Ultrasound-Guided Spinal Procedures for Pain: A Review

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Key points

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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

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.

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      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.

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      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

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    Disclosures: The author has no disclosures.

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