Atlas of Ultrasound-Guided Procedures in Interventional Pain Management (eBook)

Samer N. Narouze, MD, MSc, DABPM, FIPP Chairman, Pain Management Department Summa Western Reserve Hospitals Cuyahoga Falls, OH, USA

Atlas of Ultrasound- Guided Procedures in Interventional PainManagement 3
Foreword 7
Preface 9
Acknowledgments 11
Contents 13
Contributors 25
1: Imaging in Interventional Pain Management 30
Introduction 30
C-Arm FDCT 32
Ultrasound 34
Intra-Articular Injections 35
Trigger Point and Muscular Injections 35
Zygapophyseal and Medial Branch Blocks 35
Epidural Blocks 36
Sympathetic Blocks 36
Combined US and CT/Fluoroscopy 37
Conclusion 37
References 38
2: Basics of Ultrasound Imaging 40
Introduction 40
Basic Principles of B-Mode US 41
Generation of Ultrasound Pulses 41
Ultrasound Wavelength and Frequency 41
Ultrasound–Tissue Interaction 42
Recent Innovations in B-Mode Ultrasound 45
Conclusion 46
References 46
3: Essential Knobology for Ultrasound-Guided Regional Anesthesia and Interventional Pain Management 47
Introduction 48
Frequency and Probe Selection 48
Depth 49
Gain 51
Time Gain Compensation 52
Focus 52
Presets 54
Color Doppler 55
Power Doppler 56
Compound Imaging 57
Tissue Harmonic Imaging 58
Optimization Button 58
Freeze Button and Image Acquisition 59
References 59
4: How to Improve Needle Visibility 60
Introduction 61
Training and Phantom Simulation 61
Training with Adequate Mentorship 61
Phantoms 62
High-Fidelity Simulation 63
Combined Ultrasound and Flouroscopic Phantom Simulators 64
Procedural Needle-Related Visibility Factors 67
Basic Sonography and Needle Image Interpretation 67
Acoustic Impedance as the Basis for Procedure Needle Visualization 68
Size (Gauge) of the Procedure Needle and Its Echogenicity 68
The Skin Insertion Site Selected and Angle of Procedure Needle Passage 68
Echogenic Procedure Needles 70
Procedure Needle Tip 72
The Ultrasound Device and Procedure Needle Visibility 76
Ultrasound Imaging Artifacts and Procedure Needle Visibility 76
Impact of Various Sonographic Modes on Procedure Needle Visibility 77
Compound Spatial and Frequency Image Reconstruction Following Acoustic Beam Steering and Variable Frequency 77
Frequency of the Ultrasound Probe (AKA Depth) Acoustic Power and Gain 78
Time Gain Compensation and Harmonic Imaging 79
Brightness, Motion, and Doppler Modes 79
3D and 4D Ultrasound Imaging 79
Recent Advances in Ultrasound Imaging and Procedure Needle Visibility 82
Needle-Probe Alignment 83
Need for Procedure Needle and Ultrasound Probe Alignment 83
“In-Plane” and “Out-of-Plane” Needle Approach: Classical Probe-Needle Interpositions 83
Oblique Plane Needle Approach for Ultrasound-Guided Pain Management 85
Biplane Needle Imaging Approach for Ultrasound-Guided Pain Management 86
Mechanical and Optical Procedure Needle Guides 86
Advanced Procedure Needle Positioning Systems 87
The “ART” of Scanning for Better Procedure Needle Visualization 89
Ergonomics for Better Procedure Needle Visibility 90
Enhancement and Techniques to Improve Procedure Needle Localization 91
Basic Sonographic Effect of Enhancement 91
Enhancement with Priming, Insertion of Stylet or Guide Wire, and Vibration 92
Hydrolocalization of the Procedure Needle 93
Procedure Needle Visibility by Agitated Solutions or with Ultrasound Contrast Agents 94
Localization of the Procedure Needle Tip with the Aid of Nerve Stimulation 96
Summary 96
References 97
5: Spine Anatomy and Sonoanatomy for Pain Physicians 102
Introduction 103
Basic Spine Anatomy (Figures 5.1–5.13) 103
Cervical Spine 103
Thoracic Spine 106
Lumbar Spine 107
Sacrum 110
Sonoanatomy of the Cervical Spine 113
Superficial (Figures 5.14–5.21) 113
Deep (Figures 5.22–5.25) 117
Sonoanatomy of the Thoracic Spine 119
Superficial (Figures 5.26 and 5.27) 119
Deep (Figures 5.28 and 5.29) 121
Sonoanatomy of the Lumbar Spine 122
Superficial (Figures .5.30–5.33) 122
Deep (Figures 5.34–5.36) 124
Sonoanatomy of the Sacrum and Sacroiliac Joint 126
Superficial (Figures 5.37–5.40) 126
Deep (Figures 5.41 and 5.42) 127
6: Ultrasound-Guided Third Occipital Nerve and Cervical Medial Branch Nerve Blocks 129
Anatomy 129
Indications for Cervical Medial Branch Block 130
Why Ultrasound-Guided Facet Nerve Block? The Literature and Our Experience 131
Possible Advantages of Ultrasound for Cervical Facet Nerve Blocks 132
Limitations of Ultrasound 132
Ultrasound-Guided Technique for TON and Cervical Medial Branch Block 132
Scanning Before Injection 132
Identifying the Correct Level: Method 1 132
Identifying the correct Level: Method 2 136
Practical Performance of Block 136
Conclusion 138
References 138
7: Ultrasound-Guided Cervical Zygapophyseal (Facet) Intra-Articular Injection 140
Anatomy of the Cervical Facet Joints 140
Indications for Cervical Zygapophyseal Joint Intra-Articular Injection 141
Literature Review of Ultrasound-Guided Cervical Facet Injections 141
Ultrasound-Guided Technique for Cervical Facet Intra-Articular Injection 141
Lateral Approach 141
Posterior Approach 141
References 143
8: Ultrasound-Guided Cervical Nerve Root Block 145
Anatomy of Cervical Nerve Root 145
Indications 146
Limitations of the Fluoroscopy-Guided Techniques 146
Literature Review of Ultrasound-Guided Cervical Nerve Root Block 146
Sonoanatomy of the Cervical Spine and Identification of the Cervical Level 147
Ultrasound-Guided Technique for Cervical Selective Nerve Root Block 148
References 150
9: Ultrasound-Guided Thoracic Paravertebral Block 152
Introduction 153
Anatomy 153
Mechanism of Blockade 155
Techniques of TPVB 155
Ultrasound-Guided TPVB 156
Sonoanatomy Relevant for TPVB 157
Basic Considerations 157
Transverse Scan of the Thoracic Paravertebral Region 158
Sagittal Scan of the Thoracic Paravertebral Region 160
Techniques of USG TPVB 163
Transverse Scan with Short-Axis Needle Insertion (Technique 1) 163
Paramedian Oblique Sagittal Scan with In-Plane Needle Insertion (Technique 2) 163
Transverse Scan with In-Plane Needle Insertion or the Intercostal Approach to the TPVS (Technique 3) 164
Conclusion 165
References 166
10: Ultrasound-Guided Lumbar Zygapophysial (Facet) Nerve Block 168
Introduction 168
Anatomy 169
Literature Review 169
Scanning Technique 170
Injection Technique 173
Lumbar (L1–L4) Zygapophysial Medial Branch and L5 Dorsal Ramus Nerve Block 173
Limitations of Ultrasound-Guided Zygapophysial Nerve and Joint Injection 175
References 175
11: Ultrasound-Guided Lumbar Nerve Root (Periradicular) Injections 176
Introduction 176
Ultrasound-Guided Technique 177
Limitations of the Ultrasound-Guided Technique 177
References 178
12: Ultrasound-Guided Central Neuraxial Blocks 180
Introduction 181
History 181
Ultrasound Imaging of the Spine 182
Basic Considerations 182
Axis of Scan 182
Spinal Sonoanatomy 183
The Water-Based Spine Phantom 184
Ultrasound Imaging of the Sacrum 184
Ultrasound Imaging of the Lumbar Spine 187
Ultrasound Imaging of the Thoracic Spine 189
Ultrasound-Guided CNB 190
Caudal Epidural Injection 191
Lumbar Epidural Injection 192
Thoracic Epidural Injection 193
Spinal Injection 194
The Evidence 194
Education and Training 194
Conclusion 195
References 196
13: Ultrasound-Guided Caudal, Ganglion Impar, and Sacroiliac Joint Injections 198
Ultrasound-Guided Caudal Epidural Injections 199
Anatomy 199
Indications for Caudal Epidural Injection 199
Limitations of the Landmark “Blind” Technique 199
Literature Review of Ultrasound-Guided Caudal Epidural Injections 199
Ultrasound-Guided Caudal Injection Is Better than the “Blind” Technique 200
Ultrasound-Guided Technique for Caudal Epidural Injection 200
Limitations of the Ultrasound-Guided Technique 201
Ultrasound-Guided Ganglion Impar Block 202
Anatomy 202
Indications 202
Limitations of the Current Technique 202
Literature Review on Ultrasound-Guided Ganglion Impar Block 203
Technique of Ultrasound-Guided Ganglion Impar Block 203
Limitations of the Ultrasound-Guided Technique 204
Ultrasound-Guided Sacroiliac Joint Injection 204
Anatomy 204
Indications for SIJ Injection 205
Literature Review on Ultrasound-Guided SIJ Injection 205
Technique of Ultrasound-Guided SIJ Injection 205
Limitations of Ultrasound-Guided SIJ Injection 205
References 207
14: Ultrasound-Guided Transversus Abdominis Plane (TAP) Block 210
Introduction 210
Anatomy 211
The Classic Approach 211
Ultrasound-Guided Technique 212
Summary 213
References 214
15: Ultrasound-Guided Celiac Plexus Block and Neurolysis 215
Introduction 215
Anatomy of the Celiac Plexus 216
Current Techniques for Celiac Plexus Block 216
The Anterior Percutaneous Approach 217
Advantages of US-Guided Anterior Approach 218
Limitations of US-Guided Anterior Approach 218
Sonoanatomy of the Epigastrium and Relevant Structures 218
Percutaneous Ultrasound-Guided Celiac Plexus Block Technique 219
References 222
16: Ultrasound-Guided Blocks for Pelvic Pain 223
Introduction 224
Ilioinguinal, Iliohypogastric, and Genitofemoral Nerves 224
Anatomy 225
Literature Review on the Injection Techniques for Ilioinguinal, Iliohypogastric, and Genitofemoral Nerve Block 226
Ultrasound-Guided Technique of Ilioinguinal, Iliohypogastric,and Genitofemoral Nerve 227
Ilioinguinal and Iliohypogastric Nerves 227
Genital Branch of Genitofemoral Nerve 228
Piriformis Syndrome 230
Anatomy 231
Literature Review on Piriformis Muscle Injections 232
Ultrasound-Guided Technique for Piriformis Muscle Injection 233
Pudendal Neuralgia 234
Anatomy 234
Literature Review on the Pudendal Nerve Injections 235
Ultrasound-Guided Technique for Pudendal Nerve Injection 236
Conclusion 237
References 237
17: Ultrasound-Guided Nerve Blocks of the Upper Extremity 242
Introduction 243
Brachial Plexus Anatomy 243
Interscalene Block 244
Anatomy 244
Indication 244
Procedure 244
Supraclavicular Block 245
Anatomy 245
Indication 245
Procedure 245
Infraclavicular Block 247
Anatomy 247
Indication 247
Procedure 247
Axillary Block 248
Anatomy 248
Indication 248
Procedure 249
Distal Peripheral Nerves in the Upper Extremity 249
Summary 251
References 251
18: Ultrasound-Guided Nerve Blocks of the Lower Limb 253
General Considerations 254
Femoral Nerve Block 255
Clinical Application 255
Anatomy (Figures .18.3 and .18.4) 255
Preparation and Positioning 255
Ultrasound Technique 256
Single-Injection Technique 257
Continuous Catheter Technique 258
Sciatic Nerve Block 258
Clinical Application 258
Anatomy 258
Preparation and Positioning 258
Ultrasound Technique 259
Sciatic Nerve Blockade in the Popliteal Fossa 260
Clinical Application 260
Anatomy 260
Preparation and Positioning 261
Ultrasound Technique 261
Lumbar Plexus Block 262
Clinical Application 262
Anatomy 262
Preparation and Positioning 263
Ultrasound Technique 263
Obturator Nerve Block 264
Clinical Application 264
Anatomy 264
Preparation and Positioning 265
Ultrasound Technique 265
Lateral Femoral Cutaneous Nerve Block 266
Clinical Application 266
Anatomy 266
Preparation and Positioning 266
Ultrasound Technique 267
Saphenous Nerve Block 267
Clinical Application 267
Anatomy 267
Preparation and Positioning 268
Ultrasound Technique 268
Ankle Block 269
Clinical Application 269
Anatomy 269
Preparation and Positioning 270
Ultrasound Technique 270
Posterior Tibial Nerve Block 271
Deep Peroneal Nerve Block 271
References 272
19: Ultrasound-Guided Continuous Peripheral Nerve Blocks 273
Introduction 274
Applications 274
Overview of Ultrasound-Guided Perineural Catheter Insertion 274
Nerve in Short Axis, Needle In-Plane Approach (Figure 19.1) 274
Nerve in Short Axis, Needle Out-of-Plane (Figure 19.2) 275
Nerve in Long Axis, Needle In-Plane 275
Preparation for Ultrasound-Guided Perineural Catheter Insertion 276
Sterile Technique 276
Standard Perineural Catheter Equipment 276
Ultrasound-Guided Perineural Catheter Insertion Techniques for Common Surgical Procedures 277
Interscalene CPNB 277
Infraclavicular CPNB 278
Femoral CPNB 278
Subgluteal Sciatic CPNB 279
Popliteal Sciatic CPNB 281
Tranversus Abdominis Plane CPNB 282
Conclusion 282
References 283
20: Ultrasound-Guided Cervical Sympathetic Block 287
Introduction 287
Anatomy 288
Existing Techniques 288
Technique for Ultrasound-Guided Injection 290
References 292
21: Ultrasound-Guided Peripheral Nerve Blockade in Chronic Pain Management 293
Introduction 294
Lateral Femoral Cutaneous Nerve Block 294
Anatomy 294
Literature Review of Injection Techniques 295
Ultrasound-Guided Block Technique 295
Suprascapular Nerve Block 296
Anatomy 296
Literature Review of Injection Techniques 297
Ultrasound-Guided Block Technique 299
Intercostal Nerve Block 299
Anatomy 300
Literature Review of Injection Techniques 300
Ultrasound-Guided Block Technique 301
Conclusion 303
References 303
22: Ultrasound-Guided Shoulder Joint and Bursa Injections 306
Introduction 307
Subacromial/Subdeltoid Bursa 308
Anatomy 308
Clinical Presentation 308
Limitations of the Blind Approach 308
Ultrasound-Guided Technique 308
Biceps Tendon Sheath (Biceps – Long Head) 310
Anatomy 310
Clinical Presentation 310
Ultrasound-Guided Technique 310
Acromio-Clavicular Joint 311
Anatomy 311
Clinical Presentation 312
Ultrasound-Guided Technique 312
Glenohumeral Joint 312
Anatomy 312
Clinical Presentation 313
Limitations of the Blind Approach 314
Ultrasound-Guided Technique 314
The Rotator Interval Approach 314
Subscapularis Tendon/Subscapularis Bursa 316
Anatomy 316
Clinical Presentation 316
Ultrasound-Guided Technique 316
Sternoclavicular Joint 317
Anatomy 317
Clinical Presentation 317
Ultrasound-Guided Technique 318
Conclusion 318
References 319
23: Ultrasound-Guided Hand, Wrist, and Elbow Injections 320
Introduction 321
Ultrasound-Guided Carpal Tunnel Injections 321
Anatomy 321
Literature Review on Ultrasound-Guided Carpal Tunnel Injections 322
Ultrasound-Guided Technique for Carpal Tunnel Injection 323
Ultrasound-Guided Trigger Finger Injections 324
Anatomy 324
Literature Review on Ultrasound-Guided Trigger Finger Injections 324
Ultrasound-Guided Trigger Finger Injection Technique 324
Ultrasound-Guided Wrist Injections 325
Anatomy 325
Literature Review on Ultrasound-Guided Wrist Injections 326
Ultrasound-Guided Technique for Wrist Injections 327
Ultrasound-Guided Injections for Tendon Dysfunction 329
Anatomy 329
de Quervain’s Tenosynovitis 329
Intersection Syndrome 329
Lateral Epicondylitis 329
Tendon Impingement 330
Ultrasound-Guided Technique for Tendon Dysfunction 330
Ultrasound-Guided Elbow Injections 332
Anatomy 332
Literature Review on Ultrasound-Guided Elbow Injections 332
Ultrasound-Guided Elbow Injection Technique 333
References 334
24: Ultrasound-Guided Hip Injections 337
Introduction 337
Anatomy of the Hip Joint 338
Intra-Articular Hip Injections 338
Limitations of the Blind Technique 338
Evidence for Ultrasound-Guided Hip Injections 339
Technique of Ultrasound-Guided Hip Injections 339
Conclusion 341
References 341
25: Ultrasound-Guided Knee Injections 343
Introduction 343
Limitations of the Current Surface Landmarks Technique 343
Technique for Ultrasound-Guided Knee Joint Injection 344
Conclusion 346
References 346
26: Ultrasound-Guided Peripheral Nerve Stimulation 348
Introduction 348
Current Evidence 349
Patient Selection and Role of Neurolysis 350
Anatomical Considerations 350
Radial Nerve Stimulation 350
Ulnar Nerve 351
Median Nerve 351
Sciatic Nerve at Popliteal Bifurcation 352
Posterior Tibial Nerve 354
Conclusion 354
References 354
27: Ultrasound-Guided Occipital Stimulation 355
Introduction 355
Limitations of the Current ONS Technique 356
Anatomy of the GON 356
Occipital Field Stimulation vs. Peripheral Nerve Stimulation 357
Technique of US-Guided ONS Lead Implant 357
References 358
28: Ultrasound-Guided Groin Stimulation 359
Introduction 359
Limitations of the Current Technique 360
Anatomy of the Ilioinguinal and Iliohypogastric Nerves 360
Groin Field Stimulation vs. Peripheral Nerve Stimulation 360
Technique of Ultrasound-Guided IL/IH PNS Lead Implant 360
Reference 362
29: Ultrasound-Guided Atlanto-Axial and Atlanto-Occipital Joint Injections 363
Introduction 363
Anatomy of the Atlanto-Axial and Atlanto-Occipital Joints 364
Ultrasound-Guided Atlanto-Axial and Atlanto-Occipital Joint Injection Technique 364
References 367
30: Ultrasound-Assisted Cervical Diskography and Intradiskal Procedures 368
Introduction 368
Limitations of the Fluoroscopically Guided Cervical Diskography 369
Technique of Ultrasound-Assisted Cervical Diskography 369
References 371
Index 372