T E C H N I Q U E S I N R E G I O N A L AN E S T H E S I A A N D P A I N MA N A G E M E N T 17 (2013) 96–106

Available online at www.sciencedirect.com

www.elsevier.com/locate/trap

Ultrasound-guided interventional procedures for

lumbar pain
Alejandro Ortega-Romero, MDa,n, Tomás Domingo-Rufes, MDb,
Concepción del-Olmo, MDa, Maryem-Fama Ismael, MDc, Víctor Mayoral, MDb
a
Department of Anesthesiology and Pain Medicine, Hospital ASEPEYO, Calle Joaquín de Cardenas 2, 28820 Coslada,
Madrid, Spain
b
Department of Anesthesiology, Chronic Pain Unit, University Hospital of Bellvitge, Barcelona, Spain
c
Deparment of Traumatology, Hospital ASEPEYO, Coslada, Madrid, Spain

article info abstract

Keywords: The possibility of performing the majority of the pain-control interventions in the lumbar
Ultrasound-guided spine without using fluoroscopy is a very promising alternative. A clear description of the
Spine most relevant sonoanatomy of the lumbar spine and the proposal for a systematic
Epidural injection approach to perform principal lumbar spine blocks may help those that are beginning to
Lumbar facet joint use ultrasound and increase the interest of professionals that normally perform these
Lumbar medial branch block blocks with x-rays. Therefore, the structures that are easily identifiable by ultrasound from
the muscular blocks and the facet joints are first described.
& 2014 Elsevier Inc. All rights reserved.

Introduction to conduct further studies that support the efficacy and safety
of ultrasound-guided techniques.2-4
In daily medical practice, interventional techniques are used A clear description of the most relevant sonoanatomy of
to treat lumbar pain, which are the most prevalent patholo- the lumbar spine and the proposal for a systematic approach
gies in pain clinics.1 This causes the need to be in surgery and to perform principal lumbar spine blocks may help those that
in permanent contact with the fluoroscope or x-ray are beginning to use ultrasound. The ultrasound guide and
equipment. fluoroscope are complementary, especially when learning
The interest in learning these blocks using ultrasound is and interpreting ultrasound images of the lumbar spine.
hampered by the difficulties in ultrasound visibility of the For all spinal blocks, the 3 basic orientations of the ultra-
vertebral spine at the lumbar level. Low-frequency probes sound probe and beam must be mastered: transverse or axial,
must be used that have a much lower resolution than linear paramedian sagittal (PS), and paramedian sagittal oblique
probes. These limitations are directly proportionate to body (PSo) (Figure 1). The steps described by Chin et al5 to perform
mass index (BMI), where the higher the BMI, the more neuroaxial blocks guided by ultrasound are applicable to the
visibility difficulty is encountered. Obesity is the principal interventional techniques that are mainly used to treat
limiting factor in using ultrasound for lumbar spine blocks, lumbar pain (Figure 2). For all ultrasound-guided neuroaxial
owing to the incapacity to see the intravascular or epidural lumbar blocks, the identification technique to mark interver-
diffusion of the substances administered. tebral levels must be mastered. To do so, locating the
Recent systematic reviews of the principal studies con- lumbosacral junction must be done with the probe oriented
ducted on ultrasound-guided blocks in the lumbar spine in the PSo view showing the lamina. The probe is then moved
clearly demonstrate these limitations and encourage others in a caudal direction until a continuous hyperechoic line

n
Corresponding author.
E-mail address: [email protected] (A. Ortega-Romero).

1084-208X/$ - see front matter & 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1053/j.trap.2014.01.013
 TE C H N I Q U E S I N R E G I O N A L AN E S T H E S I A A N D P A I N MA N A G E M E N T 17 (2013) 96–106 97

Fig. 1 – Probe orientations for spinal blocks: (A) transverse or axial; (B) paramedian sagittal (PS); and (C) paramedian sagittal
oblique (PSo).

(the sacrum) and a short hyperechoic line (lamina L5) are the psoas muscles are the only muscles of the spine with a
identified. A space should be visible between these 2 lines. moderate level of evidence for reproducing painful points and
Once the L5-S1 space is located in the PSo view, the probe is reflective pain.7,8 They are also the only spinal muscles where
moved in the cephalic direction, and the skin is marked at the a fluoroscope-guided infiltration procedure has been described,
midpoint of the probe that corresponds with each of the L5-L1 and where ultrasound could be used as an alternative. Myo-
lamina. Marking the skin at the different lumbar levels in the fascial pain derived from the quadratus lumborum or psoas
PSo helps to avoid erroneous identification of the level while muscles or both is a frequent and underdiagnosed cause of
exploring the transverse view (Figure 3). nonspecific lumbar pain.9 In fact, these muscles together with
the erector spinae muscles participate synergistically with the
vertebrae to stabilize the vertebral spine.
Lumbar muscles (quadratus lumborum and psoas In patients with chronic lumbago, atrophy of the psoas and
muscle) the paravertebral musculature has been documented by
computed tomography as well as with asymmetrical images
Anatomy and sonoanatomy of the quadratus lumborum muscle.10,11
Identifying the erector spinae muscles, quadratus lumbo-
Professionals who only perform fluoroscope-guided interven- rum muscle, and psoas muscle may be the first step in
tional techniques may first be interested in identifying mus- understanding all of the lumbar spine sonoanatomy.
cular structures surrounding the lumbar spine. Dysfunction of Anatomical knowledge of the quadratus lumborum muscle
the lumbar muscles may cause acute and long-term lumbar insertions and its integrated relationship with the perito-
pain, as well as a target point in the multidisciplinary treat- neum are the primary sonoanatomical references in locating
ment of lumbar pain.6 The quadratus lumborum muscles and the quadratus lumborum and psoas muscles.

Fig. 2 – Neuraxial ultrasound. Five sonographic views of the neuraxial spine.

98 TE C H N I Q U E S I N R E G I O N A L A N E S T H E S I A A N D P A I N M A N A G E M E N T 17 (2013) 96–106

Fig. 3 – The technique to identify and mark the intervertebral levels. The lumbar interspaces are readily identified in the PS
oblique view by counting upward from the lumbosacral junction (the gap between the line of the sacrum and the sawtooth of
the L5 lamina). We can make a corresponding mark on the skin at the midpoint of the long edge of the probe. Panoramic
ultrasound image of the laminaes, PSo view, and anterior complex (AC). (Color version of figure is available online.)

The quadratus lumborum muscle inserts from the iliac ultrasound planes that divide the peritoneum must be care-
crest to the transverse process of the L1-L4 lumbar vertebrae fully differentiated. In thinner patients, it is possible to
and to the twelfth rib, always in a retroperitoneal position distinguish more hyperechogenic images from inside the
and with a close relationship to the kidneys in some portions. psoas muscle corresponding to the posterior lumbar plexus
Transverse sections of the quadratus lumborum muscle show and locate the foramen and lumbar root. In a study that
a greater thickness of the muscle at the L3-L4 level, coincid- included 30 young volunteers to demonstrate the sonoanat-
ing with the lateral insertion in the iliac muscles.12 omy of paravertebral structures of the roots and lumbar
For correct ultrasound visualization of the quadratus lum- plexus in the lumbar region L3-L4-L5, 57% of the volunteers
borum muscle, the patient is placed in a decubitus or lateral showed good visibility of these structures.13 This study also
decubitus position. The transverse process 3-4 cm from the established a strong correlation between the age and echoin-
midline is the target to be found in a PS view (PS transverse tensity of the muscles. There is a reduction in skeletal muscle
process view) with a low-frequency probe. The hyperecho- mass in elderly people (sarcopenia), a substitution of the
genic images with posterior acoustic shadows that look like a contractile elements in the muscles for fat and connective
trident in the PS view can be identified (Figure 2). On rotating tissue, and an increase in extracellular water content in the
the probe to a transverse view with slight lateral inclination muscles. The ultrasound images of the paravertebral lumbar
(traverse paramedian view), a hyperechogenic linear image is region in elderly people appear to be whiter and shinier
observed that represents the entire length of the transverse showing decreased contrast between muscle and adjacent
process (Figure 4). The patient is asked to inhale to differ- structures. Muscle mass is also substituted for fat in patients
entiate the retroperitoneal planes, and the quadratus lumbo- with obesity, making ultrasound exploration in the lumbar
rum muscle at the distal end of the transverse process area more difficult to evaluate.
becomes visible. If the probe is moved in a slight caudal
direction, the transverse process image is lost and the muscle Block technique
masses of the psoas and the quadratus lumborum muscles
can be differentiated in 1 image (Figure 5). The psoas muscle Locating the quadratus lumborum muscle as previously
inserts in a proximal position into the lateral side of the described with a low-frequency ultrasound probe of
vertebral bodies and intervertebral discs. The interaction of 3-8 MHz, the block can be performed in a short axis view
the quadratus lumborum muscle with the iliac muscles can with the patient in a decubitus position (Figure 5) or along the
also be confirmed in a more lateral view. long axis, if the patient is in a lateral decubitus position
In patients with obesity, the focus, gain, and depth param- (Figure 6). It is recommended in plane technique in which the
eters of the ultrasound device must be optimized, and the whole-needle path is under control at any time to avoid
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Fig. 4 – Transverse view showing a hyperechogenic linear image that represents the entire length of the transverse process (3),
section of the quadratus lumborum muscle (1), and paraspinal muscles (2). (Color version of figure is available online.)

retroperitoneal puncture. The short axis view of the quad- The lumbar facet joint capsule and the surrounding structures
ratus lumborum muscle allows for the infiltration to be are innervated, and, therefore, chemical, electrical, or mechan-
performed in 1 puncture of both the psoas and the quadratus ical stimulation of the lumbar facet joint causes reflective back
lumborum muscles. pain. Repetitive stress on the lumbar facet joint may lead to
The dry puncture technique of the “trigger points” has been osteoarthritis, where inflammation and stretching of the joint
used in treating myofascial pain at the lumbar level, as well capsule cause axial lumbar pain that irradiates to the leg.
as the injection of local anesthetic substances, corticoste- The L3-L5 lumbar vertebrae are those that are most frequently
roids, or botulinum toxin.14,15 involved in spinal pathologies as these vertebrae carry the
majority of the body weight and support the greatest tension
of the entire vertebral column. With the exception of the fifth
Intra-articular: lumbar facet (L1-L4) lumbar vertebra, L1-L4 show similar anatomical characteristics.
Each vertebra is connected to the adjacent level by the
Anatomy and sonoanatomy anterior intervertebral disc and the zygapophyseal or facet
joints in the posterior portion. The vertebral body is a dense
Zygapophyseal (facet) joint syndrome is a common diagnosis in cortical bone and the pedicles are 2 short, round processes
patients with long-term back pain. After epidural corticosteroid that extend from the lateral posterior margin of the dorsal
injection, the lumbar facet block is the second most performed vertebral body. The laminas are 2 flat plates of bone that
intervention for treating long-term pain and has probably been extend in a medial direction from the pedicles to form the
the first application where the use of ultrasound guidance posterior wall of the vertebral foramen. Anatomical varia-
was described for interventional treatment of lumbar pain.16,17 tions of the lumbar spine, including scoliosis, sixth lumbar

Fig. 5 – Transvese view under lumbar transverse process: the quadratus lumborum muscle (1), paraspinal muscles (2), psoas
muscle (4), vertebral body (5), and peritoneum (6). The arrow marks the needle path for quadratus lumborum muscle block
(short axis view). (Color version of figure is available online.)
100 TE C H N I Q U E S I N R E G I O N A L A N E S T H E S I A A N D P A I N M A N A G E M E N T 17 (2013) 96–106

Fig. 6 – Paramedian sagittal view close the lumbar transverse process: the quadratus lumborum muscle (1), paraspinal
muscles (2), psoas muscle (4), vertebral body (5), peritoneum (6), and kidney (6). The arrow marks the needle path for
quadratus lumborum muscle block (long axis view). (Color version of figure is available online.)

vertebra, sacralization of the fifth lumbar vertebra, and lamina can also be differentiated as it is narrower than the
pseudoarthrosis can make correctly identifying the interver- other lamina and becomes visible before the sacral line.
tebral levels difficult, leading to incorrect needle insertion in The cranial and caudal movements of the ultrasound probe
an ultrasound-guided approach. The position of the facets in the PSo view allow for the localization of the spaces from
varies greatly, with frequent asymmetry and angulations. S1-L1. Each of the levels that are examined can be marked on
Therefore, the imaging studies provided by the patient must the patient's skin. To do so, the image is centered on the lamina
be reviewed before planning an ultrasound-guided interven- on the screen of the ultrasound, making a mark that corre-
tional procedure to decrease and prevent difficulties that may sponds with the midpoint of the probe on the skin (Figure 3).
arise during an ultrasound-guided puncture. Once the vertebral levels and the vertebral structures are
It is important to understand that these are diarthrosis- located in a parasagittal or longitudinal view (long axis view),
type facet joints with a synovial membrane and an articular each of the dorsal surfaces of the lumbar vertebrae can be
cavity between the bone endings, cramped by various tense observed to identify the facet joint in a transverse view or
ligaments (transverse capsular ligaments). It will, therefore, transverse interlaminar view. In this view, it should be
be difficult to perform intra-articular infiltrations and fre- possible to differentiate the linear hyperechogenic line of
quently only the periarticular area will be reached.18 the sacrum, the image over the spinous process with 1 view
The patient is placed in a prone position with a pillow under of the hyperechogenic line with a large posterior acoustic
their abdomen to decrease lumbar lordosis. A convex probe of shadow or the image of the intervertebral space, where the
3-8 MHz is used to perform the test. The vertebral spine is then facet joint can be identified (transverse interlaminar view)
explored after the sequence to obtain the images described in (Figure 2). The sonoanatomical image of the L5-S1 face is
Figure 2 to identify and mark the intervertebral levels. different in that it is closely related with the sacrum.
From the PS transverse process view, the probe is moved in
a medial direction until a hyperechogenic line is observed Block technique
that looks like a line of “camel humps” in the PS articular
process view. In this view, each camel hump represents the The intra-articular infiltration of the facet joint is not always
facet articulation formed by superior and inferior articular possible owing to the presence of hypertrophy and being a
processes of the successive vertebrae. This continuous line is very narrow joint with great tension between its ligaments
located at a more superficial depth than the discontinuous and its capsule. Performing a periarticular block instead of an
line of the transverse processes. Once the view of the intra-articular block is frequently considered. Anatomical
articular processes has been obtained, the probe is inclined variations are an added difficulty for visibility. These include
to point the ultrasound beam in a lateral to medial direction deformities of the spine, degenerative processes, obesity,
toward the PSo view. A succession of “sawtooth” hyperecho- with low-frequency probes also contributing to difficult vis-
genic lines is observed in this view that corresponds with the ibility. For this reason, the different intervertebral levels and
lamina of the lumbar vertebrae. Unlike the articular process the line where the facets can be seen in a PS articular process
view, the hyperechogenic line is discontinuous. With the PSo view must be marked on the skin during the exploration
view, the probe is moved in a caudal direction until a technique previously described.
continuous hyperechogenic horizontal line can be differenti- With the patient in a prone position, a pillow is placed
ated that corresponds with an ala of the sacrum. The L5 under the abdomen to decrease lumbar lordosis. A convex
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probe of 3-8 MHz is selected, using routine sterility procedures lateral branches. The medial branch at the corresponding and
for ultrasound-guided blocks (ultrasound probe covered with superior levels innervates each facet joint. These medial
a sterile sheath and sterile ultrasound gel), and optimizing branches pass through small tunnels formed by the corre-
ultrasound parameters. sponding superior articular process and the transverse proc-
With the intervertebral reference levels already marked on ess. During sonoanatomy exploration to block the medial
the skin, an optimal ultrasound view of the facet joint to be branch, the same sequence should be followed as the one
blocked is sought in a transverse view, or transverse inter- used to perform the facet joint block. The patient is posi-
laminar view. The block is performed by inserting the tioned in a decubitus position and a low-frequency probe of
22-gauge needle in plane until establishing contact with the 3-8 MHz is used. We mark on the skin lumbar levels L5-L1 in
bone surface of the facet joint. A 1-2 mL of mixture of local PSo view as we have described previously (Figure3).
anesthetic and depo-steroid is routinely used (Figure 7). An in-plane transverse exploration is performed on the
If visibility is poor in the transverse view, it is possible to level where the block will be carried out with a slight para-
perform the periarticular facet block in a longitudinal view, median inclination to see a continuous hyperechogenic line
therefore, allowing for the interventional to perform the facet from the spinous process, articular processes, and the trans-
block at various levels with the same approach (Figure 8). The verse process. This image is similar to a staircase where the
facet joint block from L5-S1 may be harder to perform in target point to locate the medial branch would be the angle of
plane owing to the proximity of the iliac crest, meaning it the inferior step formed by the transverse process and the
must be performed out of plane. superior articular process (Figure 9A).
The clinical efficacy of the ultrasound-guided facet blocks is To view this angle better, the probe can be moved in a
very high. Both Galiano et al19 and Ha et al20 achieved a lateral direction and make small angulation movements with
midterm to long-term pain reduction in all patients. This data the ultrasound probe that help to capture a better hyper-
correlate with the high success rate (80%-88%) of the studies echogenic line on the bone surface of the transverse process.
that validate the ultrasound-guided technique using fluoro- The angle and placement of the probe are similar to those
scope or scanner or both in cadavers.21,22 Although there are used to locate the quadratus lumborum muscle and its
contradictory studies, it seems that both the injection of insertion in the transverse process. This point or target,
intra-articular corticosteroids or joint denervation with radio- where the medial branch travels in the transverse view, does
frequency alleviate lumbar pain and functional improvement not differentiate whether the probe is at the cranial or caudal
during a period of at least 6 months, without large differences level of the transverse process. Therefore although in the
between the different treatments.23 Therefore, performing longitudinal view of the exploration, it must be double
facet joint blocks using an ultrasound-guided technique must checked that the probe is in the cranial extreme of the
be mastered before learning to block the spinal nerves. transverse process (Figure 9B).

Block technique
Nerves Given that the medial branches cannot be seen with ultra-
sound, as occurs with the fluoroscope, it is of utmost
Lumbar medial branch (L1-L4) importance that the target point of the bone reference
previously described is located. In the transverse interlam-
Anatomy and sonoanatomy inar view, in-plane approach is performed with a 22-gauge
The lumbar nerve roots divide into ventral and dorsal needle in the angle formed by the transverse process and the
branches when they emerge from the foramen. The dorsal superior articular process. After establishing bone contact in
branch produces 3 branches: the medial, intermediate, and the target point, the probe is rotated in the longitudinal axis

Fig. 7 – Transverse interlaminar view showing the facet joint to be blocked in plane (arrow needle). Transverse process (1),
zygapophyseal (facet) joint (2), spinous process (3), and anterior complex (AC). (Color version of figure is available online.)
102 TE C H N I Q U E S I N R E G I O N A L A N E S T H E S I A A N D P A I N M A N A G E M E N T 17 (2013) 96–106

Fig. 8 – Paramedial sagittal articular process view allows us to perform the facet block at various levels with the same
approach. Two facet joints. (Color version of figure is available online.)

of the spine to observe that the probe is located in the cranial intravascular injection. The out-of-plane view can be used for
extreme of the transverse process. At this level, the mix of the orientation at the level of the transverse process. Agitation of
local anesthetic substance with the corticosteroid is depos- the needle and hydrolocalization (rapid injection of a small
ited or neurolysis by radiofrequency is performed or both are quantity of liquid, 0.5-1 mL) will help to identify its position in
performed. this out-of-plane sonographic view.
Failure to identify the needle tip or the diffusion of the local Studies that have validated the use of the ultrasound-
anesthetic or both indicates an improper needle placement or guided approach for performing the medial branch block

Fig. 9 – (A) Transverse view showing an image is similar to a staircase, where the target point to locate the medial branch
would be the angle of the inferior step formed by the transverse process and the superior articular process (red dot). (B)
Paramedial sagittal transverse process view, the target should be in the cranial extreme of the transverse process (red dot).
(Color version of figure is available online.)
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show that the precision of the block decreases in the lowest by Galiano et al regarding needle advancement underneath
lumbar levels and in patients with a BMI 430 kg/m2. Rauch the transverse process toward the neural foramen, if applied
et al24 found that the accuracy rate decreased to 62% when an in a clinical environment, could reach the neuroaxial com-
ultrasound-guided approach for lumbar medial branch blocks partment. For this, they propose, in a preclinical study, the
was evaluated in patients with obesity by using fluoroscopy as a most medial visible shadow of the vertebral body as the
comparator. Using volumes greater than 0.2-0.5 mL can increase ultrasound target point. Spinal needles were inserted using
diffusion at the paraforaminal level or epidural levels or both.25 the in-plane approach, aiming for the most medially visible
The precision needed to locate the target point, the tip of the shadow of the vertebral body. If the exiting nerve was seen,
needle, and the difficulties in viewing the diffusion of small the transducer was shifted caudally to avoid trespassing the
volumes of the local anesthetic substance require a mixed nerve root. When the needle is resting at the bone, no further
learning curve between the ultrasound and fluoroscope that advancement into the neuraxial compartment is possible.
decrease the interpretation biases of the ultrasound images. The contrast-spread pattern in this position of the needle tip
resulted in the transforaminal epidural flow in most cases.
Selective nerve roots
Interlaminar epidural injection
The lumbar nerve roots can be especially difficult to visualize
with ultrasound owing to their location in a deeper depth and Anatomy and sonoanatomy
the fact that they are surrounded by bone structures of the The epidural injection of corticosteroids is the most commonly
lumbar vertebral spine, making it very difficult for the ultra- performed intervention in pain clinics in the United States and
sound beam to penetrate. On the contrary, there is a rich in the rest of the world.33 Many times these techniques are
vascularization around the lumbar roots that may lead to performed in out-patient situations and without the use of
unintentional intravascular injection of the local anesthetic image control. Locating the interlaminar epidural space with
substance and the corticosteroids. All of the events published external references may have a failure rate of up to 42% in
on permanent neurologic lesions were related to the injection patients with obesity.34 The use of the ultrasound at the spinal
of nonsoluble particulate steroids.26 The current recommenda- level has shown that it increases the success rate of the
tions for transforaminal injections include increased certainty neuroaxial blocks in comparison with blind techniques. It
and precision as to the puncture location. A contrast substance allows better identification of the medial line and the inter-
must be administered before the corticosteroid to discard the vertebral level, as well as the needle insertion angle and the
subtraction of said substance by intravascular injection, as well required depth.35 Thanks to the information that the
as using water-soluble steroids and blunt-tip needles.27 The ultrasound-guided technique provides, the number of punc-
limitations of the ultrasound-guided techniques are added to ture attempts can be decreased and performing the epidural
the controversy of the transforaminal lumbar injections among puncture in the intervertebral spaces can be considered where
doctors that perform interventional pain techniques for the external anatomical references (L5-S1) cannot be palpated.
precise view of the tip of the needle, the diffusion of injected The anatomy of the intervertebral space goes from more to
substances, and the prevention of intravascular injection. less superficial in a transverse slice by the supraspinous and
Although recent developments in ultrasound technology have interspinous ligaments, ligamentum flavum, posterior epi-
achieved improvements in the images produced with low-fre- dural space, posterior dura mater, intrathecal space, anterior
quency probes, viewing lumbar roots continues to be a chal- epidural space, posterior longitudinal ligament, and vertebral
lenge (Figure 10). The study by Chin et al5 showed that using body. The ligamentum flavum and interspinous ligaments
latest generation ultrasound probes in healthy, young volun- take on a triangular form as occurs with the posterior epidural
teers with a BMI under 25 kg/m2, lumbar roots were only able to space. This posterior epidural space narrows on the sides and
be viewed in 57% of the cases. This also shows that the study establishes closer contact with the posterior dura mater. Inside
could not be applied to elderly patients or patients with obesity. the thecal sac, the medullary cone terminates at the first
The 4 studies28-31 that describe the ultrasound-guided lumbar vertebral body (L1) level in adults. However, its location
technique to locate lumbar roots base themselves on imaging may vary from the center of the 12th thoracic vertebra (T12) to
tests (fluoroscope or computed tomography), and the only the upper one-third of the 3rd lumbar vertebra (L3).36 The
study conducted in patients required neural stimulation to medullary cone continues with the cauda equina and the
identify the roots. filum terminale. In ultrasound images of adult interlaminar
The studies conducted by Loizides et al28 and Sato et al29 spaces, it will not be possible to differentiate all of these
used the PS transverse view as a reference. They searched for structures. The ligamentum flavum, the epidural space, and
the hyperechogenic linear image between the 2 transverse the dura mater appear to be fused in a hyperechogenic line
processes that correspond with the intertransverse ligament that is called the posterior complex. The intrathecal space is
and propose an in-plane or out-of-plane approach similar to hypoechoic in a uniform manner and in some cases pulsing
the ultrasound-guided blocks described to block the lumbar hyperechogenic images can be distinguished in its interior that
plexus at the psoas level (psoas compartment block).30 correspond with the cauda equina and the filum terminale.
Galiano et al31 propose an in-plane approach with the ultra- The anterior dura mater, the posterior longitudinal ligament,
sound probe in the transverse view (transverse interlaminar and the vertebral body can be seen as a single hyperechogenic
view) with a paramedian orientation that allows observation line that is called the anterior complex (Figure 2).
of the paravertebral zone underneath the transverse process These 2 hyperechogenic lines of the anterior and posterior
(Figure 9). Gofeld et al32 suggest that the technique described complexes can be seen in the transverse interlaminar view
104 TE C H N I Q U E S I N R E G I O N A L A N E S T H E S I A A N D P A I N M A N A G E M E N T 17 (2013) 96–106

Fig. 10 – Paramedian oblique transverse scan of lumbar paravertebral region through the space between 2 adjacent transverse
processes. Note the lumbar nerve root as it emerges from the intervertebral foramen (1), the posterior aspect of the psoas
muscle (4), vertebral body (2), and retroperitoneal space (3). (Color version of figure is available online.)

Fig. 11 – Surface marking to guide the needle insertion. In the paramedian sagittal PS oblique view, each interspace is
centered in turn on the ultrasound screen (A) and (B). The probe is then turned 901 to obtain the transverse interlaminar view
(C). The midline is centered on the ultrasound screen, and skin marks are made at the midpoint of the probe's long and short
edges (D). The intersection of these 2 marks provides an appropriate needle insertion point for a midline approach to the
epidural at that level. The distance is measured from the skin to the posterior complex with ultrasound measuring
instruments. (1) Posterior complex and (2) anterior complex. (Color version of figure is available online.)
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Fig. 12 – Ultrasound guide L5-S1 epidural injections. PS oblique view interspace L5-S1 is centered, in turn, on the ultrasound
screen (A). The probe is then turned 901 to obtain the transverse interlaminar view (B), the inclination of the ultrasound probe
that best distinguishes the posterior and anterior complexes will determine the inclination angle of the needle. The distance
is measured from the skin to the posterior complex with ultrasound measuring instruments. (1) Posterior complex and (2)
anterior complex. (Color version of figure is available online.)

and in the PSo view. However, owing to the triangular form of the 2 exploration views. This maneuver helps to avoid
the interspinous ligaments and the posterior epidural space, confusion of the posterior complex with the anterior complex
the posterior complex has more anisotropy than the anterior in the transverse approach. The distance is measured from
complex. The result is that posterior complex cannot always the skin to the posterior complex with ultrasound measuring
be differentiated in the transverse view. Nonetheless, given instruments. The symmetry is also confirmed between bone
that the posterior epidural space narrows on both sides and structures of the articular processes and the transverse
stays parallel to the dura mater, the 2 hyperechogenic lines processes, in the transverse plan, and the inclination of the
separated by a hypoechoic image can be differentiated in the probe that best distinguishes the 2 anterior and posterior
PSo view. These 2 hyperechogenic lines correspond with the complexes. This way the 4 midpoints of the long and short
ligamentum flavum and the posterior dura mater separated edges of the probe can be marked in the transverse view with
by the hypoechoic epidural space. This double vision in the 2 the probe placed symmetrically in the midline. The probe is
views (transverse and PSo view) allows for confirmation of the removed and a horizontal line is drawn that joins the 2 points
depth of the intrathecal or epidural spaces, which decreases of the long axis of the probe and a vertical line is drawn that
interpretation errors of the ultrasound image. joins the short axis. The optimal point for needle insertion is
found where the 2 lines cross (Figure 11).
Antiseptic measures are applied to the area to be punc-
Block technique
tured, taking special care not to erase the marks on the skin.
The steps to be followed for performing an ultrasound-guided
The epidural puncture is performed guided by the optimal
interlaminar epidural block are described in Figure 2.
puncture point marked on the skin and knowing at what
The patient is placed in a seated position, a low-frequency
distance the posterior duramater is found. The inclination of
(2-5 MHz) probe is selected, and the ultrasound parameters
the ultrasound probe that best distinguishes the posterior
are adjusted for frequency, depth, focus, and gain according
and anterior complexes will determine the inclination angle
to the patient's dimensions. The previously described steps
of the needle (Figure 12).
are then followed to obtain the images of the transverse
processes, articular processes, lamina, and intervertebral
levels are identified in the PSo view.
refere nces
The desired level to perform the interlaminar puncture is
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