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Iliopsoas Bursa Injection

Discussion in 'Pain Medicine' started by knoxdoc, Jan 7, 2010.

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  1. knoxdoc

    knoxdoc New Member

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    Anyone have a good method to do these under fluoro (I'm not an US guru)? I have read that you can shoot an AP of the hip and aim for the superomedial aspect of the femoral head (11 o'clock on the left and 1 o'clock on the right), touch the overlying acetabulum, pull back 5mm, and shoot the dye.

    Hopefully you don't skewer the fem nerve with this method. In the words of Ralph Wigham, that would make "two owwies."
  2. SSdoc33

    SSdoc33

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    for iliiopsoas TENDON, i just go straight AP down to the lesser trochanter (its attachment), hit bone, contrast, then inject. never had a problem, N of about 40 or so. its always been significantly lateral to the femoral neurovascular bundle. as far as the bursa, im not sure. im also not sure how you could clinically tell the difference between an iliopsoas tendonitis and bursitis. ? MRI?
  3. knoxdoc

    knoxdoc New Member

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    You are right - you can't distinguish them clinically, but MRI can sometimes show inflammation in the bursa. I will try PT first for presumed tendinitis, and if she is not better I will try an injection. Going after the tendon insertion at the lesser troch seems like a good and safe first option to me - thanks.
  4. Mister Mxyzptlk

    Mister Mxyzptlk

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    This is pretty much what I do.

    In women, don't forget the possibility of femoral hernias as an etiology for groin pain.
  5. knoxdoc

    knoxdoc New Member

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    Fortunately the GYN ruled that out first. Thanks for the confirmation on the approach.
  6. Tenesma

    Tenesma Senior Member

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    i have gotten a few femoral blocks despite being "lateral" to the neurovascular bundle.... using the above technique... it also gets tricky in obese patients, cause you may end up going through bowel... if it is a tough patient, ill get a CT/MRI first to get a sense of what i am going through to get to the target
  7. drusso

    drusso Moderator Emeritus Lifetime Donor

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    knox,

    I've done a couple of these. Fenton describes a good technique in his "green" MSK injection book. Agree with the methods outlined by SSdoc and Mister M. I'll email you a pdf when I'm back in the office.
  8. SSdoc33

    SSdoc33

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    wow. if you have to worry about bowel, your patients have WAY more serious problems. you'll avoid the femoral block by only using a small amount of LA ( 1 mL). the cortisone is whats helping, anyway.
  9. Jcm800

    Jcm800

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    what symptoms and what exam/diagnostic criteria are u using to make the diagnosis of ilopsoas tendonitis?
  10. knoxdoc

    knoxdoc New Member

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    26 y/o F kickboxer with focal R groin pain, non-radiating, exacerbated by climbing uphills or bouncing her child on her knee. No change with weight bearing on flat surface (walking). No radiation of the pain. No numbness/tingling. Neg xrays. Hip maneuvers negative except resisted hip flexion is painful. Thomas test reproduces pain. Tender in lateral aspect of femoral triangle, over iliopsoas. Neurologically intact. Neg reverse SLR.

    Haven't gotten an MRI yet. No need at this point. If she doesn't get better with PT, inj, etc, then will need to rule out other stuff (femoral neck stress rxn/fx, labral tear, avulsion, etc).
  11. SSdoc33

    SSdoc33

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  12. drusso

    drusso Moderator Emeritus Lifetime Donor

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  13. Jcm800

    Jcm800

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  14. Mister Mxyzptlk

    Mister Mxyzptlk

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    Try lifting up the panniculus before you insert the needle. :laugh:
  15. Tenesma

    Tenesma Senior Member

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    most of my iliopsoas tendinitis patients are older (>50) who are 6-12 months out from a hip replacement.... usually because the acetabular cup is too big and the tendon is catching/rubbing against it.... usually what they need is the cup re-sized but you all know how much orthopods love doing that... so instead they get shipped to me for these injections with the hope that the patient gets used to the sensation... surprisingly most do...
  16. knoxdoc

    knoxdoc New Member

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  17. glacier azul

    glacier azul

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    In residency- have seen this done blind. No flouro. Landmarks, obviously lateral to neurovasc bundle, palpable pulse is obvious.

  18. knoxdoc

    knoxdoc New Member

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    That makes sense - I have needled the iliopsoas plenty of times for EMG and got right in 1" lateral to the femoral artery. Then its just a matter a going through the muscle to the bursa.
  19. Pain Applicant1

    Pain Applicant1

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  20. PinchandBurn

    PinchandBurn

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    how is this billed? Trigger Point/Bursa Injection. If TPI, then cant bill for fluro....
  21. bedrock

    bedrock Member

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    You can't bill flouro guidance for a trigger point? I've never done that anyway, but I believe that powermd bills ultrasound guidance for his trigger points and gets paid.


    You can use similar codes for joint/bursa injections. It's a large bursa, so I'd bill it as 20610(major joint/bursa) + 77002(flouro) or 76942 (US).
  22. PinchandBurn

    PinchandBurn

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    You can bill for Ultrasound for TPI, but from what I gather you can not bill a TPI with fluro.
  23. powermd

    powermd Lifetime Donor

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    Yup. Sure is easier to see that neurovascular bundle too!

    I hate not being able to bill fluoro for TPs because there are many times I want to inject the origins of the lumbar erector spinaes along the sacrum (or PSIS) in fat people. Can't see well beyond 4-5 cm with my US.
  24. pmrmd

    pmrmd

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    An origin isn't a TP though. Its more like 20551, fluoro-billable, than 20552.
  25. specepic

    specepic

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    I find it interesting how many folks on here advocate (or at least do not object to) fluoro guidance for IP bursa injection who have previously derided the idea of SIJ or ESIs with US. Lets apply the same appropriate standards. US is so clearly superior for an injection like this that fluoro has no real role in 2012 (almost wrote 2011 :)).

    No, I cannot cite a DBRCT but you can see my needle tip in the bursa with US, not imply its location based on bony landmarks. Also, esp for this inj, you can be quite close to NVB, which you can SEE with US. In a forum that emphasizes quality and safety...

    High horse over
  26. epidural man

    epidural man ASA Member

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    :thumbup:
  27. drf

    drf New Member

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    Ya. These are fairly straight forward with US. Hip IA. Trochanteric bursa. Iliopsoas tendon. Iliopsoas bursa. Lat fem cutaneous nerve. hip is one of my favorite targets!

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