The Fluoroscopic assessment of accuracy of

needle placement in US Guided

Transforaminal Periradicular Lumbar
Nerve Root Injection Dr Supriya Thakur
Post Graduate Student
Department of Anaesthesia
Dr.Rajendra Prasad Government
Medical College Tanda,Kangra
 Introduction
All individuals have experienced pain at some point in
their life.
Low back pain (LBP) is one of the most significant clinical
concern affecting people.
Prevalence of lifetime LBP is between 60-80%.
It can be due to significant spinal disease,nerve root
compromise/ spinal canal stenosis and non specific LBP.

Airaksinen O, Brox JI, Cedraschi C, et al. European guidelines for the management
of chronic nonspecific low back pain. Euro Spine J. 2006;15(Suppl 2):192.
Lumbar transforaminal epidural injection (TFEI)- One of
the frequently used approaches for managing LBP.
Traditional injections are conducted under real-time
fluoroscopic guidance with contrast agents to improve
visibility of the injectate track and reduce intravascular
injections.
In this study fluoroscopic assessment of accuracy of
needle placement in neural foramen is done under real
time USG which is the primary objective of the study.

Silbergleit R, Mehta BA, Sanders WP, et al. Imaging-guided injection techniques with
fluoroscopy and CT for spinal pain management. Radiographics. 2001;21(4):927-39.uidance
 Materials and Methods
This is a prospective observational study done in
Department of Anaesthesia Dr. RPGMC Tanda over a
period of 12 months in 40 patients who were having
LBP with radiculopathy for atleast 6 weeks, not relieved
by conservative treatment.
These patients were of either gender between 18-65
years, BMI between 18-35, having neurogenic
claudication or radiculopathy with MRI proven
intervertebral disc prolapse compromising neural
foramina or examination indicating a nerve root
involvement and positive Lasegue’s sign.
Written informed consent was obtained.
On the day of procedure patient was allowed to take
light meal in the morning. Patient received in OT, IV
access was established with 20 G cannula.Basic vital
monitoring- Pulse, BP, SpO2 and ECG were attached,
recorded before and during the procedure.Patients
were asked to lie prone on OT table with a pillow
placed below abdomen to reduce lumbar lordosis.
The procedure was performed under AAP using
portable USG machine with a curved probe.
 After scan was complete

1-2 ml 1% Lignocaine inserted locally

23G Quincke’s Spinal Needle inserted at 45 Deg.in “In plain

technique”

As it hits facet joint, withdrawn 2-3 mm and directed 5-8

mm anterior to facet joint

If patient had tingling sensation and shooting pain needle

withdrawn 2-3 mm
Once satisfactory needle position achieved ( confirmed by lateral
view taken from C arm)
C- arm shot taken after injecting Iohexol (0.5- 1ml)300mg/ml to
rule out intravascular or intrathecal spread
If contrast dilineated nerve roots
0.5-1ml Dexamethasone followed by 1-2 ml 0.125% Bupivacaine.
Patients were monitored for PR,NIBP,RR,SpO2,VNRS
preprocedurally,during the procedure and post procedurally at
5 min, 30 min and 2 hours. Patients were monitored for motor
blockade during, post procedure and discharged from hospital
on the same day.
 Patients were followed up for VNRS on day 1, after one
week, 6 weeks and 12 weeks post procedure.
If facet joint and tranverse joints cannot be observed in
even 4th attempt procedure was abandoned.
Procedural observations include:
1) Ultrasound visibility score
2) Number of attempts for localization of neural foramen
3) Number of adjustments and time done to localize the
space
4) Number of radiation exposures
5) Whether needle touches cortex of bone or not
6) Any complications (intravascular, intra-neural,
subarachnoid injection).
 Statistical analysis
In this study data normality was checked by using Shapiro-Wilk
test and following statistical tests were applied for the results:
1. The association of the variables which were quantitative
and not normally distributed in nature were analyzed using
the Mann Whitney test (for two groups) and Kruskal Wallis
test (for more than two groups). Wilcoxon signed rank test
was used for comparison of pre procedural VNRS
quantitatively with follow up data.
2. The association of the variables which were qualitative in
nature were analysed using Chi-Square test. If any cell had an
expected value of less than 5 then Fisher’s exact test was
used.
3. Bhapkar test was used for comparison of pre procedural
VNRS for pain distribution with follow up.
Association of successful positioning of needle with respective
transforaminal space: p value=0.33

Association of number of attempts for localization of transforaminal

space of respective nerve root: p value < 0.0001
Association of time taken for needle insertion to localize
transforaminal space (in seconds) with respective
transforaminal space: p value = 0.09
 Discussion
Present study suggests that US- guided technique is convenient and
safe alternative treatment modality with reduced radiation
exposure with accuracy of 93.3% to 100%.
Total Ultrasound Visibility Score:
In our study no significant difference statistically as well as clinically
was found in TUVS in relation to age, gender and BMI.
Accuracy/Successful needle placement:
We reached at desired locations with 100% accuracy under US
guidance except in two cases at L5 level even after 4th attempt.So
accuracy at L5 level is 93.3%, also not significant.
Time taken for needle placement:
Time taken for needle placement was less in our study as compared
to other studies done in past.This may be due to selection of
patients, expertise to do the procedure and the point at which we
abandon our procedure.
Radiation exposure time:
As sonography is used as image guiding modality for needle
placement and fluoroscopy was used just to confirm needle
position.So C- arm shots were restricted to mean number 3.
Complications:
None of patients had major complications like worsening of
leg pain, nerve root irritation, circulatory disturbances.
Some patients complained soreness of back 3-5 days after
injection which was managed by usual doses of NSAIDS.
VNRS for pain:
In this study pre- procedural VNRS for pain with post
procedural VNRS at one week, six weeks and three months
and found significant decrease in post procedural VNRS at
all intervals with p value < 0.0001, which proves
effectiveness of the study.
 Conclusion
In this study it was concluded that USG guidance was
not only precise and reliable but also feasible and safe
approach.These advantages include feasibility,
reproducibility, real time monitoring of needle
advancement, visualization of distinct anatomic
structures, reduction in drug dosage, reduced
procedure time and radiation exposure.