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Original papers Med Ultrason 2013, Vol. 15, no. 1, 10-15DOI: 10.11152/mu.2013.2066.151.jo1ugc2

Abstract

Objectives:A prospective randomized clinical trial was conducted to evaluate accuracy, time-saving, radiation doses and

pain relief of ultrasound-guided (US) facet joint injections versus Computed Tomography (CT)-controlled interventions in the

cervical spine. Material and methods: Forty adult patients were consecutively enrolled and randomly assigned to the US- or

CT group. US-guided facet joint injections were performed on a standard ultrasound device using a broadband linear-array

transducer. The corresponding comparison group underwent CT-guided instillations which were performed under standard-

ized procedures using the CT-positioning laser function. Results:The accuracy of ultrasound-guided interventions was 100%.

The mean time (min:sec) to nal needle placement in the US group was 04:46 versus 11:12 (p

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12 Jochen Obernauer et al Ultrasound-guided versus Computed Tomography-controlled facet joint injections

of the area of interest. Consistent with the US procedure,

elapsing time was recorded with the start of the initial

scan. For a precise calculation of the needle pathway, a

topogram through the targeted area was obtained with a

low-dose protocol (120 kV, 120 mA) at 3 mm slice thick-

ness. The point of entry, the angle and the depth of ap-

proach were selected and calculated. The needle entry

point was marked on the patients skin using the obtained

calculations and the CT-positioning laser function. Then

a spinal needle (20 GA 3.00 IN, 0.9 x 75 mm; BD Spinal

Needle, Becton Dickinson, Madrid, Spain) was advanced

toward the facet joint of interest, according to the prelimi-

nary calculations. To control the present and nal needle

tip position, several CT scans were obtained repeatedly,

i.e. after each reposition, until the needle was estimated

to be the in correct position. At that time the elapsed time

was recorded. Exactly as in the US procedure, 1 mL

mixture of betamethasone (CELESTAN solubile 4 mg/ml; essex-pharma GmbH, Munich, Germany) and bupi-

vacainehydrochloride (Bucain 0.25%, 2.5 mg/ml, Delta

Select GmbH, Pfullingen, Germany) was injected.

Measurements and Statistics

For both groups the periods of intervention time and

the radiation doses (as dose-length products; DLPs) are

reported. Time and radiation dose were compared sepa-

rately for one- and two-leveled injections. To follow up

the clinical benet, neck pain was assessed via a visual

analog scale (VAS) before, 30 minutes after and 4 weeks

after the intervention. Feasibility of the US procedure was

dened as percentage of patients with clearly, partially, orinvisible targets (respectively inter-articular space). Accu-

racy was calculated as CT-veried exact needle tip place-

ment. The number of repositions, unexpected problems

and complications were also recorded for both groups.

Statistical analyses were done according to the intention-

to-treat principle [23]. The primary outcomes were accu-

racy and time to nal needle placement. For the evaluation

of VAS changes we used the comparison of percentage

VAS reduction from pre- to 30-minutes post-intervention-

al and from pre- to 4-weeks post-interventional interval.

The trial was designed to detect an absolute difference of

one standard deviation with a power of 80% at a two-sid-

ed signicance level of 0.05 and a maximum dropout rate

of 20%. Comparisons between groups were performed

with an unpaired t-test, or in case of nonparametric val-

ues, with a Mann-Whitney U-test.

Results

After randomization there were no signicant differ-

ences between the two groups (table I). All patients who

were randomly assigned to the US group were judged

to be feasible for the US-guided procedure. In 20 pa-

tients the inter-articular space of the targeted facet joint,

as well as the bony landmarks, were clearly depicted by

US (100%). In 19 of these patients (95%) the interven-

tion was performed as planned and the needle was posi-

tioned correctly, as also conrmed by CT (95%). In one

case (5%) the intervention was aborted because of the

patients missing compliance (the patient was unable to

deal with the pain of needle positioning). In the US group

no needle had to be repositioned (accuracy = 100%). In

the CT group a needle reposition was necessary in 13

cases (65%): in 3 cases (15%) the respective needle po-

sition was changed once, in 6 cases (30%) twice, in 2

cases (10%) three times and in another 2 cases (10%)

even four times. Regarding the necessary needle reposi-

tions the US-guided procedure statistically showed a sig-

nicantly higher accuracy (p

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13Med Ultrason 2013; 15(1): 10-15

showed a signicant DLP saving for one- (p

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14 Jochen Obernauer et al Ultrasound-guided versus Computed Tomography-controlled facet joint injections

performed to reduce the risk of unintentional injection in

such paraspinal, e.g. radicular, vessels [27].In the present

US technique, the advantage of utilizing a real-time in-

plane needle access from dorsal is striking: any relevant

vessel is so avoided, as based on normal topography

none usually crosses the needle pathway. Also, if the

target is clearly visible under US guidance, no further

radiographic control and no systemic application of con-

trast agents or other ionizing modalities are necessarily

required. In this context, the use of Duplex-mode US im-

aging as a further guidance tool is conceivable, but was

not used in the present study because of its questionable

additional benet.

In this trial, CT controls in the US group were per-

formed only for study purposes. The recordings of these

DLPs showed that the mean radiation dose in the US

group was signicantly lower than the mean dose of

patients who had undergone CT-guided-only interven-tions, which implies a benet of US guidance even if

performed with subsequent CT control (maybe due to

forensic necessities). Although the necessary radiation

dose for one single CT-guided intervention may be rather

low, our study showed that cumulative effects have to be

taken into account, as some CT-guided instillations in our

trial required up to four CT scans. For such repeated and

multilevel injections, which are quite popular, US guid-

ance would be the recommended procedure.

A further benet of US guidance is that it helps to

minimize the risk of unexpected side effects, as those are

often associated to the application of contrast agents re-quired for the positioning control under CT- or uorosco-

py-guided procedures. The fact that US-guided injections

can be performed rather easily is mostly based on the di-

rect depiction of the structures of interest, i.e. cervical

facet joints, by US. Thus, with a little exercise, a needle

can be advanced to the target structure itself in just a few

seconds under safe and real-time controlled conditions

[1,13,16].If such an intervention is performed under CT-

guidance, calculations on access angles and entry points

of the needle are based on landmarks, followed by an

actually blind needle-positioning which is then control-

led by a subsequent scan and often followed by multiple

repositions. Control scans, if necessary, are potentially

harming to the patients, as described above, but are also

laborious and costly compared to the US procedure pre-

sented here. US-guided facet joint instillations may even

be performed very efciently under bed-side condi-

tions, e.g. in outpatients. This saves time and resources,

as US is comparatively inexepensive and broadly avail-

able, and does not imply any therapeutic compromises

for the patient, as accuracy is obviously sufcient for the

purpose described here [13].

According to the analysis on increasing numbers and

costs of spinal injection therapies, published by Carrino

et al 2002 [11], the overall cost-effectiveness of cervical

instillations must be evaluated as well. This is however

beyond the scope of this study.

Limitations

Limiting factors might be that outcome was only

measured by patient satisfaction and that the long-term

follow-up was only performed four weeks after the in-

stillation.

Conclusion

The US-guided facet joint injection in the middle

and lower cervical spine is accurate, feasible, and bears

minimal risk. It results in a signicant pain reduction,not different from CT-guided instillations. Addition-

ally a reduction of time, radiation dose and resources is

highly evident. However, as with any form of instillation

therapy needing practice for good results, a specic and

mandatory learning curve to achieve good visualization

and guidance of the instillation needle has to be taken

into account with US guidance. Upcoming projects are

supposed to evaluate this and the value of the US-guided

procedure during daily routine.

Conict of interest: none

References

1 Galiano K, Obwegeser AA, Bale R, et al. Ultrasound -guid-

ed and CT-navigation-assisted periradicular and facet joint

injections in the lumbar and cervical spine: a new teach-

ing tool to recognize the sonoanatomic pattern. Reg Anesth

Pain Med 2007; 32: 254-257.

2 Kim PS. Role of injection therapy: Review of indications

for trigger point injections, regional blocks, facet joint in-

jections, and intra-articular injections. Curr Opin Rheuma-

tol 2002; 14: 52-57.

3 van Eerd M, Patijn J, Lataster A, et al. 5. Cervical facet

pain. Pain Pract 2010; 10: 113-123.

4 Boswell MV, Shah RV, Everett CR, et al. Interventional tech-

niques in the management of chronic spinal pain: evidence-

based practice guidelines.Pain Physician 2005; 8:-47.

5 SenogluN, Senoglu M, Safavi-Abbasi S, Shedd SA, Craw-

ford NR. Morphologic evaluation of cervical and lumbar

facet joints: intra-articular facet block considerations. Pain

Pract2010; 10: 272-278.

6 Fukui S, Ohseto K, Shiotani M, et al. Referred pain dis-

tribution of the cervical zygapophyseal joints and cervical

dorsal rami. Pain 1996; 68: 79-83.

8/10/2019 joint (1)

6/6

15Med Ultrason 2013; 15(1): 10-15

7 Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal

joint pain patterns. I: A study in normal volunteers. Spine

1990; 15: 453-457.

8 Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal

joint pain patterns. II: A clinical evaluation. Spine 1990;

15: 458-461. 9 Pawl RP. Headache, cervical spondylosis, and anterior cer-

vical fusion. Surg Annu 1977; 9: 391-498.

10 Windsor RE, Nagula D, Storm S, Overton A, Jahnke S.

Electrical stimulation induced cervical medial branch refer-

ral patterns. Pain Physician 2003; 6: 411-418.

11 Carrino JA, Morrison WB, Parker L, Schweitzer ME, Lev-

in DC, Sunshine JH. Spinal injection procedures: volume,

provider distribution, and reimbursement in the U.S. medi-

care population from 1993 to 1999. Radiology 2002; 225:

723-729.

12 Gangi A, Dietemann JL, Mortazavi R, Peger D, Kauff

C, Roy C. CT-guided interventional procedures for pain

management in the lumbosacral spine. Radiographics

1998;18:621-633.

13 Galiano K, Obwegeser AA, Bodner G, et al. Ultrasound-

guided facet joint injections in the middle to lower cervi-

cal spine: a CT-controlled sonoanatomic study. Clin J Pain

2006; 22: 538-543.

14 Pekkafahli MZ, Kiralp MZ, Basekim CC, et al. Sacroiliac

joint injections performed with sonographic guidance. J Ul-

trasound Med 2003; 22: 553-559.

15 Galiano K, Obwegeser AA, Bodner G, et al. Ultrasound

guidance for facet joint injections in the lumbar spine: a

computed tomography-controlled feasibility study. Anesth

Analg 2005; 101: 579-583.

16 Galiano K, Obwegeser AA, Bodner G, et al. Ultrasound-

guided periradicular injections in the middle to lower cervi-cal spine: an imaging study of a new approach. Reg Anesth

Pain Med 2005; 30: 391-396.

17 Galiano K, Obwegeser AA, Bodner G, et al. Realtime sono-

graphic imaging for periradicular injections in the lumbar

spine: a sonographic anatomic study of a new technique. J

Ultrasound Med 2005; 24: 33-38.

18 Eichenberger U, Greher M, Kapral S, et al. Sonographic

visualization and ultrasound-guided block of the third oc-

cipital nerve: prospective for a new method to diagnose C2-

C3 zygapophysial joint pain. Anesthesiology 2006; 104:

303-308.

19 Greher M, Scharbert G, Kamolz LP, et al. Ultrasound-guid-

ed lumbar facet nerve block: a sonoanatomic study of a new

methodologic approach. Anesthesiology 2004; 100: 1242-

1248.20 Loizides A, Gruber H, Peer S, Brenner E, Galiano K, Ober-

nauer J. A new simplied sonographic approach for para-

radicular injections in the lumbar spine: a CT-controlled

cadaver study. AJNR Am J Neuroradiol 2011; 32: 828-831.

21 Loizides A, Peer S, Plaikner M, et al. Ultrasound-guided

injections in the lumbar spine.Med Ultrason 2011; 13: 54-

58.

22 Loizides A, Obernauer J, Peer S, Bale R, Galiano K, Gruber

H. Ultrasound-guided injections in the middle and lower

cervical spine. Med Ultrason 2012;14):235-238.

23 Lachin JM. Statistical considerations in the intent-to-treat

principle.Control Clin Trials 2000; 21: 167-189.

24 Baker R, Dreyfuss P, Mercer S, Bogduk N. Cervical trans-

foraminal injection of corticosteroids into a radicular artery:

a possible mechanism for spinal cord injury. Pain 2003;103:

211215.

25 Benny B, Azari P, Briones D. Complications of cervical

transforaminal epidural steroid injections. Am J Phys Med

Rehabil 2010; 89: 601-607.

26 Brouwers PJ, Kottink EJ, Simon MA, Prevo RL. A cervical

anterior spinal artery syndrome after diagnostic blockade of

the right C6-nerve root. Pain 2001; 91: 397399.

27 Verrills P, Nowesenitz G, Barnard A. Penetration of a cervi-

cal radicular artery during a transforaminal epidural injec-

tion. Pain Med 2010; 11: 229231.

28 Heckmann JG, Maihofner C, Lanz S, Rauch C, Neundorfer

B. Transient tetraplegia after cervical facet joint injectionfor chronic neck pain administered without imaging guid-

ance. Clin Neurol Neurosurg 2006; 108: 709-711.

29 Edlow BL, Wainger BJ, Frosch MP, Copen WA, Rathmell

JP, Rost NS. Posterior circulation stroke after C1-C2 in-

traarticular facet steroid injection: evidence for diffuse mi-

crovascular injury. Anesthesiology 2010; 112: 1532-1535.

30 Jasper JF. Role of digital subtraction uoroscopic imaging

in detecting intravascular injections. Pain Physician 2003;

6: 369372.