Computed Tomography Guidance for Spinal Intervention: Basics of Technique, Pearls, and Avoiding Pitfalls

The utilization of spinal interventional pain techniques has grown rapidly over the lastdecade. However, practitioners use widely different techniques in these procedures,particularly in the use of image guidance. The importance of image guidance washighlighted by the fact that in recent systematic reviews on therapeutic effectivenessof epidural steroid injections and facet joint interventions, only studies that used imageguidance were included. The choice of image guidance remains a matter of physicianpreference with conventional fluoroscopic or Computed Tomography (CT) guidancemost common.There are many advantages to CT guidance for certain spinal interventional painprocedures, mainly due to increased needle tip positioning accuracy. CT guidanceprovides greater anatomical detail that facilitates accurate needle trajectory planning,monitoring and final placement. Unlike conventional fluoroscopy that may be hinderedby tissue overlap and lack of surrounding anatomical detail CT guidance offers directvisualization of the entire needle trajectory and the surrounding soft tissue and bonestructures. Large osteophytes and adjacent vascular structures can be identified andsafely avoided.The goals of this narrative review are to provide a basic overview of CT techniquesavailable for spinal interventional pain procedures, to discuss the potential advantagesand disadvantages of CT guidance, to provide a simple step-by-step approach to useof CT guidance, to share technical pearls, and to discuss methods to avoid potentialpitfalls. This review will provide interventional pain physicians with knowledge ofrelevant CT image acquisition techniques and appropriate radiation dose reductionstrategies. This will contribute to increased technical success rates while reducingradiation dose to the patient and staff.Key words: Computed tomography, fluoroscopy, analgesia, epidural injection, spinalinjection, back pain, safety