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Ultrasound-guided cervical selective nerve root injections: a narrative review of literature
  1. Reza Ehsanian1,
  2. Byron J Schneider2,
  3. David J Kennedy2 and
  4. Eugene Koshkin3
  1. 1Division of Physical Medicine and Rehabilitation, Department of Orthopaedics & Rehabilitation, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
  2. 2Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  3. 3Department of Anesthesia & Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
  1. Correspondence to Dr Eugene Koshkin, Department of Anesthesia & Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA; hsc-painmedicine{at}


Background/Importance Ultrasound (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.

Objective Review the accuracy and effectiveness of US guidance in avoiding vascular puncture (VP) and/or intravascular injection (IVI) during CSNRI.

Evidence Review Queries included PubMed, CINAHL and Embase databases from 2005 to 2019. Three authors reviewed references for eligibility, abstracted data, and appraised quality.

Findings The 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.

Conclusion US 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.

  • injections
  • spinal
  • back pain
  • neck pain
  • pain management
  • ultrasonography

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  • Contributors RE and BJS: Formal analysis; Methodology; Project administration; Visualization; Writing - original draft; Writing - review & editing. DJK and EK: Project administration; Writing - original draft; Writing - review & editing.

  • Funding All authors declare that they have no financial and personal relationships with other people or organizations that could inappropriately influence (bias) their work. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval If applicable, the authors state that they have obtained appropriate institutional review board approval or have followed the principles outlined in the Declaration of Helsinki for all human or animal experimental investigations. In addition, for investigations involving human subjects, informed consent has been obtained from the participants involved.

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

  • Data availability statement Data analyzed in this study were a re-analysis of existing data, which are openly available at locations cited in the reference section. Further documentation about data processing is not applicable.