Image-guided epidural injections are among the most performed invasive non-surgical procedures in managing chronic spinal pain with or without extremity pain, in different indications such as herniated discs, spinal stenosis, axial discogenic pain, and post-surgery syndrome. Epidural injections are provided through caudal, interlaminar, and transforaminal approaches. Facet joint injections target the small joints linking the spinal vertebrae, known as the facet joints.

Epidural injections and facet joint injections are image-guided interventions using fluoroscopy or computed tomography (CT) to reach the correct anatomical target, documenting the needle placement and contrast distribution, allowing the identification of inadvertent punctures and the subsequent correction of the needle position. Other image-guided technologies such as ultrasound or magnetic resonance imaging (MRI) have also been used for needle guidance in spinal injections, but less frequently.

We performed a guideline synopsis to both identify indications for the use of image-guided interventions and summarise the subsequent recommendations. We also considered potential organisational or social aspects.

Ten clinical guidelines fulfilled our eligibility criteria. Seven were related to epidural injections in four indications (axial discogenic pain, disc herniation, spinal stenosis, post-surgery syndrome) and five clinical guidelines on facet joint injections in one indication (axial facet joint pain). The majority were pertaining to the lumbar spine. Only three guidelines on epidural injections and four on facet joint injections provided recommendations on imaging modalities. The synopsis of recommendation for epidural injections is inconsistent in two clinical indications, axial discogenic pain and spinal stenosis, with conflicting recommendations across clinical guidelines (CGs). The same is true for facet joint injections, for both nerve block and intraarticular injections. The other two clinical indications for epidural injections, disc herniation and post-surgery syndrome, included both strong and weak recommendations for using epidural injections.

There are no clear recommendations for or against a specific imaging technology. Fluoroscopy may be given preference for safety reasons due to lower radiation exposure for patients. Where CGs stated an imaging technique, all referred to fluoroscopy in epidural injections. For facet joint interventions, fluoroscopic or CT are mentioned. Only one low-quality CG mentioned ultrasound for cervical medial branch block.

The final choice for imaging technology, in both epidural injections and facet joint injections, also depends on the organisational context and the available infrastructure or preference by the interventionalist or referring physician.