Ultrasound- versus fluoroscopy-guided injections in the lower back for the management of pain: a systematic review

Purpose Ultrasound-guided spinal injections are less common than fluoroscopy-guided injections. Although unable to penetrate bones, ultrasound guidance has a number of advantages including convenience and reduced exposure to ionizing radiation. However, it is not known how ultrasound-guided injections compare to fluoroscopy-guided injections in the management of lower back pain. Our objective is to systematically review the literature comparing ultrasound-guided injections to fluoroscopy-guided injections for the management of lower back pain. Methods Medline, Cochrane CENTRAL Register of Controlled Trials, Embase, and NHSEED were searched from 2007 to September 26, 2017. Inclusion criteria included (1) randomized controlled trial design, (2) compared ultrasound-guided and fluoroscopy-guided injections for lower back pain, (3) dose and volume of medications injected were identical between trial arms, and (4) reported original data. Results One hundred one unique records were identified, and 21 studies were considered for full-text inclusion. Nine studies formed the final data set. Studies comparing ultrasound- and fluoroscopy-guided injections for lower back pain management reported no difference in pain relief, procedure time, number of needle passes, changes in disability indices, complications or adverse events, post-procedure opioid consumption, or patient satisfaction. Conclusion Fluoroscopic guidance of injections for the management of lower back pain is similar in efficacy to ultrasound guidance. The exact role of ultrasound guidance needs to be further studied, especially for nerve root injections, where safety is the major concern. Key Points • There were no differences in pain relief, procedure time, number of needle passes, changes in disability indices, complications or adverse events, post-procedure opioid consumption, or patient satisfaction between ultrasound- and fluoroscopy-guided injections for the management of lower back pain. • Given the lack of evidence to demonstrate superior efficacy and the added harms with fluoroscopic guidance, ultrasound guidance may be the preferred method of guidance for injections to manage lower back pain in appropriate patients. Further study is required to understand the exact role of ultrasound in image-guided injections.