Image-Guided Spine Procedures¶

Definition¶

Image-guided spine procedures encompass a range of diagnostic and therapeutic interventions performed under real-time imaging guidance — primarily fluoroscopy and CT — to precisely target spinal structures. These procedures include injections, biopsies, drainage, and ablation techniques used for pain management, diagnosis, and treatment of spinal pathology.

Guidance Modalities¶

Fluoroscopy¶

• Most commonly used for routine spine injections
• Real-time X-ray imaging allows needle positioning with contrast confirmation
• Advantages: widely available, fast, allows dynamic contrast injection to confirm needle position
• Limitations: limited soft tissue visualization; radiation exposure to patient and operator

CT Guidance¶

• Provides cross-sectional imaging for precise needle placement
• Advantages: superior anatomic detail; can target structures not accessible under fluoroscopy; confirms avoidance of critical structures
• Limitations: no real-time imaging (intermittent scans); higher radiation dose than fluoroscopy; more time-consuming
• CT fluoroscopy — near-real-time CT imaging; combines advantages of both

Ultrasound Guidance¶

• Increasingly used for superficial procedures (facet injections, sacroiliac joint injections)
• Advantages: no radiation; real-time imaging; portable
• Limitations: limited deep visualization; operator-dependent; not suitable for all spine procedures

Common Procedures¶

Epidural Steroid Injections (ESI)¶

Facet Joint Procedures¶

• Intra-articular facet injection — diagnostic and therapeutic injection of anesthetic and steroid into the facet joint
• Medial branch block (MBB) — anesthetic injection onto the medial branch of the dorsal ramus that innervates the facet joint; used for diagnosis
• Radiofrequency ablation (RFA) — thermal ablation of the medial branch nerve; performed after positive diagnostic MBBs; provides longer-lasting pain relief (6–12 months)

Sacroiliac Joint Injection¶

• Fluoroscopic or CT-guided injection into the SI joint
• Diagnostic (anesthetic) and therapeutic (steroid)

Vertebral Augmentation¶

• Vertebroplasty — injection of polymethylmethacrylate (PMMA) bone cement into a fractured vertebral body under fluoroscopic or CT guidance
• Kyphoplasty — a balloon is first inflated within the vertebral body to create a cavity and restore height before cement injection
• Indications: painful osteoporotic vertebral compression fractures refractory to conservative management

Percutaneous Biopsy¶

• CT-guided biopsy of vertebral body lesions, paravertebral masses, or disc space (for suspected infection)
• Core needle biopsy provides tissue for histopathologic and microbiologic analysis
• Coaxial technique allows multiple samples through a single access

Abscess Drainage¶

• CT-guided percutaneous drainage of paravertebral, psoas, or epidural abscesses
• Often combined with antibiotic therapy
• May be definitive treatment or a bridge to surgery

Complications¶

• Infection — rare with proper sterile technique
• Bleeding — epidural hematoma (higher risk with anticoagulation)
• Nerve injury — from direct needle trauma or intraneuronal injection
• Dural puncture — headache; CSF leak
• Spinal cord infarction — rare but catastrophic; related to arterial injection
• Cement leakage — in vertebroplasty/kyphoplasty; can cause radiculopathy or embolism if severe
• Allergic reaction to contrast or medications
• Radiation exposure — to patient and operator

Key Points¶

• Fluoroscopy is the standard guidance modality for routine spine injections; CT provides superior anatomic detail for complex cases
• Epidural steroid injections are the most common image-guided spine procedure
• Facet joint diagnosis involves a stepwise approach: diagnostic MBB → confirmatory MBB → RFA
• Vertebral augmentation (vertebroplasty/kyphoplasty) treats painful compression fractures
• CT-guided biopsy is essential for tissue diagnosis of unknown vertebral lesions
• Non-particulate steroids should be used for transforaminal injections above L3 to minimize vascular risk

References¶

1. Patel K, Chopra P, Martinez S, Upadhyayula S. Epidural Steroid Injections. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470189/
2. Helm S II, Harmon PC, Noe C, Calodney AK, Abd-Elsayed A, Knezevic NN, Racz GB. Transforaminal Epidural Steroid Injections: A Systematic Review and Meta-Analysis of Efficacy and Safety. Pain Physician. 2021;24(S1):S209-S232. Available from: https://pubmed.ncbi.nlm.nih.gov/33492919/
3. Cohen SP, Bhaskar A, Bhatia A, et al. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Reg Anesth Pain Med. 2020;45(6):424-467. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7362874/
4. Chandra RV, Maingard J, Asadi H, Slater LA, Mazwi TL, Marcia S, Barr J, Hirsch JA. Vertebroplasty and Kyphoplasty for Osteoporotic Vertebral Fractures: What Are the Latest Data? AJNR Am J Neuroradiol. 2018;39(5):798-806. Available from: https://pubmed.ncbi.nlm.nih.gov/29170272/
5. Wiesner EL, Hillen TJ, Long J, Jennings JW. Percutaneous CT-Guided Biopsies of the Cervical Spine: Technique, Histopathologic and Microbiologic Yield, and Safety at a Single Academic Institution. AJNR Am J Neuroradiol. 2018;39(5):981-985. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7410669/
6. Transforaminal epidural steroid injection. Radiopaedia.org. Available from: https://radiopaedia.org/articles/transforaminal-epidural-steroid-injection

Related Articles¶

• CT of the Spine
• Spine Radiography (X-ray)
• Spinal Arterial Supply
• Facet Joints
• Intervertebral Disc