Interventional Procedures

2/27/2015
Objectives
Interventional Techniques
The Musculoskeletal Ultrasound
Skills Course
Gregory R. Saboeiro, M.D.
Chief, Divisions of Ultrasound and
Interventional Radiology
Hospital for Special Surgery
New York, New York
• To review the basic principles of ultrasound
utilization in the performance of
interventional procedures
• To demonstrate several interventional
procedures that may be performed with
ultrasound guidance
Why use ultrasound for MSK
interventions?
Disclosures
Research fundingHarvest Technologies (platelet rich plasma)
Consultant/speakerBioventus
• Ultrasound allows visualization and
injection of many soft-tissue structures not
otherwise seen (tendon sheaths, bursae,
etc.)
• Can localize and inject area of maximal
discomfort after real-time examination of
patient
Common ultrasound-guided
interventions
Ultrasound-guided interventions
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Joint injections and aspirations
Tendon sheath injections
Bursal injections
Perineural injections
Intratendinous interventions
Cyst aspirations
Calcific tendinosis lavage aspiration
Biopsies
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Glenohumeral joint
Biceps tendon sheath
Calcific tendinosis
Paralabral cysts
Epicondylitis
De Quervain’s
Ganglion cysts
Basal joint of thumb
Hip joint
Iliopsoas tendon
Trochanteric bursitis
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Hamstring origins
Sciatic nerve/piriformis
Knee joint
Popliteal cyst
Pes anserine bursitis
Achilles tendinosis
Retrocalcaneal bursitis
Plantar fascitis
Intermetatarsal neuroma
Small joints of feet
Ankle tendons
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Ultrasound vs. fluoroscopy
• Direct ultrasound visualization of needle
throughout the injection confirms accuracy
and avoidance of neurovascular structures
• No contrast is necessary- the injectate acts
as contrast and is visualized sonographically
Ultrasound guidance for MSK
interventions
• All joint, tendon and bursa injections are
easier and safer with ultrasound than with
fluoroscopy
• Guarantees filling of the joint, bursa or other
target without extravasation
• Be familiar with both long and short axis
scan positions as well as in-plane and out of
plane needle approaches to all joints
Probe selection for MSK
interventions
• Curved low-frequency probes- generally
needed only for deep structures (anterior hip
joint, piriformis)
• Mid-range linear probes- ideal for general
MSK use (shoulder, knee, elbow, hip)
Ultrasound vs. fluoroscopy
• Avoids radiation for
patient, physician,
and technologist
Interventional techniques
• Basic principles
• Sterile procedure guidelines
• Technique tips
• Needle visualization
Probe selection for MSK
interventions
• High-frequency small footprint linear
probes- best for superficial structures of
hands, feet, elbow, etc.
18 MHz
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Sterile technique
• No set guidelines but consistency in your
practice is vital
• Sterile preparation of the skin site
• Sterile preparation of the probe surface
• Sterile gloves
• Gown? Mask?
• Using same medication vial for multiple
patients?
Diagnostic injections
Pre-packaged set used for all sonographicallyguided interventional procedures
Therapeutic Injections
• 1% Lidocaine
• 1% Lidocaine
• 0.25-0.75 % Sensorcaine, Ropivacaine, etc.
• 0.25-0.5 % Sensorcaine, Ropivacaine, etc.
• Patient is asked to perform any activities
over the next 1-6 hours that would usually
elicit pain and record their response
• Corticosteroid
Corticosteroids
• Triamcinolone (Kenalog)- 40 mg/ml
• Betamethasone (Celestone)- 6 mg/ml
• Methylprednisolone (Depo-Medrol)- 40
mg/ml
Steroid Injections
• Mechanism of response is via their antiinflammatory properties but is poorly understood
• Shown to decrease the production of cytokines,
which decreases the pain sensation in the joint,
tendon sheath, or bursa injected
• Length of response is highly variable- generally
weeks to months
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Alteration of neutrophil chemotaxis and function
Increases viscosity of synovial fluid
Stabilization of cellular lysosomal membranes
Alteration of hyaluronic acid synthesis
Transient decrease in synovial fluid
complement
Alterations in synovial permeability
Needle size
• 25 gauge for local anesthesia
• 18-20 gauge for joint fluid aspiration (16
gauge for complex or viscous collections)
• 22-25 gauge for joint injection
Change in synovial fluid leukocyte
count and activity
Potential complications
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bleeding / hematoma
infection
paresthesia
failure to relieve pain or inflammation
“flare” response
skin discoloration at site
regional fat atrophy
ligament or tendon rupture
Corticosteroid injections and
diabetes
“Flare response”
• localized reaction to the crystal suspension
of the steroid
• more common with particulate agents
• localized pain and swelling
• self-limited but must distinguish from
infection
Typical post-injection course
• systemic effect of steroid injections is
generally minimal
• anesthesia will persist for 4-5 hours if longacting type is used
• patients may see temporary rise in blood
glucose levels for 12-48 hours and should be
warned in advance
• steroids usually are effective within 2-7 days
• length of response is highly variable
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Post-procedure care
Needle visualization
• Appropriate depth and focus settings
• limited activity (depending on joint injected)
• ice and po pain / anti-inflammatory meds as
needed
• Choose a needle approach as parallel to the
probe surface as possible
• Slow up and down movements of needle
• Turn needle for bevel visualization
• Inject and observe fluid location
Needle visualization
• For injections of deeper structures (hip
joint, piriformis, hamstrings, etc.) a
curvilinear probe may be helpful
• Power Doppler
• Echogenic-tipped needles
Variations in
needle angulation
Pearls and pitfalls
• Never advance a needle that you can’t see
• Seeing some of the needle is great but you
MUST see the tip
• Never look for a moving needle with
ultrasound-let go of the needle and find it
before continuing
• Look down at the probe and the needle
often- this greatly expedites finding the
needle
Needle size
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Needle size
Needle size
Shallow approach bevel rotation
Ultrasound-guided interventional
techniques
• Freehand technique
• 2 different approaches:
– Needle perpendicular or parallel to the beam
In plane
Out of plane
Steep approach bevel rotation
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Injection Approach
In plane
Out of plane
See entire needle
See only tip of needle
1st MTP joint injectionout of plane approach
Popliteal cyst aspirationin-plane approach
Posterior tibialis tendon sheath injectionin-plane approach
Joint injections
• Glenohumeral joint
• Hip joint
• Acromioclavicular joint • Knee joint
2nd tarsal-metatarsal joint injectionout of plane approach
• Elbow joint
• Ankle joint
• Radiocarpal joint
• Small joints of the foot
• Basal joint of thumb
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Basic principles of joint aspirations
or injections
Basic principles of joint injections
• Review prior imaging
• Continuous visualization of needle throughout
procedure
• Preliminary scan to identify approach and
locate any regional neurovascular structures
• Test injection of anesthetic to confirm appropriate
needle position within joint, tendon sheath, etc.
• Mark skin site for approach
• Sterile preparation of skin and probe
Preliminary aspiration of
joint/bursal/tendon sheath fluid
• Often provides prompt symptomatic
improvement (Baker’s cyst, joint effusion,
etc.)
• May be helpful in excluding infection,
crystals, etc.
• Allows more space for the injected cortisone
(especially small joints)
• Decreases the dilution of the injected
cortisone
Shoulder joint injectionneedle contacting humeral head cartilage-
• Aspirate any fluid present
• Injection of corticosteroid-anesthetic preparation
under continuous sonographic visualization while
filling the joint
Ultrasound guided aspirations and
injections
• Fluid within any joint, bursa or tendon
sheath makes the best and easiest target
• If you contact cartilage- you are in the joint
of interest
• The injectate should flow easily, even
through a very small needle (25 gauge)
Hip joint injection- long axis approach
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Bursal injections
Synovial bursa
• A closed, fluid-filled sac that functions as a
gliding surface to reduce friction between
tissues of the body
• Develop in utero
• 2 types:
• Allow frictionless movement between
muscles/tendons/ligaments/bones/skin
• Synovial (constant) bursa
• Adventitial (reactive) bursa
Adventitial bursa
• Do not develop in utero
• No synovial lining
• Develop in response to abnormal contact
betweenmuscles/tendons/ligaments/
bones/skin
• Example: plantar bursa over the metatarsal
heads of the foot, bursa over osteochondromas
• Lined by synovium
• Examples: subacromial-subdeltoid bursa,
olecranon bursa, iliopsoas bursa
Basic principles of bursal procedures
• Sterile preparation of the region and the
ultrasound probe
• Continuous visualization of the needle
throughout the procedure
• Aspirate bursal fluid if present and send for
fluid analysis (r/o infection, crystal analysis,
etc.) if indicated
Common bursal
aspirations/injections
Basic principles of bursal procedures
• Injection of anesthetic/cortisone mixture
into the bursa under direct sonographic
visualization, if indicated
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Subacromial-subdeltoid bursa
Olecranon bursa
Iliopsoas bursa
Trochanteric bursa
Prepatellar bursa
Peri-Achilles bursa
Intermetatarsal bursa
Plantar bursa of the foot
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Decubitus position
Subacromial bursa injection
Subacromial
bursa injection
Olecranon
bursitish/o RA
Fluid and inflamed
hyperemic soft tissues
Pre-aspiration
Post-aspiration
Tendon sheath injections
• Biceps tendon
• 1st dorsal compartment of wrist (De
Quervain’s)
• Posterior tibial tendon
• Peroneal tendons
Cultures:
Staph aureus
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Tendon Sheath Injections
• Evaluate tendon first for high-grade tears (?
cortisone)
• Locate and avoid regional neurovascular
structures
• Tendon sheath effusion makes an excellent
target
• Injected fluid should flow along the course
of the tendon within the sheath
Biceps tendon sheath injection
Ganglion cysts
• Mucinous filled cyst usually adjacent to joint capsule or tendon
sheath
• 60-70% of dorsal wrist ganglia originate from scapholunate
ligament
• Volar ganglia are often in close proximity to radial artery and nerve
• Firm, round, tender mass
Posterior tibial tendon sheath injection
• Contain clear, colorless or yellow gelatinous-like fluid, often with
internal debris and septations
Ganglion cysts
• Material in cysts is often extremely thick
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• Use larger (16-20) gauge needle
• Frequently need saline lavage to break up and then
aspirate cyst contents
• Fenestrate cyst and inject steroid preparation as
indicated
• Consider Celestone- less skin side effects for superficial
injections
coronal
axial
Radial volar ganglion
sagittal
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Median nerve
Large volar
ganglion
adjacent to
radial artery
Short axis
Pre-aspiration
Post-aspiration
Ganglion at volar wrist
Intratendinous interventions
• Peritendinous corticosteroid injections
• Needle tenotomy/fenestration of the
abnormal tendon
• Platelet rich plasma (PRP) or other biologic
agent injection following needle tenotomy
PRP
• Autologous whole blood- 93% RBC, 6
% platelets, 1 % WBC
• PRP- markedly increased platelet
concentration (amount varies by
manufacturer) and generally 3-8 times
that of whole blood
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PRP
• Platelets- important
in release of many
growth factors that
could improve and
accelerate tissue
repair when injected
into damaged
tendons or other
structures
Potential PRP Benefits
• Stimulate new cell growth
• Attract “healing” cells
• Stimulate collagen production within
tendons, etc.
• Promote angiogenesis
Technique- percutaneous needle
tenotomy
• Review any prior imaging of the tendon of concern
long axis
Needle tenotomy:
Disrupts abnormal tendon fibers
Promotes regional bleeding and reactive
hyperemia (increased growth factors?)
Creates a space for subsequent injection
of PRP or other agent as indicated, filling the area
of abnormal tendon
Technique- percutaneous needle
tenotomy
• Preliminary ultrasound to identify areas of abnormal
tendon
• Localize regional neurovascular structures with
ultrasound
• Full sterile preparation- patient and probe
• Liberal administration of anesthetic to the margin of
the tendon- within tendon (?)
Common flexor tendinosis and tenotomy
• Continuously visualize the tendon and areas of
tendinopathy throughout the procedure
• Tenotomy of abnormal areas with needle (18-22
gauge), generally in the long axis
of the tendon (maximal fiber disruption) and with
needling of osseous attachment of tendon if
involved
• As indicated, injection of agent (PRP, etc.) through
the tenotomy needle into the fenestrated region of
the tendon at conclusion
Coronal IR and PD MRIcommon flexor tendinosis
and small split tear
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thickened and
hypoechoic
tendon
Medial
epicondyle
partial tear
Long axis of
common flexor
tendinosis/tear
Needle tenotomycommon flexor tedinosis
Perineural injections
Medial
epicondyle
Tenotomize tendon and also
needle the periosteal attachment
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Posterior interosseous nerve
Ulnar nerve
Median nerve
Lateral femoral cutaneous nerve
Saphenous nerve
Common and superficial peroneal nerves
Morton’s neuroma
Perineural injections
• Often done with anesthetic only as a
diagnostic tool in complex cases
• May also inject cortisone for a longer effect
• Ideally will surround the nerve with injectate
at the conclusion of the injection
Perineural injection of the sural nerve
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inguinal ligament
Normal
LFCN
location
(left)
ASIS
medial
Inject superficial and
deep to the
LFC nerve
lateral
short axis
sartorius
lateral
medial
Preinjection
ASIS
deep
ASIS
superficial
short axis
Radial nerve bifurcation and
recurrent radial artery
Postinjection
Inject
superficial and
deep to nerve
Biopsies
• Tumors
• Synovium (hip arthroplasties, PVNS, etc.)
• Muscle
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Guide needle- 13 gauge
Bard Monopty biopsy device- 14 gauge
Core biopsy device- phantom
long axis
Synovium
metal head
metal neck
Hip arthroplasty
anatomy
short axis
Metal neck
femur
Prominent synovium
at head-neck
junction
Metal neck
Guide needle to
edge of synovium
Core biopsy device
for synovial samples
Hip arthroplasty
synovial biopsy
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Conclusion
• Ultrasound is an important modality in the
safe and accurate performance of multiple
interventional procedures
Soft tissue mass biopsy
Thank You
[email protected]
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