Ultrasound-Guided Injection to the Fifth Cervical Spinal Nerve Root Level

Background/ImportanceUltrasound (US)-guided cervical selective nerve root injections (CSNRI) have been proposed as an alternative to fluoroscopic (FL) -guided injections. When choosing US guidance, the proceduralist should be aware of potential issues confirming vertebral level, be clear regarding terminology, and up to date regarding the advantages and disadvantages of US-guided CSNRI.ObjectiveReview the accuracy and effectiveness of US guidance in avoiding vascular puncture (VP) and/or intravascular injection (IVI) during CSNRI.Evidence ReviewQueries included PubMed, CINAHL and Embase databases from 2005 to 2019. Three authors reviewed references for eligibility, abstracted data, and appraised quality.FindingsThe literature demonstrates distinct safety considerations and limited evidence of the effectiveness of US guidance in detecting VP and/or IVI. As vascular flow and desired injectate spread cannot be visualized with US, the use of real-time fluoroscopy, and if needed digitial subraction imaging, is indicated in cervical transforaminal epidural injections (CTFEIs). Given the risk of VP and/or IVI, the ability to perform and to retain FL images to document that the procedure was safely conducted is valuable in CTFEIs.ConclusionUS guidance remains to be proven as a non-inferior alternative to FL guidance or other imaging modalities in the prevention of VP and/or IVI with CTFEIs or cervical selective nerve root blocks. There is a paucity of adequately powered clinical studies evaluating the accuracy and effectiveness of US guidance in avoiding VP and/or IVI. US-guided procedures to treat cervical radicular pain has limitations in visualization of anatomy, and currently with the evidence available is best used in a combined approach with FL guidance.

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Ultrasound-guided cervical selective nerve root injections: a narrative review of literature

Ehsanian

Schneider

Kennedy

et al. 2021

Reg Anesth Pain Med

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Low-Volume Local Anesthetics for C5 and Supraclavicular Nerve Blocks for Mid and Lateral Clavicle Surgery: A Case Series

et al. 2020

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After institutional ethics committee approval and informed consent, 20 patients with clavicle fractures were recruited. An ultrasound-guided C5 root block was performed by injecting 3 mL of 0.5% bupivacaine with a subsequent ultrasound-guided supraclavicular nerve (SCN) block with 3 mL of 0.5% bupivacaine. A combination of low-volume C5 root block and SCN block provided reliable awake anesthesia and postoperative analgesia in patients with fractured clavicles. This technique can avoid a general anesthesia for fractures of the mid and lateral clavicle. Further studies should focus on the optimal volume of local anesthetics required for the success of this technique.

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C5 ventral ramus block for clavicle surgery: How low concerning the volume can we go?

Diwan

Feigl

Nair³

2021

Journal of Anaesthesiology Clinical Pharmacology

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Background and Aims: Clinical case reports mention 3-5 ml of local anesthetic (LA) at the cervical root 5 (C5) for surgical anesthesia essential for clavicle surgeries with reasonable success. A volume of 5 ml LA has been shown to cause hemidiaphragmatic paresis. Material and Methods: We implement the 3–5 ml LA for awake clavicle surgeries along with a supraclavicular nerve (SCN) block with another 2 ml. To understand the spread of injectate, we conducted anatomic macroscopic dissection on Theil based cadavers. Post ultrasound injection of 3 ml of blue latex in one cadaver and green latex in the other, we dissected one cadaver and the other cadaver underwent a cross-section. Results: Dissection confirmed a vertical spread of dye more caudad than cephalad. There was no neuraxial spread visualized in the cross-section. The phrenic nerve (PN) was not stained in both cadavers, but a possibility exists depending on its course. Conclusion: Based on this limited study we recommend a volume of LA of 3 ml at the level of C5 and another 2 ml at the level SCN of LA for clavicle surgeries.

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Ultrasound-Guided Injection to the Fifth Cervical Spinal Nerve Root Level

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Cited by 3 publications

References 7 publications

Ultrasound-guided cervical selective nerve root injections: a narrative review of literature

Ultrasound-guided cervical selective nerve root injections: a narrative review of literature

Low-Volume Local Anesthetics for C5 and Supraclavicular Nerve Blocks for Mid and Lateral Clavicle Surgery: A Case Series

C5 ventral ramus block for clavicle surgery: How low concerning the volume can we go?

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