Ultrasound-Guided Injections Useful for Cervical Radiculopathy

Nancy A. Melville

March 06, 2012

March 6, 2012 (Vienna, Austria) — The use of ultrasound to guide transforaminal epidural steroid injections (TF-ESIs) for the treatment of cervical radiculopathy is an effective radiation-free alternative to fluoroscopic or computed tomography (CT) guidance, according to research presented here at the European Congress of Radiology 2012.

Cervical radiculopathy can cause substantial pain. Invasive therapies, including CT, fluoro-guided TF-ESIs, and/or surgery, are common interventions in refractory cases.

These interventions can have serious complications of their own, however, according to lead author Waseem A. Bashir, MD, from the Department of Radiology, Ealing Hospital NHS Trust in London, United Kingdom.

"There is increasing literature illustrating a potential for brain and spinal cord infarction following injection. Ultrasound allows safe, accurate, and real-time injection," said Dr. Bashir.

The use of ultrasound to guide injections could not only eliminate exposure to ionizing radiation, but could also allow for a more accurate injection in real time, Dr. Bashir explained.

"With fluoro-guided and noncontrast CT, you cannot see the vascular structures with total confidence, and any contrast use itself has the potential for reaction in some patients," he explained.

In a pilot study to evaluate ultrasound in such cases, Dr. Bashir and colleagues enrolled 40 patients with refractory cervical radiculopathy who had been referred for cervical TF-ESIs and normally would have undergone fluoroscopic or CT-guided injection.

Instead, the patients received ultrasound-guided injections with a 25-gauge spinal needle in a transforaminal position. Nerve root levels were mapped by identifying transverse processes and counting nerve roots cranially.

"For the injection, the transducer was placed transversely to identify the carotid and jugular vessels," Dr. Bashir explained. "It was then moved slightly laterally, keeping in the transverse plane, to identify the nerve roots in a traffic-light fashion."

"We were able to scrutinize the morphology of the cervical nerves fairly accurately, and were also able to identify a measurable thickening of the clinically suspected cervical nerve, which correlated well with the individual's symptoms."

Dr. Bashir noted that the needle position is clearly visible at all times, and that "color Doppler allows scrutiny of vascular flow and, therefore, the investigator can have greater confidence in avoiding an intravascular injection."

Six months after therapy, pain scores showed significant reductions from baseline. Ultrasound evaluation showed evidence of a reduction in nerve thickness after the steroid injection. No complications from the treatment were reported.

"All patients in this study showed improvement in their symptoms, with significant reductions in pain scores," Dr. Bashir said. "The results indicate that sonographic guidance allows accurate real-time visualization with high resolution of local anatomy and needle trajectory."

The risk for serious complications has prompted some clinicians to avoid transforaminal epidural steroid injections altogether in recent years, explained Gerard A. Malanga, MD, director of pain management at Overlook Hospital in Summit, New Jersey.

"Unfortunately, we've learned over the years that it's very common to be in the blood vessel and not even realize it," said Dr. Malanga.

"You can have the needle around the nerve and the blood vessel, but the nerve kind of obscures the blood vessel," he told Medscape Medical News. "Unfortunately, over the past 5 to 10 years, we've had dozens of catastrophic injuries, including paralysis, stroke, and even death from transforaminal cervical injection."

Ultrasound offers clarity so these problems can be avoided, Dr. Malanga said.

"It's more efficient, safer, and probably more cost-effective. There is a bit of a learning...but with persistence and practice, it's readily learned."

The improvement in recent years in ultrasound technology should make the technique a front-line approach, Dr. Malanga added.

"In the past 5 years, ultrasound had made a tremendous resurgence in musculoskeletal medicine in terms of imaging tendons, ligaments, and visualizing peripheral nerves."

"The spine was always felt to be a little harder to visualize, but with newer technology, more and more people are getting comfortable with imaging various structures in the spine," Dr. Malanga said.

"This [approach] is still new and is certainly not the mainstay of treatment," he cautioned, "but I bet that in 2 to 5 years it will be the way everyone is doing it."

Dr. Bashir and Dr. Malanga have disclosed no relevant financial relationships.

European Congress of Radiology (ECR) 2012: Abstract B-0298. Presented March 2, 2012.

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