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Ultrasound (US) has become a more common imaging modality for spinal interventions.
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US has some advantages and disadvantages compared with fluoroscopy and other imaging modalities.
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Most typical spinal pain procedures described under fluoroscopy have also been described with US guidance.
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Although there are multiple studies demonstrating the accuracy of US-guided spine procedures using cadaveric dissections as well as comparing their accuracy to procedures with CT or fluoroscopic guidance, there are
Physical Medicine and Rehabilitation Clinics of North America
Ultrasound-Guided Spinal Procedures for Pain: A Review
Section snippets
Key points
Anatomy
The cervical spine is composed of 7 vertebral levels with the atlanto-occipital (C0-C1) and atlantoaxial (C1-C2) having unique anatomic features. This article’s focus is on the middle and lower cervical joints. Potential pain generators at each level include the vertebral body, facets, nerve roots, and disks. Under US guidance, the cervical facets and medial branches are relatively accessible in most patients.1 At the C2-C3 level, the facet may refer pain to the third occipital nerve (TON),
Anatomy
The thoracic spine is composed of 12 vertebral levels. Thoracic back pain is not as common as lumbar or cervical pain; however, it is present in approximately 15% of adults. This pain can be chronic and severe.7 Common pain generators include the disks, facets, and nerve roots. Additional sources of pain, however, include the costovertebral and costotransverse joints. With US imaging alone, the disks and costovertebral joints are not commonly injected due to poor visualization. US-guided facet
Ultrasound-guided lumbar spine procedures
Lumbar pain and radicular leg pain are leading reasons people seek treatment with their primary care provider.10, 11 Typical treatment options include physical therapy, oral analgesic/anti-inflammatory medications, and injection therapies. Recently, image-guided interventions have become common among pain specialists.12 Over the past decade, more evidence is building that US is a viable imaging modality for lumbar spinal procedures.13, 14
Anatomy
The sacroiliac joint (SIJ) links the spine to the pelvis. Typically, the more caudal portion of the joint has true synovium, whereas the more proximal portion may contain only fibrocartilage.18 The posterior SIJ is innervated by the dorsal S2-S4 nerve roots, whereas the anterior joint is innervated by the L2-S2 nerve roots.19
Indications
Typically, patients present with pain in the area of the rejoin of the SIJ. Provocative maneuvers and imaging studies do not provide highly reliable diagnostic information
Anatomy
Typically, the sacral hiatus can be located around the level of S4 and S5 along the midline of the posterior sacrum. The sacral cornua create the lateral borders of the hiatus whereas the posterior sacrum creates the floor. Distally, the hiatus is covered by the sacrococcygeal ligament. The epidural space extends all the way to the sacral hiatus whereas typically the dura only extends to the S2 level. The anterior component of the sacral epidural space tends to be the most vascular.23
Indications
Typically,
Anatomy
At the level of the thoracic spine, there are 12 interlaminar spaces posteriorly between T1 and L1. The spinous processes of the thoracic spine slope caudally covering a significant portion of the posterior interlaminar opening. In addition, the ligamentum flavum may be absent at the midline in the upper thoracic spine.25 At the lumbosacral level, there are 5 posterior openings between L1 and the sacrum. The largest opening is typically at the L5-S1 level. With age, the ligamentum flavum
Summary
US has become increasingly common as an imaging modality for spinal interventions. It has advantages and disadvantages versus CT and fluoroscopic guidance and should be considered an option among the interventional spine clinician's repertoire. Large studies comparing the safety and efficacy of US-guided spinal interventions versus CT and fluoroscopy are needed to further define the role of these procedures.
References (30)
On the definitions and physiology of back pain, referred pain, and radicular pain
Pain
(2009)- et al.
Ultrasound-guided lumbar medial-branch block: a clinical study with fluoroscopy control
Reg Anesth Pain Med
(2006) - et al.
Landmarks of the sacral hiatus for caudal epidural block: an anatomical study
Br J Anaesth
(2005) - et al.
The feasibility of color Doppler ultrasonography for caudal epidural steroid injection
Pain
(2005) - et al.
Anatomy of the lumbar epidural region using magnetic resonance imaging: a study of dimensions and a comparison of two postures
Int J Obstet Anesth
(1997) - et al.
Efficacy of ultrasound imaging in obstetric epidural anesthesia
J Clin Anesth
(2002) - et al.
Ultrasound imaging of the thoracic epidural space
Reg Anesth Pain Med
(2002) - et al.
Ultrasound anatomy of the nerves supplying the cervical zygapophyseal joints: an exploratory study
Reg Anesth Pain Med
(2011) - et al.
Sonographic visualization and ultrasound-guided block of the third occipital nerve: prospective for a new method to diagnose C2-C3 zygapophysial joint pain
Anesthesiology
(2006) - et al.
Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study
Spine (Phila Pa 1976)
(1996)
Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain
N Engl J Med
Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, sonoanatomy, and procedures. Part II: axial structures
Reg Anesth Pain Med
A shortened radiofrequency denervation method for cervical zygapophysial joint pain based on ultrasound localization of the nerves
Pain Med
A population-based study of spinal pain among 35-45-year-old individuals. Prevalence, sick leave, and health care use
Spine (Phila Pa 1976)
Ultrasound-guided thoracic facet injections: description of a technique
J Ultrasound Med
Cited by (30)
Different exposure times of flexion distraction technique in the L5-S1 distance and local pain of patients with chronic low back pain: A feasibility study
2024, International Journal of Osteopathic MedicineUltrasound for Lumbar Spinal Procedures
2018, Physical Medicine and Rehabilitation Clinics of North AmericaCitation Excerpt :Given various approaches, sonoanatomic landmarks, and potential risks associated with transforaminal injections, it is recommended that ultrasound-guided transforaminal injections are performed only by seasoned practitioners with extensive ultrasound injection experience. SI joint-mediated pain is a common source of low back pain with reported prevalence rates of 10% to 30%.18–20 The SI joint is a large diarthrodial joint with a fibrous posterosuperior component and a synovial anteroinferior component.
Sonography guided lumbar nerve and facet blocks: The first report of clinical outcome from Iran
2018, RadiographyCitation Excerpt :Classically, they are performed under fluoroscopy or computed tomography (CT) guidance, which have the disadvantages of ionizing radiation exposure to both the patient and operator, and the need for equipment that are not available in all settings (i.e. available only in the hospital operation room and radiology department, and not outpatient clinics).6–9 In the last decade, there have been efforts to perform the blocks under ultrasound (US) guidance, which has the advantages of greater availability, no radiation exposure, and the option to perform the procedure in most inpatient and outpatient settings.10 Previously, US has been used in peripheral nerve, lumbar and brachial plexus, and neuraxial blocks.11–13
Cervical Facet Arthropathy
2018, Essentials of Physical Medicine and Rehabilitation: Musculoskeletal Disorders, Pain, and RehabilitationMechanical Needling With Sterile Water Versus Lidocaine Injection for Lumbar Spinal Stenosis
2024, Global Spine Journal
Disclosures: The author has no disclosures.