Viscosupplementation choice

I prefer synvisc (2mlx3), NOT synvisc one

We use Euflexxa. I think it works better than any of the others that I have used (Synvisc, Hyalgan), but have no evidence to support that. Psuedoseptic reaction in scares me away from Synvisc.

mid|ine said:

I prefer synvisc (2mlx3), NOT synvisc one

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Why don't you like synvisc one? Do you think is too much to inject at one time? Better to bill for three visits than one?

Louisville04 said:

Why don't you like synvisc one? Do you think is too much to inject at one time? Better to bill for three visits than one?

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Too much to inject at one time and have tried it a few times on pts that have done well w/ x 3 in the past and no one has done well with ONE.

I agree that for me, the volume is the biggest issue. People usually have some mild discomfort with even the 2 mL because of viscosity, but 6 mL would be much more uncomfortable.

I have been using Synvisc One for a couple of years and it works just as well as the old 2x3. If I didn't have S-1 my schedule would be clogged with knee injections. All the orthos here use S-1. I only use the other preps if there is an allergy to S-1.

lobelsteve said:

Nonsense. We routinely pull off 60-150cc fluid from swollen knees.

6cc is not the issue.

The data from the Synvisc people shows that more people got better relief with series of 3 than their single shot Synvisc 1. More folks had return of pain at 6 months with One than Three.

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6 cc is nothing. I inject 6 cc routinely of local and steroid.

Jcm800 said:

6 cc is nothing. I inject 6 cc routinely of local and steroid.

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Again its the viscosity of the Synvisc, not the volume. When I do knee arthrograms it is 15 cc of MRI contrast that patients tolerate well. In my experience, the viscosity of viscosupplimentation causes discomfort for people. In full disclosure I have not tried synvisc one, but that is the reason I stay away.

QUOTE=nvrsumr;13555375]Sensei does not have an ultrasound machine or would love
schedule clogged with knee injections.[/QUOTE]

Sensei has c-arm but is not interested in building the bill, and can also help more patients by a ratio of 3:1. Sensei knows azzwhole down the street doing TPI's with ultrasound.

Azzwhole down street doing rhomboid never hit lung.

In all seriousness, I don't use US for paraspinal, most traps, supra/infraspinatous. But it comes in handy on occasion for rhomboid and levator.

jonnylingo said:

Azzwhole down street doing rhomboid never hit lung.

In all seriousness, I don't use US for paraspinal, most traps, supra/infraspinatous. But it comes in handy on occasion for rhomboid and levator.

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Agree. Deep muscles, muscles near lung.

I can't imagine doing blind ileoinguinals, or even blind genitofemorals or lat fem cutaneous blocks.... I have done one abdominal internal obliques.

Not to hijack but I am, where did you guys learn to do US guided ilioinguinal, GF and LFCN blocks. Is there a site I can go to? ASRA? Due to time and money and my uncanny ability to assimilate new information quickly, I don't want to go to a course. Any suggestions on where I can pick this up quickly or can someone walk me through it, landmarks, probe positioning etc?

clubdeac said:

Not to hijack but I am, where did you guys learn to do US guided ilioinguinal, GF and LFCN blocks. Is there a site I can go to? ASRA? Due to time and money and my uncanny ability to assimilate new information quickly, I don't want to go to a course. Any suggestions on where I can pick this up quickly or can someone walk me through it, landmarks, probe positioning etc?

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easiest way... do youtube search. online, there are a few good sites. NYSORA has good descriptors too.

Sonosite has a nice little app you can put on your smartphone so that you can review images before you do the injection.

3rd easiest way - talk to your former training program and spend a day with them.

i always, in my mind, review how i would do it without the ultrasound for the anatomic location (you know, 2 cm from ASIS, etc.) as a rough guideline. then i review in my mind the kind of images i am going to look for.

clubdeac said:

Not to hijack but I am, where did you guys learn to do US guided ilioinguinal, GF and LFCN blocks. Is there a site I can go to? ASRA? Due to time and money and my uncanny ability to assimilate new information quickly, I don't want to go to a course. Any suggestions on where I can pick this up quickly or can someone walk me through it, landmarks, probe positioning etc?

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There's a few on youtube. This is the best (Sonosite)

http://www.youtube.com/watch?v=6E3ynIn6Ud4

MSK videos from Sonosite:

https://www.youtube.com/watch?v=pHBQ-_XPy2s&list=PLEF41F6DAEE3FD1A8

clubdeac said:

Not to hijack but I am, where did you guys learn to do US guided ilioinguinal, GF and LFCN blocks. Is there a site I can go to? ASRA? Due to time and money and my uncanny ability to assimilate new information quickly, I don't want to go to a course. Any suggestions on where I can pick this up quickly or can someone walk me through it, landmarks, probe positioning etc?

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Pubmed or a book. Narouze's US pain management book is pretty good.

clubdeac said:

Not to hijack but I am, where did you guys learn to do US guided ilioinguinal, GF and LFCN blocks. Is there a site I can go to? ASRA? Due to time and money and my uncanny ability to assimilate new information quickly, I don't want to go to a course. Any suggestions on where I can pick this up quickly or can someone walk me through it, landmarks, probe positioning etc?

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Netter and a lot of practice. My partners helped me get started with the basic concepts.

A lot of blocks work (I think) by releasing nerves from entrapment between muscle layers. You can often figure out where to inject just by studying Netter, and then examining your patient carefully with the US.

For example, the ilioinguinal nerve passes between the external/internal obliques just medial to the ASIS. Inject in between the obliques at this location in such a way as to create very accurate tissue separation, and you should get good results. I apply the same technique all over the body with great success. One of my favorites is a release of the ulnar nerve mid way up the forearm. You need to identify the nerve at the confluence of a bunch of muscles, and then inject right into that space to release the nerve. It works well in patients with true ulnar nerve entrapment.

Thanks for the pointers and video! I will probably end up buying that book as well. Thanks