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Review
. 2025 Jun;14(3):841-863.
doi: 10.1007/s40122-025-00731-9. Epub 2025 Apr 2.

The Importance of Image Guidance in Common Spine Interventional Procedures for Pain Management: A Comprehensive Narrative Review

Martina Rekatsina  1 , Philip W H Peng  2
Affiliations
Review

The Importance of Image Guidance in Common Spine Interventional Procedures for Pain Management: A Comprehensive Narrative Review

Martina Rekatsina et al. Pain Ther. 2025 Jun.

Abstract

Introduction: Image-guided spinal injections are commonly performed by pain physicians and supported by literature. A recent survey showed that half of the Canadian providers still perform landmark-guided injections. This comprehensive review aims to describe the evidence supporting imaging modalities (fluoroscopy, computed tomography (CT) and ultrasound) in improving the accuracy and safety in several commonly performed spine injections. Relevant anatomy and pitfalls of landmark-guided injections are also discussed.

Methods: An extensive literature search was conducted in PubMed, Medline and Embase databases, complemented by a manual search. Search terms included all spine interventions and imaging modalities.

Results: Literature shows that incorrect needle placement without imaging guidance can reach 50% in caudal, 30.4% in lumbar interlaminar and 53% in cervical interlaminar epidural steroid injections. Lumbar and cervical transforaminal steroid injections require imaging to identify intravascular or intradiscal needle placement; misplacement rates can be as high as 20% at cervical, 8% at thoracic, 6-15% at lumbar and 16.5-21% at sacral levels. Imaging techniques for sacroiliac joint steroid injections are superior to non-imaging techniques, while medial branch blocks and facet joint injections require image guidance.

Conclusion: Image guidance is a mandatory requirement when performing spinal procedures for pain management. Fluoroscopy enhances the safety and accuracy of spinal injections, with stored images benefiting patient records. Ultrasound also has an increasingly important role either alone or with fluoroscopy. CT is also effective but with limited accessibility.

Keywords: Accuracy; DSA; Fluoroscopy; Image guidance; Safety; Spinal procedures; Spine injections; Ultrasound computed tomography (CT).

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Conflict of interest statement

Declarations. Conflict of Interest: Martina Rekatsina is an Editorial Board member of Pain and Therapy. Martina Rekatsina was not involved in the selection of peer reviewers for the manuscript nor any of the subsequent editorial decisions. Philip Peng has received equipment support from Sonosite Fujifilm Canada. Philip Peng is also Steering Committee chair in the development of Spine Intervention Guidelines. Ethical Approval: This article is based on previously conducted studies and does not contain any new studies with human participants.

Figures

Fig. 1
Fig. 1
PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registries only
See this image and copyright information in PMC

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