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2019년 6월 9일

프롤로의원

정재욱 M.D

Introduction

• Interventional pain procedures with image-guidance: fluroscopy, CT, US, or without image guidance utilizing surface landmarks

• Ultrasound (US) guided interventional proceduresa. Aspiration of fluid collectionb. Injection into joint cavity and tendon sheaths or para-articular soft

tissuesc. Biopsies of space-occupying massesd. Removal of foreign bodiese. US-guided regional anesthesiaf. Treatment of painful neuroma

Atlas of Ultrasound Guided Musculoskeletal Injections.2014.

Introduction

Steroid Injection Procedures with US-guidance

far more effective and fewer side-effects

especially useful in small or deep joints and tendon sheaths which are more difficult to inject blindly

Should recommend the patient to keep the joint relatively immobile to maximize the therapeutic effect of the injected drugs and reduce their possible diffusion into the adjacent tissues

Atlas of Ultrasound Guided Musculoskeletal Injections.2014.

Introduction

An entrapment neuropahty is defined as a pressure-induced injury to a peripheral nerve in a segment of its course due to anatomic structures or pathologic processes

Peripheral nerve entrapments can cause a variety of painful conditions as diverse as headache, backache, “sciatica”, and foot pain. The pain will have a burning, shooting, or lancinating quality

Nerve entrapment has been reported from multiple etiologies such as stretching, blunt trauma, compression with hypoxia, fibrosis with entrapment, suture ligature

Limited literature about pharmacologic treatment for entrapment syndrome, but still both systemic medicine and topical agents, as monotherapy or combined therapy, can be utilized for pain relief associated with entrapment syndrome

Peripheral Nerve Entrapments. Clinical diagnois and treatment. 2016.

Introduction

Peripheral Nerve Entrapments. Clinical diagnosis and treatment. 2016.

Injection therapy can treat the nerve entrapment, with mechanisms including

hydrodissection, the anti-inflammatory effect, nerve regeneration, dilution and flushing out of inflammatory mediators

Nerve hydrodissection Use of fluid injection under pressure to purposely and more completely separate

nerves from surrounding tissue US is used to guide the needle and fluid (hydro) to separate and release the nerves

form the surrounding soft tissue/fascia

Types of injections: Nerve block using steroid and lidocaine mixed solution Perineural injection (PIT)

Technique of injections into scars or fascia to release entrapped nerves Dextrose 5% (D5W): neurotrophic effects on growth factors and subsequent

nerve repair and decreased pain

Regenerative injection: PRP, PL(platelet lysate)

Introduction

Dextrose hydrodissection(HD) mechanism

Downregulation of the transient receptor potential vanilloidreceptor-1 (TRPV-1) ion channel (Malek et al. Mol Cell Neurosci.2015)

Correct hypoglycemia effect (Maclver et al. Anesthesiology 1992) Hyperpolarization effect in normoglycemia (Paprottka et al. J Nucl

Med. 2016) Improve nerve movement through fascia via a release effect and by

reduction of edema (Lam et al. Biomed Res Int. 2017)


Headache

GON block (US- guided)

GON is related to occipital neuralgia and cervicogenic headache

GON originates from the medial branch of the dorsal ramus of the C2 spinal nerve and after emerging from the suboccipital triangle, the nerve courses cephalad in and oblique trajectory between the semispinalis capitis(SC) and oblique capitus inferior (OCI) muscles

GON block (US guided)

GON can aid in the diagnosis and treatment of occipital neuralgia and have shown efficacy in the diagnosis and treatment of cervicogenicheadache

C-arm guided VS US-guided

GON block (US-guided)

IOC

Trap

SC

GON block (US-guided)

Shoulder

Hydrodilation of the shoulder

• For the management of frozen shoulder• IA triamcinolone injection, SSNB, Hydrodilation of the shoulder

Hydro-dilation of shoulder, sono-guided

• A total volume of 40-80 ml volume of physiologic saline should be injected

• No evidence adding steroids has an additive effect

• Recommended procedure to improve frozen shoulder during the frozen phase both in diabetic and non-diabetic patients

• Maximum of two distension procedures have proven to more effective than a larger No. of them

Shoulder Stiffness. Current concepts and concerns.2015.

Hydro-dilation of shoulder, sono-guided

Wrist and Hand

Carpal tunnel syndrome(CTS)

• Pain, numbness, weakness and a feeling that the hand is swollen in the median nerve territory

• Ddx:

CTS with shoulder impingement, cervical radiculopathy and disc herniation

Trigger thumb, CMC joint arthritis

CRPS

Carpal tunnel syndrome(CTS) Diagnosis

• The gold standard for diagnosis remains nerve conduction studies (NCV) and electromyography(EMG)

• US criteria for CTS include median nerve cross-sectional area(CSA) at the distal wrist crease > 15mm, median nerve CSA ratio between distal wrist crease and 12 cm proximally > 1.5 or 2.0 and bowing of the flexor retinaculum

Hobson et al. Clin Neurophysiol.2008;119(6);1353-1357.

Carpal tunnel syndrome (CTS) injection, sono-guided

• Techniques of CTS injection Short axis technique directing needle into the interval

between the median nerve and the FCR

Long-axis US-guided injection technique at the level of the pisiform

Carpal tunnel syndrome (CTS) injection, Hydro-dissection

• Real-time ultrasound-guided hydrodissection carpal tunnel injection for non-surgical treatment of CTS

• Hydrodissection disrupting adhesions between the median nerve in the carpal tunnel and the adjacent connective tissue, allowing the injection material to encircle the target nerve

Yung-Tsan et al. Scientific Reports7(94),2017

Carpal tunnel syndrome (CTS) injection, sono-guided

Trigger finger

• Stenosing tenosynovitis of the flexor tendons with thickening of the A1 pulley

• US imaging findings of trigger finger include swelling of the tendons, hypoechoicthickening of the A1 pulley, hypervascularization, synovial sheath effusion, and dynamic change in the shape of the sheath during flexion and extension

Ultrasound of the Musculoskeletal System

Trigger Finger injection: Sono-guided (Long-axis)

• US-guided trigger finger injection in one prospective study of 50 of 52

consecutive trigger fingers showed this result, noting complete resolution of symptoms in 94% of fingers at 6 months, 90% at 1 year, 65% at 18 months, and 71% at 3 years. The results were statistically significant and compared favorably to the 56% success rates reported at 1 year for blind injections

Peters VC. Ann Rheum Dis.2008;67(9):1262-1266

Trigger Finger injection: Sono-guided (short-axis)

• Target for injection is a triangle under the A1 pulley whose borders consist of the FDS and FDP tendons and volar plate, the distal metacarpal bone, and the pulley

• 0.5 – 1.0 ml of 10-15 mg triamcinolone and lidocaine are injected

Atlas of Ultrasound-Guided Procedures in Interventional Pain Management

Trigger Finger injection: Sono-guided

Knee: Genicular nerve hydrodissection

Introduction: Genicular nerves

• The knee joint is innervated by the articular branches of various nerves : femoral, common peroneal, saphenous, tibial and obturator nerves

• Articular branches around the knee joint : known as genicular nerves

• The word “genicular” means the knee group of small nerves : providing sensory innervation to joint capsule and internal and external ligaments of knee joint

• All these genicular nerves anastomose with each other

• Difficult to be visualized by ultrasound d/t very small in size

• Genicular arteries : used as landmarkssame trajectories as the genicular nerves

Peripheral Nerve Entrapments. Clinical diagnois and treatment. 2016.Musculoskeletal US for Regional anaesthesia and pain medicine. 2016.

Anatomy: Genicular nerve

Musculoskeletal US for Regional anaesthesia and pain medicine. 2016.

Anatomy: Genicular arteries


Indications for genicular nerve HD

• Patients with chronic knee pain secondary to OA

• Patients with failed knee replacement

• Patients unfit for knee replacement

• Patients who want to avoid surgery

• Patients with neuropathic pain due to inflamed genicular nerves


Case: F/48, Medial side knee pain

Ankle and Foot

Nerve territories of ankle and foot


Superficial peroneal nerve entrapment

SPN compression Pain in the distal anterolateral calf, ankle,

and dorsum of the foot with or without paresthesia

Weakness of foot eversion Pain worsens with physical activity, such

as walking

Sports are a relatively common cause of SPN entrapment, such as skiing, soccer, basketball, track, etc.

History relevant to superficial peroneal nerve entrapment: Sports, Extrinsic compression, Trauma, Surgery, Weight loss

SPN dysfunction is underdiagnosed


Superficial peroneal nerve entrapment

Entrapment of the SPN may occur by several mechanisms

The presence of a long peronealtunnel increasing the risk of entrapment in the tunnel or at its outlet

Existence of a defect in the fascia at that site which allows herniation of the lateral compartment muscle with exercise

The SPN may be compressed at the lateral calf or ankle due to its superficial location during inversion injuries


Superficial peroneal nerve: US findings

EDL: Extensor digitorum longus musclePBM: Peronues brevis muscleTA: Tibial artery


US-guided superficial peroneal nerve(SPN) HD

Sural nerve entrapment

Patients with distal sural nerve entrapment usually present with pain at the posterior and lateral aspect of the ankle and foot, often associated with paresthesias over the lateral ankle and the dorsum and lateral aspect of the foot

The pain can increase at night and with exercise

The pain is worse with palpation, foot eversion, and prolonged standing


The sural nerve(SN) travels just lateral to the Achilles tendon so injury or rupture of Achilles

tendon is potential source of SN injury

The SN is subject to compression neuropathy secondary to repeated microtrauma, compression, fifth metatarsal fracture, calcaneal or cuboid fracture, or space-occupying lesions

Entrapment involving the sural nerve typically occurs at the musculotendinous junction of the gastrocnemius muscle and the Achilles tendon within the calf, as the nerve travels through a fibrous arcade “superficial sural aponeurosis”, at the ankle, or in the lateral foot near the base of the fifth metatarsal

Sural nerve can be subject to distraction and injury during ankle sprains along the course of the nerve, leading to neurapraxia injury

Sural nerve entrapment


Sural nerve anatomy

Sural nerve complexMedial sural cutaneous nerve Lateral sural cutaneous nervePeroneal communicating nerveSural nerve Peripheral Nerve Entrapments. Clinical

diagnois and treatment. 2016.

US findings


Case: F/37, Rt. Ankle inversion injury

US-guided sural nerve hydrodissection

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