Ultrasound procedures

[sweetalkr]

---

Members don't see this ad.

Curious, what procedures and how often are y'all using ultrasound? I have a few guys I work with that use it quite a bit. I am comfortable doing regional blocks but not many if any chronic pain procedures i do a lot.
What are yalls thoughts on it, and what courses do you recommend to getting started on ultrasound? also, what procedures do yall recommend? Thanks in advance. I am beginning to feel like I will be left behind if I don't catch up on this.

 

[drf]

Stellate, TAP, ilioinguinal, all joints, saphenous, sural, superficial peroneal, deep peroneal, carpal, tarsal, piriformis, obturator internus, genital branch of genitofemoral, suprascapular, intercostal, medial antebrachial, posterior femoral, any other specific branch in arms or legs, any specific bursa or tendon or muscle

 

[lobelsteve]

Good: Shoulders, hips, knees, weird tendons, rare entities, carpal tunnel, little joints
Bad: CESI, LESI, TFESI, SIJ

Meh: MBB

GFY: trigger points.

 

[epidural man]

GFY: trigger points.

I'll bet ya 1$ you change your mind on this. Now I don't know what kind of person you are and you may never change your mind just to win your dollar - but...if you are not the kind of prideful person that can't ever be wrong - you'll owe me a dollar someday. 😉

 

[epidural man]

Stellate, TAP, ilioinguinal, all joints, saphenous, sural, superficial peroneal, deep peroneal, carpal, tarsal, piriformis, obturator internus, genital branch of genitofemoral, suprascapular, intercostal, medial antebrachial, posterior femoral, any other specific branch in arms or legs, any specific bursa or tendon or muscle

Nice list.

Medial antebrachial? it seems like i just saw something on this but didn't get a chance to read it. Any more thoughts you can add? Where? Why? When? and 3 more W words of your choosing.

I have used it for lateral antebrachial - which seems to be in a more consistent place with anitomical landmark easily found with US.

 

[Aether2000]

Most of these are great acute nerve blocks but these have little utility in the management of chronic pain. Unless there is something further (ie. neurolytic procedure) you have available, the blocking of acute nerves is a very short acting expensive solution to a long term problem.

 

[PinchandBurn]

Most of these are great acute nerve blocks but these have little utility in the management of chronic pain. Unless there is something further (ie. neurolytic procedure) you have available, the blocking of acute nerves is a very short acting expensive solution to a long term problem.

Yes and no. I did read that article a few months ago that suggsted something like this in Pain Medicine News.

However, clinically, I can say that perhaps by resetting the peripheral/central sensitization,etc.

I've got patients that have had >6-8mo relief with just 1 injection (one was the lateral fem cut nerve and the other iliioinguinal nerve). There is something to be said about it that.

 

[Ducttape]

ICNB feel a lot "safer" using US.

i do sometimes cheat and do a quick scout film to determine levels - easier than counting them from T12 upwards (course, dont bill for that one film).

and i do get good long term results from ilioinguinal and lat fem cut nerve blocks, generally 3 months of pain relief, using bupiv + depo. also, I pRF these nerves with ultrasound assistance, for longer results.

 

[DOctorJay]

The others above answered the procedures.

In terms of courses AIUM at Mayo every July is fantastic. Tons of hands on. A couple of our anesthesia pain attendings teach at the course so you can buddy up with them to get more of the pain procedures.

All the big names in ultrasound usually teach there and you won't feel rushed at any of the stations. There is also a cadaver portion. I highly recommend it. PM me if you have any specific questions.

AAPM did a good job this year but there wasn't any cadaver section so no practice with a needle except on the phantom.

essr.org has some excellent teaching material for joints in their education section.

usra.com or something like that has a focus on more of the pain procedures.

If youre serious about this get Narouze's text and jacobsons text.

 

[Ducttape]

i have not gone, but my program directors have raved about the ASRA meeting...

 

[sweetalkr]

I really appreciate all the responses. I truly feel inadequate as an ultrasound tech today, but it's a chink in the armor I plan to improve over the next few months. i'll keep everybody posted on what i felt was a good training course and anyone else please let me know.

 

[PMR 4 MSK]

Most of these are great acute nerve blocks but these have little utility in the management of chronic pain. Unless there is something further (ie. neurolytic procedure) you have available, the blocking of acute nerves is a very short acting expensive solution to a long term problem.

Agree 100%.

I use US to insure the proper structures or spaces recieve the meds I am injecting. If I need to know I put the meds in the right place with 90%+ certainty, I'll use US if fluoro is not practical, and vice versa.

 

[drf]

Medial antebrachial i block A bit distal than axillary block. It is more superficial than median nerve.

 

[drf]

Most of these are great acute nerve blocks but these have little utility in the management of chronic pain. Unless there is something further (ie. neurolytic procedure) you have available, the blocking of acute nerves is a very short acting expensive solution to a long term problem.

Some block effect. Diagnostic for post surgical neuralgias. Follow with pRF, PNS, surgical referral for entrapment or transect and bury.

 

[powermd]

Please explain to me how US is any better than a blind anatomical stick for shoulders and knees Dr. GFY. Do you have some magical US that allows you to actually see beyond the portion of the patella (or acromion) you can manually palpate?

TPs work a whole lot better when you can see what you're attempting to hydrodissect.

Blind = dumb luck at best.

Good: Shoulders, hips, knees, weird tendons, rare entities, carpal tunnel, little joints
Bad: CESI, LESI, TFESI, SIJ

Meh: MBB

GFY: trigger points.

 

[lobelsteve]

Please explain to me how US is any better than a blind anatomical stick for shoulders and knees Dr. GFY. Do you have some magical US that allows you to actually see beyond the portion of the patella (or acromion) you can manually palpate?

TPs work a whole lot better when you can see what you're attempting to hydrodissect.

Blind = dumb luck at best.

I can only report what fair literature supports. You feeling good about hydrodissecting a a trigger point alludes more towards your own idiocy than I can comprehend. And I'm at least a 60w bulb. Never been enamored with a procedure lacking a good anatomic-physiologic correlate (except in the rabbit studies), with low interrater reliability, and lacking benefit for more than a few hrs or days if the patient is lucky. I guess that's why in Georgia, the PT's do the trigger points.

 

[PinchandBurn]

what's GFY?

 

[lobelsteve]

what's GFY?

Got fraud y'all?

 

[jonnylingo]

Got fraud y'all?

I gotta disagree. While I do most TPIs without guidance, when I'm aiming for rhomboid or levator, esp on an obese pt, I use it and it's always nice to see the needle tip right in muscle belly. Not a lot of wiggle room with pleura next door.

 

[lobelsteve]

I gotta disagree. While I do most TPIs without guidance, when I'm aiming for rhomboid or levator, esp on an obese pt, I use it and it's always nice to see the needle tip right in muscle belly. Not a lot of wiggle room with pleura next door.

Nah. Having a rib cage underlying the muscle makes it terribly unlikely. We all do a ton of intercostal blocks under fluoro where we touch down on inferior posterior rib. Almost always 2-3" depth, especially in large Americans.

 

[PinchandBurn]

In fellowship, our attendings have told us multiple stories of expert witness testimonies they had to do for catastrophic events after TPIs.

In fact, if I recall correctly, the most commonly litigated against procedure was TPI. It probably has something to do with the fact that it's done very commonly (if you include Fam pract,etc that are doing it).

Nevertheless....I've heard horror stories such as PTX and hitting the kidneys while doing TPIs. In some patinets you can not be 100% certain that you are in the belly of a muscle w/o ultrasound hydrodissection. Not saying it's necessary for all. But it does provide greater visual assurance your needle hasnt strayed somewhere it shouldnt.

As with anything, it's dependent on the operator as well....

 

[drf]

Please explain to me how US is any better than a blind anatomical stick for shoulders and knees Dr. GFY. Do you have some magical US that allows you to actually see beyond the portion of the patella (or acromion) you can manually palpate?

TPs work a whole lot better when you can see what you're attempting to hydrodissect.

Blind = dumb luck at best.

Shoulders: I can see rotator cuff tendons and abnormalities. Biceps tendon and fluid around it. I can watch fluid distend the joint space anterior or posterior. I can see the sasd bursa, look for fluid, watch it expand on injection. I can see ac joint. I can see supraspinatus and supra scapular nerves.

Knees: the supra patellar bursa is the target. I can watch it distend by palpating below the patella easily with effusion. This is more difficult with no effusion, but appropriate spread is still very clear once I inject. The medial patellar portal approach is helpful in fat people with no effusion. Place the needle, inject and watch Hoffa distend then move probe to supra patellar bursa and watch it distend with air or fluid. Knee is probably most difficult joint to learn. Also nIce for superficial and deep infra patellar bursa, checking out some of the tendons, pea anserine in fatties, saphenous nerve blocks,

 

[powermd]

Nah. Having a rib cage underlying the muscle makes it terribly unlikely. We all do a ton of intercostal blocks under fluoro where we touch down on inferior posterior rib. Almost always 2-3" depth, especially in large Americans.

You sound like a dinosaur man... US is so the way to go for ICNBs.

And US for TPs is NOT fraud. It's turned a poor to mediocre procedure into a great one and enabled diagnosis and treatment for a vast array of otherwise elusive pain problems. One day you will see the light here.

I can no longer easily count the patients referred to me for cervical radiculitis that other doctors performed gazillions of epidurals on who were found to have 100% relief with injection of the lateral cervical trap.

Cervical trap myofascial pain + some DDD + CTS = radicular pain for a lot of doctors who should know better.

 

[powermd]

Thanks drf.

I can identify the supraspinatus and bicipital tendons and inject these with good accuracy. Haven't learned subscapularis tendon injection yet. AC is easy, although very shallow.

What's your indication for injecting the supraspinatus and/or supra scapular nerves?

How do you do an intra-articular shoulder joint injection with US in a reliable way?

I'll have to play around with the probe and an anatomy book to get what your saying about the supra patellar bursa. Are you saying with injection of the joint, this bursa distends similarly to manually distending it by pressing on an effusion from below?

Shoulders: I can see rotator cuff tendons and abnormalities. Biceps tendon and fluid around it. I can watch fluid distend the joint space anterior or posterior. I can see the sasd bursa, look for fluid, watch it expand on injection. I can see ac joint. I can see supraspinatus and supra scapular nerves.

Knees: the supra patellar bursa is the target. I can watch it distend by palpating below the patella easily with effusion. This is more difficult with no effusion, but appropriate spread is still very clear once I inject. The medial patellar portal approach is helpful in fat people with no effusion. Place the needle, inject and watch Hoffa distend then move probe to supra patellar bursa and watch it distend with air or fluid. Knee is probably most difficult joint to learn. Also nIce for superficial and deep infra patellar bursa, checking out some of the tendons, pea anserine in fatties, saphenous nerve blocks,

 

[drf]

I gotta disagree. While I do most TPIs without guidance, when I'm aiming for rhomboid or levator, esp on an obese pt, I use it and it's always nice to see the needle tip right in muscle belly. Not a lot of wiggle room with pleura next door.

Agreed. I sometimes get colleague referrals for US guided injections after blind failed or the pt is too skinny or fat. Last week this guy had just this ONE spot that hurt and seemed Myofascial but TP didn't help. Prolly around t3 medial to scapula. I started with the most superficial muscle layer and worked my way in one step at a time. Trap, rhomboids, external intercostal, inner intercostal, and finally 4 mm from pleura a combined innermost intercostal and the likely covered nerve here. In the clinic in 4-5 minutes.

Also fantastic for specific neck like scalenes and specific abdomen in thin or fat. I've had rectus injections where I visualized the aorta pumping away at 1.5-2 cm deep to skin where I was injecting. Also seen rectus at 8-10 cms past a huge gut.

Of course I don't pick up the probe for routine TPs. But sometimes it helps.

 

[Ligament]

shoulders: I can see rotator cuff tendons and abnormalities. Biceps tendon and fluid around it. I can watch fluid distend the joint space anterior or posterior. I can see the sasd bursa, look for fluid, watch it expand on injection. I can see ac joint. I can see supraspinatus and supra scapular nerves.

Knees: The supra patellar bursa is the target. I can watch it distend by palpating below the patella easily with effusion. This is more difficult with no effusion, but appropriate spread is still very clear once i inject. The medial patellar portal approach is helpful in fat people with no effusion. Place the needle, inject and watch hoffa distend then move probe to supra patellar bursa and watch it distend with air or fluid. Knee is probably most difficult joint to learn. Also nice for superficial and deep infra patellar bursa, checking out some of the tendons, pea anserine in fatties, saphenous nerve blocks,

+1

 

[Ligament]

shoulders: I can see rotator cuff tendons and abnormalities. Biceps tendon and fluid around it. I can watch fluid distend the joint space anterior or posterior. I can see the sasd bursa, look for fluid, watch it expand on injection. I can see ac joint. I can see supraspinatus and supra scapular nerves.

Knees: The supra patellar bursa is the target. I can watch it distend by palpating below the patella easily with effusion. This is more difficult with no effusion, but appropriate spread is still very clear once i inject. The medial patellar portal approach is helpful in fat people with no effusion. Place the needle, inject and watch hoffa distend then move probe to supra patellar bursa and watch it distend with air or fluid. Knee is probably most difficult joint to learn. Also nice for superficial and deep infra patellar bursa, checking out some of the tendons, pea anserine in fatties, saphenous nerve blocks,

+1

 

[jonnylingo]

Nah. Having a rib cage underlying the muscle makes it terribly unlikely. We all do a ton of intercostal blocks under fluoro where we touch down on inferior posterior rib. Almost always 2-3" depth, especially in large Americans.

2-3"?? That all depends on how far lateral you are from midline. In a slender guy, at 3cm I'm in rhomboid, at 4cm I'm in lung. 2-3" is 5.1 to 7.6 cm. That's lung biopsy on a slender guy. I find little margin of error. You mention rib cage, what about the ~50% not covered by rib? Intercostals are at best 1.5cm thick, more likely 1cm. In larger patient, depth truly is a crapshoot. I used to err on the shallow side, no doubt I was in trap or fat most of the time before US. Now for a trap TPI, that's blind - no problem. But deeper scap stabilizers is US for sure.

 

[drf]

Thanks drf.

I can identify the supraspinatus and bicipital tendons and inject these with good accuracy. Haven't learned subscapularis tendon injection yet. AC is easy, although very shallow.

What's your indication for injecting the supraspinatus and/or supra scapular nerves?

How do you do an intra-articular shoulder joint injection with US in a reliable way?

I'll have to play around with the probe and an anatomy book to get what your saying about the supra patellar bursa. Are you saying with injection of the joint, this bursa distends similarly to manually distending it by pressing on an effusion from below?

Supraspinatus rare diagnostic injections. Suprascapular for shoulder pain not responding to IA and poor candidate for surgery.


Eur Radiol (2009) 19: 722–730 DOI 10.1007/s00330-008-1200-x
Matthieu J. C. M. Rutten James M. P. Collins
Bas J. Maresch
Jacques H. J. M. Smeets Caroline M. M. Janssen Lambertus A. L. M. Kiemeney Gerrit J. Jager
MUSCULOSKELETAL
Glenohumeral joint injection: a comparative study of ultrasound and fluoroscopically guided techniques before MR arthrography

Shows some pics of the knee. Couldn't find a better ref in a hurry.

http://www.ajronline.org/content/174/5/1353.full

 

[PinchandBurn]

One thing I learned is that people were likely and still likely to err on the 'shallow' side when doing a TPI, especially in the thoracic regions and around the flank region, d/t concern of hitting the lungs and kidneys. I'm sure a lot of "TPIs" were simply subcutaneously injections of local anesthsetic. I think now with ultrasound, there's certainly a more comfort level added. The only problem I find is that it takes longer. As some have mentioned above, the results are promising...

 

[clubdeac]

powermd and drf - you guys seem to be the masters at US here. My question is, where did you learn your skills? I assume you both learned after fellowship.

And regarding your statement, " Cervical trap myofascial pain + some DDD + CTS = radicular pain for a lot of doctors who should know better." - I could see how I may be tricked by this combo, however, if it truly is myofascial pain in the trap, do you cure it with a tpi? It seems like any tpi I've done only helps for a short while. There was a time when I aggressively treated trigger points with injections every few weeks, rehab, and massage. I would even look for underlying systemic disorders claimed to be related to recurrent trigger points i.e. Vit D deficiency, anemia, electrolyte imbalances etc

 

[Ligament]

For nonsurgical candidates with frozen shoulders or intractable glenohumeral pain. Suprascapular RF or chemo denervation is a great procedure.

 

[epidural man]

powermd and drf - you guys seem to be the masters at US here. My question is, where did you learn your skills? I assume you both learned after fellowship.

And regarding your statement, " Cervical trap myofascial pain + some DDD + CTS = radicular pain for a lot of doctors who should know better." - I could see how I may be tricked by this combo, however, if it truly is myofascial pain in the trap, do you cure it with a tpi? It seems like any tpi I've done only helps for a short while.

This is anecdotal of course, but it seems to me that since I have started doing TPI's with ultrasound, they work better, and last a LOT longer.

What is often cool, is it seems that I can sometimes see the "abnormality" under ultrasound, and most times, when I start the injection into the usually more hyper echoic area (compared to the surrounding similar structures), they say - unprompted - "Oh Yeah...that's the spot."

Also, anectotally, I have found that a lot of the trigger point areas seem to be along the fascia right above the rib - and I never targeted this area before.

One thing I don't see under ultrasound, which was always cool doing them blind - is that twitch you get when you DO hit the right spot - probably because it is under the probe.

 

[epidural man]

Please explain to me how US is any better than a blind anatomical stick for shoulders and knees Dr. GFY. Do you have some magical US that allows you to actually see beyond the portion of the patella (or acromion) you can manually palpate?

TPs work a whole lot better when you can see what you're attempting to hydrodissect.

Blind = dumb luck at best.

ARen't there plenty of studies to show that people who think they are soooo good at blind injections have been shown to miss A LOT with blind, and it takes imaging to get it in the right spot MOST of the time?

I swear I have read these.

 

[epidural man]

I gotta disagree. While I do most TPIs without guidance, when I'm aiming for rhomboid or levator, esp on an obese pt, I use it and it's always nice to see the needle tip right in muscle belly. Not a lot of wiggle room with pleura next door.

jonnylingo....haha. funny.

Mahana you ugly!

 

[101N]

I invented ultrasound and now I'm putting in cardiac stents with it. I've got a paper coming out on how I'm doing brain surgery and cardiac bypasses with it. I cure people with ultrasound.

What? You mean you guys aren't using it for surgery, psychotherapy, and trigger point injections? Jeebus, you guys are so passé.

What a freaking pissing contest this has become.

 

[epidural man]

I invented ultrasound and now I'm putting in cardiac stents with it. I've got a paper coming out on how I'm doing brain surgery and cardiac bypasses with it. I cure people with ultrasound.

What? You mean you guys aren't using it for surgery, psychotherapy, and trigger point injections? Jeebus, you guys are so passé.

What a freaking pissing contest this has become.

Haven't you seen that video (produced in the 60s - shown in psychology classes) where they have an ultra powerful ultrasound beam that suspends these little squares of paper.

Ultrasound dude.....

- why do you hate sound?

 

[drf]

I invented ultrasound and now I'm putting in cardiac stents with it. I've got a paper coming out on how I'm doing brain surgery and cardiac bypasses with it. I cure people with ultrasound.

What? You mean you guys aren't using it for surgery, psychotherapy, and trigger point injections? Jeebus, you guys are so passé.

What a freaking pissing contest this has become.

My ortho oncologists are currently doing a study along with IR on...high frequency ultrasound denervation of bony mets!

 

[drf]

For nonsurgical candidates with frozen shoulders or intractable glenohumeral pain. Suprascapular RF or chemo denervation is a great procedure.

For frozen shoulders I like an IA and suprascapular done followed by aggressive ranging to break it up. Satisfying crush and doesn't require propofol and an anesthesiologist to do in the OR.

 

[drf]

powermd and drf - you guys seem to be the masters at US here. My question is, where did you learn your skills? I assume you both learned after fellowship.

And regarding your statement, " Cervical trap myofascial pain + some DDD + CTS = radicular pain for a lot of doctors who should know better." - I could see how I may be tricked by this combo, however, if it truly is myofascial pain in the trap, do you cure it with a tpi? It seems like any tpi I've done only helps for a short while. There was a time when I aggressively treated trigger points with injections every few weeks, rehab, and massage. I would even look for underlying systemic disorders claimed to be related to recurrent trigger points i.e. Vit D deficiency, anemia, electrolyte imbalances etc

I had my regional anesthesia month the same month my program got its first US machine. Learned the basics. Pain fellowship was all blind and fluoro. After I finished I bought some radiology MSK US books and started doing simple chronic pain blocks. I did the first 5 of most things in the OR with fluoro confirmation when possible. All weird tiny nerves got done with stim confirmation.

Nowadays there is much more formal USPM education and workshops as well as Samer Narouzes textbook. I bought it when it came out but quickly realized all his techniques and references were the same ones I'd been using to learn the stuff. Got to throw out a 4 inch pile of hard copy case reports and articles.

I use trigger points as a means to convince the pain is in the muscle and du to deconditioning. No narcs. Go to PT.

 

[Ducttape]

Now i am a big ultrasound fan, but one of the most recent studies looked at US for preanesthetic blocks, and found little to no difference in the quality of the block itself. Obviously, this was primarily for brachial plexus and femoral nerve blocks...

from my standpoint, one of the main reasons i use ultrasound is to ameliorate the risk of complications, from, for example, PTX. i dont use it for TPI.

ps anyone who has an iphone, you can get youtube vids of various US guided blocks, but i also have an app from Sonosite that has almost all the anesthesia ones and a few of the pain blocks. On the laptop, i will look at the NYSORA website, which is pretty nice.

 

[Jcm800]

I invented ultrasound and now I'm putting in cardiac stents with it. I've got a paper coming out on how I'm doing brain surgery and cardiac bypasses with it. I cure people with ultrasound.

What? You mean you guys aren't using it for surgery, psychotherapy, and trigger point injections? Jeebus, you guys are so passé.

What a freaking pissing contest this has become.

i don't believe your claim you invented ultrasound.

 

[DOctorJay]

powermd and drf - you guys seem to be the masters at US here. My question is, where did you learn your skills? I assume you both learned after fellowship.

I'm learning all this in residency. I've already done close to 150 ultrasound guided injections on my own and have another month in April that will be all msk ultrasound guided injections (should get at least another 75). We take an annual 6 month course on how to use ultrasound for Dx and interventions. We also have 2 separate cadaver labs. This is part of our didactic curriculum.

Best course is AIUM held every July at Mayo Rochester
Beginner book - Jacobson
Advanced pain book - Narouze
Websites essr.org and usra.com

 

[DOctorJay]

http://www.youtube.com/watch?v=RskrEsAGzec&feature=related

This is probably the best video to help you understand ultrasound probe and needle manipulation.

 

[Ligament]

The studies looking at use of U/S for REGIONAL anesthesia are not necessarily relevant to pain managment. Massive volumes of local anesthetic is used in Regional anesthesia. Therefore, a decent block can be obtained by essentially volume conduction, whether the needle is on/next to nerve or not.

As we in pain managment are not injecting 40cc of 0.5% marcaine into our patients, accuracy is much more important for beneficial block.

 

[101N]

i don't believe your claim you invented ultrasound.

Yor mother smells of elderberries!

 

[lobelsteve]

The studies looking at use of U/S for REGIONAL anesthesia are not necessarily relevant to pain managment. Massive volumes of local anesthetic is used in Regional anesthesia. Therefore, a decent block can be obtained by essentially volume conduction, whether the needle is on/next to nerve or not.

As we in pain managment are not injecting 40cc of 0.5% marcaine into our patients, accuracy is much more important for beneficial block.

Actually, I do my MBB's with 40cc of 0.5% Marcaine, but it's divided up as 0.5cc per level.

 

[Jcm800]

Yor mother smells of elderberries!

Now go away before I taunt you a second a second time....

 

[Ducttape]

The studies looking at use of U/S for REGIONAL anesthesia are not necessarily relevant to pain managment. Massive volumes of local anesthetic is used in Regional anesthesia. Therefore, a decent block can be obtained by essentially volume conduction, whether the needle is on/next to nerve or not.

As we in pain managment are not injecting 40cc of 0.5% marcaine into our patients, accuracy is much more important for beneficial block.

why stop at 40cc?

generally speaking, the blocks that i did for anesthesia were of lower volume than 40 cc of 0.5%. if i remember correctly, scalenes were 10 cc, supraclaviculars were 20 cc, femorals were 20-30 cc.


i am a fan of ultrasound, but ultrasound does not "make" the block - the person and his skill doing the injection "makes" the block successful.

 

[101N]

Now go away before I taunt you a second a second time....

🙂