Ultrasound-guided facet block to low back pain: a case report

RevBrasAnestesiol.2014;64(4):278---280

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

CLINICAL

INFORMATION

Ultrasound-guided

facet

block

to

low

back

pain:

a

case

report

Ana

Ellen

Q.

Santiago,

Plinio

C.

Leal,

Elmiro

Helio

M.

Bezerra,

Ana

Laura

A.

Giraldes,

Leonardo

C.

Ferraro,

Andre

H.

Rezende,

Rioko

Kimiko

Sakata

UniversidadeFederaldeSãoPaulo,SãoPaulo,SP,Brazil

Received19April2012;accepted19September2012 Availableonline24May2014

KEYWORDS

Facetblock; Lowbackpain; Ultrasound

Abstract

Background: osteoarthrosisisacommoncauseoflowbackpain.Thediagnosisisclinicaland canbeconfirmedbyimagingstudies.Paintreatmentandconfirmationofdiagnosisaremadeby intra-articularinjectionofcorticosteroidandbylocalanestheticuse,duetoclinical improve-ment.Adirectmonitoringoftheprocedurecanbedoneunderfluoroscopy,aclassictechnique, orelsebyanultrasound-guidedprocedure.

Casereport: femalepatient,88yearsold,1.68mand72kg,withfacetosteoarthrosisatL2---L3, L3---L4andL4---L5fortwoyears.Onphysicalexamination,sheexhibitedpainonlateralization andspinalextension.Weoptedinfavorofanultrasound-guidedfacetjointblock.A midline spinallongitudinalscanwasobtained,withidentificationofthedesiredjointspaceatL3---L4.A 25Gneedlewasinsertedintotheskinbytheechographicoff-planeultrasoundtechnique.1mL ofcontrastwasadministered,withconfirmationbyfluoroscopy.Afteraspirationofthecontrast, 1mLofsolutioncontaining0.25%bupivacainehydrochlorideand10mgofmethylprednisolone acetatewasinjected.InjectionsintoL3---L4,L2---L3andL1---L2totherightwereapplied.

Conclusions:thevisualizationofthefacetjointbyultrasound involvesminimalrisk,besides reductionofradiation.Thisoptionissuitableforalargepartofthepopulation.However, flu-oroscopyandcomputedtomography remainasmonitoringtechniquesindicated for patients with specific characteristics, such as obesity,severe degenerative diseasesand anatomical malformations,inwhichtheultrasoundtechniqueisstillinneedoffurtherstudy.

©2013SociedadeBrasileiradeAnestesiologia.PublishedbyElsevier EditoraLtda.Allrights reserved.

PALAVRAS-CHAVE

Bloqueiofacetário; Lombalgia; Ultrassom

Bloqueiofacetárioguiadoporultrassomparalombalgia:relatodecaso

Resumo

Justificativa:Aosteoartrosefacetáriaécausafrequentededorlombar.Odiagnósticoéclínico epodeserconfirmadoporimagem.Otratamentodadoreaconfirmac¸ãododiagnósticosão feitospelainjec¸ãointra-articulardecorticosteroideeanestésicolocal,porcausadamelhoria clínica.Amonitorac¸ãodiretadoprocedimentopodeserfeitaporfluoroscopia,técnicaclássica, ouguiadaporultrassom.

∗_{Correspondingauthor.}

E-mail:riokoks.dcir@epm.br(R.K.Sakata).

Ultrasound-guidedfacetblocktolowbackpain 279

Relatodecaso: Pacientedosexofeminino,88anos,1,68me72kg,comosteoartrosefacetária emL2---L3,L3---L4eL4---L5haviadoisanos.Noexamefísico,doràlateralizac¸ãoeàextensão da coluna. Optou-sepelo bloqueioda articulac¸ãofacetáriaguiado porultrassom.Foi feito escaneamentolongitudinalnalinhamédiadacoluna vertebraleidentificadooespac¸o artic-ulardesejadoemL3---L4.Umaagulha25Gfoiintroduzidanapelepelatécnicaforadeplano ecográfico.Foiadministrado1mLdecontraste,confirmadocomfluoroscopia.Apósaspirac¸ão docontraste,foiinjetado1mLdesoluc¸ãocontendocloridratodebupivacaína0,25%e10mg deacetatodemetilprednisolona.Foramfeitasinjec¸õesnosespac¸osL3---L4,L2---L3eL1---L2à direita.

Conclusões: Avisualizac¸ãodaarticulac¸ãofacetáriapeloultrassomdeterminamínimoriscoe reduc¸ãodaradiac¸ãoeéindicadaparagrandepartedapopulac¸ão.Aindaassimafluoroscopia eatomografiacomputadorizadapermanecemcomomonitorac¸ãoindicadaparapacientescom característicasespecíficas,comoobesidade,doenc¸asdegenerativasintensasemalformac¸ões anatômicas,nasquaisoultrassomaindanecessitademaisestudos.

©2013SociedadeBrasileira deAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.

Introduction

Theultrasonographictechniquewasintroducedinregional anesthesia for visualization of paraspinal and neuraxial structures.Thistechniqueisalsousedtoaidinthe visual-izationofepiduralspaceinobstetricanesthesiaprocedures inobese1,2_{anddifficulttopuncture}3_{patients,aswellasin}

peripheral nerveblocks.4 _{The use ofultrasound for}

treat-ment of pain is still in the development stage5 _{and the}

proceduremaybeusefulforstellate6,7_{andsacrococcigeal}8

ganglion, obturator andfemoral nerve,9 _{andcervical and}

lumbarfacetjointblocks.10,11

Case

report

Woman,Caucasian,88yearsold,1.68mand72kg, witha diagnosisof bilateralfacet osteoarthrosisat L2---L3,L3---L4 and L4---L5 for two years. In the initial interview, the patient was complaining of lower back pain radiating to the lateraland posterior regions of the right thigh, with-outimprovementwiththeuseofparacetamol,weakopioids and transcutaneous electrical stimulation. As precedent, thepatientsustainedatranstrochantericfractureoftheleft femurwithsurgicalcorrection withoutcomplications, and withaclinicallystableosteoarthosis.Onphysical examina-tion,thepatientmentionedbilateralpainonlumbarspine lateralization,moremarkedontheright,andalsowithpain onextension. The painwasrelieved during flexionof the lumbar spine. On compression, the vertebrae were pain-less;theintervertebralspaceswerepalpable.The patient wasLasegue-andPatrick-Faber-negativeandwithno alter-ationsoftactile,thermalorpainfulsensationandofmotor strengthinherlowerlimbs.Thelaboratoryworkuprevealed bloodcount,creatinineandelectrolyteswithinnormal lim-its,andher electrocardiogramshowedleftbundlebranch block.

The patient was informed about the advantages and disadvantages of corticosteroid injection into the zigoapophysaryjoint.Theprocedurewasperformedina sur-gicalcenteronanoutpatientbasis,withfastingbeforethe blockade.

The ultrasound study was performed with a SonoSite M-turbo® _{machinewitha3---9MHzcurvedtransducer.} Anti-sepsis of the skin wasapplied, with placementof sterile fields;the transducer was alsocovered withsterile field. Thepatientwasplacedinpronepositionwithapillowunder theabdomen to decreasethe lumbar lordosis. Sterile gel wasappliedonthe skin where the referencepointswere marked. A longitudinal scan was initiated on the midline ofthe spine, starting at the sacrum.After the identifica-tion of the desired joint space at L3---L4, the transducer was perpendicularly rotated. The facet joint was identi-fied and a 25G needle was inserted into the skin by an echographicoff-plane(i.e., outofplane) technique.1mL ofnon-ioniccontrastwasinjected underultrasonic direct visualizationintothefacet joint.The locationofthe nee-dletipintothefacetjointwasconfirmedwithfluoroscopy inananteroposteriorandobliqueincidence.Then,the con-trast wasaspirated and1mLof solution containing0.25% bupivacainehydrochlorideand10mgofmethylprednisolone acetatewasintra-articularlyinjectedinrealtimeandwith ultrasoundguidance.Duringtheinjection,hypoechoic dis-tensionoffacet jointwasobserved ---a phenomenonthat determinesthesuccessoftheprocedureandthatexempts theuseofintravascularinjection.Injectionsweremadeto therightofL3---L4,L2---L3andL1---L2.

During her transfer to the anesthesia care unit, the patient exhibited no symptoms of pain, was cooperative andmaintaininghemodynamicandrespiratorystability.She wasdischarged,remaininginclinicalfollow-upinthePain Service.Theassessmentofpainintensitywasobtainedwith theuseofanumericalscale of0---10;during thenextfive months,herscoresremainedat3points.

Discussion

Thefacetjointwasrecognizedasacauseoflowbackpain in1933,andsincethenitstreatmentisbeingmorewidely discussed.11---13 _{Thepaincausedby facetarthrosishas}

280 A.E.Q.Santiagoetal.

lower limb.14 _{The diagnosis is mainly clinical and can be}

confirmed by radiological examination (CT or MRI).2 _The

diagnosiscan beconfirmedby themedialbranchblock or by an intra-articular injection of local anesthetic with or withoutcorticosteroids,becauseofthereliefofpain origi-natingfromthefacet.5,11 _{Insomecases,thefirstoptionis}

atestblockwithlocalanestheticandsubsequentlya corti-costeroid---oramedialbranchblock.5,11

The facetjointblockisindicated forpatientswithlow backpainformorethansixmonthsandwithimaging stud-ies(computedtomography ormagnetic resonanceimaging of the lumbar spine) to confirm the facet osteoarthrosis. Thesepatients must not havelocal or systemicinfection, allergytocorticosteroids or anesthetics, coagulopathy, or bepregnant.Thepainworsenswithmaneuversofipsilateral lateralizationandspinalextension;thepainisrelievedwith contralateral lateralization and spinal flexion. Paraspinal musclecontracturemayalsooccur.Imagingstudiesmustbe negativefor vertebraltumor, discitis,diskherniation,and spinalfractureandinstability.15

Currently,techniquessuchasfluoroscopyandcomputed tomographyhave been usedtoaid inpositioningthe nee-dleandinthesuccessofintra-articularinjection.Butboth areexpensiveprocedures;furthermore,thereisaneedfor a suitable place for their application, and the patient is subjecttoradiation exposure.5,11 _{The ultrasonographyhas}

occupiedanincreasinglygreaterspaceinregional anesthe-siaandinthoseproceduresusedforthetreatmentofchronic pain,16 _{byenabling adynamic/real-timemonitoringofthe}

approachedsite.15_{Theultrasound-guidedprocedurecanbe}

doneintheclinic,eliminatingthepresenceofthe radiolo-gist,ortheneedofanoperatingroom.5,15

Theultrasonographicexaminationof thespinerequires the acquisition of a sequence of images, allowing visual-ization of soft tissues (paraspinal muscles, ligaments and dura-mater)andbonystructures.Inthelumbarspine,the scanprocedure beginsat thesacrum,withthetransducer longitudinally positionedat the midline, withan approxi-mate6---8′′ _{deepadjustment.Thefirstviewedprominence}

is the bony crest of the sacrum as a hyperechoic signal witha bone shadowjust below. The transducer is moved cephalwarduntilahyperechoicstructureisdisplayed.This structurecorresponds tothesubarachnoidspaceof L5---S1 andisreflectiveoftheCSFintheventralduramater.Ina morecephaliclevel,itispossibletoviewotherhyperechoic signal,correspondingtothespinousprocessofL5.The guid-anceofthetransducertoamorecephalicregionallowsusto identifyallthespinousprocesses,correlatingthemwiththe previouslymadeskin marks.When thetransducer reaches thedesiredsitefortheinjectionintothefacet,thedevice isrotated90degrees.Withthismaneuver,threeshadowsof thelumbarvertebraaredepicted.Themostsuperficiallayer isthespinousprocess;thefacetjointisimmediatelybelow; andthetransverseprocessislocatedbelowandlaterallyto thespinousprocessandarticularfacet.

Inourcase,wechosethecombinationofultrasoundwith fluoroscopy.Sincethatultrasonographyfor facet blocksis a recent procedure, the fluoroscopy wasused to confirm thelocationoftheneedleandthepossibilityof doingthe procedurewiththeexclusiveuseofultrasound.

In conclusion, the ultrasonic visualization of the facet jointinvolvesminimalriskandradiationreduction.But flu-oroscopy andcomputedtomography remain asmonitoring procedures indicated for patients withspecific character-istics, such as obesity, severe degenerative diseases and anatomicalmalformations.11,14,16,17

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

References

1.GrauT, Leipold RW,Horter J.The lumbarepidural space in pregnancy: visualization by ultra sonography. Br J Anaesth. 2001;86:798---804.

2.ArzolaC,DaviesS,RofaelA. Ultrasoundusing thetransverse approachtothelumbarspineprovidesreliablelandmarksfor laborepidurals.AnesthAnalg.2007;104:1188---92.

3.Lee Y, Tanaka M, Carvalho JC. Sonoanatomy of the lumbar spine in patients with previous unintentional dural punc-tures duringlaborepidurals. Reg Anesth Pain Med.2008;33: 266---70.

4.LuyetC,EichenbergerU,GreifR.Ultrasound-guided paraverte-bralpunctureandplacementofcathetersinhumancadavers: animagingstudy.BrJAnaesth.2009;102:534---9.

5.Gofeld M. Ultrasound-guided zygapophysial nerve and joint injection.TechRegAnesthPainManag.2009;3:150---3. 6.GofeldM,BhatiaA, Abbas S.Developmentand validationof

anewtechniqueforultrasound-guidedstellateganglionblock. RegAnesthPainMed.2009;34:475---9.

7.GulJ,BumSK,Kyung-BaeS.Theoptimalvolumeof0.2% ropiva-cainerequiredforanultrasound-guidedstellateganglionblock. KoreanJAnesthesiol.2011;60:179---84.

8.LinCS,ChengJK,HsuYW. Ultrasound-guidedganglionimpar block:atechnicalreport.PainMed.2010;11:390---4.

9.HelayelPE,daConceic¸ãoDB,PaveiP.Ultrasound-guided obtu-ratornerveblock:apreliminary reportofa caseseries.Reg AnesthPainMed.2007;32:221---6.

10.FinlaysonRJ, Grupta G, AlhujairiM. Cervical medial branch block:anoveltechniqueusingultrasoundguidance.RegAnesth PainMed.2012;37:219---23.

11.ShimJK,MoonJC,YoonKB.Ultrasound-guidedlumbar medial-branchblock: a clinicalstudy withfluoroscopy control. Reg AnesthPainMed.2006;31:451---4.

12.GhormleyR.Lowbackpainwithspecialreferencetothe artic-ularfacet,withpresentationofanoperativeprocedure.JAMA. 1933;101:1773---7.

13.BogdukN.Ondiagnosticblocksforlumbarzygapophysialjoint pain.MedRep.2010;2:1---3.

14.GreherM,KirchmairL,EnnaB.Ultrasound-guidedlumbarfacet nerveblock:accuracyofanewtechniqueconfirmedby com-putedtomography.Anesthesiology.2004;101:1195---200. 15.Galiano K, Obwegeser AA, Bodner G. Ultrasound real-time

imaging for periradicular injections in the lumbar spine: a sonoanatomicstudy of a new technique. J Ultrasound Med. 2005;24:33---8.

16.GreherM,ScharbertG,KamolzLP.Ultrasoundguidedlumbar facetnerveblock:asonoanatomicstudyofanewmethodologic approach.Anesthesiology.2004;100:1242---8.