Ultrasound‐Guided Cervical Intervertebral Disc Injection Without Fluoroscopy

Abstract

Cervical disc degeneration commonly results in referred neck pain, which is traditionally diagnosed via fluoroscopy-guided provocative discography. Herein, we discuss three cases of neck and shoulder pain treated with cervical intradiscal injections administered under ultrasound (US) guidance. The most painful intervertebral disc was identified using the sonopalpation technique, which involved palpation while visualizing anatomical structures using US. Injectant spread within the intervertebral disc was validated using superb microvascular imaging rather than fluoroscopy. Symptoms significantly improved following blocks at the identified sites, suggesting that US can be used to guide cervical intradiscal injections even in the examination room.Key Words-cervical intervertebral disc; cervical intradiscal injection; disc degeneration; discogenic neck pain; neck pain N eck pain is a significant public health problem worldwide. 1,2 Cervical discogenic pain is among the most common causes of neck pain, 3 the diagnosis of which is usually confirmed by reproducing the concordant pain via provocative discography with contrast under fluoroscopic guidance. Advancements in magnetic resonance imaging (MRI) have enabled us to identify the causative degenerated disc segment quite precisely. 4 However, if the lesion is extensive, it can be difficult to narrow down to the disc generating pain prior to discography using MRI alone. Therefore, we introduced the sonopalpation technique, which involves palpation under ultrasound (US) guidance to identify areas of tenderness and aid in visualizing potential lesions. 5 US is increasingly being utilized during pain interventions owing to several advantages, such as portability, real-time guidance, and lack of radiation exposure. Moreover, US can provide a detailed depiction of soft tissue structures, making it especially beneficial for cervical spine injections given that multiple vulnerable nerves and vessels are compacted within this small region. Additionally, advancements in probe technology have made it possible to visualize the inside of the intervertebral disc, 6 allowing safe guidance of the needle into the nucleus pulposus with a clear view of the spinal cord. Superb microvascular imaging (SMI) 7,8 can also be used to confirm the spread of the injectant, which is traditionally confirmed with contrast under fluoroscopy, enabling clinicians to perform provocative discography in the examination room.

Direct Visualization of Cervical Interlaminar Epidural Injections Using Sonography

“…Unlike CT and fluoroscopy, SMI helps visualize not only microvessels with slow blood flow but also the movement of liquid (injectant) flow without contrast injection [ 20 ], and it can be a useful tool to confirm if the needle tip is in proper anatomical position e.g., the epidural space. Under SMI, the spread of the injectant can be visualized using US while simultaneously confirming the proper placement of the tip of the needle between the ligamentum flavum and dura matter ( Figure 3 ) [ 6 ]. The major difference is that it offers real-time, radiation-free guidance for interventions.…”

“…It is also important to examine the placement of the needle tip and the spread of the injectant to ensure its effectiveness [ 6 ]. The loss-of-resistance (LOR) method is performed for blinded or fluoroscopic epidural injections.…”

“…Sonography offers an alternative method for performing cervical interlaminar epidural steroid injections (CILESIs). It could help reduce the risk of injury, avoid the pitfall of false-positive LOR, and avoid radiation exposure or the use of contrast media by allowing direct visualization of the location of the needle tip during the procedure with cross-sectional imaging [ 6 ].…”

Novel Ultrasound-Guided Cervical Intervertebral Disc Injection of Platelet-Rich Plasma for Cervicodiscogenic Pain: A Case Report and Technical Note

“…Moreover, with further advances in US technology and improvements in penetration and image resolution, needle placement in the disc’s center can be achieved, as the lateral mass of the contralateral side of the disc is usually visible. Furthermore, with the technology known as “superb microvascular imaging”, the spread of the injectate inside the desiccated disc can be clearly visualized [ 5 ]. Other pitfalls of this techniques are related to the trajectory of the needle, as the needle has to pass through the fascial space between the thyroid (or thyroid cartilage if above C4 level) and the carotid artery.…”

“…The transverse process of C7 usually has a rudimentary anterior tubercle or only a posterior tubercle. Direct digital palpation of the desiccated discs was performed with ultrasound guidance [ 5 ]. The transducer was placed in the sagittal plane of the cervical spine between the carotid artery and the thyroid.…”