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A. Ventana sagital paramedial oblicua para el acceso de la rama medial del nervio raquídeo posterior guiado ecográficamente. Rev Soc Esp Dolor 2015; 22(3): 134-141. ABSTRACT Objectives:The most used ultrasound guided medial branch block method requires the use of a biplane ultrasound technique. Using this technique the cannula is positioned not parallel to the medial branch by limiting their use to perform conventional radiofrequency. Using a sonographic parasagittal obliqua view allows placing the cannula parallel to the nerve, achieving sensory and motor stimuli and making possible radiofrequency above L5 lumbar segments. In the present study we determined the effectiveness of this new approach by using fluoroscopy and by obtention of sensory and motor stimuli.Material and methods: Thirty-one patients diagnosed with lumbar facet joint pain proposed for diagnostic medial branch blocks were studied. We describe four lumbar sequential sonographic views necessary to include patients in the study. Once obtained, the target point is located using a parasagittal oblique sonographic view to achieve the external face of the superior articular process and the more dorsal part of the transverse process. Puncture is performed guided in plane to place the tip at the junction between superior articular process and transverse process. Once the cannula located in the target proceeds to sensory stimulus 50 Hz and Motor 2 Hz to perform a cannula repositioning in case there were no stimuli. Once obtained either motor or sensory stimulus a caudal to craneal 30° oblique projection is performed by fluoroscopy to check the location of the needle tip.Results: In 16% of patients cannot identify the four ultrasound views so the procedure is aborted. In the remaining 84% is achieved by placing the needle into the target point at 100% of the cases on the first attempt or by once a repositioning of the needle.Conclusion: Ultrasound oblique parasagittal view allows us a tangential approach to the lumbar medial branch with a high rate of success to position the radiofrequency cannula similar to when using fluoroscopy. The sonographic identification of the four windows described in the study allows us to screening tributary patient for ultrasound medial branch blocks. RESUMENObjetivos: el método de abordaje ecográfico más utilizado para el bloqueo del ramo medial del nervio raquídeo posterior (RmNRp) requiere de la utilización de una técnica ecográfica biplanar con punción guiada en plano en ventana transversal, para situar la cánula perpendicular al RmNRp, limitando la realización de radiofrecuencia.La utilización de una ventana ecográfica parasagital oblicua permite el acceso al RmNRp permitiendo situar la cánula de forma paralela al nervio, logrando estímulos sensitivos y motores, y posibilitando la realización de radiofrecuencia térmica para segmentos lumbares por encima de L5.En el presente estudio valoramos la eficacia de este nuevo abordaje ecográfico mediante la comprobación fluoroscópica de la situación de la cánula y la comprobaci...

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The sonoanatomical knowledge of the upper cervical and occipital region is critical for the identification of structures involved in the pathophysiology of cervicogenic headache and neck pain. We propose a systematic caudo-cranial ultrasound scan using a paramedial transverse view. The first relevant structure to identify is the Obliquus Capitis Inferior Muscle (OCIM) that in turn will allow us to locate the Great Occipital Nerve (GON), the C1-C2 joint, the C2 dorsal root ganglion, medial to the joint, and the Vertebral Artery, lateral to the joint. Sonogram 1 demonstrates the great occipital nerve (GON) between the seminspinalis capitus muscle (SMCEM) and obliquus Capitis Inferior Muscle (OCIM) and the C1-C2 joint. Aligning the transducer obliquely along the long axis of the OCIM, may allow for better visualization of the muscle. With a cranial displacement of the probe, one can identify the posterior arch of C1 and the vertebral artery as it transverses from lateral to medial crossing the medial posterior aspect of the atlanto-occipital joint (sonograms 2 and 3). Finally, with more cranial scan, one can identify the occipital bone and the occipital artery near the distal branches of the greater occipital nerve and third occipital nerve more medially (Sonogram 4). With continued cranial scanning the GON will be more superficial as it pierces the trapezius aponeurosis.