral lateral branch radiofrequency neurotomy (SLBRFN). Few SLBRFN studies have used stringent block selection criteria such as ≥80 % pain reduction following dual sacral lateral branch blocks (SLBB).

Objective

Evaluate the effectiveness of SLBRFN in patients with ≥80 % pain relief following dual SLBBs.

Methods

Retrospective single-arm cohort study of consecutive patients from two Canadian musculoskeletal and pain clinics who underwent first-time SLBRFN after report of ≥80 % pain relief following dual diagnostic SLBBs. Patients were identified by electronic medical record query between 2016 and 2022. The primary outcome was the proportion of individuals with a ≥50 % reduction in the numeric pain rating scale (NPRS) score three months after SLBRFN. Secondary outcomes included the proportion of responders achieving the minimal clinically important difference (MCID) on the pain disability quality-of-life questionnaire (PDQQ), and the duration and mean percentage of pain relief among those with recurrent symptoms after a successful SLBRFN.

Results

Of the 70 participants included, 32 (45.7 %; 95 % CI = 34.6-57.3) reported a ≥50 % reduction in NPRS, and 35 (50.0 %; 95 % CI = 38.6-61.4) achieved the MCID on the PDQQ at 3-months. Among the 17 patients who reported a return of symptoms, the mean duration of relief was 8.0 ± 3.5 months, and the mean percentage of pain relief was 77.9 % ± 16.4 %. Logistic regression models revealed that the use of multi-tined RF probes and lower patient BMI were associated with treatment success.

Discussion/conclusion

SLBRFN reduced pain and disability in approximately 50 % of patients at 3 months when selected using relatively restrictive selection criteria. Treatment success was associated with multi-tined RF probe type and lower patient BMI. Larger prospective studies assessing long-term outcomes are needed to further evaluate the impact of different selection criteria and techniques on SLBRFN effectiveness.

A novel simplified sonographic approach with fluoroscopy-controlled L5 transforaminal epidural injections in patients with high iliac crest: a retrospective study

BACKGROUND

To explore a novel ultrasound (US) modality for lumbar transforaminal epidural injections (TFEIs) in patients with low back pain (LBP) and L5 radicular pain combined with high iliac crest (HIC).

METHODS

One-hundred and forty-one patients were retrospectively stratified into two groups based on the treatment they received: novel group, receiving US-guided and fluoroscopy (FL)-controlled TFEIs using a sagittal oblique approach between the superior articular process of L5 and S1, and control group, receiving US-guided TFEIs with conventional transverse approach combined with FL confirmation. Accuracy of contrast dispersing into lumbar epidural space was set as the primary endpoint. Radiation dosages, procedure time, numeric rating scale (NRS) scores, Modified Oswestry Disability Questionnaire (MODQ) scores, adverse events, and rescue analgesic requirement were also recorded. The generalized liner mixed model (GLMMs) was employed to compare the repeatedly measured variables between groups, taking individual confounding factors as covariance.

RESULTS

The accuracy of TFEIs was 92.8% and 65.2% in novel and control group, with a significant difference of 26.7% (95% CI: 15.4%, 39.8%) between two modalities (p < 0.001). Significant pain relief was observed in novel group as opposed to control group after one injection. Procedure time in novel group (8.4 ± 1.6 min) was shorter than control group (15.8 ± 3.5 min) (p < 0.001) with less radiation dosage (3047 ± 5670 vs. 8808 ± 1039 μGy/m2, p < 0.001). Significantly, lower incidence of L5 paresthesia occurred in novel group. Statistical differences of NRS scores between the novel and control group were reached at 1 week after procedure (1 (IQR: - 1-3) vs. 3 (IQR: - 1-7), p = 0.006), while not reached at both 1- (1 (IQR: 0-2) vs. 1 (IQR: - 1-3), p = 0.086) or 3-month follow-up (0 (IQR: - 1-1) vs. 1 (IQR: 0-2), p = 0.094). Both groups showed similar functional improvement (F = 0.103, p = 0.749) during follow-up.

CONCLUSIONS

The novel sonographic technique provided superior accuracy needle placement and better pain-relieving effect through one injection as compared to the routine transverse approach. Consequently, in situations where the HIC imposed limitations for TFEIs performance on L5, the novel technique should be recommended to consider increasing accurate puncture, minimizing radiation exposure, consuming procedure time, and reducing the risk of neuraxial injury.

Ultrasound-guided lateral branch radiofrequency neurotomy for sacroiliac joint pain after lumbosacral spinal fusion surgery

Our study evaluated the clinical feasibility of ultrasound-guided lateral branch radiofrequency neurotomy for sacroiliac joint (SIJ) pain after lumbosacral spinal fusion surgery (LSFS). This prospective study included a total of 46 patients who were diagnosed with SIJ pain after LSFS, did not respond to conservative treatment and therefore underwent ultrasound-guided SIJ radiofrequency neurotomy (RFN) from January 2019 to January 2022. These patients were followed up for twelve months after the procedure. Patients were assessed with the Numeric Rating Scale (NRS) and the Oswestry Disability Index (ODI) preprocedural and postprocedural for 1 month, 6 months and 12 months follow-ups. There was a significant improvement in postprocedural NRS and ODI scores (p < 0.001). Thirty-eight patients (82.6%) had a satisfactory response and good global perceived effect (GPE) after twelve months. No significant complications were observed during the 12-month follow-up. The ultrasound-guided radiofrequency device designed as a safe, easily applied and encouraging method could avoid revision surgery. It is a promising technique and has shown good results in providing intermediate pain relief. In addition to the limited series reported in the literature, future studies will add meaning to this topic by including it in routine practice.

Ultrasound-guided radiofrequency Ablation for SI joint pain:An observational study

Objective

An ultrasound (US) guided RFA technique for the SIJ, utilizing bipolar RF cannula placements along the lateral sacral crest (LSC), has been proposed in anatomical studies. This study evaluated changes in pain intensity, function and quality of life following this technique.

Methods

Patients achieving ≥50% pain relief on two blocks (one FL- and one US-guided) were included. US-guided SIJ RFA was performed with sequential bipolar lesions using two multitined RF cannulae placed along the LSC. The Pain, Disability, Quality of Life Questionnaire-Spine (PDQQ-S), which includes an 11-point (0-10) numeric rating scale (NRS) for pain intensity, was completed pre-RFA, and 2, 6, 9, 12 and 16 months post-RFA. Outcomes at 2 months post-RFA were compared between US-guided and FL-guided SIJ RFA in participants with previous FL-guided SIJ RFA.

Results

31 patients were included. Statistically significant decreases in pain intensity were observed up to 9 months after US-guided SIJ RFA (Baseline NRS: mean ​= ​6.8 SD ​= ​1.6, 95%CI [6.169, 7.347]; 9 month: mean ​= ​4.8, SD ​= ​2.6, 95%CI [3.891, 5.786]; p ​= ​0.0005), and up to 12 months for PDQQ-S. A clinically significant ≥2 point reduction in pain intensity on the NRS was seen in 48.4% of participants at 9 months. 11 participants had previous FL-guided SIJ RFA; no statistically significant differences were found in pain intensity or PDQQ-S scores between US- and FL-guided SIJ RFA 2-months post-RFA.

Conclusions

Preliminary results suggest that SIJ RFA could be performed using US guidance. Further study is required to establish effectiveness.

Evaluation of an Ultrasound-Assisted Longitudinal Axis Lateral Crest Approach to Radiofrequency Ablation of the Sacroiliac Joint

OBJECTIVE

The aim of the study was to evaluate the effectiveness and procedural characteristics of a novel, ultrasound/fluoroscopically guided technique (longitudinal axis sacroiliac joint radiofrequency ablation) for sacroiliac joint denervation.

DESIGN

A single-arm cohort with historical cohort comparison was used in this study.

METHODS

Thirty-seven participants underwent longitudinal axis sacroiliac joint radiofrequency ablation after 50% or more pain reduction after diagnostic dual-block criterion. Outcomes were the proportion of participants with 50% or more pain reduction and mean Pain Disability Quality of Life Questionnaire change. Subanalysis included longitudinal axis sacroiliac joint radiofrequency ablation procedural and fluoroscopy times compared with participants previously treated with palisade radiofrequency ablation technique.

RESULTS

Primary outcome worst case analysis demonstrated a responder rate of 64.9% (95% confidence interval = 48.8%-78.2%) and 59.5% (95% confidence interval = 43.5%-73.7%) at 3 and 6 mos. There was significant decrease in mean Pain Disability Quality of Life Questionnaire at 3 (45.6 ± 9.5 to 21.4 ± 16.0, P < 0.001) and 6 mos (45.6 ± 9.5 to 23.0 ± 16.5, P < 0.001). Longitudinal axis sacroiliac joint radiofrequency ablation required more procedure time than the palisade technique (38.2 ± 7.9 vs. 32.1 ± 6.9 mins, P = 0.031) but less fluoroscopy time (35.0 ± 11.8 vs. 57.6 ± 16.8 secs, P < 0.001).

CONCLUSIONS

Longitudinal axis sacroiliac joint radiofrequency ablation resulted in improvement in pain, disability, and quality of life at 3 and 6 mos. Compared with the palisade technique, longitudinal axis sacroiliac joint radiofrequency ablation required greater procedure time but less fluoroscopy time.

Sacroiliac Joint Anatomy

The sacroiliac joint can be a source of low back pain. This review article summarizes current anatomic evidence of the innervation of the intraarticular and extraarticular parts of the sacroiliac joint relative to bony landmarks identifiable with fluoroscopy and ultrasound. This article aims to provide clinicians with an anatomic basis for clinical application to diagnostic blocks and radiofrequency ablation for sacroiliac pain to optimize clinical outcomes.

Sacroiliac Joint Diagnostic Block and Radiofrequency Ablation Techniques

Radiofrequency ablation (RFA) is a potential treatment for those with sacroiliac joint (SIJ) pain. There is no consensus on the optimal procedural techniques for SIJ diagnostic blocks, or RFA. This article describes different techniques for SIJ diagnostic blocks and RFA, including the relevant innervation that underlies these techniques. SIJ RFA techniques differ in important ways, including lesioning techniques, needle placements, and type of RFA cannula used. Clinicians utilize a variety of image guidance modalities for SIJ RFA; fluoroscopic guidance is standard, although endoscopic and ultrasound-guided techniques are described. Additional studies are necessary to delineate potential differences between SIJ RFA techniques.

Ultrasound-guided L5 dorsal ramus block: validation of a novel technique

BACKGROUND

Although the value of ultrasound-guided (USG) lumbar medial branch blocks (MBB) has previously been examined in several clinical trials, blocking the L5 dorsal ramus (DR) remains a technical challenge and we sought to examine the accuracy of a novel technique targeting this level.

METHODS

In this prospective cohort study, 115 patients scheduled for an L4 MBB and L5 DR block underwent an ultrasound scan to assess their lower spine sonoanatomy. Subjects in whom the necessary landmarks could be visualized underwent a USG L5 DR block using a pivot technique, which involved redirecting a needle from its position on the L5 transverse process after an L4 MBB. Success was determined by a blinded observer who examined the contrast distribution on postprocedural X-ray images. In addition to the final needle position, performance time, the number of needle passes, and any complication were recorded.

RESULTS

A total of 100 patients had a USG block and 15 patients (13%) were excluded because of poor landmark visibility. The latter group presented a significantly higher body mass index (38.90±7.50 vs 26.31±4.25 kg/m², p=0.004). A total of five failures were noted (95% success rate), this included three patients with transitional anatomy in whom needles were placed at the wrong level and two cases of incomplete contrast coverage possibly related to the partial intravascular injection. Performance time was 153.93±41.56 s and the median number of needle passes was 2 (range 4). No significant complications were noted.

CONCLUSION

The pivot technique provides a reliable approach for USG L5 DR ramus blocks.

TRIAL REGISTRATION NUMBER

NCT03805906.

Echo-guided invasive pain therapy: indications and limitations

PURPOSE OF REVIEW

The purposes of this review are to summarize the advantages and limitations of ultrasound-guided pain interventions, and to illustrate those interventions with peripheral, axial and musculoskeletal pain procedures.

RECENT FINDINGS

With the capability of locating the interfascial plane, ultrasonography has led to the emergence of a series of plane blocks for the thoracoabdominal region in the recent decade.Ultrasonography for musculoskeletal procedures has been of growing interest because of the major advantage of direct visualization and scanning of various soft tissues and real-time spread in the injectate, thereby enhancing precision and efficacy, reducing risk of trauma and avoidance of radiation. For spine and intra-articular structures, ultrasonography is complicated by the bony shadow artefact and often deep location of the structure, making acquisition of ultrasound image challenging. Despite these difficulties, there is growing interest in applying ultrasonography for cervical spine and sacroiliac joint procedures.

SUMMARY

Pain intervention under ultrasound guidance is particularly valuable in peripheral and musculoskeletal procedures. There is growing interest of its application in cervical spine and sacroiliac joint. More outcome studies are required in the future to make ultrasound-guided pain intervention as the established procedure.

Ultrasonography and Italian anesthesiology: a national cross-sectional study

PURPOSE

In recent years, ultrasound has seen a rapid development with numerous applications in anesthesia, intensive-care medicine, and pain medicine, increasing efficacy and safety of procedures. We investigated the prevalence of ultrasound use among Italian anesthetists.

METHODS

A cross-sectional prevalence study was carried out on a sample of 735 anesthetists. The research was conducted during the ultrasound training in anesthesia and intensive care, in the Italian Associazione Anestesisti Rianimatori Ospedalieri - Emergenza Area Critica "SimuLearn^®" training centre (Bologna, Italy).

RESULTS

The overall prevalence of a dedicated ultrasound devices in the operating room was 70% [95% CI 66-73%], while 74% [95% CI 69-78%] in northern Italy, 61% [95% CI 52-68%] in southern Italy, and 70% [95% CI 63-77%] in central Italy, indicating a significant difference between the north and south of Italy. The prevalence of regular use of ultrasound was high for regional anesthesia and for central venous cannulation [82-95% CI 79-85%] and low for pain therapy procedures [7-95% CI 6-10%]. Multivariate logistic analysis showed that the presence of a dedicated ultrasound device and high expertise were factors associated with routine use of ultrasound for regional anesthesia in upper and lower limb blocks and in vascular access.

CONCLUSION

The appropriate training in the use of ultrasound in anesthesia, intensive-care medicine, and pain therapy should be implemented in south of Italy to make uniform the widespread of ultrasonography in anesthesia, in all Italian regions.