Ultrasound-guided costovertebral joint injection-technique description and fluoroscopy and computerized tomography combined controlled cadaveric feasibility study.

OBJECTIVES: To describe and assess the feasibility of an ultrasound-guided technique for intra-articular injection of the costovertebral joints, in an unembalmed cadaveric specimen, utilizing fluoroscopy and cone beam computerized tomography for confirmation of contrast spread and needle tip position, respectively. METHODOLOGY: A single unembalmed cadaveric specimen was obtained. A single interventionist performed the placement of the needles under ultrasound guidance. Contrast dye was then injected through each of the needles under real-time fluoroscopy. Finally, the specimen was submitted to a cone beam computerized tomography with 3-dimensional acquisition and multiplanar reformatting to assess final needle tip position relative to the costovertebral joints. RESULTS: In total, 18 spinal needles were placed under ultrasound guidance. Fluoroscopy showed 4 distinct patterns of contrast spread: intra-articular in the costovertebral joint (13 levels in total), epidural (1 level), intra-articular in the facet joint of the target level (3 levels), and undetermined (1 level). Cone-beam computerized tomography confirmed 13 out of 18 needles to be adequately placed in the costovertebral joints (72% of the total) and 5 out of the 18 needles to be misplaced: 3 needles were placed in the facet joint of the target level, and 2 needles were placed in the epidural space. CONCLUSIONS: This study suggests that, when performed by experienced interventionists, this technique has an accuracy rate of 72%. Further studies are warranted before these results can be extrapolated to daily clinical practice.

Ultrasound-guided fascial plane blocks for post-breast surgery pain syndrome.

INTRODUCTION: Persistent pain following breast surgery is common and may be challenging to treat. In patients refractory to conservative treatments, ultrasound-guided fascial plane blocks of thoracic nerves can be a useful option. RESULTS: This type of neuro blockade technique provides advantages in terms of safety and efficacy that are convenient for physicians managing refractory and complex cases of post-breast surgery syndrome. CONCLUSION: This technical review aims to present an up-to-date summary of the most common ultrasound-guided fascial plane blocks for chronic pain in post-breast surgery patients, provide a detailed technical description of each intervention, and propose preferred injections based on the anatomical location of the pain.

Ultrasound-Guided Gluteal Fascial Plane Block for the Treatment of Chronic Refractory Greater Trochanteric Pain Syndrome - Technique Description and Anatomical Correlation Study.

INTRODUCTION: Greater trochanteric pain syndrome may often mimic pain generated from other sources. However, it is most commonly caused by gluteus medius and gluteus minimus tendinopathy or tear. The purpose of this technical report was to: 1) describe the ultrasound-guided fascial plane block technique targeting the superior gluteal nerve in the plane between gluteus medius/gluteus minimus to treat moderate-to-severe, chronic, refractory greater trochanteric pain syndrome; 2) anatomically correlate the procedure with cadaveric dissections demonstrating the structures being imaged and the tissues along the needle trajectory; 3) demonstrate the feasibility of the technique with serial dissection of one cadaveric specimen following injection with color dye. TECHNIQUE DESCRIPTION: The ultrasound-guided fascial plane block targeting the superior gluteal nerve to treat moderate-to-severe, chronic, refractory greater trochanteric pain syndrome has been outlined with supporting ultrasound scans and anatomical dissections. The cadaveric dissections are correlated to the ultrasound scans of a healthy volunteer and provide visualization of the tissues in the needle trajectory. The feasibility study in a cadaveric specimen showed adequate stain of the superior gluteal nerve without spread to the piriformis muscle belly, the sciatic nerve, or the inferior gluteal nerve. CONCLUSIONS: This ultrasound-guided fascial plane block is a feasible option for blocking the superior gluteal nerve without inadvertent involvement of the sciatic and inferior gluteal nerves. Further randomized controlled clinical trials are necessary to assess the clinical efficacy of the gluteus medius/gluteus minimus fascial plane block to treat moderate-to-severe, chronic, refractory greater trochanteric pain syndrome.

Gender Diversity in Primary Care Sports Medicine Leadership.

ABSTRACT: Diversity, equity, and inclusion have been recognized as important drivers of excellence and innovation in the physician workforce. Given the historical underrepresentation of women in medicine, gender diversity is of interest. In this cross-sectional study, we sought to quantify leadership representation of female physicians in primary care sports medicine settings, including primary care sports medicine fellowship programs, select sports medicine societies, and select sports medicine-related scientific journals. Data were collected by querying the corresponding web site for each fellowship program, society, and journal and analyzed in a descriptive manner. Results showed that fewer female physicians hold primary care sports medicine leadership roles than men do. This work establishes a baseline for female representation in primary care sports medicine leadership; efforts should continue to increase the presence of women in leadership positions.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation for the Treatment of Chronic Intractable Pain Originating From a Lipofibromatous Hamartoma of the Median Nerve.

This case report presents an application of peripheral nerve stimulation to the median nerve to treat a patient with intractable pain due to a lipofibromatous hamartoma of the left upper extremity. Ultra high-frequency ultrasound was used to determine the boundaries of the hamartoma. The patient then underwent an ultrasound-guided implantation of 2 stimulator electrodes distal to the elbow along the median nerve with stimulation coverage achieved at 1.2 and 1.4 mA, respectively. After an uneventful procedure, the pain score immediately decreased from 9 out of 10 to less than 6 on a numeric rating scale. Two weeks after the procedure, the patient reported substantial pain relief, with an average pain level of 5 to 6 out of 10. Twelve months after implantation, the patient maintained significant pain relief, rating her average pain level as a 4 to 6 out of 10. Placement of a percutaneous peripheral nerve stimulator was safe and effective with no adverse events being reported at the 12-month follow-up.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation for the Treatment of Lower Extremity Pain: A Rare Case Report.

OBJECTIVE: This case report presents an application of percutaneous peripheral nerve stimulation to the right superficial peroneal nerve to treat a patient with chronic intractable L5-S1 radiculopathy pain that conventional treatment failed to ameliorate. METHODS: The patient underwent an uneventful implantation of a percutaneous peripheral nerve stimulator. The implanted lead (15 cm in length and 1.2 mm in diameter) containing the receiver coil and 3 stimulation electrodes (Bioness Stimrouter® , Valencia, CA, U.S.A.) was implanted parallel with the trajectory of the right superficial peroneal nerve. RESULTS: Two weeks after implantation of the percutaneous peripheral nerve stimulator, the patient experienced excellent pain relief and reported a significant increase in mobility. At the 3-month follow-up consultation, the patient reported maintenance of the reduction of pain in his right lower extremity as well as improved performance in his daily activities. CONCLUSION: Percutaneous peripheral nerve stimulation offers an alternative treatment option for intractable pain associated with chronic radiculopathy, especially for patients in whom conventional treatment options have been exhausted. Further clinical series involving larger numbers of patients are warranted in order to assess the definitive role of percutaneous peripheral nerve stimulation for the treatment of chronic intractable radiculopathy pain.

Ultrasound-guided procedures for the management of chronic thoracic back pain: a technical review.

Pain arising from the thoracic region has been reported to be potentially as debilitating as cervical or lumbar back pain, and may stem from a vast number of spinal sources, including zygapophysial, costovertebral and costotransverse joints, intervertebral discs, ligaments, fascia, muscles, and nerve roots. Over the last two decades, the use of ultrasound in interventional spinal procedures has been rapidly evolving, due to the ultrasound capabilities of visualizing soft tissues, including muscle layers, pleura, nerves, and blood vessels, allowing for real-time needle tracking, while also reducing radiation exposure to both patient and physician, when compared to traditional fluoroscopy guidance. However, its limitations still preclude it from being the imaging modality of choice for some thoracic spinal procedures, notably epidural (interlaminar and transforaminal approaches) and intradiscal injections. In this technical review, we provide an overview of five thoracic spinal injections that are amenable to ultrasound guidance. We start by discussing their clinical utility, followed by the relevant topographic anatomy, and then provide an illustrated technical description of each of the procedures discussed: (1) erector spinae plane block; (2) intra-articular thoracic zygapophyseal (facet) joint injection; (3) thoracic medial branch block; (4) costotransverse joint injection; and (5) costovertebral joint injection.

Peripheral Nerve Stimulation for Chronic Intractable Neuropathic Pain Following a Brachial Plexus Avulsion Injury: A Case Report.

Brachial plexus avulsion injuries result in permanent motor and sensory deficits, leading to debilitating symptoms. We report the case of a 25-year-old man with chronic pain following right-sided C5-T1 nerve root avulsion without evidence of peripheral nerve injury. His pain was recalcitrant to medical and neurosurgical interventions. However, he experienced substantial (>70%) pain relief with peripheral nerve stimulation targeting the median nerve. These results agree with data suggesting collateral sprouting of sensory nerves occurs following a brachial plexus injury. Further study is needed if we are to understand the mechanisms of the peripheral nerve stimulator as a treatment option.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation of the Musculocutaneous Nerve for Refractory Antecubital ElbowPain-Brief Technical Report and Illustrative Case Report.

Chronic pain following distal biceps rupture (DBR) is often nonspecific in that it may arise due to the injury, subsequent surgical repair, or a combination of factors, making the painful symptoms challenging to treat. Peripheral nerve injury in the setting of DBR most commonly affects the musculocutaneous nerve or one of its terminal branches and may lead to chronic neuropathic pain involving the elbow and lateral/radial aspect of the forearm. In this brief technical report, we describe an ultrasound-guided (USG) technique for percutaneous implantation of a peripheral nerve stimulator (PNS) targeting the musculocutaneous nerve, along with an illustrative case report of successful treatment of chronic refractory pain following DBR utilizing this technique. Six months postimplantation, the patient reported a greater than 60% baseline pain intensity reduction, and no complications were noted.

La douleur chronique consécutive à une rupture distale du biceps est souvent non spécifique en ce sens qu'elle peut survenir en raison de la blessure, de la réparation chirurgicale ultérieure, ou d'une combinaison de facteurs, rendant les symptômes douloureux difficiles à traiter. La lésion du nerf périphérique dans le cadre d'une rupture distale du biceps affecte le plus souvent le nerf musculo-cutané ou l'une de ses branches terminales et peut entraîner des douleurs neuropathiques chroniques au niveau du coude et de la face latérale/radiale de l'avant-bras. Dans ce bref rapport technique, nous décrivons une technique guidée par ultrason pour l'implantation percutanée d'un stimulateur nerveux périphérique ciblant le nerf musculo-cutané, ainsi qu'un rapport de cas illustratif du traitement réussi de la douleur réfractaire suite à une rupture distale du biceps en utilisant cette technique. Six mois après l'implantation, le patient a signalé une réduction de plus de 60 % de l'intensité de la douleur initiale, et aucune complication n'a été observée.

Pain Associated With Monkeypox Virus: A Rapid Review.

International concerns for another pandemic arose after emerging reports of an ongoing outbreak of the monkeypox virus (MPXV) in Europe and the United States in 2022. Severe pain is one of the most distressing complications for patients in the current outbreak, but there is a general paucity of relevant peer-reviewed medical literature from which to draw clear recommendations on appropriate pain therapies. The Centers for Disease Control recently published a letter in July 2022 urging providers to conduct further studies concerning pain management. Thus, a rapid literature search was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search of several databases from inception until August 19, 2022, was conducted. All published studies describing pain in patients who tested positive for MPXV with original data and written in English were included. Sixty-nine studies were initially identified for screening. After initial screening, 27 papers were considered for full-text review, and 15 papers met the inclusion criteria. A total of 1043 positive cases were included in this study. Most patients were men. Treatment options proposed by the authors include acetaminophen, ibuprofen, opioids, lidocaine gel, metamizole, and rectal suppositories containing emollients or steroids with oral laxatives for severe anal pain. Although most cases were mild requiring outpatient treatment, a considerable number of patients were admitted due to serious complications. Severe pain was often the reason to seek medical attention and hospital admission for pain control. Analgesic plans included oral and topical analgesia. In severe cases, pain was managed with opioids. To our knowledge, this rapid review is the first study to comprehensively summarize proposed treatments for pain associated with MPXV. Guidelines may be needed to help direct the best management to avoid morbidity in patients, particularly as adjuvants may play a key role but are not commonly utilized in published reports.

Ultrasound-guided percutaneous peripheral nerve stimulation for chronic refractory neuropathic pain: a unique series.

During the last two decades, with the advent of recent technology, peripheral nerve stimulation has become an appealing modality at the forefront of pain management. In this case series, we document the clinical rationale and technical considerations on three of the most challenging cases, refractory to previous interventions, that were treated by our team with an ultrasound-guided percutaneous peripheral nerve stimulator targeting the musculocutaneous, bilateral greater occipital and subcostal nerves. At the 6-month follow-up, all patients experienced greater than 50% relief of baseline pain, with a near-complete resolution of pain exacerbations. Furthermore, to our knowledge, this is the first report of an ultrasound-guided percutaneous technique of a peripheral nerve stimulator targeting the musculocutaneous and subcostal nerves.

Peripheral nerve stimulation is a new tool used in the treatment of peripheral nerve pain. In this study, we share our experience using this technology in three unusual, difficult-to-treat chronic nerve pain presentations, targeting the musculocutaneous, bilateral greater occipital and subcostal nerves. All patients were asked about how pain levels had changed since the peripheral nerve stimulation device had been implanted. In every case, patients reported a decline in their pain level from day one. After 6 months of peripheral nerve stimulator use, all patients reported a greater than 50% pain relief.

Autologous Platelet-Rich Plasma Applications in Chronic Pain Medicine: Establishing a Framework for Future Research - A Narrative Review.

BACKGROUND: During the last decades, platelet-rich plasma has been studied for the treatment of multiple chronic pain conditions, in addition to being employed in the enhancement of healing after tissue injury. OBJECTIVE: To establish a framework for future research regarding the utilization of platelet-rich plasma in the treatment of chronic tissue injuries. METHODS: Preclinical and clinical studies from 2000-2020 relevant to applications of platelet-rich plasma for the treatment of chronic pain conditions were extracted from PubMed and Medline databases. The studies were analyzed on the basis of the study population, type of intervention, method of platelet-rich plasma preparation, the number of treatments administered, the timeframe of injections, and clinical outcomes. RESULTS: Although several preclinical studies and double-blind, randomized trials have shown promising results in the application of platelet-rich plasma for the treatment of multiple chronic pain conditions, various studies have also reported controversial results. Additionally, the methods employed for obtaining the platelet-rich plasma have not been standardized between studies, resulting in different concentrations of blood components between the preparations utilized. Moreover, differences between studies were also found regarding the number of injections administered per treatment. CONCLUSIONS: Future research addressing the utilization of platelet-rich plasma in the treatment of chronic pain conditions should focus on shedding light on the following major questions: a) Is there a dose-effect relation between the platelet count and the clinical efficacy of the preparation?; b) What pathology determinants should be considered when selecting between leukocyte-enriched and leukocyte-depleted concentrates?; c) What is the role of platelet activation methods on the clinical efficacy of platelet-rich plasma?; d) Is there an optimal number of injections and time frame for application of multiple injection treatment cycles?; e) Does the addition of local anesthetics affect the clinical efficacy of platelet-rich plasma?; and f) Is there potential for future platelet-rich plasma applications for the treatment of neuropathic pain of peripheral origin?

Ultrasound-guided hydrodissection of the superficial peroneal nerve for chronic neuropathic pain: a war veteran's story.

Aim: This case report presents the application of ultrasound-guided hydrodissection of the superficial peroneal nerve to treat chronic refractory neuropathic pain, rated by the patient with an average intensity of 6/10 on the numerical rating scale. Materials & methods: Under ultrasound guidance, the nerve was identified compressed by a herniation of the peroneus brevis. An in-plane hydrodissection was performed using a solution of 10 ml of ropivacaine and methylprednisolone until the epineurium was entirely separated from the surrounding tissue. Results: At the 2-month follow-up, the patient reported a decrease of pain, which he rated a 2/10 on the numerical rating scale. At this point, night-time episodes of moderate pain persisted. The procedure was repeated and at the 6-month follow-up, the patient remained pain free. Conclusion: This case report suggests that consecutive ultrasound-guided hydrodissection techniques might be a valuable option in the treatment of superficial peroneal nerve entrapment neuropathy.

Peripheral neuropathic pain is a debilitating pain condition. Management can be challenging and clinicians often rely on oral medications and surgical options. This case report presents the treatment of a case of longstanding, moderate-to-severe superficial peroneal nerve entrapment neuropathy due to a grenade explosion, with consecutive nerve hydrodissection using a solution containing an anesthetic and a corticosteroid. Immediately after the second procedure and at the 6-month follow-up the patient reported near-total relief.

Revisiting the Genicular Nerve Block: An Up-to-Date Guide Utilizing Ultrasound Guidance and Peripheral Nerve Stimulation - Anatomy Description and Technique Standardization.

BACKGROUND: Over the last decade, several authors have reported that percutaneous peripheral nerve stimulation (PNS) can be used to assist in verifying the position of the procedure needle tip in relation to nerve structures, and that the combined technique using both ultrasound (US) guidance and PNS may serve as a reliable method for confirmation of the correct position of the procedure needle tip. It has also been reported that, when combined with US guidance, PNS may increase the success rate of pain management interventions. OBJECTIVES: The aim of this technical report was to standardize an effective and easy to learn illustrated step-by-step technical approach to nerve identification during US-guided genicular nerve blocks, using percutaneous PNS as a verification instrument for procedure needle tip location. STUDY DESIGN: This technical protocol was developed based on the results of the authors' most recent cadaveric study on the innervation of the knee joint capsule. The technique was developed and tested by 4 different interventionists with different levels of expertise in US-guided procedures. SETTING: The cadaveric study of the knee joint capsule innervation was performed at the laboratory of the Division of Anatomy of one institution. The technical protocol using US and PNS was later developed at the medical simulation center of a different institution. METHODS: A team of anatomists from a division of anatomy of one institution performed the cadaveric study on the innervation of the knee joint capsule. A team of physicians then developed the step-by-step approach to this technical protocol at the medical simulation center of  a different institution. Finally, the illustrated step-by-step approach was tested by 4 different interventionists with different levels of expertise in US-guided procedures (1 beginner-level user; 1 intermediate-level user; 2 expert-level users), using a portable percutaneous PNS and 2 different US transducers at 2 different institutions. RESULTS: This technical protocol was successfully developed based on the results of the cadaveric study on the innervation of the knee joint capsule. Additionally, it was later successfully tested by interventionists with various levels of expertise utilizing different US equipment at separate institutions. LIMITATIONS: By combining US and nerve stimulation, this protocol requires the availability of both US equipment and necessary equipment for nerve stimulation that must all be made available in the sterile field. Another potential disadvantage is that nerve stimulation controls and the US image screen are generally located on 2 separate display panels, which could cause difficulty with visualization and simultaneous calibration for 2 individual devices. CONCLUSIONS: Our illustrated step-by-step technical protocol can be effectively and safely utilized as a reliable method of training, by which physicians with little to moderate US experience can improve their skills in accurately identifying the genicular nerves while performing US-guided examinations with the intent of executing a peripheral nerve block.

Counting ribs and thoracic levels under ultrasound: a systematized technical protocol for both posterior and anterior approaches.

Over the last two decades, the clinical applications of diagnostic and interventional ultrasound have expanded rapidly. When analyzing the chest wall and thoracic region, ultrasound has previously been shown to reliably identify chest wall pathologies like rib fracture and slipping rib syndrome, as well as having fundamentally changed perioperative management and patient outcomes after the emergence of point-of-care ultrasound. In addition, ultrasound guidance has recently become more popular for multiple blocks in the field of regional anesthesia and pain medicine. In this technical report, we systematize an ultrasound-guided protocol for counting ribs and thoracic levels for both posterior and anterior approaches, which does not require level confirmation by fluoroscopy. With this protocol, we hope to create an effective educational resource to support physicians from any specialty background as they engage in point-of-care ultrasound applications in the thoracic region.

Accuracy of sonographically guided intra-articular injections in the native adult hip.

OBJECTIVE: The purpose of this study was to determine the accuracy of sonographically guided intra-articular injections performed in the native adult hip using contrast-enhanced fluoroscopy as a reference standard. METHODS: Twenty-eight consecutive patients (ages 32-91 years; mean, 68 years) referred to the pain clinic for intra-articular hip injections were recruited to participate. In each case, a 2- to 6-MHz curvilinear array transducer was used to place the needle into the hip joint at the femoral head-neck junction using an oblique sagittal approach. A contrast-enhanced fluoroscopic examination was then completed and assessed by an independent observer to determine needle placement accuracy. Once accurate placement was confirmed, the therapeutic injection proceeded. RESULTS: Thirty hip injections were completed in 15 women and 13 men (1 man and 1 woman received bilateral injections). The patients' body mass index (BMI) ranged from 20 to 39 kg/cm(2) (mean, 28 kg/cm(2)) and procedure time from initial scanning to injection averaged 112 seconds (range, 47-187 seconds). Overall, 97% of sonographically placed needles were accurate. The single inaccurate placement resulted from inadvertent needle withdrawal from the joint capsule during connection of the extension tubing for contrast agent injection in a young patient with a BMI of 28 kg/cm(2) and no hip effusion. CONCLUSIONS: Sonographic guidance can be used to inject the native adult hip joint with acceptable accuracy. When using the oblique sagittal approach, operators must be aware of the possibility of needle withdrawal from the joint due to the limited intra-articular space within the target region, particularly in the absence of effusion.

Ultrasound-guided intra-articular injection of the trapeziometacarpal joint: description of technique.

OBJECTIVE: To describe a new technique to perform an ultrasound-guided intra-articular injection of the trapeziometacarpal (TMC) joint. DESIGN: Ultrasound-guided injection of the TMC joint was completed on fresh frozen cadaver hand specimens using diatriazoate meglumine contrast. A fluoroscopic posteroanterior image of the TMC joint was then obtained to verify intra-articular placement of the contrast. SETTING: Anatomy lab in a medical college. SPECIMENS: Seventeen fresh frozen cadaver hand specimens. INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURE: Verification of this technique was confirmed using fluoroscopy and contrast. RESULTS: Sixteen (94%) of 17 joints injected showed contrast material within the TMC joint with a single cutaneous puncture. One intra-articular injection was initially misplaced into the scaphotrapeziotrapezoid joint. CONCLUSIONS: Ultrasound may be used to accurately perform intra-articular TMC injections. Ultrasound provides a viable alternative to fluoroscopy when accurate injection into the TMC joint is required for diagnostic or therapeutic purposes.

Accuracy of ultrasound-guided versus fluoroscopically guided contrast-controlled piriformis injections: a cadaveric study.

OBJECTIVE: The purpose of this study was to compare the accuracy of ultrasound-guided piriformis injections with fluoroscopically guided contrast-controlled piriformis injections in a cadaveric model. METHODS: Twenty piriformis muscles in 10 unembalmed cadavers were injected with liquid latex using both fluoroscopically guided contrast-controlled and US-guided injection techniques. All injections were performed by the same experienced individual. Two different colors of liquid latex were used to differentiate injection placement for each procedure, and the injection order was randomized. The gluteal regions were subsequently dissected by an individual blinded to the injection technique. Colored latex seen within the piriformis muscle, sheath, or both was considered an accurate injection. RESULTS: Nineteen of 20 ultrasound-guided injections (95%) correctly placed the liquid latex within the piriformis muscle, whereas only 6 of the 20 fluoroscopically guided contrast-controlled injections (30%) were accurate (P = .001). The liquid latex in 13 of the 14 missed fluoroscopically guided contrast-controlled piriformis injections and the single missed ultrasound-guided injection was found within the gluteus maximus muscle. In the single remaining missed fluoroscopically guided contrast-controlled piriformis injection, the liquid latex was found within the sciatic nerve. CONCLUSIONS: In this cadaveric model, ultrasound-guided piriformis injections were significantly more accurate than fluoroscopically guided contrast-controlled injections. Despite the use of bony landmarks and contrast, most of the fluoroscopically attempted piriformis injections were placed superficially within the gluteus maximus. Clinicians performing piriformis injections should be aware of the potential pitfalls of fluoroscopically guided contrast-controlled piriformis injections and consider using ultrasound guidance to ensure correct needle placement.

Ultrasound-Guided Spinal Procedures for Pain: A Review.

As the population ages, more patients are developing degenerative changes of the spine and associated pain. Although interventional procedures for axial and radicular spine pain have been available for decades, common imaging modalities have relied on ionizing radiation for guidance. Over the past decade, ultrasound has become increasingly popular to image both peripheral musculoskeletal and axial structures. This article reviews the use of ultrasound in the guidance of spine procedures, including cervical and lumbar facet injections and medial branch blocks, third occipital nerve blocks, thoracic facet and costotransverse joint injections, sacroiliac joint injections, and caudal and interlaminar epidural injections.