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Ultrasound-guided L5 dorsal ramus block: validation of a novel technique
  1. John-Paul B Etheridge1,
  2. Frederick De Villiers2,
  3. Jan Venter3,
  4. Pam Squire4,
  5. Brenda Farnquist5 and
  6. Roderick J Finlayson3
  1. 1 Anesthesia, Kelowna General Hospital, Kelowna, British Columbia, Canada
  2. 2 Family medicine, Kelowna General Hospital, Kelowna, British Columbia, Canada
  3. 3 Anesthesia, McGill University, Alan Edwards Pain Managment Unit, Montreal, Québec, Canada
  4. 4 Family Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
  5. 5 Radiology, Kelowna General Hospital, Kelowna, British Columbia, Canada
  1. Correspondence to Dr Roderick J Finlayson, Anesthesia, McGill University, Montreal, QC H3A 0G4, Canada; roderick.finlayson{at}


Background Although the value of ultrasound-guided (USG) lumbar medial branch blocks (MBB) has previously been examined in several clinical trials, blocking the L5 dorsal ramus (DR) remains a technical challenge and we sought to examine the accuracy of a novel technique targeting this level.

Methods In this prospective cohort study, 115 patients scheduled for an L4 MBB and L5 DR block underwent an ultrasound scan to assess their lower spine sonoanatomy. Subjects in whom the necessary landmarks could be visualized underwent a USG L5 DR block using a pivot technique, which involved redirecting a needle from its position on the L5 transverse process after an L4 MBB. Success was determined by a blinded observer who examined the contrast distribution on postprocedural X-ray images. In addition to the final needle position, performance time, the number of needle passes, and any complication were recorded.

Results A total of 100 patients had a USG block and 15 patients (13%) were excluded because of poor landmark visibility. The latter group presented a significantly higher body mass index (38.90±7.50 vs 26.31±4.25 kg/m2, p=0.004). A total of five failures were noted (95% success rate), this included three patients with transitional anatomy in whom needles were placed at the wrong level and two cases of incomplete contrast coverage possibly related to the partial intravascular injection. Performance time was 153.93±41.56 s and the median number of needle passes was 2 (range 4). No significant complications were noted.

Conclusion The pivot technique provides a reliable approach for USG L5 DR ramus blocks.

Trial registration number NCT03805906

  • interventional pain management
  • ultrasound in pain medicine
  • chronic pain: back pain
  • chronic pain: imaging

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  • Contributors J-PBE: participated in the conception, design, data acquisition, data analysis, and reporting. FDV and PS: participated in the conception, design, data acquisition, and reporting. JV and RJF: participated in the conception, design, data analysis, and reporting. BF: participated in the conception, design, data acquisition, study image evaluations, and reporting.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study received ethical approval from the University of British Columbia, Vancouver, Canada (H18-02638).

  • Provenance and peer review Not commissioned; externally peer reviewed.