CRP Improvement Similar With US- vs CT-Guided Transforaminal Steroid Injection

Compared with conventional CT-guided TFSI for CRP, ultrasound-guided TFSI avoids radiation exposure and allows visualization of critical vessels.

In the treatment of cervical radicular pain (CRP), ultrasound (US)-guided transforaminal steroid injection (TFSI) provided noninferior contrast dispersion, shorter procedure time, and comparable clinical outcomes compared with computed tomography (CT)-guided TFSI.  These findings, from a randomized, controlled, noninferiority trial, were published in the Clinical Journal of Pain.

Investigators sought to compare the contrast dispersion, efficacy, safety, and outcomes of transforaminal steroid injection guided by US vs CT for the treatment of cervical radicular pain.

The study included 430 patients with CRP at the Nanjing Maternity and Child Health Care Hospital in China between 2019 and 2021. Patients were randomly assigned in a 1:1 ratio to receive US- (n=215) or CT- (n=215) guided TFSI in the lower cervical spine. Both groups received 0.5 mL contrast medium and the TFSI comprised 0.5 mL of 2% lidocaine, 0.5 mL compound betamethasone, 0.5 mL mecobalamin, and 0.5 mL 0.9% saline. Patients reporting a less than 50% reduction in the numeric rating scale (NRS) pain score at 1 week were administered a second injection. The primary outcomes were changes to NRS pain scores and Neck Disability Index (NDI) functional disability status.

In the US vs CT groups, patients mean (SD) age was 60.96 (11.79) vs 63.10 (13.57) years; 53.0% vs 46.5% were female; 54.4% vs 50.2% had affected right side; and NRS at baseline was 4.61 (1.34) vs 4.54 (1.50) points, respectively.

This study demonstrated that US provided a noninferior injectate spread pattern and similar improvement of radicular pain and functional status when compared with CT-guided TFSI.

During the procedure, C5-6 puncture was most common (46.0%-48.8%), followed by C6-7 (29.8%-35.3%), and C4-5 (18.6%-21.4%). The US procedure was associated with a significantly shorter puncture time (mean, 201.9 vs 386.5 seconds; P <.05).

The proportion of patients receiving only 1 injection was 33.0% for US-guided treatments vs 39.5% for CT-guided treatments.

The US and CT guidance resulted in similar rates of optimal (50.7% vs 62.8%), good (41.4% vs 33.0%), and poor (7.9% vs 4.2%) contrast distribution, respectively. There was no significant difference in the overall satisfactory rate of contrast distribution (c2, 2.620; P =.156).

Compared with baseline, significant improvements in mean NRS scores were observed at 1 month (US: 2.30; CT: 1.94 points; both P <.05) and 3 months (US: 2.09; CT: 1.70 points; both P <.05) among both groups. Similarly, mean NDI scores decreased from 36.13 points at baseline among the US group to 26.12 points at 1 month (P <.05) and 13.52 points at 3 months (P <.05) and from 34.73 points at baseline to 23.67 and 12.83 points (both P <.05) at 1 and 3 months for the CT group, respectively.

The overall changes in NRS (F, 2.49; P =.115) and NDI (F, 0.29; P =.592) scores did not differ significantly between groups.

Side effects related to the steroid and anesthetics, such as dizziness, nausea, vomiting, and facial flushing, were reported by 0.9% of participants in the US cohort vs 2.3% in the CT cohort. All reactions resolved after 30 minutes. Inadvertent vascular puncture occurred among 5.7% of the CT group.

The major limitation of this study was that blinding for the proceduralist was not possible.

The study authors concluded, “This study demonstrated that US provided a noninferior injectate spread pattern and similar improvement of radicular pain and functional status when compared with CT-guided TFSI. US may be advantageous during this procedure because it allows visualization of critical vessels and avoids radiation exposure.”


Yue L, Zheng S, Hua L, et al. Ultrasound-guided versus computed tomography fluoroscopy-assisted cervical transforaminal steroid injection for the treatment of radicular pain in the lower cervical spine: a randomized single-blind controlled noninferiority study. Clin J Pain. 2023;39(2):68-75. doi:10.1097/AJP.0000000000001091