Ultrasound guidance for interventional pain management

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1 Faculty Disclosure Ultrasound guidance for interventional pain management Dr. Roel Mestrum, MD, FIPP Anesthesiology, Intensive Care Medicine and Multidisciplinary Pain Centre Regionaal Ziekenhuis Heilig Hart Tienen Ziekenhuis Oost Limburg Genk BELGIUM

2 NO DISCLOSURES Faculty Disclosure

3 Ultrasound-Guided Interventional Procedures in Pain Medicine (USPM) Soft tissues: Muscles, ligaments, vessels, nerves, joints

4 Ultrasound-Guided Interventional Procedures in Pain Medicine (USPM) Soft tissues: Muscles, ligaments, vessels, nerves, joints Bony surfaces

5 Ultrasound-Guided Interventional Procedures in Pain Medicine (USPM) Soft tissues: Muscles, ligaments, vessels, nerves, joints Bony surfaces Real-time needle advancement

6 Ultrasound-Guided Interventional Procedures in Pain Medicine (USPM) Soft tissues: Muscles, ligaments, vessels, nerves, joints Bony surfaces Real-time needle advancement Real-time appreciation of injectate

7 Ultrasound-Guided Interventional Procedures in Pain Medicine (USPM) Soft tissues: Muscles, ligaments, vessels, nerves, joints Bony surfaces Real-time needle advancement Real-time appreciation of injectate No risks of radiation

8 Ultrasound-Guided Interventional Procedures in Pain Medicine (USPM) Soft tissues: Muscles, ligaments, vessels, nerves, joints Bony surfaces Real-time needle advancement Real-time appreciation of injectate No risks of radiation Dynamic diagnostic examination

9 Ultrasound-Guided Interventional Procedures in Pain Medicine (USPM) Soft tissues: Muscles, ligaments, vessels, nerves, joints Bony surfaces Real-time needle advancement Real-time appreciation of injectate No risks of radiation Dynamic diagnostic examination Portable Cheaper than fluoroscopy / C-arm

10 Operator dependent Learning curve Limitations USPM Poor image quality in certain areas: Intravascular

11 Operator dependent Learning curve Limitations USPM Poor image quality in certain areas: Obesity Degenerative diseases Acoustic shadow artifact (high attenuation coefficient of bone) Deep structures (low resolution of low-frequency probe) Thin needles or steep angle (echogenic needles) Intravascular

12 Comparison among 3 applications of USPM Target structures Peripheral Axial MSK Peripheral soft tissue Spine Bursa/Joint/Tendon US visualisation Good to moderate Poor to moderate Good to moderate Conventional or existing technique for injection Mostly blind Image guided Mostly blind Level of difficulty I-II II-III I-II Level I: basic Level II: intermediate Level III: advanced From usra.ca

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14 Reg Anesth Pain Med Sep-Oct;34(5): Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, sonoanatomy, and procedures: Part I: nonaxial structures. Peng PW 1, Narouze S. Reg Anesth Pain Med Jul-Aug;35(4): Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, sonoanatomy, and procedures. Part II: axial structures. Narouze S 1, Peng PW. Reg Anesth Pain Med Nov-Dec;36(6): Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, sonoanatomy, and procedures. Part III: shoulder. Peng PW 1, Cheng P. Reg Anesth Pain Med Jul-Aug;38(4): Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, sonoanatomy, and procedures. Part IV: hip. Peng PW 1. Reg Anesth Pain Med Sep-Oct;39(5): Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, sonoanatomy, and procedures. Part V: knee joint. Peng PW 1, Shankar H.

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16 Ultrasound-Guided Interventional Procedures in Pain Management Evidence-Based Medicine Samer N. Narouze, MD, MS CONCLUSIONS RAPM Volume 35, Number 2, Supplement 1, March-April 2010 Ultrasound is a valuable tool for imaging soft-tissue structures and bony surfaces, guiding needle advancement and confirming the spread of injectate around the target, without exposing health care providers and patients to the risks of radiation. There is a rapidly growing interest in USPM as evidenced by the surging number of publications in the last few years. However, most of these publications are small feasibility studies. Currently, we have only weak evidence that US is superior to CT in lumbar facet intraarticular injections (1 small RCT, level Ib). Although we do have a few reports suggesting that US-guided cervical injections have advantages over fluoroscopy-guided approaches (especially in stellate ganglion and cervical nerve root blocks), there are no RCT-driven data to support this. Future research directions should focus on the cervical spine, peripheral pain blocks (intercostal nerve, suprascapular nerve, etc), and muscle and joint injections as US looks promising in these areas. We are in need for more studies to report on the efficacy and safety of US-guided techniques.

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22 Curr Opin Anaesthesiol Oct;30(5): Pulsed radiofrequency in chronic pain. Vanneste T PRF treatment has progressively gained a place in the management of chronic pain syndromes. The concept is appealing because long-lasting effects are reported without complications.

23 Curr Opin Anaesthesiol Oct;30(5): Pulsed radiofrequency in chronic pain. Vanneste T PRF treatment has progressively gained a place in the management of chronic pain syndromes. The concept is appealing because long-lasting effects are reported without complications.

24 SUPRASCAPULAR NERVE

25 Liu SR Pain Pract 2016

26 Peng, Narouze RAPM 2009 Gofeld et al RAPM 2009 Stellate ganglion block (SGB)

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28 C6 C7 LCp: Longus capitis muscle Lco: Longus colli muscle Gofeld, RAPM 2009 Narouze, Peng,

29 ILIOINGUINAL / ILIOHYPOGASTRIC NERVES 2 from 1 IHN L1 IIN L1 2 from 2 GFN L1 + L2 LFCN L2 + L3 2 from 3 FN L2 + L3 + L4 ON L2 + L3 + L4

30 Conclusion Posterpresentation ESA 2014, Stockholm Data suggest: PRF of n.ilioinguinalis is a valuable treatment for inguinal neuralgia (34.6% by blind-technique vs 36.4% by ultrasound-guidance) US-guided diagnostic block followed by US-guided PRF increases responder rate to 57.1% Future investigations: validation by larger studies analysis of long-term results other potential improvements such as combined US-guided PRF of n.iliohypogastricus and n.ilioinguinalis.

31 Lateral femoral cutaneous nerve Hurdle MF, Arch Phys Med Rehabil. 2007

32 Long term effects of ultrasound-guided pulsed radiofrequency therapy of the lateral femoral cutaneous nerve DE CANG MIEKE, BUYSE KLAAS, PUYLAERT MARTINE, VAN ZUNDERT JAN, HEYLEN RENE, MESTRUM ROEL, posterpresentation ESA 2016, London 33 out of 38 patients had a positive US guided diagnostic block (>50% pain relief with 2 ml lidocaine 2%) Obesity was the most prevalent risk factor. More than 70% had a BMI 25, 21% lumbar spine surgery 7% diabetic 5% hip surgery At 2 months (19/33) 58% had GPE>50%. After 2 months 4 patients were lost to follow up. There was still pain relief in 41% (12/29)of patients at 3 months, 34% (10/29) at 6 months 21% (6/29) at 12 months. 7 patients required a redo treatment resulting in a GPE > 50% at 2 months in 57% of the patients. The mean time of recurrence after successful treatment was 8,5 months No complications were observed.

33 Intercostal block

34 Intercostal block

35 PIRIFORMIS MUSCLE

36 PIRIFORMIS MUSCLE

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39 Ultrasound assisted interventions

40 Flying bat

41 Gofeld Reg Anesth Pain Med 2012 Anesthesiology May;100(5): Ultrasound-guided lumbar facet nerve block: a sonoanatomic study of a new methodologic approach. Greher M, Scharbert G, Kamolz LP, Beck H, Gustorff B, Kirchmair L, Kapral S. Reg Anesth Pain Med Jul-Aug;32(4): Ultrasound-guided versus computed tomography-controlled facet joint injections in the lumbar spine: a prospective randomized clinical trial. Galiano K, Obwegeser AA, Walch C, Schatzer R, Ploner F, Gruber H

42 Sacro-iliac Joint

43 Sacro-iliac Joint Gofeld Pain Manage. (2012) 2(4),

44 Sacro-iliac Joint Gofeld Pain Manage. (2012) 2(4),

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46 Ultrasound-Guided caudal block From: Atlas of USG Procedures in Interventional Pain Management by Narouze

47 RF Knee (genicular nerves) What s new?: peri articular nerves of the knee Inferomedial Superomedial Superolateral NOT inferolateral (common peroneal nerve: neck of the fibula) Choi et al Pain 2011

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49 Reg Anesth Pain Med Jan/Feb;42(1):62-68

50 Faculty Disclosure THANK YOU FOR YOUR ATTENTION!