Ultrasound Guided Techniques
Posterior Muscles
Cervical
Cervical multifidus
Rectus capitis posterior major
Rectus capitis posterior minor
Obliquus capitus superior
Obliquus capitus inferior
These paraspinal muscles are important in postural control of the head on the neck and assist with rotation and extension of the head and upper neck. The suboccipital muscles can become overworked following ligament injuries with resulting instability in the upper cervical spine.
Pertinent Anatomy
Obliquus capitis inferior runs from the spinous process of the axis (C2) to the transverse process of the atlas (C1).
Obliquus capitis superior runs from the transverse process of the atlas (C1) to the occiput, below the superior nuchal line.
Rectus capitis posterior major runs from the posterior tubercle of the axis (C2) to the lateral occiput, inferior to the nuchal line.
Rectus capitis posterior minor runs from the posterior tubercle of the atlas (C1) to the medial occiput, inferior to the nuchal line.
The cervical multifidus muscles originate from the facet joint capsules in the lower cervical and transverse processes of the upper thoracic spine, span 2 to 5 segments, and insert on the spinous processes and laminae of the vertebrae above.
Common Pathology
Atrophy of the multifidus can occur with cervical pathology, including radiculopathy and myelopathy. , Suboccipital muscles can become atrophied after whiplash and have been shown to be associated with cervicogenic headaches.
The rectus capitis posterior minor has been noted to be hypertrophied following trauma, possibly leading to headaches related to its myodural connection.
All of these muscles can become tight and painful from compensatory overactivity in the setting of segmental instability.
Equipment
An ultrasound with high-frequency linear or curvilinear transducers. Transducer choice is dependent on body habitus and clinician preference.
27 to 25 gauge 1.25 to 2 inch needle
Common Injectates
Orthobiologics (PRP, PPP, etc.)
Injectate Volume
0.25 to 1 mL
Technique
Patient Position
Prone
Clinician Position
At the side of the patient, contralateral to the side of the muscle being treated, with the ultrasound monitor next to or on the opposite side of the patient.
Transducer Position
Short axis to the target muscle ( Figs. 12.1 to 12.3 )
Rectus capitis posterior minor visualization and injection can be performed in the long axis to the muscle belly ( Fig. 12.4 )
The obliquus capitis inferior can be visualized, and the injection can be performed in the long axis with the same positioning as for a GON injection ( Fig. 12.5 )
Needle Position
In-plane needle visualization, lateral to medial approach
Target
Care should be taken when performing these injections, with ultrasound visualization of the needle tip at all times for in-plane injections and starting shallow and doing a careful walk-down for out-of-plane injections to avoid going too deep.
Cervical Supraspinous and Interspinous Ligaments
These ligaments can be targeted in isolation for specific injuries, but more commonly are targeted in combination with other components of the functional spinal unit, , including the spinal nerves in the epidural space, facet joints, paraspinal muscles, and sometimes the intervertebral discs.
Treatment with prolotherapy has demonstrated a reduction in translation with cervical spine flexion and extension associated with pain reduction.
Pertinent Anatomy
The interspinous ligament is a thin membranous ligament that traverses adjacent spinous processes. The ligament runs from the root to the apex of each spinous process and connects anteriorly with the ligamentum flavum and posteriorly with the nuchal ligament.
The nuchal ligament is a large midline ligament lying superficial (posterior) to the spinous processes of the cervical spine spanning from the inion to C7, where it becomes continuous with the supraspinous ligament. The nuchal ligament connects anteriorly with the interspinous ligament ( Fig. 12.6 ).
Common Pathology
Ligament strain, partial tear, , relative laxity related to disc and facet pathology
Equipment
Ultrasound machine with linear or curvilinear transducer. Transducer choice is dependent on patient body habitus and clinician preference.
27 to 25 gauge 1.25 to 2 inch needle
Common Injectates
Prolotherapy
Orthobiologics (PRP, PPP, etc.)
Injectate Volume
0.25 to 1 mL
Technique
Patient Position
Prone, with the neutral cervical spine and head position.
Clinician Position
At the side of the patient with the ultrasound monitor next to or on the opposite side of the patient.
Transducer Position
Long axis to the ligaments, with visualization of both the ligament and spinous processes ( Fig. 12.7 )
Needle Position
In-plane needle visualization, caudal to cephalad approach
Target
Direct injection into the ligaments at the desired spinal level, injecting into areas of hypoechogenicity and throughout the ligaments, including the bony insertion. Filling of interstitial injuries can be seen with injectate
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Fluoroscopic contrast-dye confirmation may be used to ensure accurate placement of injectate
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These ligaments are difficult to visualize entirely, so adjacent and adjoining anatomy needs to be visualized
Greater and Lesser Occipital Nerve Block
Occipital neuralgia can come from compression or irritation of the greater or lesser occipital nerves, with greater occipital nerve (GON) irritation being much more common.
Pertinent Anatomy
The greater occipital nerve originates from the dorsal ramus of the C2 spinal nerve, loops around the obliquus capitis inferior (OCI), then courses medially and superiorly through the semispinalis capitis to reach the skin of the occiput, where it provides sensory innervation.
The lesser occipital nerve (LON) originates from the ventral ramus of the C2 and C3 spinal nerves, emerging from under the posterior margin of the sternocleidomastoid muscle to provide sensory innervation to the lateral occiput and posterior ear. ,
Common Pathology
Compression between muscles, acute or repetitive trauma, or other irritation resulting in pain between the posterior occiput and temporal region (GON) or posterior auricle (LON).
Equipment
Ultrasound with a high-frequency linear transducer.
27 to 25 gauge 1.25 to 2 inch needle
Common Injectates
Local anesthetics for blocks +/− corticosteroids
Neuroprolotherapy (5% dextrose solution)
Orthobiologics: (preferably platelet lysate, PRP, etc.)
Injectate Volume
1 to 3 mL
Technique
Patient Position
Prone, or seated, arms crossed, leaning with head on hands.
Clinician Position
At the side of the patient, contralateral to the nerve being treated for prone position, or standing behind the patient for a seated position.
Transducer Position
GON: The bifid C2 spinous process is located, then the ultrasound transducer is translated laterally and superiorly in the direction of the transverse process of the C1 vertebra. The obliquus capitis inferior muscle is identified along its long axis. The GON can be visualized in its short axis between the obliquus capitis inferior and the overlying semispinalis capitis ( Fig. 12.8 )
LON
Scan the sternocleidomastoid (SCM) transversely, inferior to the mastoid. The LON will be visualized at the posterior margin of the SCM, traversing superiorly towards the lateral occiput. ( Fig. 12.9 )
Needle Position
GON: In-plane needle visualization, posteromedial to anterolateral.
LON: In-plane needle visualization, medial to lateral
Target
GON: Perineural injection, in the fascial layer between obliquus capitis inferior and semispinalis capitis muscles
LON: perineural injection, superficial to the levator scapulae muscle and posterior to the SCM
Visual assessment of pulsations and Doppler imaging should be performed prior to needle insertion to help identify and avoid the vertebral artery. The needle tip must be kept in view at all times as it is advanced and during injection to ensure safety.
Cervical Facets
The cervical facet joints are the most common cause of chronic neck pain, most often secondary to osteoarthritis or trauma. Ultrasound can be used for the precise identification of painful facets and treatment but requires advanced skills, capability, and equipment.
Pertinent Anatomy
Cervical facet joints are diarthrodial joints formed by the articular pillars of adjacent vertebrae. Each joint is stabilized by a tough collagen capsule enclosing a fine synovial membrane, with joint fluid and hyaline-cartilage-covered articular surfaces inside. The joints are gradually inclined 40° to 60° posteriorly and 20° to 0° medially from C2-3 to C6-7. The medial branches of the dorsal rami of the respective spinal nerves innervate the joints, with the exception of the third occipital nerve (TON), which innervates the top half of C2-3.
Pain from the facet joints is experienced in the neck, radiating to the trapezius and typically exacerbated by neck rotation ( Fig. 12.10 ). Pain from the C2-3 facet joint can cause occipital headaches. X) [7 (link from fluoro cervical facet anatomy section)].?
Common Pathology
Osteoarthritis, post-traumatic microfractures, and capsular ruptures. Capsular ruptures may be present when the capsule does not distend or distends then collapses during injection.
Indications
Neck Pain
Trapezius Pain
Occipital Headache
Impaired Neck Rotation
Facet Joint Tenderness
Equipment
High-performance ultrasound machine with high-frequency (5-12 MHz) linear transducer
27-gauge 1.25 inch needle.
Common Injectates
Local anesthetics for diagnostics, corticosteroids, Orthobiologics (PRP).
Technique
Patient Position
Side-lying with the head on a pillow, slightly tilted and rotated away from the side being injected, the neck relaxed.
Clinician Position
Standing next to the patient’s head and neck, looking at and over the transducer and needle (aerial view) as the needle is advanced in-plane to ensure correct angle and alignment.
Transducer Position
The initial position is with the long axis of the transducer placed along the lateral aspect of the neck ( Figs. 12.11 to 12.14 ). The cervical facet joints appear as undulations. The C2-3 facet joint is the most superior and a bit posterior, beyond which the pulsations of the vertebral artery can be seen (see Fig. 12.13B ). Younger joints have smooth undulations with small joint openings, whereas older ones have a rough appearance, larger gaps, osteophytes, and effusions ( Fig. 12.15 ; see also Fig. 12.13B ). The transducer is rotated carefully over the opening of the C2-3 facet joint to obtain a transverse view ( Fig. 12.16 ). Sonopalpation is then performed, one joint at a time. Once the desired joint is selected for injection, the transducer is aligned with the ramus of the mandible and adjusted to optimize the joint opening. The needle is inserted typically using an anterior or posterior approach, typically anterior for a right hand dominant physician injecting the patient’s right side, but also depending on the orientation of the joint opening ( Figs. 12.17 and 12.18 ).
Needle Position
In-plane .
Target
Joint opening, effusion, or capsule.
Injectate Volume
The transducer is kept immobile over the target during the injection. This is done via the two-tripod technique, with the first consisting of the thumb, index, and middle finger holding the transducer, and the second consisting of the ring and little finger and transducer maintaining a stable position on the neck. Cervical facet joint openings are very small, so a slight slip of the transducer means that the target disappears from view. Successful performance of this procedure requires steady alignment of the transducer, needle, and the joint opening, requiring superior equipment, experience, skill, and hand-eye coordination. Patients with thick necks and difficult to see anatomy are not candidates for this procedure. Once the needle enters the joint, it should not be advanced more than a few millimeters because of the unlikely possibility of passing through the joint. Particulate injectates should not be used because of the remote possibility of an intra-arterial injection.
Interscalene Brachial Plexus Block
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The Interscalene brachial plexus block is performed at the interscalene groove where the roots of the plexus pass between anterior scalene and middle scalene muscles, at the level of C6 tubercle or Chassaignac’s tubercle.
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The block can be performed by paresthesia technique, neuromuscular stimulation, or by using ultrasound.
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It can be used as an anesthetic or adjunct to general anesthesia or postoperative pain control.
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Ultrasound is used for defining anatomic landmarks, identification of blood vessels, and identification of nerves. The use of ultrasound has increased the safety and accuracy of the block.
Pertinent Anatomy
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The brachial plexus is a network of nerves formed by the ventral rami of the lower four cervical nerves (C5-C8) and 1st Thoracic nerve.
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The plexus is responsible for sensory innervations of the upper extremity with the exception of the axilla and motor innervations of all the upper extremity muscle groups with the exception of trapezius and levator scapulae.
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The plexus communicates with the sympathetic chain.
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The brachial plexus can be divided into roots, trunks, divisions, and cords which can be further divided into peripheral nerves.
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Interscalene block is performed at the posterior border of sternocleidomastoid muscle at the level of C6 anterior tubercle known as Chassaignac or carotid tubercle.
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This is most prominent among the anterior tubercle of the transverse process of the cervical vertebra, and it corresponds with the level of Cricoid cartilage.
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Chassaignac’s tubercle separates the carotid artery and vertebral artery.
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Internal Jugular vein and anterior scalene muscles are located lateral to the carotid artery ( Fig. 12.20 ).
Fig 12.20
Cervical spine cross-sectional anatomy. Note the relationship between the interscalene plexus and scalene muscles and the longus colli muscle and the stellate ganglion.
Fig 12.21
ASM, Anterior scalene muscle; BP, brachial plexus; CA, carotid artery; IJV, internal jugular vein; LA, local anesthetic; MSM, middle scalene muscle; SCM, sternocleidomastoid muscle.
Fig 12.22
C4 TP, transverse process of 4th cervical vertebra; DCP, deep cervical plexus; LC, Longus Coli; VA, vertebral artery; SCM, Sternocleidomastoid muscle.
Common Pathology
- •
Interscalene block is used in surgeries or procedures of the shoulder joint, upper arm, and clavicle.
Equipment
- •
High frequency (9 to 18 MHz) linear ultrasound probe
- •
25 to 22 gauge 2-inch short bevel needle
Common Injectates
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Local anesthetic
Injectate Volume
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5 to 20 mL
Technique
Patient Position
- •
The patient can be placed supine or in the lateral decubitus position.
- •
Instruct the patient to rotate his neck at an angle of 45 degrees and raise his head off the bed keeping the head rotated. This contracts the scalene muscles, and one can palpate the interscalene groove between the muscles running in craniocaudal direction.
Clinician Position
- •
Ipsilateral side of the patient if supine or standing behind the patient if in the lateral decubitus position.
Transducer Position
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The probe is placed transversely over the anterolateral part of the neck at the level of Chassaignac’s tubercle
- •
The ultrasound view shows a pulsating anechoic structure, which is the Carotid artery, then the ultrasound probe is moved posterior-laterally, maintaining the same level at C6 to view the Internal Jugular vein and anterior scalene muscle (ASM).
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The roots of the brachial plexus can be visualized laterally to ASM in the interscalene groove between the anterior scalene and middle scalene muscles.
- •
The ultrasound probe can be rotated or tilted slightly to obtain a clearer view. The probe can be moved craniocaudal directions to see the formation of the brachial plexus trunks and divisions from the cervical roots and to obtain an optimal site for injection where 2 or 3 roots are visualized.
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Sternocleidomastoid (SCM) muscle lies superficial to the plexus and is seen as a triangle structure on ultrasound. The plexus lies 1 to 3 cm deep from the skin level.
Needle Position
- •
In-plane technique going from lateral to medial.
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Avoiding the external jugular vein.
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Needle travels through interscalene groove, crossing the middle scalene muscle
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Injectionists may feel the pop entering the prevertebral fascia.
Target
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Needle tip should end just adjacent to the plexus
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Aspirate to check for blood or CSF, then inject, visualizing the spread of the injectate as it infiltrates the vicinity of nerve roots keeping the roots intact.
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Intravascular injection:
- •
Brachial plexus lies lateral to carotid artery, external and Internal jugular vein and vertebral artery; therefore, there is a high risk for intravascular injection.
- •
Visualize the needle tip at all times with ultrasound during the procedure.
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Confirm the tip of the needle seen under ultrasound is the real tip and not the needle falling off the ultrasound beam by injecting small amounts of local anesthetic and watch it exiting the needle tip.
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- •
Phrenic nerve block:
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Performing the interscalene block higher than the C6 level or injection of high volumes of local anesthetics can cause ipsilateral phrenic nerve block.
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Healthy patients may not be symptomatic, but patients with compromised pulmonary function may have shortness of breath or difficulty maintaining oxygen saturation.
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Using a lower concentration of local anesthetic and keeping local anesthetic injection to lower volumes may avoid phrenic nerve block.
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Horner’s syndrome:
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Horner’s syndrome is due to sympathetic block caused by an accidental spill of local anesthetic into the stellate ganglion.
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A patient complains of ptosis, anhydrosis, mydriasis, redness of the eye on the ipsilateral side.
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Pneumothorax:
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It can rarely occur with lower cervical injection site, though patients with obstructive lung disease can be prone because of the higher pleural dome, and it should be suspected if the patient complains of shortness of breath or is unable to maintain normal saturation.
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Pneumothorax may share the same clinical picture as phrenic nerve paralysis; however, there are reduced or absent breath sounds in patients with pneumothorax.
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An upright chest x-ray will help diagnose both conditions.
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Subarachnoid injection:
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Although rare, injection into dural sleeves of cranial nerves or spread of local anesthetic injection into cervical epidural space can cause a high spinal block, resulting in hypotension, difficulty breathing, numbness and muscle weakness of upper extremities, and loss of consciousness.
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Supraclavicular Brachial Plexus Block
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Supraclavicular block can be used as an alternative or adjunct to general anesthesia or used for postoperative pain control for the upper extremity from the upper part of the arm to the hand.
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The brachial plexus above the clavicle area forms trunks and divisions as they pass under the clavicle in very close proximity to the chest cavity.
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Brachial plexus trunks and divisions are arranged very close, so the local anesthetic spreads easier, and a superior block can be obtained.
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The plexus passes over above the 1st rib between the insertions of middle scalene and anterior scalene muscles roughly at the midpoint of the clavicle.
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The plexus is in very close proximity to the pleura and lung, increasing the risk of pneumothorax.
Pertinent Anatomy
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Surface Anatomy
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Supraclavicular block can be performed in the supraclavicular fossa at the midpoint of the superior border of the clavicle.
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The plexus forms three trunks, upper (C5 & C6), middle (C7), and lower (C8 &T1).
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Both the brachial plexus and subclavian artery lie on top of the 1st rib between the insertions of the anterior scalene muscle and the middle scalene muscle.
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The brachial plexus is located posterior and lateral to the subclavian artery, and in very close proximity to the pleura.
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You can palpate pulsations of the subclavian artery and the 1st rib in the midclavicular area above the clavicle.
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Ultrasound Anatomy:
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The ultrasound probe is placed horizontally above the clavicle in the midclavicular area. The subclavian artery is seen as a round anechoic pulsating structure.
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Located underneath the subclavian artery, you can see the hyperechoic 1st rib. Since the ultrasound waves are completely reflected back, it casts a dark shadow underneath the rib.
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On either side of the first rib, you can see a hyperechoic pleural shadow.
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Some of the ultrasound waves pass through the pleura into lung tissue filled with air, so it gives the characteristic appearance of cosmic dust under the pleura.
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Make a mental note of the location and depth of the 1st rib and pleura since you have to make sure the needle does not pass beyond this depth.
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Now focus your attention on the subclavian artery, where the brachial plexus can be seen as hypoechoic fascicles both superficial and deep to the artery.
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The ultrasound probe can be moved proximally and distally along the brachial plexus to visualize its trunks and divisions.
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The brachial plexus lies at 1 to 2 cm depth below the skin at this location.
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Common Pathology
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Used for anesthesia for upper extremity procedures
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Also, consider for brachial plexus neuritis or plexopathy
Equipment
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Linear ultrasound transducer
- •
25 gauge 2-inch spinal needle
Common Injectates
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Local Anesthetic
Injectate Volume
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10 to 25 mL
Technique
Patient Position
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Supine position with neck in the midline position. Turn the patient’s chin to 45 degrees in the opposite direction to open up the supraclavicular fossa
- •
Lateral decubitus with 1 pillow under the head so that the neck is tilted slightly away from the targeted side.
- •
It can be done in a sitting position but is not preferred.
Clinician Position
- •
Ipsilateral side of the patient.
Transducer Position
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The transducer is placed transversely above the clavicle in the midclavicular area.
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Identify the hyperechoic line that the 1st rib casts and the pleura on either side of the rib. It is mandatory to stay superficial to 1st rib and pleura
Needle Position
- •
Introduce the needle in-plane from the lateral side of the probe using ultrasound guidance.
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Visualize the needle tip and direct it towards the brachial plexus, which is seen as hypoechoic fascicles. It is mandatory that the needle tip stays superficial to 1st rib and pleura.
Target
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Enter the fascia that covers the brachial plexus; a pop may be felt
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Target injection inside the fascia sheath in between the brachial plexus trunks
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Vascular Injection: The brachial plexus is close to the subclavian artery and lies superficial and deep to the artery.
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Intra-arterial injection can be minimized by aspirating the needle prior to injection, watching the spread of local anesthetic live as the injection is performed, and using incremental doses during the injection.
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Pneumothorax: Brachial plexus block has the highest incidence of pneumothorax. It is mandatory to identify the 1st rib and pleura prior to insertion of the needle and keep needle tip superficial to those structures.
Nerve injury: The use of ultrasound has reduced the risk of nerve injury. Nerve injury can be avoided by performing the block in-plane technique, making sure the nerve bundle maintains its integrity during the injection, and performing it on an awake or minimally sedated patient so that the patient can alert the practitioner to nerve pain.
Cervical Plexus Block
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Cervical plexus blocks were first performed by Halsted in 1884.
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The cervical plexus can be done by the posterior or lateral approach.
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Currently, the most commonly performed is the lateral approach of cervical plexus block.
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Superficial cervical plexus block is used for superficial surgeries of the neck and shoulder.
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Deep cervical plexus block is used for surgeries on deeper structures of the anterior and lateral neck, like surgeries of the carotid artery, thyroid, neck lymph nodes, etc.
Pertinent Anatomy
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The cervical plexus is formed by anterior divisions of upper cervical nerve nerves C2 to C4.
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The cervical nerves emerge for their respective foramina and divide into anterior and posterior divisions. The anterior divisions exit behind the vertebral artery in a gutter formed by the anterior and posterior tubercle of the transverse process at corresponding cervical vertebrae.
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The anterior rami divide into ascending and descending branches forming series of loops known as the cervical plexus.
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The plexus divides into superficial and deep branches giving rise to a series of nerves.
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The branches of the superficial cervical plexus pierce the deep fascia of the neck at the midpoint of the posterior margin of sternocleidomastoid muscle to emerge, forming the lesser occipital nerve, greater auricular nerve, transverse cervical nerve, and supraclavicular nerve.
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It supplies the skin area of the anterior neck and shoulder area.
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The deep cervical plexus supplies the deep structures of the anterior and lateral neck and also gives branches to the phrenic nerve.
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To locate the deep cervical plexus, a straight line is drawn from the tip of the mastoid process to Chassaignac’s (C6) tubercle; the line will indicate the positions of cervical transverse processes.
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On this line, the transverse process of C2 is located 2 cm below the tip of the mastoid process corresponding to the level of the hyoid bone; the transverse processes of C3 and C4 are located 1.5 and 3 cm below the mark for the C2 transverse process.
- •
C4 transverse process corresponds to the level of the superior border of the thyroid cartilage.
Common Pathology
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The cervical plexus can be used as an anesthetic or adjunct to general anesthesia or postoperative pain relief for surgeries of the neck and shoulders.
Equipment
- •
High frequency (9 to 18 MHz) linear ultrasound probe
Common Injectates
- •
Local anesthetics
Injectate Volume
- •
5 to 10 mL
Technique
Patient Position
- •
The patient is positioned in a supine position
- •
The head is rotated 45 degrees away to slide the SCM muscle away from the site of injection.
Clinician Position
- •
Ipsilateral to targeted side
Transducer Position
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The superficial cervical plexus block is performed by placing the probe transversely over the posterior border of SCM at the midpoint of the muscle.
- •
Visualize hypoechoic fascicles under the posterior border or emerging out through the fascia posterior to the SCM muscle.
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The deep cervical plexus block is performed by placing the high-frequency linear ultrasound probe over the posterior border of the SCM muscle; therefore, SCM is seen as a triangle.
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The transverse process of the C4 vertebra can be seen as a hyperechoic structure.
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By tilting the probe in the craniocaudal direction, you can visualize the C4 nerve root exiting the foramen and going in between the anterior and middle scalene muscles.
Needle Position
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For a superficial cervical plexus block, enter the skin over the midpoint of the posterior border of SCM muscle.
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Guide the needle through the long axis to pass through the superficial part of the deep cervical fascia.
- •
For the deep cervical plexus block, the needle is inserted and directed towards the C4 nerve root in the groove between the anterior and middle scalene muscles
Target
- •
For a superficial cervical plexus injection, under the superficial layer of deep cervical fascia near the superficial cervical plexus
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Aspirate first to ensure no vascular uptake and make sure there is an adequate spread of injectate near the nerve branches
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For the deep cervical plexus, the needle should contact the anterior tubercle of the C4 transverse process
- •
Aspirate to make sure there is no blood or cerebrospinal fluid, then inject
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Apply gentle pressure over the C5 tubercle to prevent the local anesthetic spread in the caudal direction
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Intravascular injection: The neck is highly vascular; accidental intravascular injection of local anesthetic can occur into external and internal jugular veins, external and internal carotid arteries, or vertebral artery. A very small amount of local anesthetic injected into the carotid artery, or vertebral artery can cause seizures or loss of consciousness.
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High spinal block: Local anesthetic injection into epidural and subdural spaces can occur due to penetration of the dural sleeve. Careful aspiration prior to injection can avoid intravascular or subarachnoid injection.
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Phrenic nerve block: Transient phrenic nerve block occurs in 100% of the patients as the phrenic nerve mainly arises from the C4 nerve root with minor branches from C3 and C5 nerve roots. Cervical plexus block should be avoided in patients who have severe respiratory illnesses.
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Horner’s syndrome: Upper and middle cervical sympathetic ganglion can be blocked during this procedure if the local anesthetic spreads anteriorly to the prevertebral fascia.
Fluoroscopy Guided Techniques
Transforaminal Cervical Epidural Injections
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A transforaminal cervical epidural injection can be used for both diagnostic and therapeutic purposes.
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Since the injection is done at a specific level, it has a higher diagnostic value as long as the injectate volume is kept low.
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Radiculitis at the cervical region can be secondary to disc, uncovertebral joint, or cervical facet pathology.
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Transforaminal epidural steroid injection is done to suppress the inflammation of the cervical nerve root and treat radicular pain.
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Under fluoroscopy, the cervical facets joints look like pillars on both sides of the vertebral column and therefore are called lateral masses or articular pillars.
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The location of the needle tip in relation to the articular pillar during the cervical injections is crucial to avoid complications.
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In the cervical region, the dural sleeve around the cranial nerve can extend up to the midpoint of the articular pillar.
Anatomic Consideration
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The roof of the intervertebral foramen is formed by the corresponding vertebral pedicle, and the floor of the foramen is formed by the pedicle of the vertebra below. The anterior part foramen is formed by the uncovertebral joint, and the posterolateral part is formed by the facet joints.
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The facet joints are formed by the inferior articular process of the corresponding vertebra and the superior articular process of the vertebral below.
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The transverse process of the cervical vertebra has a foramen called the transverse foreman.
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The vertebral artery (VA) runs through the transverse foramen of C1 to C6 vertebra and lies medial to the midline of the lateral masses or articular pillar; however, there is significant variation of the position of VA along the lateral masses.
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The cervical intervertebral foramina are positioned anterolaterally at 45 degrees and directed slightly inferior.
- •
The cervical spinal nerves from C3 to C7 exit in the groove for the spinal nerve. The groove has an inferior bony floor and anterior and posterior tubercle formed by the transverse process of the vertebra (see Figs 12.23 and 12.24 ).
Equipment
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C-arm fluoroscopy
- •
Needle: 25 gauge 2 to 3.5 inch spinal needle depending on neck girth
- •
non-ionic contrast material (Omnipaque or Isovue)
Common Injectates
- •
local anesthetics for diagnostics, nonparticulate corticosteroids
- •
Orthobiologics (platelet lysate)
- •
Do not use particulate steroids epidurally
Injectate Volume
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1 to 3 mL
Technique
Patient Position
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The patient is in the supine position, and the head should be turned away from the side of the procedure. This will prevent the overlap of the jaw and facial bones and optimizes the visualization of the foramen.
Clinician Position
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Ipsilateral side of the injection
C-Arm Position
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The C-arm is turned into oblique position significantly, usually 30 degrees or more, to maximize the opening of the neural foramen ( Fig. 12.23 ).
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