Imaging in Interventional Pain Management

  • Marc A. Huntoon


Interventional pain procedures are commonly performed either with image-guidance ­fluoroscopy, computed tomography (CT), or ultrasound (US) or without image guidance utilizing surface landmarks. Recently, three-dimensional rotational angiography (3D-RA) suites, also known as flat detector computed tomography (FDCT) or cone beam CT (CBCT) and digital subtraction angiography (DSA) have been introduced as imaging adjuncts. These systems are indicative of a trend toward increased use of specialized visualization techniques. Pain medicine practice guidelines suggest that most procedures require image guidance to improve the accuracy, reproducibility (precision), safety, and diagnostic information derived from the procedure. Historically, pain medicine practitioners were slow adopters of image-guidance techniques, largely because the most common parent specialty (anesthesiology) had a culture of using surface landmarks to aid the perioperative performance of various nerve blocks and vascular line placements. Indeed, some pain medicine practitioners in the 1980s and early 1990s felt that studies advocating the inaccuracy of epidural steroid injections performed with surface landmarks were published more for specialty access than to increase patient safety or improve outcomes.


Digital Subtraction Angiography Cone Beam Compute Tomography Trigger Point Image Guidance Flat Panel Detector 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Manchikanti L, Boswell MV, Singh V, et al. Comprehensive evidence-based guidelines for ­interventional techniques in the management of chronic spinal pain. Pain Physician. 2009;12:699–802.PubMedGoogle Scholar
  2. 2.
    Huntoon MA. Ultrasound in pain medicine: advanced weaponry or just a fad? Reg Anesth Pain Med. 2009;34:387–388.PubMedCrossRefGoogle Scholar
  3. 3.
    el-Khoury GY, Ehara S, Weinstein JN, Montgomery WJ, Kathol MH. Epidural steroid injection: a procedure ideally performed with fluoroscopic control. Radiology. 1988;168:554–557.PubMedGoogle Scholar
  4. 4.
    American College of Occupational and Environmental Medicine. Low Back Disorders. Occupational Medicine Practice Guidelines. 2nd ed. Elk Grove Village, IL: American College of Occupational and Environmental Medicine; 2008 [chapter 12].Google Scholar
  5. 5.
    Manchikanti L, Singh V, Derby R, et al. Review of occupational medicine practice guidelines for interventional pain management and potential implications. Pain Physician. 2008;11:271–289.PubMedGoogle Scholar
  6. 6.
    Manchikanti L, Singh V, Helm S II, Trescot A, Hirsch JA. A critical appraisal of 2007 American College of Occupational and Environmental Medicine practice guidelines for interventional pain management: an independent review utilizing AGREE, AMA, IOM, and other criteria. Pain Physician. 2008;11:291–310.PubMedGoogle Scholar
  7. 7.
    Berrington de Gonzalez A, Mahesh M, Kim K-P, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009;169:2071–2077.PubMedCrossRefGoogle Scholar
  8. 8.
    Brenner DJ, Hall EJ. Computed tomography – an increasing source of radiation exposure. N Engl J Med. 2007;357:2277–2284.PubMedCrossRefGoogle Scholar
  9. 9.
    Gofeld M. Ultrasonography in pain medicine: a critical review. Pain Pract. 2008;8:226–240.PubMedCrossRefGoogle Scholar
  10. 10.
    Galiano K, Obwegeser AA, Walch C, et al. Ultrasound-guided versus computed tomography-controlled facet joint injections in the lumbar spine: a prospective randomized clinical trial. Reg Anesth Pain Med. 2007;32:317–322.PubMedGoogle Scholar
  11. 11.
    Huntoon MA. Anatomy of the cervical intervertebral foramina: vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections. Pain. 2005;117:104–111.PubMedCrossRefGoogle Scholar
  12. 12.
    Orth RC, Wallace MJ, Kuo MD. C-arm cone-beam CT: general principles and technical ­considerations for use in interventional radiology. J Vasc Interv Radiol. 2008;19:814–821.PubMedCrossRefGoogle Scholar
  13. 13.
    Siewerdsen JH, Moseley DJ, Burch S, et al. Volume CT with flat-panel detector on a mobile, isocentric C-arm: pre-clinical investigation in guidance of minimally invasive surgery. Med Phys. 2005;32:241–254.PubMedCrossRefGoogle Scholar
  14. 14.
    Goldschneider KR, Racadio JM, Weidner NJ. Celiac plexus blockade in children using a three-dimensional fluoroscopic reconstruction technique: case reports. Reg Anesth Pain Med. 2007;32: 510–515.PubMedGoogle Scholar
  15. 15.
    Knight JR, Heran M, Munk PL, Raabe R, Liu DM. C-arm cone-beam CT: applications for spinal cement augmentation demonstrated by three cases. J Vasc Interv Radiol. 2008;19:1118–1122.PubMedCrossRefGoogle Scholar
  16. 16.
    Eichenberger U, Greher M, Kirchmair L, et al. Ultrasound-guided blocks of the ilioinguinal and iliohypogastric nerve: accuracy of a selective new technique confirmed by anatomical dissection. Br J Anaesth. 2006;97:238–243.PubMedCrossRefGoogle Scholar
  17. 17.
    Gofeld M, Christakis M. Sonographically guided ilioinguinal nerve block. J Ultrasound Med. 2006;25:1571–1575.PubMedGoogle Scholar
  18. 18.
    Hurdle M-F, Weingarten TN, Crisostomo RA, et al. Ultrasound-guided blockade of the lateral femoral cutaneous nerve: technical description and report of 10 cases. Arch Phys Med Rehabil. 2007;88:1362–1364.PubMedCrossRefGoogle Scholar
  19. 19.
    Harmon D, Hearty C. Ultrasound guided suprascapular nerve block technique. Pain Physician. 2007;10:743–746.PubMedGoogle Scholar
  20. 20.
    Rofaeel A, Peng P, Louis I, Chan V. Feasibility of real-time ultrasound for pudendal nerve block in patients with chronic perineal pain. Reg Anesth Pain Med. 2008;33:139–145.PubMedGoogle Scholar
  21. 21.
    Byas-Smith MG, Gulati A. Ultrasound-guided intercostal nerve cryoablation. Anesth Analg. 2006;103:1033–1035.PubMedCrossRefGoogle Scholar
  22. 22.
    Galiano K, Obwegeser AA, Bodner G, et al. Real-time sonographic imaging for periradicular injections in the lumbar spine: a sonographic anatomic study of a new technique. J Ultrasound Med. 2005;24:33–38.PubMedGoogle Scholar
  23. 23.
    Narouze S, Vydyanathan A, Kapural L, Sessler DI, Mekhail N. Ultrasound-guided cervical selective nerve root block: a fluoroscopy-controlled feasibility study. Reg Anesth Pain Med. 2009;34(4): 343–348.PubMedCrossRefGoogle Scholar
  24. 24.
    Eichenberger U, Greher M, Kapral S, et al. Sonographic visualization and ultrasound-guided block of the third occipital nerve: prospective for a new method to diagnose C2/3 zygapophysial joint pain. Anesthesiology. 2006;104:303–308.PubMedCrossRefGoogle Scholar
  25. 25.
    Galiano K, Obwegeser AA, Bodner G, et al. Ultrasound-guided facet joint injections in the middle to lower cervical spine: a CT-controlled sonoanatomic study. Clin J Pain. 2006;22:538–543.PubMedCrossRefGoogle Scholar
  26. 26.
    Kapral S, Krafft P, Gosch M, Fleischmann M, Weinstabl C. Ultrasound imaging for stellate ­ganglion block: direct visualization of puncture site and local anesthetic spread. A pilot study. Reg Anesth. 1995;20:323–328.PubMedGoogle Scholar
  27. 27.
    Hayek SM, Jasper J, Deer TR, Narouze S. Occipital neurostimulation-induced muscle spasms: implications for lead placement. Pain Physician. 2009;12(5):867–876.PubMedGoogle Scholar
  28. 28.
    Sibbitt WL Jr, Peisajovich A, Michael AA, et al. Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol. 2009;36:1892–1902.PubMedCrossRefGoogle Scholar
  29. 29.
    Smith J, Hurdle M-F, Locketz AJ, Wisnewski SJ. Ultrasound-guided piriformis injection: ­technique description and verification. Arch Phys Med Rehabil. 2006;87:1664–1667.PubMedCrossRefGoogle Scholar
  30. 30.
    Botwin KP, Sharma K, Saliba R, Patel BC. Ultrasound-guided trigger point injections in the ­cervicothoracic musculature: a new and unreported technique. Pain Physician. 2008;11:885–889.PubMedGoogle Scholar
  31. 31.
    Fitzgibbon DR, Posner KL, Domino KB, et al. Chronic pain management: ASA Closed Claims Project. Anesthesiology. 2004;100:98–105.PubMedCrossRefGoogle Scholar
  32. 32.
    Higa K, Hirata K, Hirota K, Nitahara K, Shono S. Retropharyngeal hematoma after stellate ­ganglion block. Anesthesiology. 2006;105:1238–1245.PubMedCrossRefGoogle Scholar
  33. 33.
    Narouze S. Beware of the “serpentine” inferior thyroid artery while performing stellate ganglion block. Anesth Analg. 2009;109(1):289–290.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Department of Anesthesiology, Division of Pain MedicineMayo ClinicRochesterUSA

Personalised recommendations