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Background and Aims Transforaminal Epidural steroid injection is an extremely valuable tool in the conservative management of cervical radicular pain. For decades this injection has been performed under fluoroscopic guidance and while complications are serious and infrequent, this imaging technique cannot prevent inadvertent arterial puncture. Considering delicate cervical anatomy, ultrasound may bring a valid alternative, allowing for real time needle advancement, at no radiation expenses. Recent medical studies have supported the use of Ultrasound as a pivotal imaging tool and as an alternative to the gold standard of this procedure. The aim of this presentation is to illustrate the Cervical TESI, comparing the ultrasound to the already consolidated imaging tool.

Methods This review describes advantages and disadvantages of US guided cervical epidural steroid injection techniques compared to the fluoroscopic guidance, as encountered in the recent medical literature.

Results Despite the lack of foraminal flow visualization, recent medical studies have demonstrated correct target identification with immediate and long- term effectiveness of extraforaminal (periradicular) US guided steroid injections. A higher volume showed an increase in the foraminal flow, without modifying the outcome. Also, recently, a new technique of US guided transforaminal epidural injection has been described and investigated.

Conclusions Ultrasound guided injections have several meaningful advantages over any other imaging technique, providing real time visualization and possibly preventing inadvertent vascular canulation. However, the US guided technique cannot demonstrate utility regarding the posterior foraminal vasculature, thus still relying on aspiration and fluoroscopic confirmation. Until further research, a combination of both US and Fluoroscopic guided techniques remains the recommended approach.