PONOS · Ultrasound-guided injections
Ultrasound-guided cervical injections
Joints, medial branches and nerve roots: a targeted diagnostic and therapeutic pathway for neck pain.
When neck pain requires a precise target
Neck pain may arise from the posterior joints, peripheral nerves or an irritated nerve root. Clinical assessment guides the working diagnosis, but imaging alone does not always identify the pain generator. An ultrasound-guided injection can therefore have two roles: providing targeted treatment and observing the clinical response during a controlled test.
The PONOS pathway may consider cervical osteoarthritis and facet-related pain, cervicobrachialgia, selected cervical radiculopathies and persistent pain that has not responded adequately to conservative treatment.
Main indications
Posterior joint pain
A medial branch block or intra-articular injection may help assess the facet-related component and, when appropriate, reduce pain.
Radiculopathy and cervicobrachialgia
In selected cases, a periradicular injection may be considered for radiating pain after urgent surgical indications have been excluded.
Persistent pain
When conservative care is insufficient, the test may help define the next step, including possible medial branch radiofrequency treatment.
Why ultrasound guidance
Ultrasound helps identify soft tissues, muscles, vessels and nerves, including structures not directly visible on an X-ray.
Needle movement and injectate spread can be observed during the procedure according to the selected target and technique.
Ultrasound-guided injections do not use X-rays. Fluoroscopic guidance remains appropriate for specific procedures and targets.
Testing and treatment in one pathway
When appropriate, the block can be performed during the consultation, reducing waiting times and organisational costs while providing immediate clinical feedback.
An observable response
Changes in pain and movement after local anaesthetic help assess the target and decide whether to proceed with targeted treatment.
Observing injectate spread
For cervical nerve roots, ultrasound visualisation of tissue planes and injectate spread is particularly useful when performing a selective injection.
The vertebral artery and vessels near nerve roots
Before injection, ultrasound scanning and Doppler help identify visible vessels along the planned needle path. Vessel positions vary, so each patient is assessed individually. Ultrasound imaging alone cannot exclude every possible intravascular injection.
Anatomy of the neural structures
Select an image to enlarge it.
From diagnostic test to radiofrequency
The test is performed with local anaesthetic and, when appropriate, an anti-inflammatory medicine. Pain and normally provocative movements are assessed; the immediate response should not be confused with long-term benefit.
Hypothesis supported
Relief consistent with the target strengthens the indication and guides the next step.
Possible denervation
If facet-related pain is supported and relief is temporary, medial branch radiofrequency may be discussed.
Reconsider the diagnosis
Treatment is not continued automatically; the diagnosis, target and alternatives are reviewed.
How the procedure is performed
The procedure follows specialist assessment. The target, medicines, expected benefits and risks are discussed. After skin preparation, the needle is advanced under ultrasound guidance and the injectate is delivered in a controlled manner.
For cervical periradicular procedures, the medicine, volume, approach and need for radiological guidance are decided case by case. Cervical injections are not all equivalent, and not all are performed in an outpatient setting.
Medicines and regular treatment
Anticoagulants, antiplatelet agents, allergies and other medicines must be reported before the procedure. Do not stop any medicine yourself: management is decided individually according to the target and bleeding risk.
Cervical radiculopathy: the NASS recommendations
Identifying the symptomatic level
The 2010 NASS guideline considers selective nerve root blocks when imaging shows compression at several levels or when symptoms and MRI or CT myelography findings do not agree. The response is interpreted within the full clinical assessment.
Transforaminal injection
Fluoroscopy- or CT-guided transforaminal epidural steroid injection may be considered for degenerative cervical radiculopathy, with careful attention to potential complications.
Measuring pain and function
The guideline recommends NDI, VAS, SF-12 and SF-36 to assess outcomes. This Grade A recommendation concerns outcome measures, not cervical injections.
Results, limitations and safety
The anaesthetic effect may be immediate and temporary. Any anti-inflammatory benefit may develop over the following days. Duration varies according to the cause of pain.
Possible events include temporary local pain, bruising, infection, medication reactions and, rarely, neurological or vascular complications. The cervical region requires particular precision; the procedure is performed only when the expected benefit outweighs the individual risk.
New weakness, significant sensory disturbance, breathing difficulty, fever or rapidly increasing pain require prompt medical assessment.
Frequently asked questions
Do injections always confirm the diagnosis?
No. A positive response is useful diagnostic evidence, to be integrated with the clinical picture. It is not an absolute guarantee.
Is the test used to decide on radiofrequency?
It can support selection when the pain is consistent with a facet origin. The decision still requires full specialist assessment.
Is the procedure always performed as an outpatient?
Many ultrasound-guided blocks can be performed in the clinic. Periradicular procedures and higher-risk techniques are organised according to the site, target and patient factors.
Do I need to stop anticoagulants or antiplatelet medicines?
Not without advice. Management is agreed case by case, considering the procedure, medicine and individual risk.
The PONOS specialist pathway
Assessment, diagnostic testing, treatment and follow-up form a single pathway. The goal is not to inject automatically, but to identify the correct target and choose the most appropriate procedure.
Book an assessmentCervical radiofrequency (in Italian)Selected references
North American Spine Society. Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders, 2010. Full NASS guideline.
Narouze S, et al. Ultrasound-guided cervical selective nerve root block: a fluoroscopy-controlled feasibility study. 2009. Study on visualising nerve roots and vessels.
Cui X, et al. Randomised comparison of ultrasound-guided selective cervical nerve root block and fluoroscopy-guided transforaminal epidural block. Annals of Medicine, 2022. PubMed.
Schneider B, Popescu A, Smith C. Ultrasound Imaging for Cervical Injections. Pain Medicine, 2020;21:196–197. Limitations and safety considerations.
Hurley RW, Adams MCB, Barad M, et al. Consensus practice guidelines on interventions for cervical spine (facet) joint pain. Regional Anesthesia and Pain Medicine. 2022;47:3–59. PubMed · PMID 34764220.
Clinical content: Dr Evangelos Panagiotakos MD · Anaesthesiologist and Interventional Pain Specialist.