Table 1.
Summary of included studies from systematic literature search.
| Outcomes |
|||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Study | Title | Study design | Subjects | Levels targeted | Region | Intervention | Comparator | Procedural | Safety | Efficacy | Comments |
| Finlayson et al.43 | Real-time detection of periforaminal vessels in the cervical spine | Anatomic study | 102 patients | 1005 | Cervical | — | — | — | Incidental periforaminal blood vessels were found at 24% of cervical levels surveyed | — | This sonoanatomical study assessed for incidental periforaminal blood vessels in patients scheduled for cervical medial branch block |
| Siegenthaler et al.42 | Ultrasound anatomy of the nerves supplying the cervical zygapophyseal joints | Anatomic study | 50 patients | 50 | Cervical | — | — | All cervical medial branches from C3 to C6 were detected in 78% of patients, but the C7 medial branch was only visualized in 32% of patients | — | — | This sonoanatomical study assessed for the visibility of cervical medial branches in patients with chronic neck pain |
| Cervical facet joint intra-articular injection | |||||||||||
| Bodor et al.44 | Ultrasound-guided cervical facet joint injections | Prospective, single-arm, observational study | 36 patients | 60 | Cervical | Ultrasound-guided facet joint intra-articular injection | — | 92% to 98% of injections showed intra-articular contrast spread, depending on criteria to confirm accurate placement | No complications noted | — | — |
| Freire et al.45 | Ultrasound‐guided cervical facet joint injections | Cadaveric study | 4 cadavers | 40 | Cervical | Ultrasound-guided facet joint intra-articular injection | — | Needle tip localization was satisfactory in 82% of injections, verified by demonstration of intra-articular or peri-articular latex dye on dissection | — | — | — |
| Galiano et al.40 | Ultrasound-guided facet joint injections in the middle to lower cervical spine | Cadaveric study | 4 cadavers | 10 | Cervical | Ultrasound-guided facet joint intra-articular injection | — | CT confirmation of needle tip localization was satisfactory in 100% of injections | — | — | Preclinical study to demonstrate feasibility of new technique |
| Obernauer et al.46 | Ultrasound-guided versus computed tomography–controlled facet joint injections in the middle and lower cervical spine: A prospective randomized clinical trial | Randomized controlled trial | 40 patients | 54 | Cervical | Ultrasound-guided facet joint intra-articular injection | CT-guided facet joint intra-articular injection | CT confirmation of needle tip localization was satisfactory in 100% of ultrasound-guided injections, without need for further needle repositioning. CT-guided injection required needle repositioning in 65% of cases. Ultrasound guidance required less time compared to CT guidance (5 min versus 11 min for single level; 6 min versus 15 min for two levels) | No complications were noted. Radiation exposure from CT-guided injection was 88 mGy·cm for single level and 205 mGy·cm for two-level intervention | Both groups had similar reduction in VAS scores at 1-month follow-up | — |
| Cervical medial branch block | |||||||||||
| Eichenberger et al.41 | Sonographic visualization and ultrasound-guided block of the third occipital nerve | Randomized controlled trial | 14 healthy volunteers | 28 | Cervical | Ultrasound-guided third occipital nerve block | Sham ultrasound-guided third occipital nerve block (saline) | Fluoroscopic confirmation of needle tip localization was satisfactory in 82% of injections | No major complications were noted. There was one small subcutaneous hematoma | 90% of third occipital nerve blocks produced anesthesia in the desired distribution, whereas no control blocks resulted in sensory changes | — |
| Finlayson et al.50 | Cervical medial branch block: A novel technique using ultrasound guidance | Prospective, single-arm, observational study | 53 patients | 163 | Cervical | Ultrasound-guided medial branch block | — | 94% of injections were successful, as determined by appropriate contrast spread pattern. The median number of needle passes per level was 1.33 | No complications were noted. Overlying blood vessels were incidentally seen in 11 patients | — | An additional 20 patients and 46 levels were injected in a preliminary phase of the study, with 100% satisfactory needle tip placement on fluoroscopy |
| Finlayson et al.49 | A randomized comparison between ultrasound- and fluoroscopy-guided third occipital nerve block | Randomized controlled trial | 40 patients | 40 | Cervical | Ultrasound-guided third occipital nerve block | Fluoroscopy-guided third occipital nerve block | Desired contrast spread pattern was comparable with ultrasound and fluoroscopic guidance (95% versus 100%). Procedure time and required number of needle passes were lower with ultrasound guidance compared to fluoroscopy (213 s versus 397 s; two versus six needle passes) | No complications were noted. In 10% of patients, incidental blood vessels were observed on ultrasound scan. There was a 10% rate of blood aspiration in the fluoroscopy group (0% with ultrasound), and no intravascular contrast spread in either group. With fluoroscopy, there was a 15% rate of C2–C3 intra-articular spread of contrast | Sensory testing and distribution of hypoesthesia were comparable in both groups | — |
| Finlayson et al.48 | A prospective validation of biplanar ultrasound imaging for C5–C6 cervical medial branch blocks | Prospective, single-arm, observational study | 40 patients | 80 | Cervical | Ultrasound-guided medial branch block | — | Fluoroscopic confirmation of needle tip localization was satisfactory in 99% of injections. The mean procedure time was 249 s | No complications were noted. Blood vessels were visualized in 21% of blocks | — | — |
| Finlayson et al.33 | A randomized comparison between ultrasound- and fluoroscopy-guided C7 medial branch block | Randomized controlled trial | 50 patients | 50 | Cervical | Ultrasound-guided medial branch block | Fluoroscopy-guided medial branch block | Success rate was similar for both ultrasound- and fluoroscopy-guided blocks (92% versus 96%). Compared to fluoroscopy, ultrasound guidance had a shorter procedure time (233 min versus 391 min) and required fewer needle passes (two versus four) | No complications were noted. In 40% of patients, ultrasound guidance revealed an overlying blood vessel, which was avoided. In several fluoroscopy-guided blocks, there was intravascular (20%) and intra-articular (4%) spread of contrast agent | After injection, both groups reported comparably decreased pain scores | — |
| Park et al.54 | Spinal cord injury during ultrasound-guided C7 cervical medial branch block | Case report | 1 patient | 1 | Cervical | Ultrasound-guided medial branch block | — | — | — | — | This case report describes a patient who underwent ultrasound-guided C7 medial branch block and had subsequent focal intramedullary hemorrhage at C7–T1, with residual upper limb weakness at 1-month follow-up |
| Park et al.47 | Ultrasound versus fluoroscopy-guided cervical medial branch block for the treatment of chronic cervical facet joint pain: A retrospective comparative study | Retrospective, two-arm, observational study | 126 patients | 186 | Cervical | Ultrasound-guided medial branch block | Fluoroscopy-guided medial branch block | Procedure time was lower with ultrasound guidance (221 s versus 383 s, and fewer needle passes were required (two versus five needle passes) | No major complications were noted. Both groups had a similar incidence of transient headache, vasovagal reaction, and pain exacerbation. Blood aspiration was 12% in with fluoroscopic guidance (0% with ultrasound). There were no instances of intravascular contrast spread | Both groups had comparable decreases in verbal numeric pain and Neck Disability Index scores at 6-month follow-up | — |
| Siegenthaler et al.51 | Accuracy of ultrasound-guided nerve blocks of the cervical zygapophysial joints | Randomized controlled trial | 60 healthy volunteers | 180 | Cervical | Ultrasound-guided medial branch block | — | On fluoroscopy, needle tip placement was accurate in 78% of cases, and the rate of desired contrast dye spread was 84% | No major complications were noted. Two volunteers reported transient neck pain | — | Of the 180 injections in this study, 73 were purposefully misplaced a priori to determine agreement statistics for two blinded raters examining fluoroscopy images |
| Cervical medial branch radiofrequency ablation | |||||||||||
| Awad et al.53 | Ultrasound-guided versus C-arm fluoroscopy controlled radiofrequency ablation of the cervical facets | Prospective, two-arm, observational study | 40 patients | 123 | Cervical | Ultrasound-guided medial branch radiofrequency ablation | Fluoroscopy-guided medial branch radiofrequency ablation | Procedural time was lower with ultrasound guidance (10 min versus 14 min) | No major complications were noted. Both groups had a similar incidence of transient pain aggravation, paresthesia, allergic reaction, and superficial infection. One patient had mild upper limb weakness that resolved by 1-month follow-up (technique unspecified) | Both groups had comparable decreases in VAS scores at 1-month follow-up | — |
| Kim et al.39 | Ultrasound-guided pulsed radiofrequency of the third occipital nerve | Case report | 2 patients | 2 | Cervical | Ultrasound-guided pulsed radiofrequency ablation of third occipital nerve | NA | Needle tip placement was confirmed by fluoroscopy in both patients | No complications were noted | VAS scores were persistently reduced up to 4-month and 12-month follow-up in the two patients, respectively | — |
| Lee et al.52 | Ultrasound-guided radiofrequency neurotomy in cervical spine: Sonoanatomic study of a new technique in cadavers | Cadaveric study | 5 cadavers | 34 | Cervical | Ultrasound-guided medial branch radiofrequency ablation | — | 87% of radiofrequency ablations were successful, as determined by histologic examination of the medial branches | — | — | — |
| Stulc et al.55 | Ultrasound‐guided thoracic facet injections | Cadaveric study | 1 cadaver | 20 | Thoracic | Ultrasound-guided facet joint intra-articular injection | — | 80% of injections showed intra-articular contrast spread | — | — | — |
| Lumbar facet joint intra-articular injection | |||||||||||
| Galiano et al.57 | Ultrasound guidance for facet joint injections in the lumbar spine: A CT-controlled feasibility study | Cadaveric study | 5 cadavers | 10 | Lumbar | Ultrasound-guided facet joint intra-articular injection | — | There was 100% accuracy of needle tip placement, as confirmed by CT | — | — | Only one cadaver underwent needle placement; remaining four were used for studying sonoanatomy |
| Galiano et al.58 | Ultrasound-guided versus computed tomography–controlled facet joint injections in the lumbar spine: A prospective randomized clinical trial | Randomized controlled trial | 40 patients | 40 | Lumbar | Ultrasound-guided facet joint intra-articular injection | CT-guided facet joint intra-articular injection | CT assessment confirmed accurate needle tip placement in 94% of all ultrasound-guided injections. There was reduced time to needle placement with ultrasound-guidance compared to CT guidance (14 min versus 22 min) | No major complications were noted. One patient reportedly had fluid retention and peripheral edema, possibly but not clearly related to corticosteroid administration. The mean radiation dose for CT guidance was 364 mGy·cm | Both ultrasound-guided and CT-guided injections resulted in similar decreases in VAS Scores at 6-week follow-up | — |
| Gofeld et al.63 | Ultrasound-guided injection of lumbar zygapophyseal joints | Cadaveric study | 5 cadavers | 50 | Lumbar | Ultrasound-guided facet joint intra-articular injection | — | The success rate for needle-tip placement was 88%, as determined by fluoroscopy and contrast dye spread pattern | — | — | — |
| Ha et al.80 | Comparison of ultrasonography- and fluoroscopy-guided facet joint block in the lumbar spine | Retrospective, two-arm, observational study | 105 patients | 105 | Lumbar | Ultrasound-guided facet joint intra-articular injection | Fluoroscopy-guided facet joint intra-articular injection | — | There was a similar incidence of transient, minor adverse effects with both ultrasound- and fluoroscopy-guided injections | VAS and ODI scores were comparably reduced between ultrasound- and fluoroscopy-guided injections at 6-week follow-up. Procedure time was comparable between ultrasound- and fluoroscopy-guided injections. Patients were billed approximately 50% more for fluoroscopy-guided injections than ultrasound-guided injections | — |
| Karkucak et al.81 | Comparison of clinical outcomes of ultrasonography-guided and blind local injections in facet syndrome: A 6-week randomized controlled trial | Randomized controlled trial | 47 patients | — | Lumbar | Ultrasound-guided facet joint intra-articular injection | Landmark-guided facet joint intra-articular injection | — | — | Ultrasound guidance yielded a greater decrease in VAS scores at 6-week follow-up, whereas ODI decreased to a similar degree in both groups | — |
| Massone et al.67 | Real-time fusion imaging in low back pain: A new navigation system for facet joint injections | Retrospective, two-arm, observational study | 65 patients | 183 | Lumbar | Ultrasound fusion imaging-guided facet joint intra-articular injection | CT-guided facet joint intra-articular injection | Procedural time was comparable between fusion imaging– and CT-guided injections (21 min for both) | No major complications were noted. Several patients in each group had a mild subcutaneous hematoma | VAS and ODI scores were comparably decreased in both groups at 2-month follow-up. Patient satisfaction was comparable between both groups | The fusion imaging–guided technique involved real-time registration of sonographic imaging against prior CT or magnetic resonance imaging, with magnetic needle tip tracking |
| Rasoulian et al.82 | Ultrasound-guided spinal injections: A feasibility study of a guidance system | Prospective, single-arm, observational study | 4 patients | 5 | Lumbar | Ultrasound fusion imaging-guided facet joint intra-articular injection | — | — | — | — | Proof of concept study to demonstrate high degree of precision for fusion image guidance and needle tip tracking. Clinical outcomes not reported |
| Sadeghian and Motiei-Langroudi78 | Sonography guided lumbar nerve and facet blocks: The first report of clinical outcome from Iran | Prospective, single-arm, observational study | 14 patients | 18 | Lumbar | Ultrasound-guided facet joint intra-articular injection or medial branch block | — | — | No complications were noted. | VAS scores were decreased at 1-week follow-up | This was a mixed population. Four patients received selective nerve root block and ten patients received facet joint intra-articular injection |
| Santiago89 | Ultrasound-guided facet block to low back pain: A case report | Case report | 1 patient | 3 | Lumbar | Ultrasound-guided facet joint intra-articular injection | — | — | No complications noted | Numeric pain scores were decreased at 5-month follow-up | — |
| Sartoris et al.65 | In vivo feasibility of real-time MR–US fusion imaging lumbar facet joint injections | Prospective, single-arm, observational study | 38 patients | 112 | Lumbar | Ultrasound fusion imaging–guided facet joint intra-articular injection | — | Needle tip placement with ultrasound and magnetic positioning system guidance yielded 86% accuracy as assessed with fluoroscopy. The mean procedural time was 28 min | No major complications were noted. Ten patients had transient, mild subcutaneous hematoma at the injection site | VAS scores were decreased at 8-week follow-up | — |
| Tay et al.74 | Ultrasound-guided lumbar spine injection for axial and radicular pain: A single institution early experience | Retrospective, single-arm, observational study | 27 patients | — | Lumbar | Ultrasound-guided facet joint intra-articular injection | — | — | No complications noted | Reduced numeric rating scale and ODI scores at 3-month follow-up | This was a mixed population with some patients also receiving selective nerve root injections in addition to facet joint intra-articular injection and additional patients receiving selective nerve root injections only. The aggregate results of the entire sample were presented |
| Wen et al.64 | [A clinical trial of ultrasound-guided facet joint block in the lumbar spine to treat facet joint related low back pain] | Randomized controlled trial | 20 patients | 35 | Lumbar | Ultrasound-guided facet joint intra-articular injection | Landmark-guided facet joint intra-articular injection | CT confirmation of needle tip localization was satisfactory in 86% of ultrasound-guided and 31% of landmark-guided injections. Procedural time was lower with ultrasound guidance compared to landmark technique (206 s versus 397 s) | — | VAS scores were decreased in both groups at 6-week follow-up. Although ultrasound-guided injection resulted in lower VAS scores compared to landmark technique, at 30 min there was no significant difference at any other time point | — |
| Ye et al.26 | Ultrasound-guided versus low dose computed tomography scanning guidance for lumbar facet joint injections: Same accuracy and efficiency | Mixed methods (anatomic study; randomized controlled trial) | 50 patients | 74 | Lumbar | Ultrasound-guided facet joint intra-articular injection | CT-guided facet joint intra-articular injection | Needle tip positioning was accurate in 86% of ultrasound-guided facet joint intra-articular injections, as assessed with CT assessment | No major complications were noted. A comparable number of patients in both groups had a transient aggravation of low back pain | At 6-week follow-up, VAS scores were comparably improved in both groups and a similar proportion of patients still reported at least 50% pain reduction | Ten of the 40 patients did not receive injections and participated solely for assessment of sonoanatomy |
| Yun et al.66 | Efficacy of ultrasonography-guided injections in patients with facet syndrome of the low lumbar spine | Randomized controlled trial | 57 patients | 185 | Lumbar | Ultrasound-guided facet joint intra-articular injection | Fluoroscopy-guided facet joint intra-articular injection | Ultrasound-guidance had slightly longer procedural time compared to fluoroscopy (263 s versus 249 s) | No major complications were noted. | Comparable improvements in VAS, ODI, physician’s global assessment, and patient’s global assessment scores at 3-month follow-up | — |
| Lumbar medial branch block | |||||||||||
| Erdogan et al.62 | Accuracy of the anatomic placement in ultrasonography guided facet joint blockage with supervising of C-arm fluoroscopy | Prospective, single-arm, observational study | 22 patients | 67 | Lumbar | Ultrasound-guided medial branch block | — | There was an appropriate contrast spread pattern in 91% of injections | No complications were noted | VAS scores were decreased postprocedurally, with variable follow-up | — |
| Etheridge et al.60 | Ultrasound-guided L5 dorsal ramus block: Validation of a novel technique | Prospective, single-arm, observational study | 100 patients | 100 | Lumbar | Ultrasound-guided L5 dorsal ramus injection block | — | Fluoroscopic confirmation of needle tip localization was satisfactory in 97% of injections but appropriate contrast spread was only seen in 95% of injections, indicating possible intravascular injection | One patient reported a small hematoma | — | — |
| Greher et al.28 | Ultrasound-guided lumbar facet nerve block | Cadaveric study | 5 cadavers | 50 | Lumbar | Ultrasound-guided medial branch block | — | The rate of successful needle tip placement at the desired radiographic endpoint was 90%, though contrast spread to the target site was observed in 94% of injections | — | — | — |
| Greher et al.27 | Ultrasound-guided lumbar facet nerve block | Mixed methods (cadaveric study; prospective, single-arm, observational study) | 1 cadaver, 20 healthy volunteers, 5 patients | 28 | Lumbar | Ultrasound-guided medial branch block | – | The success rate for needle tip placement was 89%, as determined by fluoroscopy. Procedure time to complete four to six injections was at most 40 min | No major complications | 40% of patients were pain free 30 min postinjection and remaining patients reported 50% reduction in pain | Cadaver was used to develop ultrasound-guided injection technique. Healthy volunteers contributed to characterization of sonoanatomy but were not injected |
| Greher et al.59 | Ultrasound-guided approach for L5 dorsal ramus block and fluoroscopic evaluation in unpreselected cadavers | Cadaveric study | 10 cadavers | 20 | Lumbar | Ultrasound-guided L5 dorsal ramus injection block | — | Fluoroscopic confirmation of needle tip localization was satisfactory in 80% of injections | — | — | — |
| Han et al.73 | Ultrasound versus fluoroscopy-guided medial branch block for the treatment of lower lumbar facet joint pain | Retrospective, two-arm, observational study | 146 patients | — | Lumbar | Ultrasound-guided medial branch block | Fluoroscopy-guided medial branch block | Procedure time was lower with ultrasound guidance compared to fluoroscopic guidance (323 s versus 430 s) | No major complications were noted. Rates of transient headaches, vasovagal reactions, and low back pain aggravation were comparable with both ultrasound and fluoroscopic guidance. Blood aspiration occurred with fluoroscopic guidance (7%) but was not observed with ultrasound guidance | Verbal numeric pain scale and ODI scores decreased similarly with ultrasound and fluoroscopic guidance at 6-month follow-up | — |
| Hashemi et al.71 | Ultrasound guidance for interventional pain management of lumbar facet joint pain: An anatomical and clinical study | Prospective, single-arm, observational study | 30 patients | 89 | Lumbar | Ultrasound-guided medial branch block | — | There was 98% accuracy of needle tip placement as confirmed with fluoroscopy | No complications were noted | Verbal numeric pain scale and ODI scores decreased similarly with ultrasound and fluoroscopic guidance at 6-month follow-up | — |
| Jung et al.70 | The validation of ultrasound-guided lumbar facet nerve blocks as confirmed by fluoroscopy | Prospective, single-arm, observational study | 50 patients | 95 | Lumbar | Ultrasound-guided medial branch block | — | There was a desired contrast spread pattern in 92% of medial branch blocks | — | Visual analog scores were decreased at 3-day follow-up | — |
| Putzu and Marchesini76 | Ultrasound block of the medial branch: Learning the technique using CUSUM curves | Prospective, single-arm, observational study | 14 patients | 40 | Lumbar | Ultrasound-guided medial branch block | — | Needle-tip placement was accurate in 72% of cases, as confirmed with fluoroscopy | — | — | This study analyzed the learning curve for experienced regional anesthesiologists to acquire proficiency in ultrasound-guided lumbar medial branch block. Patient outcomes were not reported |
| Rauch et al.68 | Ultrasound-guided lumbar medial branch block in obese patients | Prospective, single-arm, observational study | 20 patients | 84 | Lumbar | Ultrasound-guided medial branch block | — | The success rate for needle-tip placement was 62%, as determined by fluoroscopy. Average procedural time was 5 min | — | Verbal rating scales were decreased at 24-h follow-up | — |
| Shim et al.72 | Ultrasound-guided lumbar medial-branch block: A clinical study with fluoroscopy control | Prospective, single-arm, observational study | 20 patients | 101 | Lumbar | Ultrasound-guided medial branch block | CT-guided medial branch block | Ultrasound-guided needle tip placement was accurate in 95% of cases, as confirmed with fluoroscopy; however, two injections had intravascular spread of contrast dye | No complications were noted | VAS scores were decreased immediately after the injections, comparable to CT-guided injection | — |
| Soni et al.69 | Diagnostic ultrasound‐guided lumbar medial branch block of dorsal ramus in facet joint arthropathy: Technical feasibility and validation by fluoroscopy | Prospective, single-arm, observational study | 60 patients | 161 | Lumbar | Ultrasound-guided medial branch block | — | The success rate was 86%, as determined by fluoroscopic verification of needle tip placement and contrast spread pattern | No complications were noted | Numeric rating scale scores were decreased at 24 h postprocedure, with 75% of patients reporting a decrease in numeric rating scale score of at least 50% | — |
| Lumbar medial branch radiofrequency ablation | |||||||||||
| Gofeld et al.61 | Magnetic positioning system and ultrasound guidance for lumbar zygapophysial radiofrequency neurotomy | Cadaveric study | 6 cadavers | 60 | Lumbar | Ultrasound- and magnetic positioning system–guided medial branch radiofrequency ablation | Fluoroscopy-guided medial branch radiofrequency ablation | Needle tip placement with ultrasound and magnetic positioning system guidance yielded 97% accuracy as assessed with fluoroscopy. Procedure time for ultrasound and magnetic positioning system guidance was comparable to fluoroscopy guidance | — | — | — |
| Lumbar medial branch cryoneurolysis | |||||||||||
| Kastler et al.38 | Lumbar medial branch cryoneurolysis under ultrasound guidance: Initial report of five cases | Prospective, single-arm, observational study | 5 patients | 8 | Lumbar | Ultrasound-guided medial branch cryoneurolysis | — | There was 100% accuracy of needle tip placement as confirmed with fluoroscopy | No complications noted | VAS and ODI scores were decreased at 3-month follow-up. Mean self-reported improvement was 77% at 12-month follow-up. There was one patient who did not benefit from the procedure | — |
CUSUM = cumulative sum; ODI = Oswestry Disability Index; VAS = visual analogue scale.