American Society of Regional Anesthesia and Pain Medicine February 2018 - 40
Ultrasound Guidance for Interventional Pain Procedures:
Recent Evidence From Around the World
U
ltrasonography (US) has unique benefits over anatomic
landmarks (ALs) and fluoroscopy (FL), including lack of
ionizing radiation, visualization of soft tissues and vascular
structures, and portability. International publications on US-guided
neuraxial, peripheral nerve, and joint-related procedures to relieve
pain indicate an expanding role for this imaging modality. The
objective of this review is to discuss important publications in the
past 5 years on the use of US in interventional pain medicine.
NEURAXIAL PROCEDURES
Cervical Spine. Two studies by a group of Canadian and Thai
researchers reported that US-guided C5 and C6 medial branch
block (MBB) needle placement was accurate in 100% and 97.5%
of procedures, respectively (as verified by FL), and vascular
penetration was avoided in 30% of procedures.1 The authors
also reported that US-guided C7 MBB required less time to
perform, used fewer needle passes than the FL-guided technique,
and avoided vascular penetration in 40% of patients without
compromising success rates, postblock analgesia, or complication
rates.2 Reduced procedural discomfort, fewer attempts, and faster
procedure times for CMBB with US as compared to fluoroscopy
were also reported by Korean investigators, with similar success
and complication rates in the two groups.3 Finally, use of US
allowed identification of critical vessels around the cervical nerve
roots while providing similar analgesic benefit as FL-guided
injections, as evident in two recent studies from Korea.4,5
Lumbar Spine. In a trial
by Korean investigators,
US-guided lumbar intraarticular injections had similar
analgesic and functional
outcomes as compared to
FL-guided injections,6 but the
mean body mass index (BMI)
of the participants was under
25 kg/m2. Cadaveric studies on US-guided lumbar facet joint and
lumbar transforaminal epidural injections from the United States
have reported 88% and 91.3% accuracy, respectively, as verified
by FL.7,8 However, targets could not be visualized with US at the
foramen between the fifth lumbar and sacral vertebrae in 8% of the
procedures because of prominent iliac crests.8 In another trial from
Taiwan, shorter performance time for US-guided lumbar nerve root
block and similar analgesic efficacy in comparison to FL-guided
injections were reported, but participants' mean BMI was less than
25 kg/m2.9
Ashutosh Joshi, MBBS, MD
Fellow
Anuj Bhatia, MD, FRCPC
Associate Professor
Department of Anesthesia and Pain Management
Toronto Western Hospital and University of Toronto
Toronto, Ontario, Canada
Section Editor: Lynn Kohan, MD
researchers from Austria, Canada, Switzerland, and Italy performed
a cadaveric study to develop a US-guided, out-of-plane technique
for this procedure with a success rate of 80%.11
Sacroiliac Joint (SIJ). US-and FL-guided SIJ intra-articular
injections were associated with similar analgesic benefits,
functional improvement, and patient satisfaction in two studies
from Korea and Canada.12,13
The authors also reported
enhanced safety with US
because blood vessels
around the SIJ could be
avoided. However, the
US-guided approach had
slightly lower accuracy12,13
and required more time13
for performing SIJ injections when compared to FL. US-guided
lateral sacral branch blocks were associated with a shorter
performance time, fewer needle passes, and a lower incidence of
vascular breach than FL-guided technique with similar analgesic
outcomes in both groups in a Canadian study. Interestingly,
the interventionists' level of experience significantly affected
performance time with US but not with FL.14
"Current evidence is stronger for using
ultrasonography to guide injections into
joints and around peripheral nerves as
compared to neuraxial procedures."
A Korean retrospective study on 146 patients who received USor FL-guided lumbar MBB reported shorter procedure time with
US while conferring similar analgesic benefits.10 A limitation of
US-guided MBB is that access to the fifth lumbar dorsal ramus
is often challenging because of prominent iliac crests. A group of
40
PERIPHERAL JOINT PROCEDURES
Lower-Limb Joints. A recent Spanish study reported similar
accuracy for US- and FL-guided injections into the hip joint.15
Furthermore, investigators from United States found that US-guided
injections of the hip were less painful than FL-guided injections
and patients who had undergone procedures with those modalities
preferred US over FL.16 We identified one systematic review and
two studies from China, Iran, and Korea, respectively, that reported
American Society of Regional Anesthesia and Pain Medicine
2018
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