Common Applications for Sonography and Guided Intervention: Shoulder

Transcription

1 Common Applications for Sonography and Guided Intervention: Shoulder Jon A. Jacobson, M.D. Professor of Radiology Director, Division of Musculoskeletal Radiology University of Michigan Disclosures: Consultant: Bioclinica Book Royalties: Elsevier Advisory Board: GE, Philips Note: all images from the textbook Fundamentals of Musculoskeletal Ultrasound are copyrighted by Elsevier Inc. Outline: Diagnostic: Rotator cuff tear and tendinosis Interventional: Joint Tendon sheath Bursa Paralabral cyst Calcific tendinosis Rotator Cuff Abnormalities: Categories: Partial-thickness tear Articular-sided Bursal-sided Intrasubstance (or interstitial) Full-thickness tear Tendinosis Supraspinatus Tears: extent Supraspinatus Tears: extent Rim-rent Tear B B Partial Articular Partial Bursal From: Fundamentals of Musculoskeletal Ultrasound Intrasubstance Full thickness From: Fundamentals of Musculoskeletal Ultrasound 1

2 Rotator Cuff Tear: Meta-analysis: 65 articles Full-thickness tears: MRA, MRI, US = in sensitivity (92 95%) MRA more specific Partial-thickness tears: MRA most sensitive (86%) and specific MRI (64%), US (67%) de Jesus, 2009; 192:1701 Rotator Cuff Tears: Most tears are hypoechoic / anechoic Larger tears: deltoid dips into tendon gap Massive tear: non-visualization Cortical irregularity greater tuberosity: indirect sign of supraspinatus tear Articular Partial-thickness Tear: supraspinatus Bursal Partial-thickness Tear: supraspinatus Sagittal T2w Full-thickness Tear: supraspinatus Full-thickness Tear: supraspinatus BT Note: Cartilage Interface Sign (open arrow) IST 2

3 Intrasubstance Tear: supraspinatus Deltoid Humerus Tendinosis No inflammatory cells Mucoid degeneration, chondroid metaplasia Hypoechoic, ill-defined Possible increased thickness No cortical irregularity* From: Hodler J, et al. J MRI; 2010: 32:165 BT *Note lack of cartilage interface sign *Radiology 2004; 230:234 Tendinosis: supraspinatus Outline: Diagnostic: Rotator cuff tear and tendinosis Interventional: Joint Tendon sheath Bursa Paralabral cyst Calcific tendinosis Needle: trocar or no trocar? May help puncture through fascial planes, bursal wall, joint capsule Avoids taking cores of tissue Avoids plugging needle with tissue Disadvantage: must set transducer down to remove trocar, connect syringe Trocar or Stylet Steroids: flush or no flush? Steroids in subcutanteous fat: Depigmentation, atrophy Flush needle: lidocaine/saline to avoid complication Needed with diluted steroid injection? Needed for deep injection? 3

4 Joint, Tendon Sheath, Bursa Aspiration: Infection, crystal disease Injection: Anesthetic: Lidocaine, Ropivacaine Steroids Therapeutic or diagnostic Joint Aspiration and Injection Know which joint recesses become distended and which are accessible For joint access: Aim for joint fluid seen at ultrasound Aim for specific joint recess If no recess, aim for joint space Glenohumeral Joint Posterior joint recess In plane Transducer: axial Lateral to medial Most reliable site* Acromioclavicular Joint In plane Transducer: coronal Lateral to medial IST C G H A Eur Radiol 2011; 21:1858 Tendon Sheath Axial versus longitudinal Aspiration: look for fluid collection Injection with steroids: Do not inject steroids into tendon Risk of tendon rupture Test needle location with Lidocaine first Biceps Brachii: sheath injection Ultrasound-guided: highest accuracy 1 Statistically significant difference in pain relief compared with blind injection at 33 weeks 2 In plane, lateral to medial: Deep to tendon: avoid SA-SD bursa Avoid anterior circumflex humeral artery Glenohumeral joint extension: if 5 ml injected 1Hashiuchi et al. J Sho Elb Surg 2011; 20:1069 2Zhang et al. Ultrasound Med Bio 2011; 37:729 4

5 Biceps Tendon Sheath Injection *Injection should surround tendon *Confirm post-injection in short and long axis Subacromialsubdeltoid Bursa In plane Posterior to anterior or lateral to medial Patient supine Test inject Avoid rotator cuff Subacromialsubdeltoid: injection Paralabral cyst Usually with labral tear Aspiration Axial plane Lateral to medial Calcific Tendinosis Hydroxyapatite deposition: dystrophic Usually do not have cuff tear Appearance: 79% hyperechoic & shadowing No shadow: 7% Two phases: Formative Resorptive: painful Farin et al. Skeletal Radiol 1996; 25:551 Tendon Calcification: Degenerative: thin, linear deposit Calcific tendinosis: Formative: well-defined, dense shadow Resorptive: Globular, amorphous Variable shadow Best success with aspiration Uhthoff. J Am Acad Ortho Surg 1997; 5:183 5

6 Degenerative Calcification Calcific Tendinosis Formative Defined, shadow Resorptive Amorphous, little shadow Calcific Tendinosis: resorptive phase Calcific Tendinosis: supraspinatus Use of Tendon Anisotropy Patient #1 Patient #2: Intra-osseous invasion Long axis Calcific Tendinosis: supraspinatus Longitudinal Transverse Calcific Tendinosis: aspiration Percutaneous lavage and aspiration Best: rounded amorphous calcification Correlate with radiography 3-10 cc syringes: Lidocaine gauge needle Position patient: syringe is dependent 6

7 Calcific Tendinosis: aspiration Inject Lidocaine, then aspirate Dilute calcification Syringe dependent Calcification will flow into needle Repeat until calcification decreases Inject steroids into adjacent bursa Calcific Tendinosis: lavage/aspiration Calcific Tendinosis 3 weeks after lavage and aspiration Calcific Tendinosis: results Calcium decrease correlates with symptom improvement Improvement: 91% at 1 year* Calcium gone in 89% Transitory recurrence at 15 weeks: 44% Improved symptoms at 1 year No difference at 5, 10 years** *del Crura, AJR 2007; 189:W128 **Serafini G, Radiology 2009; 252:157 See for syllabus 7