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PERCUTANEOUS PERIPHERAL PAIN PROCEDURES UNDER ULTRASONOGRAPHY GUIDANCE

KADER KESKINBORA
From the Division of Pain Therapy, Department of Anesthesiology, Medical faculty of Cerrahpasa, Istanbul University, Turkey INDOANESTHESIA 2013

Ultrasonography in Regional Anesthesia

Ultrasonography (US) is a recent achievement in the field of regional anesthesia and it has been increasingly used for its clinical reliability and efficiency. Moreover, US guidance is nearing to become the standard of care in regional anesthesia and for postoperative pain management.

Ultrasonographic illustration of the brachial plexus (indicated by white arrows) at the supraclavicular level, adjacent to the cervical Pleura (indicated by grey arrows). SA, Subclavian artery.

The sciatic nerve (SN) at the mid-femoral level partly surrounded by local anaesthetic, resulting in a successful block. The homogenous hypoechoic (dark) zone represents the local anaesthetic (LA).

What about Ultrasonography in Pain Medicine


Application of US in pain medicine is an emerging imaging technique and a

rapidly growing medical field in interventional pain management.


Confronted with uoroscopy, which is one of the main imaging technique used in pain medicine, US leads to complete elimination of radiation exposure to patients who often undergo the procedure many times, and nally to the operator.

Ultrasonography in Pain Medicine


However, USs role in invasive procedures in pain medicine is still discussed.

The availability of other imaging techniques like flouroscopy, CT and MRI and lack of familiarization with US imaging are some of the reasons beneath this discrepancy.

Important steps are being made lately towards the development of safe, available and clinically efficient US guided techniques for many procedures especially involving peripheral nerve.

Advantages of US guidance both in regional anesthesia and pain medicine:


1. Direct visualization of nerves: Other methods of nerve localization, such as electrical stimulation or paraesthesia may be replaced

2. Direct visualization of anatomical structures like vessels, muscles, bones, etc.:


This may help assess individual variations in anatomy and facilitate identification of nerves.

3. Real-time control of needle advancement:


This may reduce the number of needle passes, shorten the block performance time and lower the risk of complications caused by a needle e.g., vascular puncture, neuropraxia or pneumothorax

4. Assessment of LA spread around the nerves and immediate supplementary injections in case of insufficient spread:
This may improve block effectiveness., shorten latency, prolong duration, allow LA dose reduction and lower the risk of overdose.

Marhofer P, Br J Anesth,2005

US has a beter safety prole in percutaneous pain procedures

especially

allowing

visualization

of

puncture

site,

needle

tip

advancement through soft tissues and real-time image.

spread of LA and also supplying

especially for diagnostic pain procedures, US allows injecting a very low


dose of a local anesthetic directly near the nerves that supply the assumed anatomical site of pain origin.

on the other hand, US still lacks acceptable resolution at deep levels, and
it has poor utility for areas hidden by bony structures.

The application of US in pain medicine


Pheripheral
Greater Occipital Nerve Block

Spinal
Cervical Facet Joint Injections

Stellate Ganglion (Cervical Sympathetic) Block


Suprascapular Nerve Block Intercostal Nerve Block Ilioinguinal- Iliohypogastric-Genitofemoral nerve Block

Cervical Medial-Branch Block


Cervical Nerve Root Block Lumbar Medial-Branch Block Lumbar Facet Joint Injections Lumbar Nerve Root Injection Sacroiliac Joint Injection Caudal Epidural Injections

Lateral Femoral Cutaneous Nerve Block


Piriformis Muscle Injection Pudendal Nerve Injection Upper and lower extremity Peripheral Nerve blocks

Upper and Lower extremity joints injection

US GUIDED GREATER OCCIPITAL NERVE BLOCK

is frequently performed either to diagnose or to treat pain mediated by the greater ccipital nerve (GON) such as occipital neuralgia and cervicogenic headache.

Unfortunately, no US guided procedures have been described until recently completed anatomical study was published.

Greher and coworkers developed an US guided approach to block the GON. In contrast to the standard blind approach of GON block, they targeted the nerve more proximally where it was usually not divided.

Ultrasound-guided classical distal block technique Ultrasound-guided new proximal block technique

at the level of superior nuchal line at C2 where it lies superficial to the oblique capitis inferior muscle

Their findings confirmed that the GON could be visualized using US both at the level of the superior nuchal line and C2. This newly described approach superficial to the obliques capitis inferior muscle has a higher success rate and should allow a more precise blockade of the nerve.

US GUIDED STELLATE GANGLION BLOCK

may be used in patients suffering from vascular diseases or sympathetically maintained pain of the head or the upper extremity.

US allows direct visualization of the local anatomy which are all relevant anatomical structures of the middle cervical ganglion region at the C6 level, leading to better safety and block reliability.

So that, clear imaging of the muscles, fasciae, blood vessels, viscera, and bone surface makes US superior to fluoroscopy for image-guided stellate ganglion block.

Michael Gofeld, Pain Practice, Volume 8, Issue 4, 2008 226240

Ultrasound imaging for stellate ganglion block: direct visualization of puncture site and local anesthetic spread. A pilot study.
Kapral S, Krafft P, Gosch M, Fleischmann D, Weinstabl C Reg Anesth1995 Jul-Aug;20(4):323-8.

Kapral and coworkers described a technique first in 1995 and published a

case series. Compared with blind injection, the authors used a lower
volume of local anesthetic (5 mL rather than 8 mL), found no formation of hematomas (whereas 3 patients in the blind injection group had a hematoma), and rapid onset of Horner syndrome in US guided stellate ganglion block.

Anesth Analg 2007 Aug;105(2):550-1


Shibata Y, Fujiwara Y, Komatsu T

Shibata and coworkers suggested that subfascial injection would result in better spread of the injectate and more reliable sympathetic blockade

Ultrasound image during C6-stellate ganglion block injection beneath the prevertebral fasica in the longus colli muscle
white arrow indicates the prevertebral fascia distended with local anesthetic

(Reg Anesth Pain Med 2009;34: 475Y479)

Gofeld and coworkers attempted to find a pathway for needle placement away from vital neck structures

only the anterior tubercle of the C6 transverse process was visible


adjacent to the projected entry point of the needle, and no visceral or neural elements were situated on the line connecting the entry site and the lateral surface of the longus colli muscle.

US GUIDED SUPRASCAPULAR NERVE BLOCK


(SSN)

have been used in the management of a variety of painful shoulder pathologies by use of several techniques. .

In recent years, the technique for suprascapular nerve block under US guidance was defined, and a few studies using that technique have already been published. The images shown in those ultrasound-guided SSN injection reports were described as identifying the SSN within the suprascapular notch and covered by the superior transverse scapular ligament.

But, fluoroscopic and cadaver dissection

findings as shown in this study suggested


that US image of the SSN block was actually targeting the nerve on the floor of the suprascapular spine between the

suprascapular

and

spinoglenoid

notches

rather than the suprascapular notch itself.


Short axis scan of the nerve. Bold arrows=suprascapular notch Line arrows =transverse scapular ligament Similar scan with colour Doppler to show the suprascapular artery (solid arrow), which was seen underneath the transverse scapular ligament

Ultrasound-Guided Suprascapular Nerve Block, Description of a Novel Supraclavicular Approach.


Siegenthaler A, Moriggl B, Mlekusch S, Schliessbach J, Haug M, Curatolo M, Eichenberger U. Reg Anesth Pain Med. 2012 Jan 4.

The authors scanned 60 volunteers with US, both in the supraclavicular and the classic target area. And then they compared visibility of the SSN in both regions. They concluded that visualization of the SSN with US is better in the supraclavicular region as compared with the supraspinous fossa. The anatomic dissections confirmed that their novel supraclavicular SSN block technique was accurate.

US GUIDED INTERCOSTAL NERVE BLOCK


Intercostal nerve blocks are performed for a variety of pain conditions, ranging from acute postoperative pain to chronic pain syndromes.

There are very few published data on US-guided intercostal nerve blocks. Using US, the nerves are rarely seen because they lie close to or are covered by the caudal edge of the rib and are therefore masked by sonographic artifacts. In contrast, the spread of the injected solution can be seen clearly by US during the injection.

Lateral approach, in-plane

Case Report Ultrasound-guided intercostal nerve block for traumatic pneumothorax requiring tube thoracostomy
Stone MB, Carnell J, Fischer JW, Herring A, Nagdev A American Journal of Emergency Medicine (2011) 29

Stone and coworkers placed probe in a longitudinal parasagittal orientation to identify the ribs and pleural line. Then they visualized the needle approaching the inferior margin of the target ribs, and injected LA solution into each intercostal space with real-time ultrasound visualization of local anesthetic spread to the adjacent pleura

US GUIDED ILIOINGUINAL, ILIOHYPOGASTRIC, AND GENITOFEMORAL NERVE BLOCK


Because of the course of the nerves, they are at risk for injury in lower abdominal surgery or laparoscopic surgery. As a result, patients may suffer from chronic postsurgical neuropathic pain due to the nerve injury and will present with groin pain that may extend to the scrotum or the testicle in men, the labia majora in women, and the medial aspect of the thigh.

The area for optimal scanning of these nerves is the area posterior and cephalad to the superior iliac spine. With the probe placed in an orientation perpendicular to the inguinal

ligament, all the 3 layers of abdominal muscles (ExtObl, IntObl, and TranAbd), iliac crest, and

peritoneum can be well visualized .

This investigation is the first description of an US guided approach to the ilioinguinal (II) and iliohipogastric (IH) nerve in adults. They suggested using their new injection point about 5 cm cranial and posterior to the anterior superior iliac spine. At this point all three muscle layers of the abdominal wall can easily be identified by ultrasound and facilitate orientation.

US GUIDED LATERAL FEMORAL CUTANEOUS NERVE BLOCK is used for the diagnosis and conservative management of meralgia paresthetica which is a mononeuropathy of the LFCN and characterized by paresthesia, numbness, and pain in a localized area on the anterolateral aspect of the thigh.

Lateral femoral cutaneous nerve (LFCN) is a small peripheral of nerve, and the scanning good that requires knowledge region. The literature suggests that the LFCN is experienced the personnel anatomy with

around

best recognized when it courses laterally


over the sartorius muscle, which has a typical triangular shape.

Bodner and coworkers assessed the feasibility of US in visualizing the lateral femoral cutaneous nerve in a cadaver and 8 volunteers. They suggested that US enables visualization of the LFCN in a cadaver and in volunteers

US GUIDED PIRIFORMIS MUSCLE INJECTION


Piriformis syndrome is an uncommon and often underdiagnosed cause of buttock and leg pain and has features similar to those of sciatica. The management of piriformis syndrome includes the injection of the piriformis muscle with local anesthetic and steroids or the injection of botulinum toxin

Because of its small size, proximity to neurovascular structures, and deep location, the piriformis muscle injection with the use of US seems more logical. Over the past few years, US has been shown to be a reliable imaging tool for needle placement during piriformis injections. US guided injection offers a technique with a direct visualization of the piriformis muscle, real-time guidance of needle insertion, and the confirmation of injectate inside or around the piriformis muscle.

Pheng and coworkers suggested in this article that the key step for US guided injection was to align the ultrasound probe in the longitudinal axis of the piriformis muscle above the ischial spine. So that they recommended another technique rather than reported technique in the literature: Scanning was performed in the transverse plane with the probe placed over posterior superior iliac spine so that the sacroiliac joint can be seen.

Am J Phys Med Rehabil. 2011 Oct;90(10):871-2

Chen and coworkers recommended the medial-to-lateral approach when performing the US guided piriformis muscle injection

US GUIDED PUDENDAL NERVE INJECTION


serves both diagnostic and therapeutic purposes in pudendal neuralgia which is commonly presents as chronic debilitating pain in the penis, scrotum, labia, perineum or anorectal region.

US visualization of the pudendal nerve is limited for several reasons:

The diameter of the pudendal nerve at the level of the ischial


spine is very small (4 to 6 mm) and difficult to detect with an US at a depth of 5.2 cm. At the level of the ischial spine, 30% to 40% of pudendal nerves are 2- or 3-trunked. This reduces the chance of a direct depiction of the nerve with an US and may also account for poor response to the nerve stimulator. the

Pheng PWH. et al. , Reg Anesth Pain Med 2009

New, simple, ultrasound-guided infiltration of the pudendal nerve: ultrasonographic technique.


Kovacs P, Gruber H, Piegger J, Bodner G. Dis Colon Rectum. 2001 Sep;44(9):1381-5

The authors scanned deep gluteal region in two perpendicular planes as longitudinal and transverse to the internal pudendal artery. They founded that in almost one-half of the cases a direct US-guided infiltration of the pudendal nerve was possible and in the remaining cases the nerve could be detected and blocked indirectly, using the ischial spine or the internal pudendal artery as a landmark

Feasibility of real-time ultrasound for pudendal nerve block in patients with chronic perineal pain.
Rofaeel A, Peng P, Louis I, Chan V Reg Anesth Pain Med. 2008 Mar-Apr;33(2):139-45

In the literature, only this study describes the feasibility of the US guided pudental nerve injection technique.

Rofaeel and coworkers placed the US probe


and sacrotuberous ligaments, the

at the level of the ischial


pudendal artery and

spine to capture the transverse view of the ischial spine, the sacrospinous internal the pudendal nerve. Their findings were that pudendal nerve block at the ischial spine level could be reliably performed under real-time ultrasound guidance.

US GUIDED EXTREMITY

PERIPHERAL

NERVE

BLOCKS

OF

THE

UPPER

ISOLATED UPPER EXTREMITY NERVE BLOCK RADIAL NERVE BLOCK MEDIAN NERVE BLOCK ULNAR NERVE BLOCK US guidance is also very useful for peripheral nerve blocks in the upper limbs, as it allows the anaesthetist to minimize the dose of local

anaesthetic and to advance the needle to the nerve safely.


It is also possible to follow the anatomical structure of the nerves from the axilla distally to the wrist. SO THAT anatomical landmarks are no longer needed to identify nerves.

US GUIDED MEDIAN NERVE BLOCK


Used in carpal tunnel syndrome associated with tenosynovitis of the finger flexor tendons

Median nerve can be blocked from the antecubital area of elbow distally to the wrist.

the

US GUIDED EXTREMITY

PERIPHERAL

NERVE

BLOCKS

OF

THE

LOWER

LUMBOSACRAL PLEXUS BLOCK FEMORAL NERVE BLOCK OBTURATOE NERVE BLOCK SCIATIC NERVE BLOCK While peripheral nerve blocks can replace neuraxial techniques, they still require two punctures. It is therefore useful to minimize the amount of LA injected by US guidance. These blocks are useful for surgical anesthesia and postoperative pain but in interventioanl pain medicine they are olso important especially for

diagnostic as well as for theuropatic blocks.


We usually do these block and put the catheter under US guidance to manage ischemic pain of lower extremity due to peripheral vascular disease or diabetes.

US GUIDED FEMORAL NERVE BLOCK


Because of the proximity to the relatively large femoral artery, US may reduce the risk of arterial puncture that often occurs with the use of non-US techniques. Orientation begins with the identification of the pulsating femoral artery at the level of the inguinal crease. If it is not recognized, sliding the probe medially and laterally will bring the vessel into view. Immediately lateral to the

vessel, and deep to the fascia iliaca is


the femoral nerve as a typically hyperechoic and roughly triangular or oval in shape.

US GUIDED SCIATIC BLOCK AT THE POPLITEAL LEVEL


The distal branches of the sciatic and femoral nerves, including the tibial nerve at the popliteal level and the peroneal nerve distal to the head of the fibula, can also be selectively visualized under US guidance.

Figure visibility

of of

four the

position sciatic

improves nerve

the

in the

popliteal fossa. Linear probe was applied horizontally on the

posterior thigh 7 cm above the popliteal


crease. In a transverse view, the sciatic nerve appeared as a round hyperechoic
Dufour E,Reg Anesth, 2008

structure called coin sign.

US-guided injection of the upper and lower extremity joints


With improvements in transducers and image processing software, US has become an increasingly valuable tool in musculoskeletal diagnostic imaging and for guiding musculoskeletal interventions. The main advantage of US-guided joint injection over blind injection is that the needle position can be confirmed and injection of contrast medium or medication can be controlled in real-time. A limitation with regards to US guidance is the presence of any intervening osteophytes or exostoses which prevent a clear view of

the intended target.

US GUIDED THE KNEE JOINT INJECTION


in the treatment of anterior knee pain secondary to rheumatoid arthritis and osteoarthritis.

There are several advantages to treat a pathologic knee with the aid of sonography. First, US can be used as an extension of the physical examination and aid in the accurate diagnosis of arthritis.

There are few studies examining the outcomes of intraarticular knee


injections using US guidance.

J Ultrasound Med 2009; 28:14651470

Im and coworkers showed that US-guided injections via a medial patellar portion (MPP) of the knee joint had a significantly greater accuracy rate (95.6%) than blind injections (77.3%).

TAKE AWAY MESSAGE


US for pain procedure remains a very young technique that needs to be further developed. Future clinical studies should focus not only on developing and

describing techniques of US-guided procedures, but should


also provide evidence that US is at least equivalent to the already available imaging techniques or blind approaches in

terms of effectiveness and safety.

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