Sonographically guided lumbar spine procedures

Ultrasound-guided procedures for the management of chronic thoracic back pain: a technical review

Pain arising from the thoracic region has been reported to be potentially as debilitating as cervical or lumbar back pain, and may stem from a vast number of spinal sources, including zygapophysial, costovertebral and costotransverse joints, intervertebral discs, ligaments, fascia, muscles, and nerve roots. Over the last two decades, the use of ultrasound in interventional spinal procedures has been rapidly evolving, due to the ultrasound capabilities of visualizing soft tissues, including muscle layers, pleura, nerves, and blood vessels, allowing for real-time needle tracking, while also reducing radiation exposure to both patient and physician, when compared to traditional fluoroscopy guidance. However, its limitations still preclude it from being the imaging modality of choice for some thoracic spinal procedures, notably epidural (interlaminar and transforaminal approaches) and intradiscal injections. In this technical review, we provide an overview of five thoracic spinal injections that are amenable to ultrasound guidance. We start by discussing their clinical utility, followed by the relevant topographic anatomy, and then provide an illustrated technical description of each of the procedures discussed: (1) erector spinae plane block; (2) intra-articular thoracic zygapophyseal (facet) joint injection; (3) thoracic medial branch block; (4) costotransverse joint injection; and (5) costovertebral joint injection.

Ultrasound-Guided In-Plane Interlaminar Lumbar Endoscopic Approach with Smartphone and Portable Light Source: Description of a New Surgical Technique

Introduction Endoscopic spine surgery enables the minimally invasive treatment of pathologies affecting the spinal cord and roots. Herein we describe an unprecedented technique Ultrasound-Guided in-plane interlaminar lumbar endoscopic approach with a smartphone and portable light source.

Methods The interlaminar approach was performed in a cadaveric specimen at L4 to 5 and L5 to S1 bilaterally. A curvilinear 2 to 5 MHz ultrasound probe was employed, the puncture was performed with the needle, a guide wire was inserted until the flavum ligament, followed by the dilator and working cannula. A 30° spinal endoscope, with an optical adapter of the endoscope camera for smartphone and portable endoscope lighting was inserted, the flavum ligament was visualized, and an opening in this site was performed with the scissors. Open dissection of the specimen was subsequently performed by identifying the puncture site in the interlaminar window.

Results The four interlaminar punctures were successfully guided by ultrasound; the opening of the ligamentum flavum was performed in the most lateral part of the interlaminar space, near the junction of the superior and inferior articular processes of the corresponding vertebrae in all the punctures.

Discussion The ultrasound makes possible to identify facets, foramina, transverse processes, and the interlaminar space. It is possible to minimize the use of radioscopy and its associated risks, both for patients and health professionals.

Conclusions The ultrasound-guided, in-plane, interlaminar, lumbar endoscopic approach with smartphone-adapted endoscope and portable light source is feasible and practical, minimizing radiation risks and making it possible to perform endoscopic spinal surgery.

Ultrasound-guided fluoroscopic-verified trans-foraminal lumbar dorsal root ganglion pulsed radiofrequency modulation for radicular pain relief: clinical and cadaveric evaluation of the technique

Background

Ultrasound-guided lumbar pain interventions were thought to be difficult; the high acoustic impedance of bone hides the underling structures and needle path. Reviewing the sonoanatomy of the lumbar region using different planes and angles made better sonographic guidance for spine injections. The aim of this prospective study is to assess the accuracy and safety of ultrasound (US)-guided lumbar trans-foraminal pulsed radiofrequency of the dorsal root ganglion confirmed by fluoroscopic imaging in management of chronic radicular pain.

Results

Thirty-two patients, with 34 lumbar interventions, were included in the study. Thirty-one interventions out of 34 were performed successfully with overall accuracy of 91.18% and with minimal complications. The successful first trial placement of the cannula was calculated in 44.1% of interventions; multiple trials were needed in 47.1% while incorrect level was encountered in 8.8%. Visual analogue scale of pain and Oswestry Disability Index decreased significantly after intervention up to 3 months compared to the pre-intervention value. The analgesic consumption was reduced by mean of 73.44 ± 31.07% 1 month after intervention.

Conclusions

US-guided fluoroscopic-verified trans-foraminal PR of lumbar DRG is accurate, safe, and effective for CRP.

Ultrasound-guided periradicular oxygen-ozone injections as a treatment option for low back pain associated with sciatica

BACKGROUND

The social impact and economic burden of low back pain are well known among the medical community. A novel therapeutic approach is represented by oxygen-ozone therapy, whose anti-inflammatory effects could be especially useful in patients with herniated discs. The most common administration is through a palpation-guided injection technique, although the use of ultrasound guidance could allow a more precise delivery of the therapeutic substance close to the nerve root.

AIM OF THE STUDY

To describe the clinical outcomes following US-guided periradicular injection of oxygen-ozone as a treatment option for low back pain associated to sciatica in patients affected by symptomatic L5-S1 disc herniation.

CONCLUSION

Ultrasound-guided periradicular injection of oxygen-ozone in L5-S1 herniation is a safe and effective minimally invasive treatment, able to improve both low back and radiating pain.

Ultrasound-Guided Lumbar Transforaminal Epidural Injection: A Narrative Review

Transforaminal epidural steroid injection is often administered to patients with radiculopathy under fluoroscopic guidance, although it has disadvantages of radiation hazards and requirement of a special area to perform the block. To avoid these disadvantages, ultrasound-guided transforaminal injection (USTFI) has recently been described and is continually developed. This review article describes the indexed articles published on USTFI and ultrasound-guided selective nerve block (SNRB) to evaluate current evidence on best approach to perform the block. Through literature search, eight articles and one case report on USTFI and five articles on ultrasound-guided SNRB were found. Most of the studies have utilized parasagittal orientation of curvilinear probe to perform the block. Nevertheless, with the present literature, it is difficult to come to any conclusion. Further studies with larger sample size and description of dye spread patterns are recommended to come to a more definite conclusion.

Image-Guided Percutaneous Treatment of Lumbar Stenosis and Disc Degeneration

Low back pain, radicular leg pain, and lumbar spinal stenosis are the most common of all chronic pain disorders. Discogenic pain is related to distress of annular fibers and tears, whereas spinal stenosis is related to reduction of the spinal canal dimensions and compression of the neural elements; radicular pain is mainly related to disc herniation and is initially managed conservatively. The percutaneous minimally invasive approach in discogenic and radicular pain is designed to reduce the volume of the nucleus pulposus in patients with failure of medical and physical treatment prolonged for at least 6 weeks.

Ultrasound-Guided Lumbar Transforaminal Epidural Injections; A Single Center Fluoroscopic Validation Study

Objective

To investigate the success rate (technical precision) of ultrasound-guided lumbar transforaminal epidural steroid injection, which was validated by conventional fluoroscopic technique.

Methods

A total of 20 patients with unilateral single-level lumbar foraminal disc protrusion causing radiculopathy were enrolled. Using transforming route, the needle location was determined by an axial (transvers) view of the ultrasound with fluoroscopic confirmation. We determined the needle placement accuracy of ultrasound- guided lumbar transforaminal injections approach.

Results

The accuracy of ultrasound-guided interventions was 90% as confirmed by fluoroscopy. There were 2 failed cases at the L4-L5 level in the US-guided. The success rate in L5-S1 level was 100%, in L4-L5 level was 80% and in L3-L4 level was 100%. No complications were noted.

Conclusion

Ultrasound-guided lumbar transforaminal epidural injections are accurate and feasible in clinical setting with an accuracy of 90% and no complications.

Steroids Spinal Injections

Spinal pain is a common condition leading to significant disability and high cost. Spinal injections have been demonstrated to be effective short-term treatments with cost-utility superior to numerous other treatments, including surgical procedures. Appropriate patient selection-based on clinical and imaging finding-and the use of image guidance associated with technical precautions improve the safety and effectiveness of spinal injection and overall patient outcomes.

Lumbar epidural depth using transverse ultrasound scan and its correlation with loss of resistance technique: A prospective observational study in Indian population

Background and Objectives:

The objective of the present study was to evaluate the skin-epidural space distance as assessed by ultrasonography and conventional loss of resistance (LOR) technique and to find the correlation of epidural depth with body mass index (BMI).

Methods:

Ninety-eight patients of either sex, American Society of Anesthesiology I/II, BMI <30 kg/m² requiring lumbar epidural for surgery were enrolled. The epidural space was assessed with a curvilinear ultrasound (US) probe, 2–5 MHz, in the transverse plane at L3–L4 intervertebral space. Thereafter, the epidural depth from skin was assessed with conventional LOR method while performing the epidural. The needle depth (ND) was measured using a sterile linear scale, and any change in the needle direction or intervertebral space was noted.

Results:

The patients were demographically similar. Depth of epidural space measured by US depth (UD) was 3.96 ± 0.44 cm (range 3.18–5.44 cm) and by ND was 4.04 ± 0.52 cm (range 2.7–5.7 cm). The Pearson's correlation coefficient (r) between UD and ND was 0.935 (95% confidence interval: 0.72–0.92, r² = 0.874, P < 0.001), and Bland–Altman analysis revealed the 95% limits of agreement −0.494–0.652 cm.

Conclusion:

The present study demonstrates a good correlation between UD and ND and shows that the preprocedural US scan in transverse plane provides accurate needle entry site with a high success rate in single attempt for lumbar epidurals in patients with a BMI <30 kg/m².

Ultrasound for Lumbar Spinal Procedures

Ultrasonography has become an increasingly valuable and promising tool for performing image-guided spine interventions. The increase in the use of ultrasound utilization has led to more studies evaluating ultrasound-guided interventional spine procedures in comparison to fluoroscopy and computed tomography. Several studies have investigated the use of ultrasound for lumbosacral pain management procedures with favorable outcomes.

Sonographic tracking of trunk nerves: essential for ultrasound-guided pain management and research

Delineation of architecture of peripheral nerves can be successfully achieved by high-resolution ultrasound (US), which is essential for US-guided pain management. There are numerous musculoskeletal pain syndromes involving the trunk nerves necessitating US for evaluation and guided interventions. The most common peripheral nerve disorders at the trunk region include thoracic outlet syndrome (brachial plexus), scapular winging (long thoracic nerve), interscapular pain (dorsal scapular nerve), and lumbar facet joint syndrome (medial branches of spinal nerves). Until now, there is no single article systematically summarizing the anatomy, sonographic pictures, and video demonstration of scanning techniques regarding trunk nerves. In this review, the authors have incorporated serial figures of transducer placement, US images, and videos for scanning the nerves in the trunk region and hope this paper helps physicians familiarize themselves with nerve sonoanatomy and further apply this technique for US-guided pain medicine and research.

Ultrasound-guided Versus Fluoroscopy-controlled Lumbar Transforaminal Epidural Injections: A Prospective Randomized Clinical Trial

OBJECTIVES

Recently, most lumbar spine injections have been administered under ultrasound (US) guidance; however, there is no standard method for US-guided lumbar transforaminal epidural injection (TFEI). In this study, we evaluated the accuracy, effect on pain relief, and safety of US-guided lumbar TFEI.

METHODS

A total of 80 patients with low back pain and radicular pain were enrolled. The patients were randomly assigned to either the fluoroscopy (FL) group or the US group. The FL-guided approaches were performed under standardized procedures using the C-arm, whereas the US-guided injections were performed with an US device with a linear probe, and were verified by FL. The needle tip reached the lateral side of the lamina in the axis view and the middle of the adjacent facet joints in the parasagittal view. Afterward, the needle was advanced slightly deeper until the loss-of-resistance test was positive.

RESULTS

The success ratio of the US-guided interventions was 85%. The operation time in the US group (518±103 s) was shorter than the FL group (929±228 s) (P<0.05). In addition, the radiation dosage in the US group (2640±906 μGy m²) was lower than in the FL group (8992±2132 μGy m²). There was no significant difference in pain relief between the US and FL groups. No serious complication was observed in any of the patients in either group.

DISCUSSION

Lumbar TFEI under US guidance was feasible, safe, and required less radiation to achieve the same benefit as the FL-guided interventions.

Grading Osteoarthritic Changes of the Zygapophyseal Joints from Radiographs: A Reliability Study

OBJECTIVE

This study tested the reliability of a 5-point ordinal scale used to grade the severity of degenerative changes of zygapophyseal (Z) joints on standard radiographs.

METHODS

Modifications were made to a Kellgren grading system to improve agreement for grading the severity of osteoarthritic changes in lumbar Z joints. These included adding 1 grade of no degeneration, multiple radiographic views, and structured examiner training. Thirty packets of radiographic files were obtained, which included representation of all 5 grades including no degeneration (0) and Kellgren's 4-point (1-4) joint degeneration classification criteria. Radiographs were digitized to create a radiographic atlas that was given to examiners for individual study and blinded evaluation sessions. Intrarater and interrater agreement was determined by weighted κ (κw) from the examination of 79 Z joints (25 packets).

RESULTS

Using the modified scale and after training, examiners demonstrated a moderate-to-substantial level of interrater agreement (κw = 0.57, 0.60, and 0.68). Intrarater agreement was moderate (κw = 0.42 and 0.54).

CONCLUSIONS

The modified Kellgren 5-point grading system provides acceptable intrarater and interrater reliability when examiners are adequately trained. This grading system may be a useful method for future investigations assessing radiographic osteoarthritis of the Z joints.