Ultrasound-guided interventional

procedures for lumbar back pain

Dr.Dalton Silaban SpS, CIPS

RSUD dr.H.Kumpulan Pane Tebing Tinggi
RSU PT Sri Pamela Medika Nusantara Tebing Tinggi
Introduction
Definition : Low Back Pain (LBP) is defined as pain localized
between the 12th rib and the inferior gluteal ribs, with or
without leg pain.
LBP has a life time prevalence of 60-85 % .
LBP poses an economic burden to society, large number of
work days lost and less so by direct treatment cost
Treatment targets are reduction of pain and better, prevention
of disability, maintenace work capacity
Interventional modalities for LBP are higly effective when
used in conjunction with other adjuvant modalities.
Pain-sensitive structures of lumbar area

Joint structures
Intervertebral disc,
ligaments, facet joints,
Bones, blood vessels,
tendon and muscle
Fascia and aponeurosis
The dura, nerve root
sleeves and rootlets
Differential diagnosis of Low Back Pain

Mechanical
Visceral low back or
disease (2%) leg pain
(97%)

Non
Mechanical
spinal
conditions(1%)
Differential diagnosis of mechanical low
back pain
Spinal stenosis
(3%)

Vertebral
Spondylolisthesis compression
(3-4%) fracture (4%)

Lumbosacral Spondylolysis
muscle strain /
sprain (70%) (< 5%)

Lumbar Disc herniation

Spondylosis ( 5-10%)
(10%)
Manchikanti L et al. : 120 patients low back pain without any
identifiable cause
 Facet joint pain in 40 %
 Discogenic pain in 26 %
 Sacroiliac joint pain in 20 %
 Segmental dural/nerve root pain in 13 %
 No cause was identified in 19 %
Clasification of LBP

Low Back Pain Duration

Acute < 6 Weeks

Sub-acute 6-<12 weeks

Chronic 12 Or > 12 weeks

Recurrent Having previous episodes with pain free

intervals
Treatment of Pain
Clinical algorithm for the management
of chronic low back pain.
Advantages of ultrasound guided spine
injection
 No x-rays hazard
 Presentation of vessels and tissues
 Visualize the pleural and lung movements
 Portable ability
 Easily maneuver of ultrasound probe to give different axial
and longitudinal view
 Applicable and practical in the outpatient clinical setting
 No limitation in diffcult position
 More practical in diffcult surface anatomic landmarks
 Get view of anatomical differences
 Increase first pass needle success rate
Possible limitations for the ultrasound guided
spine injections
The inability to correctly visualize the target in obese individuals
The inability to accurately detect intravascular injection in such deep injections
A longer procedure time for novice
The potential need for larger gauge needles to improve visualization.
Image quality in the elderly patient population
Inaccuracy of skin marking especially in FBSS
The learning curve for ultrasound imaging of the spine
The inability to correctly visualize the target in obese individuals and FBSS
The inability to accurately detect intravascular injection in such deep injections
A longer procedure time for novice
The potential need for larger gauge needles to improve visualization.
Image quality in the elderly patient population
Inaccuracy of skin marking
The learning curve for ultrasound imaging of the spine(sacrum)
Complication of spine injection
Bleeding (epidural hematoma) and retroperitoneal hematoma
Allergic reaction
Dural puncture and following headaches
Intravascular injection (in the sacral zone there is a high possibility of
intravascular injection because of high vascularity
Arachnoiditis
Consequent of steroid injection, like suppression of cortisone level for
up to 2 weeks and increase in blood glucose level
Vasovagal reaction
Ataxia especially for cervical block
Epidural lipomatosis
Cauda equina syndrome
Interventional Therapy for Low Back Pain
Common Technique Indications
Trigger point injection Myofascial pain
Epidural steroid injection Disc prolapse and nerve root pain (neuropathic pain)

Medial branch blocks/Radiofrequency Neurotomy Pain from facet joints

Facet joint Injections

Intra-articular sacroiliac joint injection SI joint pain

Less common Technique Indications

Adhesiolysis/epiduroscopy/spinal endoscopy
Spinal cord stimulation
Intrathecal pump using opioids and adjuvants
Epidural scarring
Failed Back surgery syndrome
Neuropathic pain
Failed Back surgery syndrome
Failed Back surgery syndrome
Severe back pain due to advanced cancer not
responding to conventional treatment.
Sonoanatomy of the spine lumbal

Five sonographic views of the neuraxial spine

1. Paramedian sagittal transverse process view
2. Paramedian sagittal articular process view
3. Paramedian sagittal oblique view
4. Transverse spinosus process view
5. Transversal interlaminar view
1.Paramedian sagittal transverse process view

 The transducer 3-5 cm away

from mid line
• Two to three hyperechoic bone
shadows of TP deep to ESM
• Psoas muscle deep to TP
• Deep to psoas muscle , the
peritoneum can be seen
• The “trident sign “ represents
finger like shadowing behind
the TP

Paramedian sagittal Transverse Process View

2. Paramedian sagittal articular process view

• Moving the transducer medially

1-2 cm reveals an image with
continuous hyperechoic bone
shadow (no gap) from the
articular process (AP)
• “camel humps” represent
continuous hyperechoic bone
due to vertebra being
connected by articular process

Paramedian sagittal articular process view

3.Paramedian sagittal oblique view

 Maintaining the
transducer in the same
position with paramedian
sagittal articular process
view but tilting medially
that reveals interlaminar
window
 Through this window , the
intrathecal space (ITS)
between the lamina(L)

Paramedian sagittal oblique view

4.Transverse spinosus process view

 Placing the transducer

behind the spinosus
processus (SP), the
structures deep in the
spine will not be seen

Transverse spinosus Process view

5. Transversal interlaminar view
 The most usefull view 
transducer placed behind the
interspinosus ligament (ISL)
 reveal intrathecal space
(ITS)
 Inferior intraarticular process
(IAP) is closer to midline than
superior articular process
(SAP)

Transversal interlaminar view

Neuraxial ultrasound : Five sonographic views
of the neuraxial spine
How to count the level

1. Method sagittal view

 The intralaminar level are
indicated with PSO view including
the sacrum (upper right),
interlaminar levels marks on the
skin (yellow lines)
 The PSTP view (lower right). The
TP are counted and marked on
the skin(red lines)

Spine counting in sagittal view

How to count the level

2. Method 2 Transverse
View
 The transducer is placed close the PSIS and a
typical transview of sacrum with median crest
(MC) in the midline is reveal (yellow line)
 Moving the transducer in chepalad direction reveal
ITS and dura  L5S1 (orange line)
 Moving the transducer further cephalad and lateral,
a transverse interlaminar view with TP and SAP
(red line )

Spine counting in transverse view

Determining the target for medial branch

 Target is junction of SAP with cephalad

border of TP
 TP is bone and cast an anechoic shadow
deep in the scan (orange line and box)

Determination Of transverse process

Determining the target for
medial branch
1. Perform the paramedian sagittal
transverse process view the
cephalad part of sacrum (a)
2. ⚬
Rotate the transducer +/_ 90 with
the medial part slighty to cephalad.
(b)
3. This view all necessary bony
landmarks they are, SP of L5, facet
joint(FJ), sacral ala (SA), iliac crest
(IC)
4. The junction between the SA and FJ
is the target (✶)
Lumbar zygapophysial (Facet) nerve block
Facet joint syndrome (FJs)
prevalence 27-40% in patients
chronic LBP
Facet joint degenerative OA is the
most frequent form of the facet joint
pain
Clinical patterns included local pain
and pseudo radicular radiation,(a)
anterior aspec of the lower limb, (b)
posterior aspect of the lower limb
Anatomy
 The FJs are a set of planes types of
synovial joint between articular process
 Each lumbar FJs has a distict space
capable 1-1,5 ml of fluid
 Each FJs innervated by two medial
branches, the medial branch at the same
level and that at the level above .

The course of the medial branch of posterior ramus from the lumbar spinal
nerve. Arrows indicate nerves distributing the facet joint
Scanning injection
• Probe : curve linier
• Patient : prone with pillow
• Identify lumbal spinal levels
• Needle : 22 G
• Drugs : for IA 1 mL of mixture LA and
depo-steroid (0,5 of 2 % LA + 0,5 MP
(80 mg/mL), for MBB 0,5 mL of LA,
Dektrose or PRP to intra/periarticular
• The needle is inserted from lateral to
medial in plane toward the base of the
SAP ant Transverse process Tranverse view of medial branch block and facet joint
block .(A) medial branch block is shown the needle is
• Medial branch block + RF ablation located between the transverse process.SP:Spinosus
process,TP : Transverse Process, F;Facet joint.(B) A
facet joint itra-articular injection is shown
 Kevin Chang methode

a) The traditional ultrasound –guided lateral to medial approach for lumbar facet joint injection
The modified caudal to cranial ultrasound-guided technique for lumbar facet injection using curvelinier
(b) and linear transducer (c), SAP: superior articular process, IAP inferior articular process,TP:
transverse process, black arrow : needle
Trigger Point spinal injection for Low
Back pain
Benefit using US guidance in treating myofascial pain syndrome :
1. US can locate parts of the trigger points as hypoechoic
region within the muscle
2. US can assure the needle position
3. US guidance allows the injectate to be distributed
evenly inside the interfascial plane
4. US is more sensitive than visual inspection to monitor
local twitch response.
Lumbar muscle quadratus lumborum and
psoas muscle
 Myofascial pain derived from the
quadratus lumborum (QL) or psoas
muscle or both is freq uent and
underdiagnosed cause of non
specific lumbar pain
 The QL muscle originates from the
iliac crest and iliolumbar ligament
and inserts into the 12th rib and
transverse of L1-L5.
 The QL can refer four trigger points
low back pain, groin and gluteal
region

Location of the deep (black X) and superficial (red X) trigger point on the
quadratus lumborum muscle.The corresponding regions for referred pain are
also illustrated in the same color
Scanning-Injection Technique
 Patient position : decubitus or
lateral decubitus
 Low-frequency ultrasound
probe
 The target to be found in a PS
view  acoustic shadow Transverse view showing a hyperechogenic linier image that represents
“trident sign” a
the entire length of the transverse process (3) section of the qudratus
lumborum muscle (1), and para spinal muscle (2)

 On rotating the probe to a

tranverse view with slight
inclination (transverse
median view)

Transverse view under lumbar transverse process: the quadratus

b lumborum muscle (1), paraspinal muscle(2),psoas muscle (4),
vertebral body(5), and peritoneum (6)
Injection Technique

Drugs :
1. Lidocain or bupivacaine
2. Steroid :
 dexametason, triamsinolon,
methylprednison
 prolotherapy solusion as dextrose or
sterile saline,
 botox 6-12,5 unit per muscle
Paramedian sagittal view close the lumbar transverse process : the
qudratus lumborum muscle(1),paraspinal muscle(2),psoas muscle(4),
vertebral body(5),peritoneum(6), and kidney (6).The arrow marks the
needle path for qudratus lumborum muscle block (long axis view)
Gluteus maximus-medius- minimus trigger point
and referred pain

Gluteus medius trigger point diagram

Gluteus maximus trigger point diagram

Pyriformis syndrome scanning
Technique Injection

 Probe : curve linier

 Patient : Prone position
 Needle : 22 or 25 G, 3,5-5 inchi
 Drugs : 1-2 cc of the following:
1. LA (0,25 % bupivacaine)
2. LA + methylprednison 40 mg
3. botulinum toxin 50-100 units
 Needle orientation : in plane needle
approach : lateral to medial (or medial
to lateral)
 Target : Piriformis muscle sheat/Pi muscle

T= transducer ; Glut max = Gluteus maximus

Sacro iliaca joint injection

 Patient position : prone with pillow

under the pelvic
 Transducer position: curve linier axial
plane
 Needle: spinal 22-25 G, 3,5 inch
 Needle orientation : in plane technique
medial to lateral
 Injectate :1 mL LA  1 mL
corticosteroid

a b
(a) Example of axial probe position over SIJ with in-plain
injection technique .(b) Arrowhead indicates needle tip
entering SIJ,arrow indicates needle,asterisk indicate joint
space, sacrum and ilium labeled
Epidural steroid injection

1. transforaminal epidural block

2. interlaminal epidural block
3. cauda epidural block
Epidural steroid injection
 Effective pain relief for radiculopathy
 Relief inflammation,edema and irritation by reducing
swelling of nerve root, blocking c-fiber, stabilize nerve
membrane, and decrease ectopic discharge from
inflamed tissue
 Inflamatory mediators leak into epidural space rather
than subarachoid space
Drugs doses in common therapeutic
spinal injections
Lumbar transforaminal Scanning injection
technique

 Lumbar transforaminal is a
commonly perfomed procedure to
treat spinal radicular pain with leg
and/or back pain conservative
treatment have failed.
 Indication : disc herniation
foraminal stenosis, and lateral; disc
herniations.
 Scanning technique : Curve array 
Paramedian sagittal sonography at
the level of TP short axis view 
between two adjacent TP 
spinosus process, lamina and
dorsal part of the vertebral body
Axial sonogram of lumbar vertebra. S, indicates
 Drugs : Lidocain  corticosteroid spinosus process; L lamina ; V , vertebral body;arrow
head target for injection
Cauda epidural injection
 Administration of medication
into epidural space via the
sacral hiatus
 Success rate < 75 % without
image guidance, 100% with a
ultrasound guidance
 Patient selection : chronic LBP
with radicular pain secondary
to disc herniation or radiculitis
not responding to b c
conservative a)Sacral hiatus (arrow) with the sacral cornu (*); b)sacral
hiatus covered by sacrococcygeal ligament ; c)filum
terminal and dura in sacral canal
Scanning Injection Technique

 Position : Prone
 Probe : Linier probe, convex
probe in obese
 Needles : 22 G spinal
needle 3.5 inch
 Drugs : volume 10-20 mL
dilute LA + 40 mg
depomedrol + normal
saline 0,9%
 Injection volume 20 mL can Short axis (upper panel) and long axis (lower
reach S1 100%,L5 89%, L4 panel) scan of the caudal canal
84%, and L3 19%

Upper panel. The steep angle of entry to caudal canal.

Lower panel. Sonographic images of the needle in
shortaxis (left lower ) and long axis (right lower)
Summary
1. Ultrasound-guided spinal injection appears to be a safe,
feasible, accurate, and cost-effective procedure for the
treatment of LBP
2. Safety tips : patient selection, sterilization, monitoring of the
vital signs, preparation of the emergency rescue equipment,
and limitation of drug dosage to the comprehensive familiarity
with the ultrasound device, settings, and secondary
confirmation technique
3. Proper identification of pain generators and careful patient
selection are crucial to achieving good functional outcomes
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