Original papers

Med Ultrason 2013, Vol. 15, no. 1, 10-15

DOI: 10.11152/mu.2013.2066.151.jo1ugc2
Abstract
Objectives: A prospective randomized clinical trial was conducted to evaluate accuracy, time-saving, radiation doses and
pain relief of ultrasound-guided (US) facet joint injections versus Computed Tomography (CT)-controlled interventions in the
cervical spine. Material and methods: Forty adult patients were consecutively enrolled and randomly assigned to the US- or
CT group. US-guided facet joint injections were performed on a standard ultrasound device using a broadband linear-array
transducer. The corresponding comparison group underwent CT-guided instillations which were performed under standard-
ized procedures using the CT-positioning laser function. Results: The accuracy of ultrasound-guided interventions was 100%.
The mean time (min:sec) to fnal needle placement in the US group was 04:46 versus 11:12 (p<0.05) in the CT group for one
injected level, and 05:49 in the US group versus 14:32 (p<0.05) in the CT group for two injected levels. The mean dose-length
product (DLP, mGy*cm) radiation dose, including CT confrmation for study purposes only, was 27.6 for the US group versus
88.2 in the CT group (p<0.05) for one injected level, and 32.5 in the US group versus 205.0 in the CT group (p<0.05) for two
injected levels. Both groups showed the same signifcant visual-analog-scale (VAS) relief in pain (p<0.05), without any inter-
methodic differences (p>0.05). Conclusions: US-guided intra-articular injections show the same therapeutic effect as CT-
guided intra-articular injections and result in a signifcant reduction of procedure duration without any exposure to radiation.
Keywords: facet joints injections, cervical spine, ultrasound, computed tomography, radiation dose
Ultrasound-guided versus Computed Tomography-controlled facet
joint injections in the middle and lower cervical spine: a prospective
randomized clinical trial.
Jochen Obernauer
1
, Klaus Galiano
2
, Hannes Gruber
3
, Reto Bale
3
, Alois Albert Obwegeser
1
,
Reinhold Schatzer
4
, Alexander Loizides
3

1
Innsbruck Medical University, Department of Neurosurgery,
2
Innsbruck Medical University, WIK (Spine Center Inns-
bruck), Sanatorium Kettenbrcke,
3
Innsbruck Medical University, Department of Radiology,
4
University of Innsbruck,
C. Doppler Laboratory for Active Implantable Systems, Institute of Ion and Applied Physics, Innsbruck, Austria
Received 23.11.2012 Accepted 27.12.2012
Med Ultrason
2013, Vol. 15, No 1, 10-15
Corresponding author: Jochen Obernauer, MD
Innsbruck Medical University,
Department of Neurosurgery
Anichstrasse 35, 6020 Innsbruck, Austria
Tel: +43/512/504 27452
Fax: +43/512/504 27453
E-mail: jochen.obernauer@i-med.ac.at
Introduction
Injection therapies play a major role in the manage-
ment of various pain conditions [1,2]. With a 12-month
prevalence that varies between 30% and 50%, neck pain
is common in the general population. It occurs more of-
ten in women and shows a peak of prevalence at middle
age [3]. Facet joints are well innervated by the medial
branches of the dorsal rami and contain free and encapsu-
lated nerve endings, nociceptors and mechanoreceptors
[4]. They have been shown to be a source of pain in the
neck and related pain in the head and upper extremities
[5-10]. In 2% to 10% of the cases, facet-joint-associated
pain results in incapacity to perform daily activities. If,
despite non-steroidal anti-infammatory drug administra-
tion and nonspecifc physical therapy measures, pain be-
comes unremitting, it may be managed by intra-articular
injections or medial branch blocks [2,4,11]. The majority
of such infltrations is performed under fuoroscopy- or
computed tomography (CT) control [12]. Recently, vari-
ous groups, including ourselves, have shown the reliabil-
ity of ultrasound (US) guidance for different infltrations,
and US has been demonstrated to facilitate the locali-
11
Med Ultrason 2013; 15(1): 10-15
zation and imaging of spinal nerve roots and also bony
parts of the spine such as facet joints [13-22]. US-guided
approaches tailored for spinal interventions are already
available but only proven for their topographic feasibility
[1,13-22].
The aim of this study was to show the feasibility and
accuracy of a methodological US-based approach as
described by Galiano et al 2006 [13] for inter-articular
instillations in the middle to lower cervical spine in a pro-
spective randomized clinical trial.
Materials and methods
The protocol of this prospective randomized study
was reviewed and approved by the ethical committee
of the Innsbruck Medical University (IMU, Protocol
UN3959). The patient selection was performed consec-
utively during daily routine at the Department of Neu-
rosurgery at IMU and was performed on the basis of
standard neurological diagnostics and clinical methods
by neurosurgical specialists following evidence-based-
medicine recommendations [3]. Forty adult patients (24
women and 16 men) were prospectively enrolled, after
having given written informed consent. All subjects had
to fulfll the following inclusion criteria: (1) subacute-
chronic facet-joint-associated neck pain of the middle or
lower cervical spine; (2) available recent CT or MRI of
their cervical spine; (3) aged over 18 years old. Exclu-
sion criteria were (1) neurological defcit, (2) local or
systemic infections and discitis (3) running anticoagula-
tion therapy or uncorrectable coagulopathy, (4) allergies
to steroids, anesthetics or contrast agents, (5) diabetes,
(6) pregnancy or (7) spinal tumors. After recording the
subjects demographic data, preceding surgeries, body-
mass-index and visual analog scale (VAS) score regard-
ing their neck pain, patients were assigned to one of two
groups by chance, using a computer-generated randomi-
zation-table. One group consisted of candidates for US-
guided infltrations (US group), the other group consisted
of candidates for Computed Tomography (CT group). To
guarantee for patient safety the study was planned to be
aborted if in more than two patients of the US group the
target was not visible or CT-control scans showed an in-
correct needle position after US-guided intervention.
Ultrasound-Guided-Procedure
Ultrasound interventions were performed on a stand-
ard US device (iU22; Philips Ultrasound, Bothell, Wash-
ington), using a 12-5 broadband linear array transducer,
by a radiological specialist with relevant experience of
more than 10 years in musculoskeletal US imaging and
spinal injection therapies. Under sterile circumstances
and after covering the US probe with a sterile wrap,
Fig 1. Posterior axial scan plane of the right facet-joint C6/7 af-
ter US-guided needle-placement. Left image without and right
image with notations (joint space= yellow, superior and inferior
articular process=light blue. Arrow at needle tip).
patients were placed in prone position and the region
of interest was washed sterile and covered accordingly.
The time was taken from the moment the investigator
touched the skin the frst time with the probe after sterile
US gel was applied. Following the systematic procedure
described by Galiano et al. [13], the facet joint of inter-
est was sought through a paraxial scan position, and the
sonographer classifed the target as clearly visible, par-
tially visible or not visible. If clearly or partially visible,
a spinal needle (20 GA 3.00 IN, 0.9 x 75 mm; BD Spinal
Needle, Becton Dickinson, Madrid, Spain) was inserted
from dorsal exactly within the echo plane (fg 1). When
the sonographer was sure to have placed the needle tip
directly at the inter-articular space of the targeted facet
joint, the elapsed time was recorded. Then the accuracy of
the positioning was verifed by CT (Somatom - Sensation
Open, Siemens, Erlangen, Germany). If the sonographer
classifed the target as partially visible, the time of the
following CT verifcation was included in the procedure
time measurement. To keep the radiation dose as low as
possible, a topogram centered on the needle tip and a few
axial slices - using a low dose protocol (120 kV, 120 mA)
- were obtained. If the needle placement was correct, 1
mL mixture of betamethasone (CELESTAN solubile
4 mg/ml; essex-pharma GmbH, Munich, Germany) and
bupivacainehydrochloride (Bucain 0.25%, 2.5 mg/ml,
Delta Select GmbH, Pfullingen, Germany) was injected.
If the needle tip was not in correct position, it was re-
placed again under ultrasound guidance followed by CT
control, with the time measurement running on.
Computed-Tomography-Controlled Procedure
The CT-guided interventions were performed with the
same CT device as used for the verifcation of the US pro-
cedure and were executed by a radiology specialist with
more than 10 years of relevant experience in CT-guided
interventions. After placing the candidates in a prone po-
sition, a radio-opaque marker was positioned on the skin
12
Jochen Obernauer et al Ultrasound-guided versus Computed Tomography-controlled facet joint injections
of the area of interest. Consistent with the US procedure,
elapsing time was recorded with the start of the initial
scan. For a precise calculation of the needle pathway, a
topogram through the targeted area was obtained with a
low-dose protocol (120 kV, 120 mA) at 3 mm slice thick-
ness. The point of entry, the angle and the depth of ap-
proach were selected and calculated. The needle entry
point was marked on the patients skin using the obtained
calculations and the CT-positioning laser function. Then
a spinal needle (20 GA 3.00 IN, 0.9 x 75 mm; BD Spinal
Needle, Becton Dickinson, Madrid, Spain) was advanced
toward the facet joint of interest, according to the prelimi-
nary calculations. To control the present and fnal needle
tip position, several CT scans were obtained repeatedly,
i.e. after each reposition, until the needle was estimated
to be the in correct position. At that time the elapsed time
was recorded. Exactly as in the US procedure, 1 mL
mixture of betamethasone (CELESTAN solubile 4 mg/
ml; essex-pharma GmbH, Munich, Germany) and bupi-
vacainehydrochloride (Bucain 0.25%, 2.5 mg/ml, Delta
Select GmbH, Pfullingen, Germany) was injected.
Measurements and Statistics
For both groups the periods of intervention time and
the radiation doses (as dose-length products; DLPs) are
reported. Time and radiation dose were compared sepa-
rately for one- and two-leveled injections. To follow up
the clinical beneft, neck pain was assessed via a visual
analog scale (VAS) before, 30 minutes after and 4 weeks
after the intervention. Feasibility of the US procedure was
defned as percentage of patients with clearly, partially, or
invisible targets (respectively inter-articular space). Accu-
racy was calculated as CT-verifed exact needle tip place-
ment. The number of repositions, unexpected problems
and complications were also recorded for both groups.
Statistical analyses were done according to the intention-
to-treat principle [23]. The primary outcomes were accu-
racy and time to fnal needle placement. For the evaluation
of VAS changes we used the comparison of percentage
VAS reduction from pre- to 30-minutes post-intervention-
al and from pre- to 4-weeks post-interventional interval.
The trial was designed to detect an absolute difference of
one standard deviation with a power of 80% at a two-sid-
ed signifcance level of 0.05 and a maximum dropout rate
of 20%. Comparisons between groups were performed
with an unpaired t-test, or in case of nonparametric val-
ues, with a Mann-Whitney U-test.
Results
After randomization there were no signifcant differ-
ences between the two groups (table I). All patients who
were randomly assigned to the US group were judged
to be feasible for the US-guided procedure. In 20 pa-
tients the inter-articular space of the targeted facet joint,
as well as the bony landmarks, were clearly depicted by
US (100%). In 19 of these patients (95%) the interven-
tion was performed as planned and the needle was posi-
tioned correctly, as also confrmed by CT (95%). In one
case (5%) the intervention was aborted because of the
patients missing compliance (the patient was unable to
deal with the pain of needle positioning). In the US group
no needle had to be repositioned (accuracy = 100%). In
the CT group a needle reposition was necessary in 13
cases (65%): in 3 cases (15%) the respective needle po-
sition was changed once, in 6 cases (30%) twice, in 2
cases (10%) three times and in another 2 cases (10%)
even four times. Regarding the necessary needle reposi-
tions the US-guided procedure statistically showed a sig-
nifcantly higher accuracy (p<0.05). The mean duration
(min:sec) to needle placement for one-leveled injections
was 4:46 in the US group and 11:12 in the CT group.
The US group showed signifcant time savings (p<0.05).
The mean duration (min:sec) of two-leveled injections
was 5:49 for US-guided and 14:32 for CT-controlled
procedures. US guidance again showed statistically sig-
nifcant time savings (p<0.05). The mean DLP radiation
doses, including CT confrmation for study purposes
only in the US group, were 27.55 mGy*cm (one level)
and 32.5 mGy*cm (two levels) for US-guided interven-
tions, versus 88.2 mGy*cm (one level) and 205 mGy*cm
(two levels) for CT-guided procedures. US guidance
Table I. Patient-related pre-interventional data for both groups
CT-guided US-guided
Male/Female 5/15 11/9
Age (y) 54.7 9.5 49.6 6.0
BMI 25.8 5.1 23.9 3.8
Visual Analog Score 7.1 0.9 7.1 1.6
LEVELS
One level injected
Two levels injected
12
8
14
6
C2/3
C3/4
C4/5
2
3
4
0
2
4
C5/6 10 12
C6/7 6 7
C7/Th1 3 1
NOTE. Gender, age, BMI and VAS are reported as mean standard
deviation. Other values are numbers of patients for each sub-
group. There were no signifcant differences between the groups
(p>0.05)
13
Med Ultrason 2013; 15(1): 10-15
showed a signifcant DLP saving for one- (p<0.05) and
two-leveled (p<0.05) injections. Both groups showed a
signifcant beneft from inter-articular injections 30 min-
utes (p<0.05) and one month (p<0.05) after the injection:
30 minutes post-interventional there was a mean VAS re-
duction of 72% (one level) and 69% (two levels) in the
US group versus 50% (one level) and 52% (two levels) in
the CT group. One month post-interventional, US guid-
ance showed a mean VAS reduction of 91% (one level)
and 50% (two levels) versus 59% (one level) and 55%
(two levels) under CT guidance (table II). There were no
signifcant differences between the US and CT groups
(p>0.05) after two-leveled injections (table II). Howev-
er, there was a procedure-dependent beneft for the US
group with one-leveled injections (p<0.05).
There were no complications or unexpected side ef-
fects.
Discussion
The aim of this study was to demonstrate and to com-
pare accuracy, effcacy, time saving, radiation doses,
safety and pain relief of US-guided intra-articular facet
joint injections in the middle to lower cervical spine to
CT-guided interventions in a prospective randomized
clinical trial. Although the pain relief was signifcant af-
ter a 30-minute- and one-month follow-up in both groups
and a possible signifcance of an inter-modality differ-
ence was assessed in a prospective randomized manner,
the study was neither intended to evaluate the overall
effectiveness of intra-articular injected steroids (as in a
drug study) nor to compare intra-articular injections to
medial branch blocks, which are popular as well.
According to clinical studies evaluating lumbar facet
joint and lumbar periradicular injections under US-guid-
ance and according to anatomical studies in which accu-
racy of US-guided cervical facet joint injections has been
analyzed, the present study demonstrated that in 100% of
the performed US-guided procedures the needle place-
ment was correct, as the procedure mainly relyied on the
visibility of cervical facet joints [1,13-17,20-22]. The
study population showed BMI-values ranging up to 33.2
and different anatomical conditions, e.g. short necked
patients.
An important consideration is that all cervical injec-
tion therapies can be technically challenging, as acciden-
tal puncture of paraspinal vessels may lead to severe and
irreversible spinal complications [24-29]. This is par-
ticularly relevant for cervical injections performed under
fuoroscopic control, where the needle placement is more
or less a blind fight until contrast agent is administered
[27,30]. Following current recommendations for cervical
spinal injections, the application of contrast agent under
real-time digital subtraction fuoroscopy should thus be
Table II. Results
CT-guided US-guided p value
Time (min:sec)
One level
Two levels
11:12 ( 03:43)
14:32 ( 02:58)
04:46 ( 02:49)
05:49 ( 02:16)
<0.05
<0.05
Radiation dose (mGy*cm)
One level
Two levels
88.2 ( 58.2)
205.0 ( 199.7)
27.6 ( 21.4)
32.5 ( 29.2)
<0.05
<0.05
Needle repositions (total)
1 repositions
2 repositions
3 repositions
4 repositions
13
3
6
2
2
0
<0.05
VAS reduction (30 min)
One level
Two levels
VAS reduction (1 month)
One level
Two level
50.1 % ( 13.8)
52.0 % ( 19.7)
58.6 % ( 44.7)
55.3 % ( 40.0)
72.0 % ( 14.0)
69.2 % ( 19.7)
91.3 % ( 24.5)
50.3% ( 40.3)
<0,05
>0.05
<0.05
>0.05
NOTE. Time, radiation dose and VAS reduction are reported as mean standard deviation. Other values
are numbers of patients for each subgroup.
14
Jochen Obernauer et al Ultrasound-guided versus Computed Tomography-controlled facet joint injections
performed to reduce the risk of unintentional injection in
such paraspinal, e.g. radicular, vessels [27].

In the present
US technique, the advantage of utilizing a real-time in-
plane needle access from dorsal is striking: any relevant
vessel is so avoided, as based on normal topography
none usually crosses the needle pathway. Also, if the
target is clearly visible under US guidance, no further
radiographic control and no systemic application of con-
trast agents or other ionizing modalities are necessarily
required. In this context, the use of Duplex-mode US im-
aging as a further guidance tool is conceivable, but was
not used in the present study because of its questionable
additional beneft.
In this trial, CT controls in the US group were per-
formed only for study purposes. The recordings of these
DLPs showed that the mean radiation dose in the US
group was signifcantly lower than the mean dose of
patients who had undergone CT-guided-only interven-
tions, which implies a beneft of US guidance even if
performed with subsequent CT control (maybe due to
forensic necessities). Although the necessary radiation
dose for one single CT-guided intervention may be rather
low, our study showed that cumulative effects have to be
taken into account, as some CT-guided instillations in our
trial required up to four CT scans. For such repeated and
multilevel injections, which are quite popular, US guid-
ance would be the recommended procedure.
A further beneft of US guidance is that it helps to
minimize the risk of unexpected side effects, as those are
often associated to the application of contrast agents re-
quired for the positioning control under CT- or fuorosco-
py-guided procedures. The fact that US-guided injections
can be performed rather easily is mostly based on the di-
rect depiction of the structures of interest, i.e. cervical
facet joints, by US. Thus, with a little exercise, a needle
can be advanced to the target structure itself in just a few
seconds under safe and real-time controlled conditions
[1,13,16].

If such an intervention is performed under CT-
guidance, calculations on access angles and entry points
of the needle are based on landmarks, followed by an
actually blind needle-positioning which is then control-
led by a subsequent scan and often followed by multiple
repositions. Control scans, if necessary, are potentially
harming to the patients, as described above, but are also
laborious and costly compared to the US procedure pre-
sented here. US-guided facet joint instillations may even
be performed very effciently under bed-side condi-
tions, e.g. in outpatients. This saves time and resources,
as US is comparatively inexepensive and broadly avail-
able, and does not imply any therapeutic compromises
for the patient, as accuracy is obviously suffcient for the
purpose described here [13].
According to the analysis on increasing numbers and
costs of spinal injection therapies, published by Carrino
et al 2002 [11], the overall cost-effectiveness of cervical
instillations must be evaluated as well. This is however
beyond the scope of this study.
Limitations
Limiting factors might be that outcome was only
measured by patient satisfaction and that the long-term
follow-up was only performed four weeks after the in-
stillation.
Conclusion
The US-guided facet joint injection in the middle
and lower cervical spine is accurate, feasible, and bears
minimal risk. It results in a signifcant pain reduction,
not different from CT-guided instillations. Addition-
ally a reduction of time, radiation dose and resources is
highly evident. However, as with any form of instillation
therapy needing practice for good results, a specifc and
mandatory learning curve to achieve good visualization
and guidance of the instillation needle has to be taken
into account with US guidance. Upcoming projects are
supposed to evaluate this and the value of the US-guided
procedure during daily routine.
Confict of interest: none
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