American Society of Regional Anesthesia and Pain Medicine February 2018 - 41

higher accuracy rates (validation with FL) and more analgesic
benefit with US-guided knee injections.17,18,19 A study by French
investigators reported greater efficacy and patient satisfaction
with imaging guidance (US or FL) for ankle (tibiotalar) joint
injections than with ALs (84% and 66%, respectively). However, no
differences were observed between US or FL groups in terms of
efficacy or satisfaction.20
Upper-Limb Joints. US-guided glenohumeral (GH) joint injections
were found to be more accurate and to yield better analgesic
and functional benefits than AL-guided approach in two studies
from Iran and the United States.21,22 A study from Hong Kong and
a meta-analysis reported similar accuracy for US- and FL-guided
injections in the GH joint.23,24 Use of US significantly improved the
accuracy of intra-articular acromioclavicular joint, elbow joint, and
distal radioulnar joint injections when compared to AL technique in
studies from Switzerland and Korea.25-27
PERIPHERAL NERVE PROCEDURES
A team of investigators from Austria, Germany, and Switzerland
reported that US can be used to identify and block the greater
occipital nerve in cadavers either at the level of the C2 transverse
process or the occiput with a higher success rate at the C2
level (100% vs 86%).28 Two studies from the United States and
Canada also showed that vascular and esophageal penetration are
potential risks that can be prevented by using US to guide cervical
sympathetic blocks.29,30
US-guided ilioinguinal and iliohypogastric nerve blocks were
shown to be as effective as AL-guided blocks for the treatment of
chronic postherniorrhaphy pain by a team from the United States.31
However, inaccurate placement of injectate has been reported
in AL-guided nerve blocks.32 A team from Austria suggested an
alternative technique to block the suprascapular nerve near
its origin from the upper trunk of the brachial plexus with 81%
visualization as compared to 36% in traditional suprascapular
site.33 In another study, use of US conferred higher accuracy
and lower injectate volumes than ALs as a guidance method for
intercostal nerve injections in cadaveric study from Canada and the
United States.34 A Canadian study on cadavers and volunteers that
compared AL- and US-guided needle placement and identification
of the lateral femoral cutaneous nerve, respectively, showed a huge
improvement in accuracy with US (5.3% and 84.2%, respectively).35
However, another Canadian study found that US- and FL-guided
pudendal nerve blocks were similar in accuracy and visualization of
surrounding structures like vessels and nerves, but the procedural
time was longer with US (428 vs 219 seconds).36
CONCLUSIONS
Despite its potential to enhance accuracy, efficacy, and safety,
a paucity of high-quality trials to confirm advantages of US over
traditional modalities and a perception that experience of the

interventionalist impacts procedural performance with US guidance
are significant barriers to widespread use of US for interventional
pain. Furthermore, cadaveric studies that demonstrate the potential
of US in increasing accuracy of interventional procedures need
to be replicated in patients. Current evidence is stronger for
using ultrasonography to guide injections into joints and around
peripheral nerves as compared to neuraxial procedures. Studies
that combine use of ultrasonography (for identifying and avoiding
vessels and other structures) and fluoroscopy (for simultaneous
visualization of multiple spinal levels) may improve outcomes of
neuraxial procedures.
REFERENCES
1.

Finlayson RJ, Etheridge JP, Tiyaprasertkul W, Nelems B, Tran DQ. A prospective
validation of biplanar ultrasound imaging for C5-C6 cervical medial
branch blocks. Reg Anesth Pain Med. 2014;39:160-163. doi: 10.1097/
AAP.0000000000000043.

Finlayson RJ, Etheridge JP, Tiyaprasertkul W, Nelems B, Tran DQ. A
randomized comparison between ultrasound- and fluoroscopy-guided C7
medial branch block. Reg Anesth Pain Med. 2015;40:52-57. doi: 10.1097/
AAP.0000000000000186.

Park KD, Lim DJ, Lee WY, Ahn J, Park Y. Ultrasound versus fluoroscopy-guided
cervical medial branch block for the treatment of chronic cervical facet joint
pain: a retrospective comparative study. Skeletal Radiol. 2017;46:81-91. doi:
10.1007/s00256-016-2516-2.

Park Y, Ahn JK, Sohn Y, et al. Treatment effects of ultrasound guide selective
nerve root block for lower cervical radicular pain: a retrospective study
of 1-year follow-up. Ann Rehabil Med. 2013;37:658-667. doi: 10.5535/
arm.2013.37.5.658.

Jee H, Lee JH, Kim J, Park KD, Lee WY, Park Y. Ultrasound-guided selective nerve
root block versus fluoroscopy-guided transforaminal block for the treatment
of radicular pain in the lower cervical spine: a randomized, blinded, controlled
study. Skeletal Radiol. 2013;42:69-78. doi: 10.1007/s00256-012-1434-1.

Yun DH, Kim HS, Yoo SD, et al. Efficacy of ultrasonography-guided injections
in patients with facet syndrome of the low lumbar spine. Ann Rehabil Med.
2012;36:66-71. doi: 10.5535/arm.2012.36.1.66.

Gofeld M, Bristow SJ, Chiu S. Ultrasound-guided injection of lumbar
zygapophyseal joints: an anatomic study with fluoroscopy validation. Reg Anesth
Pain Med. 2012;37:228-231. doi: 10.1097/AAP.0b013e3182461144.

Gofeld M, Bristow SJ, Chiu SC, McQueen CK, Bollag L. Ultrasound-guided lumbar
transforaminal injections: feasibility and validation study. Spine (Phila Pa 1976).
2012;37:808-812. doi: 10.1097/BRS.0b013e3182340096.

Yang SH, Park KD, Cho KR, Park Y. Ultrasound-guided versus fluoroscopycontrolled lumbar transforaminal epidural injections: a prospective randomized
clinical trial. Clin J Pain. 2016;32:103-108.

10. Han SH, Park KD, Cho KR, Park Y. Ultrasound versus fluoroscopy-guided medial
branch block for the treatment of lower lumbar facet joint pain: a retrospective
comparative study. Medicine (Baltimore). 2017;96:e6655. doi: 10.1097/
MD.0000000000006655.
11. Greher M, Moriggl B, Peng PW, Minella CE, Zacchino M, Eichenberger U.
Ultrasound-guided approach for L5 dorsal ramus block and fluoroscopic
evaluation in unpreselected cadavers. Reg Anesth Pain Med. 2015;40:713-717.
doi: 10.1097/AAP.0000000000000314.
12. Jee H, Lee JH, Park KD, Ahn J, Park Y. Ultrasound-guided versus fluoroscopyguided sacroiliac joint intra-articular injections in the noninflammatory
sacroiliac joint dysfunction: a prospective, randomized, single-blinded study.
Arch Phys Med Rehabil. 2014;95:330-337. doi: 10.1016/j.apmr.2013.09.021.

American Society of Regional Anesthesia and Pain Medicine
2018

Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine February 2018