private practice vs. ultrasound

[lobelsteve]

Just a simple 1.5" 27 gauge needle I would use for local. I don't even use local most of the time on the skin...


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That wouldnt reach the rib surface in half of my patients.

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[Jcm800]

It won't reach the ribs in three fourths of my patients, but the ones who need intercostal blocks, tend to be skinny


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[DOctorJay]

I prefer Fluoro. I like to see bones, walk off of it, aspirate and put contrast and see a great contrast spread 1mm past the rib with a 27 gauge needle. I don't think it can be safer than that in my hands. While I appreciate being able to see lungs, it's pretty hard to see a 27 gauge needle on ultrasound

If I was better at US maybe I would think it was better, but I have both and have used both, and prefer fluoro

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True. I use a 25 gauge.

And for the record I don't do any spine procedures with ultrasound.


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[oreosandsake]

i also perform intercostals under US. I find that there is much more precision (imagine the mag on your fluoro x 100) and it is nice to be able to see the pleura.

the true target is the plane between the internal intercostal muscle and the inner-most intercostal muscle, which overlies the pleura. this gets a bit dicey as the innermost layer is typically very thin. i will stop near the border and use volume for safety, sort've like pushing the envelope of the diffusion technique.

do any of you use the Omoigui diffusion technique?

 

[oreosandsake]

I've never tried to RF a ICN... not sure how that is even done???

 

[Ligament]

I've never tried to RF a ICN... not sure how that is even done???

I usually do them under fluoro, because I want to see a nice neurogram before I place my RF cannulae. If you can visualize the intercostal nerve very well on U/s then try with U/s. Then I enter from medial to lateral and attempt to place the active tip parallel to the nerve if possible. Motor and sensory stim. Should get strong abdominal contractions. Then 4% lidocaine and multiple lesions. Do them very rarely, primarily for 12th rib syndrome in little old ladies or rib pain in elderly golfers. They WILL get a pseudo hernia in the abdomen from the palsy. If you do 2 or more levels, their belly will definitely bulge outward. Just warn them of this.

 

[Jcm800]

I usually do them under fluoro, because I want to see a nice neurogram before I place my RF cannulae. If you can visualize the intercostal nerve very well on U/s then try with U/s. Then I enter from medial to lateral and attempt to place the active tip parallel to the nerve if possible. Motor and sensory stim. Should get strong abdominal contractions. Then 4% lidocaine and multiple lesions. Do them very rarely, primarily for 12th rib syndrome in little old ladies or rib pain in elderly golfers. They WILL get a pseudo hernia in the abdomen from the palsy. If you do 2 or more levels, their belly will definitely bulge outward. Just warn them of this.

i have only done this in cases post-thoracotomy when the outlook is not good. very little chance of pneumo when the lungs is all matted down anyway. its been a little while since i last have done this.

 

[Ducttape]

I will use fluoro to identify the ribs in question. then use fluoro to target the inferior border of the rib, just like a traditional ICNB. after contacting rib and advancing downwards, I will use US probe to initially measure depth of the space, then use it to watch needle tip (using an in-plane approach) as the tip goes to the intercostal space below the rib. I tend to use low dose RFA (60 degrees) - definitely not 80 degrees. a couple of patients have had success with pulsed RFA.


fyi US may not be that expensive. you don't need to shell out $20k for a machine.

https://www.lumify.philips.com/web/products-accessories

$199/month leased. the entire device is the probe and an app on the android.

 

[drpainfree]

I will use fluoro to identify the ribs in question. then use fluoro to target the inferior border of the rib, just like a traditional ICNB. after contacting rib and advancing downwards, I will use US probe to initially measure depth of the space, then use it to watch needle tip (using an in-plane approach) as the tip goes to the intercostal space below the rib. I tend to use low dose RFA (60 degrees) - definitely not 80 degrees. a couple of patients have had success with pulsed RFA.


fyi US may not be that expensive. you don't need to shell out $20k for a machine.

https://www.lumify.philips.com/web/products-accessories

$199/month leased. the entire device is the probe and an app on the android.

wow, this is cooooool!

 

[oreosandsake]

you get what you pay for. those are decent for superficial structures, and definitely okay for needle guidance if you know what you are doing. diagnostic US is limited to gross abnormalities

 

[Ducttape]

I looked at it, and seems good for TPI, nonspine injections particularly nerves and tendons. not for spine ones.

 

[bedrock]

I looked at it, and seems good for TPI, nonspine injections particularly nerves and tendons. not for spine ones.

True, but IMHO, there is no reason to do spine injections with US, anyway as fluoro is superior for spine procedures.

 

[Ducttape]

Agree about not using for spine. But that makes this unit appropriate for most office based soft tissue injections


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