Abstract
Injection therapies play a major role in the treatment of lower back pain and are to date performed mainly under CT or fluoroscopic guidance. The benefits of US-guided instillation procedures have been shown in many studies. We conducted this study to simplify an US-guided approach to the lumbar spinal nerves and to assess the feasibility and preliminary accuracy by means of CT and anatomic dissection. Ten US-guided injections at 5 different levels (L1-L5) were performed on 1 embalmed cadaver. Images in 3 sagittal/parasagittal scanning planes were obtained at each lumbar level: 1) the plane of the spinous processes, 2) the plane of the lumbar arches/zygapophyseal-joints, and 3) the plane of the transverse processes. The PAP was then defined by positioning the transducer perpendicularly over the medial part of the respective transverse processes, depicting the hyperechoic intertransverse ligament. In the "in-plane technique," spinal needles were advanced through the respective segmental intertransverse ligament. A solution consisting of a contrast agent and a pigmented dispersion was subsequently injected into the pararadicular compartment. An anatomic dissection of the specimen and CT scans were performed to verify the exact placement of the needle tips and to evaluate fluid dispersion in the punctured compartment. CT examination confirmed that each needle tip was correctly placed within the intended compartment with sufficient contrast accumulation around the respective proximal segment of the spinal nerve. On each anatomic section, dye was identified in the correct compartment and directly around each targeted spinal nerve with needles shown in the correct position. This modified US approach for therapeutic root injections in the lumbar spine by using the intertransverse ligament as a new anatomic landmark allows an easy and correct needle placement within the pararadicular compartment.
Highlights
AND PURPOSE: Injection therapies play a major role in the treatment of lower back pain and are to date performed mainly under CT or fluoroscopic guidance
Most individuals will experience neck and/or low back pain at least once in their lives, and with increasing age, a greater number of patients with such symptoms is seen by family physicians and in outpatient clinics.[1,2,3,4]
Aside from physical therapy and other rehabilitative methods, injection therapy targeted to the facet joints or the nerve roots is well established in the treatment of lumbar radiculopathy and has been performed without image guidance for many years
Summary
Ten US-guided injections at 5 different levels (L1-L5) were performed on 1 embalmed cadaver. The PAP was defined by positioning the transducer perpendicularly over the medial part of the respective transverse processes, depicting the hyperechoic intertransverse ligament. In the “in-plane technique,” spinal needles were advanced through the respective segmental intertransverse ligament. A solution consisting of a contrast agent and a pigmented dispersion was subsequently injected into the pararadicular compartment. An anatomic dissection of the specimen and CT scans were performed to verify the exact placement of the needle tips and to evaluate fluid dispersion in the punctured compartment. CT (Syntec Synergy; GE Healthcare, Vienna, Austria) was subsequently performed to confirm the respective needle positions and fluid spreading. The specimen was dissected to definitely validate fluid spreading and position of the needles
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