Q: Ulnar nerve block

[oreosandsake]

if a patient has a ulnar entrapment in the cubital tunnel would you inject medication at the cubital tunnel? if so, what would you inject? LA and steroid?

an attending today told me that you can get nerve ischemia from compression due to the volume of injectate. (said it is in the literature)
he prefers to inject under US "anywhere along the path" except in the tunnel.

the rationale didn't really make sense to me. people inject around the median nerve and that is also in a confined compartment.

thoughts?

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[101N]

Medial epicondyle is a good target if they have normal anatomy and a nerve that doesn't sublux. Get it that close and the arguments about where become academic.

 

[delicatefade]

Ask him for the reference. I inject both median and ulnar nerve under US. Also, what does he mean by cubital tunnel? There are several potential sites of entrapment and more precise ways to define them.

 

[epidural man]

I couldn't find anything on google scholar. It appears to be a rather obscure problem if it does exist. I assume the chances of this are rather rare considering the amount of injections into this site that are done every year.

 

[lobelsteve]

Any data on effectiveness of ulnar nerve injection for cubical tunnel.

 

[oreosandsake]

Ask him for the reference. I inject both median and ulnar nerve under US. Also, what does he mean by cubital tunnel? There are several potential sites of entrapment and more precise ways to define them.

okay, he didn't say cubital tunnel.

i saw a ulnar nerve injection on his schedule for later this week. (I'm not working w/ him now) asked him where he injects, and i assumed the elbow, since most people get entrapped there...thus i pointed to my elbow and said, what's your approach and how do you decide where to inject, etc etc

and he said he injects proximal to the elbow under US, and gave me that line about nerve ischemia.

then, when i went to go clarify his rationale, he essentially said, " i can block it anywhere. i can block it up in the neck, axilla, wrist, etc anywhere BUT the elbow.

i asked if it was supported by literature and was told to look it up.... =/

as Dr. Lobel brought up, is there evidence for doing this procedure?

 

[SSdoc33]

i dont inject the carpal or cubital tunnel. just send them to the hand and upper extremity guys if they have true compression / axonal damage on EMG.

 

[bedrock]

i dont inject the carpal or cubital tunnel. just send them to the hand and upper extremity guys if they have true compression / axonal damage on EMG.

Agree. I only inject these if they fail surgery.

Weird **** can happen (ask Steve), or you get blamed for unsuccessful surgery if you provoke paresthesias during the procedure.

 

[nvrsumr]

No one likes anecdotes but I diagnose and inject CTS once a week. I have only referred out 2 patients in the last year for release....

 

[lobelsteve]

No one likes anecdotes but I diagnose and inject CTS once a week. I have only referred out 2 patients in the last year for release....

Yeah. When the shot wears off at 3 weeks they call the hand surgeon directly.

 

[nvrsumr]

Yeah. When the shot wears off at 3 weeks they call the hand surgeon directly.

Haha. Could be true. Usually cts is an incidental diagnosis for these patients and I am treating another chronic condition so I do see these patients long term. Since I am the one making the diagnosis and don't have a hand guy who sends me three emgs a week I have no secondary gain not to treat interventionally.

For what is worth I do mine with US and attempt to hydrodissect median nerve off of transverse carpal ligament. No study to back up. Just my noggin.

 

[powermd]

Haha. Could be true. Usually cts is an incidental diagnosis for these patients and I am treating another chronic condition so I do see these patients long term. Since I am the one making the diagnosis and don't have a hand guy who sends me three emgs a week I have no secondary gain not to treat interventionally.

For what is worth I do mine with US and attempt to hydrodissect median nerve off of transverse carpal ligament. No study to back up. Just my noggin.

I do these similarly using about 10 mL volume and get excellent results in most patients with many lasting months or years. They come back for other problems, so I do get follow up info on these. For ulnar nerve blocks, I simply pick the point where they say the pain/paresthesias start and inject there using US with a goal of hydrodissecting all the tissues away from the nerve. These often work well too. One of my success stories is a local referring PA (who types when she should be dictating).

As for nerve ischemia, bah. I might worry more if I served a litigious patient population, but I don't. Most are very grateful for anything I do, but I always give them a thorough warning of the risks of nerve damage before proceeding.

 

[emd123]

I do these similarly using about 10 mL volume and get excellent results in most patients with many lasting months or years. They come back for other problems, so I do get follow up info on these. For ulnar nerve blocks, I simply pick the point where they say the pain/paresthesias start and inject there using US with a goal of hydrodissecting all the tissues away from the nerve. These often work well too. One of my success stories is a local referring PA (who types when she should be dictating).

As for nerve ischemia, bah. I might worry more if I served a litigious patient population, but I don't. Most are very grateful for anything I do, but I always give them a thorough warning of the risks of nerve damage before proceeding.

Agree. There's something odd about not hesitating to inject into a stenotic cervical canal with a needle 1 mm from the cervical cord, but being so conservative as not to inject near the ulnar or median nerve, peripherally. I don't get it.

It's peripheral nerve. It's not going to necrose from a few minutes of increased pressure from injection of a couple cc's of liquid. At worst, these injections will do nothing.

 

[pjuer]

Have had my carpal tunnel injected twice by a hand surgeon in 8 years about 6 years apart. Have avoided surgery so far

 

[lobelsteve]

Personal experience is much rosier than the literature supports. 3 months relief after CTS injection. Archive PMR.
Hydrodissection a nerve away from a structure in an enclosed space. Hmm. Can see short term relief but not different than ESI for stenosis. ???

 

[emd123]

Personal experience is much rosier than the literature supports. 3 months relief after CTS injection. Archive PMR.
Hydrodissection a nerve away from a structure in an enclosed space. Hmm. Can see short term relief but not different than ESI for stenosis. ???

Exactly. Perfect for someone not willing to yet go under the knife. You tell them it's temporarily, which I tell people for every injection. This is just Pain medicine. It not rocket science, or World Peace. Just Pain.

 

[bedrock]

I think it might help this discussion of benefit and if Steve told the story of his unhappy lady with an unusual complication after carpal injection.

Up to you Steve if you feel comfortable sharing it.

 

[lobelsteve]

Complication occurred as vasospasm of 3rd distal

It took me 12 months before I injected the carpal tunnel and I have pictures of her finger afterwards.

http://www.webmd.com/pain-managemen...emporary-fix-for-carpal-tunnel-syndrome-study

 

[clubdeac]

I inject carpal tunnels frequently in my current neurology practice. Didn't really think ulnar nerve injections were that common in the treatment of CuTS. Pretty much just use neuropathics, elbow brace and then send for transposition. Maybe I'll start trying an injection if it's as successful as you all state.

As far as nerve damage/ischemia from CT injections, I've read about it but would guess it's as rare as a spinal cord infarct from a lumbar TFESI (can occur but very unlikely)

 

[jonnylingo]

I inject occasionally, w US, hydrodissect as described above, ulnar approach. Some good results, but usually just prolong the inevitable surgery. I do this when patients can't get surgery done immediately due to seasonal work or other life plans.

A word of caution... I learned my lesson injecting some young lady with all sorts of psychosomatic pain/dysfunction complaints. After the injection, she had worsened persistant paresthesias and blamed my injection. Reviewed the US video clip, looked fine. Who knows, I may have caused this, but she had all sorts of supratentorial craziness going on so who knows.

 

[-Sojourner-]

"Pulsed radiofrequency of median nerve under ultrasound guidance" Haider 2007.

At the VA we are finding pulsed RFA of peripheral mononeuropathy to be very effective for pts who fail CSI and other conservative treatment. I know the procedure hardly provides any reimbursement, but is anyone else doing these in private practice with good outcomes?

 

[emd123]

"Pulsed radiofrequency of median nerve under ultrasound guidance" Haider 2007.

At the VA we are finding pulsed RFA of peripheral mononeuropathy to be very effective for pts who fail CSI and other conservative treatment. I know the procedure hardly provides any reimbursement, but is anyone else doing these in private practice with good outcomes?

Not doing it. Haven't tried. I'm just one guy though. I stick to basic reimbursed stuff, as I'm not at an academic site.

 

[powermd]

I inject occasionally, w US, hydrodissect as described above, ulnar approach. Some good results, but usually just prolong the inevitable surgery. I do this when patients can't get surgery done immediately due to seasonal work or other life plans.

A word of caution... I learned my lesson injecting some young lady with all sorts of psychosomatic pain/dysfunction complaints. After the injection, she had worsened persistant paresthesias and blamed my injection. Reviewed the US video clip, looked fine. Who knows, I may have caused this, but she had all sorts of supratentorial craziness going on so who knows.

What lesson did you learn?

I hope it was to avoid touching patients with "all sorts of psychosomatic pain/dysfunction complaints."

These patients are always going to have something to complain about, just make sure it isn't something they can blame on you. I told a patient like this a few weeks ago I would not be recommending any interventional procedures because even if successful, there will likely be new sensations she will not like and will certainly complain about. She fired her last pain doc for something minor, so I thought it wise to nip this one in the bud.

 

[Gauss]

"Pulsed radiofrequency of median nerve under ultrasound guidance" Haider 2007.

If there's axonal damage and symptoms persisting >1 year post release or transposition I could see the utility of this.