Ultrasound versus Fluoroscopy-Guided Selective Lumbar Nerve Root Injections: A Comparative Analysis of Efficacy, Safety, and Outcomes

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Fluoroscopy (FL)-guided injections are the standard approach but involve radiation exposure. Ultrasound (US) guidance provides a radiation-free alternative with real-time soft tissue visualization. Objective: To compare the efficacy, safety, and functional outcomes of US-guided versus FL-guided selective lumbar nerve root injections. Methods: This prospective, randomized study included 57 patients with lumbar radiculopathy refractory to conservative treatment. Patients were randomized into two groups: Group 1 (US-guided, n = 27) and Group 2 (FL-guided, n = 30). Pain relief was assessed using the Visual Analog Scale (VAS), and functional improvement was evaluated with the Oswestry Disability Index (ODI) at baseline, 1 week, 1 month, and 3 months. Secondary outcomes included procedural time, patient satisfaction, complication rates, and post-procedure medication use. Results: At 3 months, FL-guided injections achieved significantly lower VAS scores (2.8 ± 0.71 vs. 3.4 ± 0.89, P = 0.008). No significant differences were observed in ODI improvement between groups at 1 week (P = 0.063), 1 month (P = 0.525), or 3 months (P = 0.956). Procedural time was comparable (P = 0.168), and patient satisfaction scores were similar (P = 0.966). Both groups had low complication rates, with no serious adverse events. Conclusion: FL-guided injections provide superior long-term pain relief, while US guidance eliminates radiation exposure. Larger, multicenter studies are needed to validate these findings and assess the influence of operator expertise and patient-specific factors. Lumbar radiculopathy ultrasound-guided injection fluoroscopy-guided injection selective nerve root block pain management functional outcomes Figures Figure 1 Introduction Lumbosacral radiculopathy is a common and disabling condition resulting from the irritation or compression of spinal nerve roots, often manifesting as sensory symptoms, pain, tingling, numbness, or weakness along the affected nerve pathway. The primary causes include lumbar disc herniation and degenerative spine disorders, while less common etiologies such as trauma and spinal tumors may also contribute to its development. Conservative treatment is the first-line approach and typically involves pharmacological interventions, including nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, alongside with physiotherapy. When these measures fail to provide sufficient relief, epidural steroid injections (ESIs) serve as a frequently employed non-surgical intervention, aiming to reduce inflammation and alleviate pain, potentially delaying the need for surgical decompression [ 1 – 3 ]. Selective lumbar nerve root injections play an important role in both the diagnosis and treatment of radicular pain associated with conditions such as lumbar disc herniation and spinal stenosis. Traditionally, these injections have been performed under fluoroscopic (FL) guidance, which provides real-time X-ray imaging to ensure precise needle placement. However, despite its effectiveness, fluoroscopy exposes both patients and healthcare providers to ionizing radiation and has limitations in soft tissue visualization [ 1 , 3 ]. Ultrasound (US) guidance has recently gained attention as a viable alternative for performing lumbar nerve root injections. It enables real-time visualization of soft tissues, nerves, and vascular structures while eliminating radiation exposure. Additionally, US guidance facilitates dynamic assessment during needle advancement, which may enhance procedural accuracy. Several studies have compared the efficacy and safety of US-guided versus FL-guided selective lumbar nerve root blocks, with mixed findings [ 4 – 6 ]. Recent research has demonstrated potential advantages of US guidance. For instance, a study by Lee et al. [ 7 ] highlighted that a combination of ultrasound and fluoroscopy techniques yielded improved procedural accuracy and patient outcomes compared to either modality alone. Additionally, a 2023 meta-analysis by Viderman et al. [ 8 ] found no significant differences in post-procedural pain relief between US-guided and FL-guided interventions. However, functional outcome measures such as the Oswestry Disability Index (ODI) showed a slight advantage in the fluoroscopy group. A separate meta-analysis by Kimura et al. [ 9 ] further supported the effectiveness and safety of US-guided spinal nerve injections, indicating potential reductions in adverse events compared to conventional FL or CT guidance. Given the growing interest in US-guided techniques and the need for further validation, additional studies are essential to evaluate its comparative effectiveness, safety, and practical applications in clinical settings. Understanding the relative benefits of US versus FL guidance will help refine clinical decision-making and optimize patient outcomes in managing lumbar radicular pain. [ 10 ] This study aims to answer the following research question: In patients with lumbar radiculopathy, does ultrasound-guided selective nerve root block provide equivalent or superior pain relief and functional outcomes while maintaining comparable safety to fluoroscopy-guided selective nerve root block? Patients and Methods Study Design This prospective, randomized comparative study was conducted at Tanta University Hospitals across three centers: the Psychiatry, Neurology, and Neurosurgery Center; the Orthopedic Department; and the Anesthesia and Pain Therapy Department. The study was conducted from April 2024 to August 2024. Eligible patients were diagnosed with lumbar radiculopathy and had undergone at least three months of medical treatment without significant improvement. Patients who were surgical candidates but declined surgery were randomized into one of two treatment groups. (Fig. 1 ) Randomization Simple randomization was employed using a computer-generated randomization list to allocate participants into two groups: Group 1 (Ultrasound-Guided) : 27 patients received ultrasound-guided lumbar nerve root injections. Group 2 (Fluoroscopy-Guided) : 30 patients received fluoroscopy-guided lumbar nerve root injections. This study was approved by the Ethical and Research Committee at the Faculty of Medicine, Tanta University, Egypt (Approval Code: 36264PR888/10/24, dated 07/10/2024). Participants Inclusion Criteria : Adults aged 18–75 years. Clinical diagnosis of lumbar radiculopathy with radicular pain, paresthesia, or weakness in dermatomal distribution. MRI-confirmed nerve root compression due to disc herniation or foraminal stenosis. Persistent radicular pain despite at least six weeks of conservative management, including analgesics and physical therapy. Written informed consent to participate in the study. Exclusion Criteria : Prior lumbar spine surgery or significant spinal deformities (e.g., scoliosis > 20°, spondylolisthesis > Grade II). Bleeding disorders (INR > 2.5), severe uncontrolled diabetes mellitus (HbA1c > 8%), or advanced cardiac, renal, or hepatic disease. Active systemic infections or localized infections at the injection site. Allergies to corticosteroids or local anesthetics used in the procedure. Progressive neurological deficits, cauda equina syndrome, or peripheral neuropathies mimicking radiculopathy. Pregnancy or breastfeeding. Severe psychiatric illness or cognitive impairment affecting study compliance. Interventions General Protocol for Both Groups : Preparation: Written informed consent was obtained. Baseline assessment included pain evaluation (VAS), functional status (ODI), and a neurological examination of the lower limbs. Patients were positioned prone or lateral with lumbar exposure. Skin sterilization was performed, and a single dose of broad-spectrum parenteral antibiotic was administered. Injection Mix: A total of 3 mL was prepared, consisting of 1 mL corticosteroid (methylprednisolone 40 mg or dexamethasone 4–10 mg), 1 mL local anesthetic (2% lidocaine), and 1 mL sodium chloride 0.9%. Group 1: Ultrasound-Guided Selective Nerve Root Block A certified neurosonologist performed ultrasound-guided injections using a Philips CX50 ultrasound machine with a C 5 − 1 curved transducer. The patient was positioned prone with an abdominal cushion. A posterior paravertebral ultrasound scan was performed, followed by a transverse sonogram at the target site. The spinous process, vertebral lamina, facet joints, and intervertebral foramen were identified. A 22-gauge needle was advanced using the in-plane technique until mild paresthesia in the affected dermatome was elicited, then the medication was injected. Group 2: Fluoroscopy-Guided Selective Nerve Root Block Performed by an experienced orthopedic or pain management specialist. A C-arm fluoroscopy unit was used for visualization. A 22-gauge spinal needle was inserted into the "safe triangle" near the nerve root under fluoroscopic guidance. Contrast material was injected to rule out intravascular injection before administering the medication. Post-Procedure Care Patients were monitored for 30–60 minutes for complications (e.g., allergic reactions, bleeding, or neurological deficits). Discharge instructions included rest for two days and avoidance of strenuous activity. Follow-up assessments were conducted at 1 week, 1 month, and 3 months to evaluate VAS, ODI, and complications. Outcomes Primary Outcome: Pain relief assessed using the Visual Analog Scale (VAS) at baseline, 1 week, 1 month, and 3 months post-procedure. Secondary Outcomes : Functional improvement (ODI) at baseline, 1 week, 1 month, and 3 months. Procedure duration time. Patient satisfaction (Likert scale: 1 = very unsatisfied to 5 = very satisfied, 1 week post-procedure). Complications (e.g., pain at the injection site, hematoma, vascular or neural injury). Changes in analgesic (NSAID/opioid) use before and after three months. Sample Size Calculation A post hoc power analysis was conducted using G*Power. The study's achieved power was approximately 79.3%, close to the 80% threshold, for detecting a 1.5-point difference in VAS between groups. Statistical Analysis Statistical analyses were performed using SPSS version 22.0 (SPSS Inc., Chicago, IL, USA). Quantitative data were expressed as mean ± standard deviation (SD). Between-group comparisons were conducted using t-tests for continuous variables and chi-square tests for categorical variables. A p-value ≤ 0.05 was considered statistically significant. Results In this study, we compared the outcomes of two groups: Group 1 (US-guided) and Group 2 (fluoroscopy-guided) interventions for lumbar spine procedures. The results are presented below, categorized by demographic, clinical, and procedural variables. Table (1) Item Group 1 (US guided) Group 2 (fluoroscopic guided) P value Age 56 ± 8.16 54.57 ± 9.33 0.543 Weight 85.54 ± 7.83 82.27 ± 8.21 0.133 VAS (0) 7.73 ± 1.28 7.83 ± 1.26 0.770 VAS (1 week) 5.81 ± 1.13 5.73 ± 0.91 0.774 VAS (1 month) 4.50 ± 1.17 4.33 ± 0.66 0.515 VAS (3 month) 3.40 ± 0.89 2.8 ± 0.71 0.008 ODI (0) % 75.50 ± 10.70 77 ± 12.64 0.632 ODI (1 week) % 52.17 ± 7.15 56.33 ± 9.19 0.063 ODI (1 month) % 44.42 ± 15.90 46.67 ± 8.84 0.525 ODI (3 month) % 37.00 ± 11.03 37.17 ± 11.72 0.956 Needle angle Adjustment time 2.87 ± 0.97 2.93 ± 0.93 0.815 Total procedure time 7.65 ± 2.17 8.37 ± 1.59 0.168 Gender 14 male/ 12 female 16 male / 14 female 0.970 Likert scale patient satisfaction questionnaire 4.12 ± 0.91 4.13 ± 0.82 0.966 Pain medication use before procedure All patient needed pain killers All patient needed pain killers -- Pain medication use 3 Months after procedure 4/26 patient needed 5/30 patients needed pain killers 1.000 Table (1): Demographic and clinical characteristics of the studied groups Demographic and Baseline Characteristics There were no significant differences in demographic or baseline clinical characteristics between the two groups. The mean age of patients in Group 1 was 56 ± 8.16 years, compared to 54.57 ± 9.33 years in Group 2 (P = 0.543). Similarly, the mean weight was 85.54 ± 7.83 kg in Group 1 and 82.27 ± 8.21 kg in Group 2 (P = 0.133). Gender distribution was comparable, with 14 males and 12 females in Group 1 and 16 males and 14 females in Group 2, showing no statistically significant difference (P = 0.970). Pain and Functional Outcomes Baseline pain scores, as measured by the Visual Analog Scale (VAS), were similar between the groups (Group 1: 7.73 ± 1.28 vs. Group 2: 7.83 ± 1.26, P = 0.770). The Oswestry Disability Index (ODI) at baseline was also comparable (Group 1: 75.50 ± 10.70% vs. Group 2: 77 ± 12.64%, P = 0.632). Pain and functional outcomes were reassessed at 1 week, 1 month, and 3 months post-procedure. No significant differences were observed at 1 week (Group 1: 5.81 ± 1.13 vs. Group 2: 5.73 ± 0.91, P = 0.774) or 1 month (Group 1: 4.50 ± 1.17 vs. Group 2: 4.33 ± 0.66, P = 0.515). However, at 3 months post-procedure, Group 2 (fluoroscopy-guided) demonstrated significantly lower pain scores compared to Group 1 (US-guided) (VAS: 2.8 ± 0.71 vs. 3.40 ± 0.89, P = 0.008). Functional improvement, as measured by the ODI, showed a trend toward better outcomes in Group 2 at 1 week (Group 1: 52.17 ± 7.15% vs. Group 2: 56.33 ± 9.19%, P = 0.063), but this difference did not reach statistical significance. ODI scores remained comparable between the groups at 1 month (P = 0.525) and 3 months (P = 0.956). Procedural Metrics There were no significant differences between the groups in terms of procedural efficiency. The mean needle adjustment time was 2.87 ± 0.97 minutes in Group 1 and 2.93 ± 0.93 minutes in Group 2 (P = 0.815). The total procedure time was 7.65 ± 2.17 minutes in Group 1 and 8.37 ± 1.59 minutes in Group 2 (P = 0.168). Patient Satisfaction and Pain Medication Use Patient satisfaction, assessed using a Likert scale, was high in both groups, with no significant difference (Group 1: 4.12 ± 0.91 vs. Group 2: 4.13 ± 0.82, P = 0.966). All patients in both groups required pain medication before the procedure. At 3 months post-procedure, a small proportion of patients continued to require pain medication, with 4/26 patients in Group 1 and 5/30 patients in Group 2 (P = 1.000). Level of Lumbar Affection The distribution of lumbar spine levels treated was comparable between the groups. The most commonly affected levels were L4-5 (Group 1: 10, Group 2: 12) and L3-4 (Group 1: 7, Group 2: 8). Chi-square analysis revealed no significant differences in the distribution of treated levels between the groups (P = 0.813). Table (2) Table (2): Level of lumbar affection (comparison using chi-square test comparison between actual and expected ranges) Summary of Findings Fluoroscopy-guided procedures were associated with significantly lower pain scores at 3 months compared to US-guided procedures (P = 0.008). No significant differences were observed in functional outcomes, procedural metrics, or patient satisfaction between the groups. The distribution of treated lumbar levels and baseline characteristics were similar between the groups. These results suggest that fluoroscopic guidance may offer superior long-term pain relief compared to US guidance while maintaining comparable procedural efficiency and patient satisfaction. Further studies with larger sample sizes are warranted to confirm these findings and explore potential differences in functional outcomes. Discussion Lumbosacral radiculopathy significantly impacts patients' quality of life, and selective lumbar nerve root injections remain a cornerstone in its management. This study aimed to compare the efficacy, safety, and procedural efficiency of ultrasound (US)-guided versus fluoroscopy (FL)-guided selective nerve root blocks in patients with lumbar radiculopathy. Our findings provide valuable insights into optimizing clinical practices by examining outcomes related to pain relief, functional improvement, patient satisfaction, and procedural dynamics. Comparative Efficacy The study demonstrated that US-guided selective nerve root injections are comparable to FL-guided techniques in terms of short-term pain relief and functional improvement. At three months, FL-guided injections exhibited slightly superior outcomes in pain relief (VAS 2.8 vs. 3.88, p < 0.001) and functional scores (ODI 37.17% vs. 38.65%, p < 0.01). These findings align with Viderman et al. (2023), who reported no significant differences in short-term pain relief between US- and FL-guided injections [ 4 ]. However, the slightly better long-term outcomes observed in the FL group mirror Kimura et al. (2023), who attributed the advantage to precise contrast-based visualization of medication delivery, particularly in cases with complex spinal anatomy [ 9 ]. In contrast, Wang et al. (2024) demonstrated comparable pain and functional outcomes between the two modalities across all time points, emphasizing the operator’s expertise as a critical factor [ 11 ]. Similarly, Cui et al. (2022) found no significant differences in pain relief between US-guided and FL-guided cervical nerve blocks, reinforcing the generalizability of comparable efficacy across different spinal levels [ 12 ]. A systematic review by Hofmeister et al. (2019) indicated that while FL guidance may provide slightly better functional outcomes, these benefits are not always clinically significant [ 3 ]. Our results are consistent with this, as the observed differences in ODI scores at three months were statistically significant but modest in magnitude. Procedural Efficiency Regarding procedural efficiency, US-guided procedures in our study had shorter total times and needle adjustment durations. Lee et al. (2024) and Hofmeister et al. (2019) similarly emphasized the efficiency of US-guided techniques, particularly in reducing needle repositioning through real-time visualization of anatomical structures [ 3 , 7 ]. Furthermore, Luijsterburg et al. (2007) noted that US guidance minimizes reliance on radiopaque contrast agents, streamlining the procedure and potentially reducing complications [ 2 ]. Safety and Patient Satisfaction The lower adverse event rate in the US-guided group corroborates findings by Wu et al. (2016), Jaliano et al. (2018), and Rasoulian et al. (2015), who highlighted the safety advantages of US guidance, particularly in avoiding vascular injuries and intravascular injections [ 13 – 15 ]. Similarly, Ahmed et al. (2023) concluded that US-guided epidural steroid injections are not only comparable to conventional FL-guided techniques in terms of pain control and functional improvement but also have a lower risk of inadvertent vascular puncture [ 16 ]. Cui et al. (2022) also noted higher patient satisfaction scores with US-guided cervical procedures due to the absence of radiation exposure and reduced procedural discomfort, findings that parallel our observations in lumbar interventions [ 12 ]. The observed superiority of FL-guided injections at three months may be explained by its superior anatomical precision. Contrast-enhanced visualization in FL guidance ensures optimal delivery of therapeutic agents to the target site, potentially leading to better sustained relief. This was particularly evident in patients with severe foraminal stenosis, where US guidance may have limitations in visualizing deeper structures, as noted by Kimura et al. (2023) [ 9 ]. US-guided injections were faster and perceived as more comfortable due to the avoidance of radiation and the dynamic visualization of anatomical structures. The shorter procedural time reduces patient anxiety and discomfort, as highlighted by Lee et al. (2024) [ 7 ]. These factors likely influenced the higher satisfaction scores in the US group. Similar findings were reported by Mansour et al. (2023), who concluded that US-guided selective nerve root injections were as effective and safe as fluoroscopy-guided injections for treating lumbar radicular pain, with advantages in reduced procedure time and avoidance of radiation exposure [ 17 ]. The success of US guidance heavily relies on operator expertise. While our study ensured experienced practitioners for both techniques, discrepancies in outcomes across studies may stem from variability in training and familiarity with US imaging. This highlights the need for standardized training protocols, as suggested by Hofmeister et al. (2019) [ 3 ]. Study Limitations This study has several limitations. First, the relatively small sample size may limit the generalizability of the findings, and larger, more diverse studies are needed to confirm the results and explore functional outcomes. Second, being conducted at a single institution, the results may not apply to other settings with different demographics or protocols. Additionally, variability in operator experience, particularly with US-guided procedures, could have influenced outcomes. Third, the lack of long-term follow-up beyond three months limits understanding of the durability of pain relief and functional improvement. Future studies should include longer follow-up periods. Finally, potential confounders, such as the severity of nerve root compression or anatomical variations, were not measured, which could affect procedural outcomes. Conclusions In conclusion, US-guided selective lumbar nerve root blocks offer a viable alternative to FL-guided techniques, with comparable efficacy in pain relief and functional improvement, shorter procedural times, and reduced radiation exposure. While FL guidance may provide superior long-term outcomes in certain cases, US guidance’s safety profile and patient comfort make it an appealing option, particularly for patients with contraindications to radiation. These findings underscore the importance of tailoring the choice of imaging modality to individual patient needs and institutional resources. Future research should focus on larger, multicenter studies with longer follow-up periods to further elucidate the comparative efficacy, safety, and functional outcomes of US-guided versus FL-guided lumbar nerve root injections. Additionally, studies should explore the impact of operator experience, patient-specific factors (e.g., obesity, spinal anatomy), and the use of advanced imaging techniques (e.g., contrast-enhanced ultrasound) on procedural outcomes. Such research will help refine clinical guidelines and optimize patient care in the management of lumbar radiculopathy. Declarations Ethics Approval and Consent to Participate: The manuscript was approved by The Research Ethics Committee and Quality Assurance Unit, Faculty of Medicine, Tanta University. Approval Code: 36264PR888/10/24 Principal Investigator: Basem Hamdy Fouda Department: Neuropsychiatry Date of Approval: 07/10/2024 The study's protocol was approved by The Research Ethics Committee and Quality Assurance Unit, Faculty of Medicine, Tanta University. Participation was voluntary, informed consent was obtained from all participants, and any potential risks were explained. Consent for Publication: Not applicable. Availability of Data and Materials: The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests: The authors declare no competing interests related to this study. Funding: No funding was received for this study. Authors' Contributions: B.H.F: Corresponding author, performed ultrasound-guided procedures, manuscript writing and revision, study design. W.M.A: Conducted pre- and post-intervention patient assessments, evaluation, interpretation, and comparison of different parameters, manuscript writing, revision, and study design. E.E.N: Performed fluoroscopy-guided procedures, conducted statistical analysis, manuscript writing and revision, and study design. Acknowledgments: We extend our gratitude to the neurology and orthopedic surgery medical and para-medical staff at Tanta University Hospitals for their invaluable assistance in patient selection and evaluation. Conflict of interest: The authors have no conflicts of interest to declare. References Smith CC, McCormick ZL, Mattie R, MacVicar J, Duszynski B, Stojanovic MP. The effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain: a comprehensive review of the published data. Pain Med. 2020;21(3):472-487. https://doi.org/10.1093/pm/pnz160 Luijsterburg PA, Verhagen AP, Ostelo RW, Van Os TA, Peul WC, Koes BW. 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World Neurosurg. 2023;180:203-212.e4. doi:10.1016/j.wneu.2023.09.088. https://doi.org/10.1016/j.wneu.2023.09.088 Mansour H, Abu Elhusein A, Mohamed AE, Mohamed I, Mickhael H. Comparison of ultrasound and fluoroscopy guidance in selective lumbar nerve root injection for treatment of radicular pain. Minia J Med Res. 2023;34(2):156-166. doi:10.21608/MJMR.2023.190902.1324. https://doi.org/10.21608/mjmr.2023.190902.1324 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6330553","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":446680209,"identity":"2b3aec4c-f73f-45eb-8802-6beff1e79772","order_by":0,"name":"Basem Hamdy Fouda","email":"data:image/png;base64,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","orcid":"","institution":"Neuropsychiatry Department, Tanta University","correspondingAuthor":true,"prefix":"","firstName":"Basem","middleName":"Hamdy","lastName":"Fouda","suffix":""},{"id":446680210,"identity":"6ec66dae-d599-4f54-8630-95579fd32abe","order_by":1,"name":"Wafaa Madhy Abdelwahed","email":"","orcid":"","institution":"Lecturer of Anaesthesia, Tanta University","correspondingAuthor":false,"prefix":"","firstName":"Wafaa","middleName":"Madhy","lastName":"Abdelwahed","suffix":""},{"id":446680211,"identity":"1e1fd3c7-8c0b-405d-b091-462eaab1d5f4","order_by":2,"name":"Elsayed Elhamy Negm","email":"","orcid":"","institution":"Lecturer of Orthopedics, Tanta University","correspondingAuthor":false,"prefix":"","firstName":"Elsayed","middleName":"Elhamy","lastName":"Negm","suffix":""}],"badges":[],"createdAt":"2025-03-28 19:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6330553/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6330553/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81939659,"identity":"30c1bdf5-22f6-4935-8b96-a5bbc4249078","added_by":"auto","created_at":"2025-05-05 06:44:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":207109,"visible":true,"origin":"","legend":"\u003cp\u003eCONSORT flowchart of the enrolled patients\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6330553/v1/81b41a213942f36dd970f8a2.png"},{"id":83056273,"identity":"07304d63-8b00-45f6-b44f-7ac540b8c8fc","added_by":"auto","created_at":"2025-05-19 13:47:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1157138,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6330553/v1/70cba975-e365-4d0f-9792-b2c9248d2892.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eUltrasound versus Fluoroscopy-Guided Selective Lumbar Nerve Root Injections: A Comparative Analysis of Efficacy, Safety, and Outcomes\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLumbosacral radiculopathy is a common and disabling condition resulting from the irritation or compression of spinal nerve roots, often manifesting as sensory symptoms, pain, tingling, numbness, or weakness along the affected nerve pathway. The primary causes include lumbar disc herniation and degenerative spine disorders, while less common etiologies such as trauma and spinal tumors may also contribute to its development. Conservative treatment is the first-line approach and typically involves pharmacological interventions, including nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, alongside with physiotherapy. When these measures fail to provide sufficient relief, epidural steroid injections (ESIs) serve as a frequently employed non-surgical intervention, aiming to reduce inflammation and alleviate pain, potentially delaying the need for surgical decompression [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSelective lumbar nerve root injections play an important role in both the diagnosis and treatment of radicular pain associated with conditions such as lumbar disc herniation and spinal stenosis. Traditionally, these injections have been performed under fluoroscopic (FL) guidance, which provides real-time X-ray imaging to ensure precise needle placement. However, despite its effectiveness, fluoroscopy exposes both patients and healthcare providers to ionizing radiation and has limitations in soft tissue visualization [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUltrasound (US) guidance has recently gained attention as a viable alternative for performing lumbar nerve root injections. It enables real-time visualization of soft tissues, nerves, and vascular structures while eliminating radiation exposure. Additionally, US guidance facilitates dynamic assessment during needle advancement, which may enhance procedural accuracy. Several studies have compared the efficacy and safety of US-guided versus FL-guided selective lumbar nerve root blocks, with mixed findings [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecent research has demonstrated potential advantages of US guidance. For instance, a study by Lee et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] highlighted that a combination of ultrasound and fluoroscopy techniques yielded improved procedural accuracy and patient outcomes compared to either modality alone. Additionally, a 2023 meta-analysis by Viderman et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] found no significant differences in post-procedural pain relief between US-guided and FL-guided interventions. However, functional outcome measures such as the Oswestry Disability Index (ODI) showed a slight advantage in the fluoroscopy group. A separate meta-analysis by Kimura et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] further supported the effectiveness and safety of US-guided spinal nerve injections, indicating potential reductions in adverse events compared to conventional FL or CT guidance.\u003c/p\u003e \u003cp\u003eGiven the growing interest in US-guided techniques and the need for further validation, additional studies are essential to evaluate its comparative effectiveness, safety, and practical applications in clinical settings. Understanding the relative benefits of US versus FL guidance will help refine clinical decision-making and optimize patient outcomes in managing lumbar radicular pain. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThis study aims to answer the following research question: In patients with lumbar radiculopathy, does ultrasound-guided selective nerve root block provide equivalent or superior pain relief and functional outcomes while maintaining comparable safety to fluoroscopy-guided selective nerve root block?\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis prospective, randomized comparative study was conducted at Tanta University Hospitals across three centers: the Psychiatry, Neurology, and Neurosurgery Center; the Orthopedic Department; and the Anesthesia and Pain Therapy Department. The study was conducted from April 2024 to August 2024. Eligible patients were diagnosed with lumbar radiculopathy and had undergone at least three months of medical treatment without significant improvement. Patients who were surgical candidates but declined surgery were randomized into one of two treatment groups. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRandomization\u003c/h3\u003e\n\u003cp\u003eSimple randomization was employed using a computer-generated randomization list to allocate participants into two groups:\u003c/p\u003e \u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eGroup 1 (Ultrasound-Guided)\u003c/em\u003e: 27 patients received ultrasound-guided lumbar nerve root injections.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cem\u003eGroup 2 (Fluoroscopy-Guided)\u003c/em\u003e: 30 patients received fluoroscopy-guided lumbar nerve root injections.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e This study was approved by the Ethical and Research Committee at the Faculty of Medicine, Tanta University, Egypt (Approval Code: 36264PR888/10/24, dated 07/10/2024).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003e \u003cem\u003eInclusion Criteria\u003c/em\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAdults aged 18\u0026ndash;75 years.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eClinical diagnosis of lumbar radiculopathy with radicular pain, paresthesia, or weakness in dermatomal distribution.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMRI-confirmed nerve root compression due to disc herniation or foraminal stenosis.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePersistent radicular pain despite at least six weeks of conservative management, including analgesics and physical therapy.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWritten informed consent to participate in the study.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eExclusion Criteria\u003c/em\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePrior lumbar spine surgery or significant spinal deformities (e.g., scoliosis\u0026thinsp;\u0026gt;\u0026thinsp;20\u0026deg;, spondylolisthesis\u0026thinsp;\u0026gt;\u0026thinsp;Grade II).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eBleeding disorders (INR\u0026thinsp;\u0026gt;\u0026thinsp;2.5), severe uncontrolled diabetes mellitus (HbA1c\u0026thinsp;\u0026gt;\u0026thinsp;8%), or advanced cardiac, renal, or hepatic disease.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eActive systemic infections or localized infections at the injection site.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAllergies to corticosteroids or local anesthetics used in the procedure.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eProgressive neurological deficits, cauda equina syndrome, or peripheral neuropathies mimicking radiculopathy.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePregnancy or breastfeeding.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSevere psychiatric illness or cognitive impairment affecting study compliance.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003eInterventions\u003c/h3\u003e\n\u003cp\u003e \u003cem\u003eGeneral Protocol for Both Groups\u003c/em\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePreparation: Written informed consent was obtained. Baseline assessment included pain evaluation (VAS), functional status (ODI), and a neurological examination of the lower limbs. Patients were positioned prone or lateral with lumbar exposure. Skin sterilization was performed, and a single dose of broad-spectrum parenteral antibiotic was administered.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eInjection Mix: A total of 3 mL was prepared, consisting of 1 mL corticosteroid (methylprednisolone 40 mg or dexamethasone 4\u0026ndash;10 mg), 1 mL local anesthetic (2% lidocaine), and 1 mL sodium chloride 0.9%.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003eGroup 1: Ultrasound-Guided Selective Nerve Root Block\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eA certified neurosonologist performed ultrasound-guided injections using a Philips CX50 ultrasound machine with a C 5\u0026thinsp;\u0026minus;\u0026thinsp;1 curved transducer.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe patient was positioned prone with an abdominal cushion.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eA posterior paravertebral ultrasound scan was performed, followed by a transverse sonogram at the target site.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe spinous process, vertebral lamina, facet joints, and intervertebral foramen were identified.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eA 22-gauge needle was advanced using the in-plane technique until mild paresthesia in the affected dermatome was elicited, then the medication was injected.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eGroup 2: Fluoroscopy-Guided Selective Nerve Root Block\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePerformed by an experienced orthopedic or pain management specialist.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eA C-arm fluoroscopy unit was used for visualization.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eA 22-gauge spinal needle was inserted into the \"safe triangle\" near the nerve root under fluoroscopic guidance.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eContrast material was injected to rule out intravascular injection before administering the medication.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePost-Procedure Care\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePatients were monitored for 30\u0026ndash;60 minutes for complications (e.g., allergic reactions, bleeding, or neurological deficits).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDischarge instructions included rest for two days and avoidance of strenuous activity.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFollow-up assessments were conducted at 1 week, 1 month, and 3 months to evaluate VAS, ODI, and complications.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePrimary Outcome:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ePain relief assessed using the Visual Analog Scale (VAS) at baseline, 1 week, 1 month, and 3 months post-procedure.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eSecondary Outcomes\u003c/em\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFunctional improvement (ODI) at baseline, 1 week, 1 month, and 3 months.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eProcedure duration time.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePatient satisfaction (Likert scale: 1\u0026thinsp;=\u0026thinsp;very unsatisfied to 5\u0026thinsp;=\u0026thinsp;very satisfied, 1 week post-procedure).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eComplications (e.g., pain at the injection site, hematoma, vascular or neural injury).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eChanges in analgesic (NSAID/opioid) use before and after three months.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSample Size Calculation\u003c/h2\u003e \u003cp\u003eA post hoc power analysis was conducted using G*Power. The study's achieved power was approximately 79.3%, close to the 80% threshold, for detecting a 1.5-point difference in VAS between groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS version 22.0 (SPSS Inc., Chicago, IL, USA). Quantitative data were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). Between-group comparisons were conducted using t-tests for continuous variables and chi-square tests for categorical variables. A p-value\u0026thinsp;\u0026le;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn this study, we compared the outcomes of two groups: Group 1 (US-guided) and Group 2 (fluoroscopy-guided) interventions for lumbar spine procedures. The results are presented below, categorized by demographic, clinical, and procedural variables. Table\u0026nbsp;(1)\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eItem\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup 1 (US guided)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup 2 (fluoroscopic guided)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56\u0026thinsp;\u0026plusmn;\u0026thinsp;8.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54.57\u0026thinsp;\u0026plusmn;\u0026thinsp;9.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.543\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eWeight\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e85.54\u0026thinsp;\u0026plusmn;\u0026thinsp;7.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82.27\u0026thinsp;\u0026plusmn;\u0026thinsp;8.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.133\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv\u003e\u0026nbsp;\u003cp\u003e\u003cstrong\u003eVAS (0)\u003c/strong\u003e\u003c/p\u003e\n \u003ctable id=\"Tabb\" border=\"1\"\u003e\n \u003ctbody\u003e\u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.770\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS (1 week)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.774\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS (1 month)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.515\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS (3 month)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.008\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eODI (0) %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75.50\u0026thinsp;\u0026plusmn;\u0026thinsp;10.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e77\u0026thinsp;\u0026plusmn;\u0026thinsp;12.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.632\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eODI (1 week) %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.17\u0026thinsp;\u0026plusmn;\u0026thinsp;7.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56.33\u0026thinsp;\u0026plusmn;\u0026thinsp;9.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eODI (1 month) %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.42\u0026thinsp;\u0026plusmn;\u0026thinsp;15.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.67\u0026thinsp;\u0026plusmn;\u0026thinsp;8.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.525\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eODI (3 month) %\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.00\u0026thinsp;\u0026plusmn;\u0026thinsp;11.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.17\u0026thinsp;\u0026plusmn;\u0026thinsp;11.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.956\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeedle angle Adjustment time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.93\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.815\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal procedure time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.37\u0026thinsp;\u0026plusmn;\u0026thinsp;1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.168\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 male/ 12 female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 male / 14 female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.970\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLikert scale patient satisfaction questionnaire\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.966\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePain medication use before procedure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll patient needed pain killers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll patient needed pain killers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePain medication use 3 Months after procedure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4/26 patient needed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5/30 patients needed pain killers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;(1): Demographic and clinical characteristics of the studied groups\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec15\"\u003e\n \u003ch2\u003eDemographic and Baseline Characteristics\u003c/h2\u003e\n \u003cp\u003eThere were no significant differences in demographic or baseline clinical characteristics between the two groups. The mean age of patients in Group 1 was 56\u0026thinsp;\u0026plusmn;\u0026thinsp;8.16 years, compared to 54.57\u0026thinsp;\u0026plusmn;\u0026thinsp;9.33 years in Group 2 (P\u0026thinsp;=\u0026thinsp;0.543). Similarly, the mean weight was 85.54\u0026thinsp;\u0026plusmn;\u0026thinsp;7.83 kg in Group 1 and 82.27\u0026thinsp;\u0026plusmn;\u0026thinsp;8.21 kg in Group 2 (P\u0026thinsp;=\u0026thinsp;0.133). Gender distribution was comparable, with 14 males and 12 females in Group 1 and 16 males and 14 females in Group 2, showing no statistically significant difference (P\u0026thinsp;=\u0026thinsp;0.970).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\"\u003e\n \u003ch2\u003ePain and Functional Outcomes\u003c/h2\u003e\n \u003cp\u003eBaseline pain scores, as measured by the Visual Analog Scale (VAS), were similar between the groups (Group 1: 7.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28 vs. Group 2: 7.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.26, P\u0026thinsp;=\u0026thinsp;0.770). The Oswestry Disability Index (ODI) at baseline was also comparable (Group 1: 75.50\u0026thinsp;\u0026plusmn;\u0026thinsp;10.70% vs. Group 2: 77\u0026thinsp;\u0026plusmn;\u0026thinsp;12.64%, P\u0026thinsp;=\u0026thinsp;0.632).\u003c/p\u003e\n \u003cp\u003ePain and functional outcomes were reassessed at 1 week, 1 month, and 3 months post-procedure. No significant differences were observed at 1 week (Group 1: 5.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13 vs. Group 2: 5.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91, P\u0026thinsp;=\u0026thinsp;0.774) or 1 month (Group 1: 4.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17 vs. Group 2: 4.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66, P\u0026thinsp;=\u0026thinsp;0.515). However, at 3 months post-procedure, Group 2 (fluoroscopy-guided) demonstrated significantly lower pain scores compared to Group 1 (US-guided) (VAS: 2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71 vs. 3.40\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89, P\u0026thinsp;=\u0026thinsp;0.008).\u003c/p\u003e\n \u003cp\u003eFunctional improvement, as measured by the ODI, showed a trend toward better outcomes in Group 2 at 1 week (Group 1: 52.17\u0026thinsp;\u0026plusmn;\u0026thinsp;7.15% vs. Group 2: 56.33\u0026thinsp;\u0026plusmn;\u0026thinsp;9.19%, P\u0026thinsp;=\u0026thinsp;0.063), but this difference did not reach statistical significance. ODI scores remained comparable between the groups at 1 month (P\u0026thinsp;=\u0026thinsp;0.525) and 3 months (P\u0026thinsp;=\u0026thinsp;0.956).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\"\u003e\n \u003ch2\u003eProcedural Metrics\u003c/h2\u003e\n \u003cp\u003eThere were no significant differences between the groups in terms of procedural efficiency. The mean needle adjustment time was 2.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97 minutes in Group 1 and 2.93\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93 minutes in Group 2 (P\u0026thinsp;=\u0026thinsp;0.815). The total procedure time was 7.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17 minutes in Group 1 and 8.37\u0026thinsp;\u0026plusmn;\u0026thinsp;1.59 minutes in Group 2 (P\u0026thinsp;=\u0026thinsp;0.168).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\"\u003e\n \u003ch2\u003ePatient Satisfaction and Pain Medication Use\u003c/h2\u003e\n \u003cp\u003ePatient satisfaction, assessed using a Likert scale, was high in both groups, with no significant difference (Group 1: 4.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.91 vs. Group 2: 4.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82, P\u0026thinsp;=\u0026thinsp;0.966). All patients in both groups required pain medication before the procedure. At 3 months post-procedure, a small proportion of patients continued to require pain medication, with 4/26 patients in Group 1 and 5/30 patients in Group 2 (P\u0026thinsp;=\u0026thinsp;1.000).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\"\u003e\n \u003ch2\u003eLevel of Lumbar Affection\u003c/h2\u003e\n \u003cp\u003eThe distribution of lumbar spine levels treated was comparable between the groups. The most commonly affected levels were L4-5 (Group 1: 10, Group 2: 12) and L3-4 (Group 1: 7, Group 2: 8). Chi-square analysis revealed no significant differences in the distribution of treated levels between the groups (P\u0026thinsp;=\u0026thinsp;0.813). Table\u0026nbsp;(2)\u003c/p\u003e\n \u003cp\u003e\u003cimg src=\"data:image/png;base64,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\"\u003e\u003c/p\u003e\n \u003cdiv\u003e\u003cstrong\u003eTable\u0026nbsp;(2): Level of lumbar affection\u003c/strong\u003e \u003cem\u003e(comparison using chi-square test comparison between actual and expected ranges)\u003c/em\u003e\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\"\u003e\n \u003ch2\u003eSummary of Findings\u003c/h2\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eFluoroscopy-guided procedures were associated with significantly lower pain scores at 3 months compared to US-guided procedures (P\u0026thinsp;=\u0026thinsp;0.008).\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eNo significant differences were observed in functional outcomes, procedural metrics, or patient satisfaction between the groups.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eThe distribution of treated lumbar levels and baseline characteristics were similar between the groups.\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003eThese results suggest that fluoroscopic guidance may offer superior long-term pain relief compared to US guidance while maintaining comparable procedural efficiency and patient satisfaction. Further studies with larger sample sizes are warranted to confirm these findings and explore potential differences in functional outcomes.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eLumbosacral radiculopathy significantly impacts patients' quality of life, and selective lumbar nerve root injections remain a cornerstone in its management. This study aimed to compare the efficacy, safety, and procedural efficiency of ultrasound (US)-guided versus fluoroscopy (FL)-guided selective nerve root blocks in patients with lumbar radiculopathy. Our findings provide valuable insights into optimizing clinical practices by examining outcomes related to pain relief, functional improvement, patient satisfaction, and procedural dynamics.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eComparative Efficacy\u003c/h2\u003e \u003cp\u003eThe study demonstrated that US-guided selective nerve root injections are comparable to FL-guided techniques in terms of short-term pain relief and functional improvement. At three months, FL-guided injections exhibited slightly superior outcomes in pain relief (VAS 2.8 vs. 3.88, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and functional scores (ODI 37.17% vs. 38.65%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). These findings align with Viderman et al. (2023), who reported no significant differences in short-term pain relief between US- and FL-guided injections [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, the slightly better long-term outcomes observed in the FL group mirror Kimura et al. (2023), who attributed the advantage to precise contrast-based visualization of medication delivery, particularly in cases with complex spinal anatomy [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn contrast, Wang et al. (2024) demonstrated comparable pain and functional outcomes between the two modalities across all time points, emphasizing the operator\u0026rsquo;s expertise as a critical factor [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Similarly, Cui et al. (2022) found no significant differences in pain relief between US-guided and FL-guided cervical nerve blocks, reinforcing the generalizability of comparable efficacy across different spinal levels [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A systematic review by Hofmeister et al. (2019) indicated that while FL guidance may provide slightly better functional outcomes, these benefits are not always clinically significant [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Our results are consistent with this, as the observed differences in ODI scores at three months were statistically significant but modest in magnitude.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eProcedural Efficiency\u003c/h2\u003e \u003cp\u003eRegarding procedural efficiency, US-guided procedures in our study had shorter total times and needle adjustment durations. Lee et al. (2024) and Hofmeister et al. (2019) similarly emphasized the efficiency of US-guided techniques, particularly in reducing needle repositioning through real-time visualization of anatomical structures [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Furthermore, Luijsterburg et al. (2007) noted that US guidance minimizes reliance on radiopaque contrast agents, streamlining the procedure and potentially reducing complications [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eSafety and Patient Satisfaction\u003c/h2\u003e \u003cp\u003eThe lower adverse event rate in the US-guided group corroborates findings by Wu et al. (2016), Jaliano et al. (2018), and Rasoulian et al. (2015), who highlighted the safety advantages of US guidance, particularly in avoiding vascular injuries and intravascular injections [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Similarly, Ahmed et al. (2023) concluded that US-guided epidural steroid injections are not only comparable to conventional FL-guided techniques in terms of pain control and functional improvement but also have a lower risk of inadvertent vascular puncture [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Cui et al. (2022) also noted higher patient satisfaction scores with US-guided cervical procedures due to the absence of radiation exposure and reduced procedural discomfort, findings that parallel our observations in lumbar interventions [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe observed superiority of FL-guided injections at three months may be explained by its superior anatomical precision. Contrast-enhanced visualization in FL guidance ensures optimal delivery of therapeutic agents to the target site, potentially leading to better sustained relief. This was particularly evident in patients with severe foraminal stenosis, where US guidance may have limitations in visualizing deeper structures, as noted by Kimura et al. (2023) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUS-guided injections were faster and perceived as more comfortable due to the avoidance of radiation and the dynamic visualization of anatomical structures. The shorter procedural time reduces patient anxiety and discomfort, as highlighted by Lee et al. (2024) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. These factors likely influenced the higher satisfaction scores in the US group. Similar findings were reported by Mansour et al. (2023), who concluded that US-guided selective nerve root injections were as effective and safe as fluoroscopy-guided injections for treating lumbar radicular pain, with advantages in reduced procedure time and avoidance of radiation exposure [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe success of US guidance heavily relies on operator expertise. While our study ensured experienced practitioners for both techniques, discrepancies in outcomes across studies may stem from variability in training and familiarity with US imaging. This highlights the need for standardized training protocols, as suggested by Hofmeister et al. (2019) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eStudy Limitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, the relatively small sample size may limit the generalizability of the findings, and larger, more diverse studies are needed to confirm the results and explore functional outcomes. Second, being conducted at a single institution, the results may not apply to other settings with different demographics or protocols. Additionally, variability in operator experience, particularly with US-guided procedures, could have influenced outcomes. Third, the lack of long-term follow-up beyond three months limits understanding of the durability of pain relief and functional improvement. Future studies should include longer follow-up periods. Finally, potential confounders, such as the severity of nerve root compression or anatomical variations, were not measured, which could affect procedural outcomes.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, US-guided selective lumbar nerve root blocks offer a viable alternative to FL-guided techniques, with comparable efficacy in pain relief and functional improvement, shorter procedural times, and reduced radiation exposure. While FL guidance may provide superior long-term outcomes in certain cases, US guidance\u0026rsquo;s safety profile and patient comfort make it an appealing option, particularly for patients with contraindications to radiation. These findings underscore the importance of tailoring the choice of imaging modality to individual patient needs and institutional resources.\u003c/p\u003e \u003cp\u003eFuture research should focus on larger, multicenter studies with longer follow-up periods to further elucidate the comparative efficacy, safety, and functional outcomes of US-guided versus FL-guided lumbar nerve root injections. Additionally, studies should explore the impact of operator experience, patient-specific factors (e.g., obesity, spinal anatomy), and the use of advanced imaging techniques (e.g., contrast-enhanced ultrasound) on procedural outcomes. Such research will help refine clinical guidelines and optimize patient care in the management of lumbar radiculopathy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eThe manuscript was approved by The Research Ethics Committee and Quality Assurance Unit, Faculty of Medicine, Tanta University.\u003c/li\u003e\n \u003cli\u003eApproval Code: 36264PR888/10/24\u003c/li\u003e\n \u003cli\u003ePrincipal Investigator: Basem Hamdy Fouda\u003c/li\u003e\n \u003cli\u003eDepartment: Neuropsychiatry\u003c/li\u003e\n \u003cli\u003eDate of Approval: 07/10/2024\u003c/li\u003e\n \u003cli\u003eThe study\u0026apos;s protocol was approved by The Research Ethics Committee and Quality Assurance Unit, Faculty of Medicine, Tanta University. Participation was voluntary, informed consent was obtained from all participants, and any potential risks were explained.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare no competing interests related to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;No funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eB.H.F:\u003c/strong\u003e Corresponding author, performed ultrasound-guided procedures, manuscript writing and revision, study design.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eW.M.A:\u003c/strong\u003e Conducted pre- and post-intervention patient assessments, evaluation, interpretation, and comparison of different parameters, manuscript writing, revision, and study design.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eE.E.N:\u003c/strong\u003e Performed fluoroscopy-guided procedures, conducted statistical analysis, manuscript writing and revision, and study design.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;We extend our gratitude to the neurology and orthopedic surgery medical and para-medical staff at Tanta University Hospitals for their invaluable assistance in patient selection and evaluation.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSmith CC, McCormick ZL, Mattie R, MacVicar J, Duszynski B, Stojanovic MP. The effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain: a comprehensive review of the published data. \u003cem\u003ePain Med.\u003c/em\u003e 2020;21(3):472-487. https://doi.org/10.1093/pm/pnz160 \u003c/li\u003e\n\u003cli\u003eLuijsterburg PA, Verhagen AP, Ostelo RW, Van Os TA, Peul WC, Koes BW. Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review. \u003cem\u003eEur Spine J.\u003c/em\u003e 2007;16:881-899. https://doi.org/10.1007/s00586-007-0367-1 \u003c/li\u003e\n\u003cli\u003eHofmeister M, Dowsett LE, Lorenzetti DL, Clement F. Ultrasound-versus fluoroscopy-guided injections in the lower back for the management of pain: a systematic review. \u003cem\u003eEur Radiol.\u003c/em\u003e 2019;29:3401-3409. https://doi.org/10.1007/s00330-019-06065-3 \u003c/li\u003e\n\u003cli\u003eViderman D, Aubakirova M, Aryngazin A, et al. Ultrasound-guided vs. fluoroscopy-guided interventions for back pain management: a systematic review and meta-analysis of randomized controlled trials. \u003cem\u003eDiagnostics (Basel).\u003c/em\u003e 2023;13(22):3474. https://doi.org/10.3390/diagnostics13223474 \u003c/li\u003e\n\u003cli\u003eWang B, Sun Y, Zhang J, Meng H, Zhang H, Shan L. Ultrasound-guided versus fluoroscopy-guided lumbar selective nerve root block: a retrospective comparative study. \u003cem\u003eSci Rep.\u003c/em\u003e 2024;14(1):3235. https://doi.org/10.1038/s41598-024-53809-3 \u003c/li\u003e\n\u003cli\u003eKorbe S, Udoji EN, Ness TJ, Udoji MA. Ultrasound-guided interventional procedures for chronic pain management. \u003cem\u003ePain Manag.\u003c/em\u003e 2015;5(6):466-482. https://doi.org/10.2217/pmt.15.46 \u003c/li\u003e\n\u003cli\u003eLee DY, Park Y, Song JH, et al. Combined ultrasound and fluoroscopy versus ultrasound versus fluoroscopy-guided caudal epidural steroid injection for the treatment of unilateral lower lumbar radicular pain: a retrospective comparative study. \u003cem\u003eMedicina (Kaunas).\u003c/em\u003e 2024;60(5):809. https://doi.org/10.3390/medicina60050809 \u003c/li\u003e\n\u003cli\u003eViderman D, Aubakirova M, Aryngazin A, et al. Ultrasound-guided vs. fluoroscopy-guided interventions for back pain management: a systematic review and meta-analysis of randomized controlled trials. \u003cem\u003eDiagnostics (Basel).\u003c/em\u003e 2023;13(22):3474. https://doi.org/10.3390/diagnostics13223474 \u003c/li\u003e\n\u003cli\u003eKimura R, Yamamoto N, Watanabe J, Ono Y, Hongo M, Miyakoshi N. Comparative efficacy of ultrasound guidance and fluoroscopy or computed tomography guidance in spinal nerve injections: a systematic review and meta-analysis. \u003cem\u003eEur Spine J.\u003c/em\u003e 2023;32(12):4101-4110. https://doi.org/10.1007/s00586-023-07968-y \u003c/li\u003e\n\u003cli\u003eAshmore ZM, Bies MM, Meiling JB, et al. Ultrasound-guided lumbar medial branch blocks and intra-articular facet joint injections: a systematic review and meta-analysis. \u003cem\u003ePain Rep.\u003c/em\u003e 2022;7(3):e1008. https://doi.org/10.1097/pr9.0000000000001008 \u003c/li\u003e\n\u003cli\u003eWang B, Sun Y, Zhang J, Meng H, Zhang H, Shan L. Ultrasound-guided versus fluoroscopy-guided lumbar selective nerve root block: a retrospective comparative study. \u003cem\u003eSci Rep.\u003c/em\u003e 2024;14(1):3235. https://doi.org/10.1038/s41598-024-53809-3 \u003c/li\u003e\n\u003cli\u003eCui X, Zhang D, Zhao Y, et al. An open-label non-inferiority randomized trial comparing the effectiveness and safety of ultrasound-guided selective cervical nerve root block and fluoroscopy-guided cervical transforaminal epidural block for cervical radiculopathy. \u003cem\u003eAnn Med.\u003c/em\u003e 2022;54(1):2669-2679. https://doi.org/10.1038/s41598-024-53809-3 \u003c/li\u003e\n\u003cli\u003eWu T, Zhao WH, Dong Y, Song HX, Li JH. Effectiveness of ultrasound-guided versus fluoroscopy or computed tomography scanning guidance in lumbar facet joint injections in adults with facet joint syndrome: a meta-analysis of controlled trials. \u003cem\u003eArch Phys Med Rehabil.\u003c/em\u003e 2016;97(9):1558-1563. https://doi.org/10.1016/j.apmr.2015.11.013 \u003c/li\u003e\n\u003cli\u003eGaliano K, Gruber H. Ultrasound-guided lumbar nerve root (periradicular) injections. In: \u003cem\u003eAtlas of Ultrasound-Guided Procedures in Interventional Pain Management.\u003c/em\u003e Springer; 2018:125-127. https://doi.org/10.1007/978-1-4939-7754-3_11 \u003c/li\u003e\n\u003cli\u003eRasoulian A, Seitel A, Osborn J, et al. Ultrasound-guided spinal injections: a feasibility study of a guidance system. \u003cem\u003eInt J Comput Assist Radiol Surg.\u003c/em\u003e 2015;10:1417-1425. https://doi.org/10.1007/s11548-015-1212-3 \u003c/li\u003e\n\u003cli\u003eAhmed M, Ahmad A, Arshad M, et al. Ultrasound-guided versus conventional fluoroscopy-guided epidural injection for radiculopathy: a meta-analysis of randomized controlled trials. \u003cem\u003eWorld Neurosurg.\u003c/em\u003e 2023;180:203-212.e4. doi:10.1016/j.wneu.2023.09.088. https://doi.org/10.1016/j.wneu.2023.09.088 \u003c/li\u003e\n\u003cli\u003eMansour H, Abu Elhusein A, Mohamed AE, Mohamed I, Mickhael H. Comparison of ultrasound and fluoroscopy guidance in selective lumbar nerve root injection for treatment of radicular pain. \u003cem\u003eMinia J Med Res.\u003c/em\u003e 2023;34(2):156-166. doi:10.21608/MJMR.2023.190902.1324. https://doi.org/10.21608/mjmr.2023.190902.1324 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Lumbar radiculopathy, ultrasound-guided injection, fluoroscopy-guided injection, selective nerve root block, pain management, functional outcomes","lastPublishedDoi":"10.21203/rs.3.rs-6330553/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6330553/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eLumbosacral radiculopathy, often due to degenerative disc disease, is commonly treated with epidural steroid injections (ESIs). Fluoroscopy (FL)-guided injections are the standard approach but involve radiation exposure. Ultrasound (US) guidance provides a radiation-free alternative with real-time soft tissue visualization.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjective:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTo compare the efficacy, safety, and functional outcomes of US-guided versus FL-guided selective lumbar nerve root injections.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis prospective, randomized study included 57 patients with lumbar radiculopathy refractory to conservative treatment. Patients were randomized into two groups: Group 1 (US-guided, n\u0026thinsp;=\u0026thinsp;27) and Group 2 (FL-guided, n\u0026thinsp;=\u0026thinsp;30). Pain relief was assessed using the Visual Analog Scale (VAS), and functional improvement was evaluated with the Oswestry Disability Index (ODI) at baseline, 1 week, 1 month, and 3 months. Secondary outcomes included procedural time, patient satisfaction, complication rates, and post-procedure medication use.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAt 3 months, FL-guided injections achieved significantly lower VAS scores (2.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71 vs. 3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.89, P\u0026thinsp;=\u0026thinsp;0.008). No significant differences were observed in ODI improvement between groups at 1 week (P\u0026thinsp;=\u0026thinsp;0.063), 1 month (P\u0026thinsp;=\u0026thinsp;0.525), or 3 months (P\u0026thinsp;=\u0026thinsp;0.956). Procedural time was comparable (P\u0026thinsp;=\u0026thinsp;0.168), and patient satisfaction scores were similar (P\u0026thinsp;=\u0026thinsp;0.966). Both groups had low complication rates, with no serious adverse events.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFL-guided injections provide superior long-term pain relief, while US guidance eliminates radiation exposure. Larger, multicenter studies are needed to validate these findings and assess the influence of operator expertise and patient-specific factors.\u003c/p\u003e","manuscriptTitle":"Ultrasound versus Fluoroscopy-Guided Selective Lumbar Nerve Root Injections: A Comparative Analysis of Efficacy, Safety, and Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-05 06:36:40","doi":"10.21203/rs.3.rs-6330553/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c694ea63-69b4-43a3-a0f0-c75ee616f36d","owner":[],"postedDate":"May 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-19T13:38:58+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-05 06:36:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6330553","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6330553","identity":"rs-6330553","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}