US guided Injection in SASD bursitis ( 쉬운가? 어려운가?)
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1 US guided Injection in SASD bursitis ( 쉬운가? 어려운가?) Jaeki Ahn, M.D. Department of Rehabilitation Medicine, Sanggye Paik Hospital, Inje University 대한신경근골격초음파학회춘계학술대회
2 Contents Cases Bursa? Impingement SD of shoulder Bursa injection with US 1.Easy? or Difficult? 2.Synovial thickness type Recommendation for good injection
3 Case 1 (1 st ) F/59 Rt. shoulder pain for 1 year recent 2 mos VAS 5 7 aggravation : side lying affected shoulder 자다가깬다 painfull arc + neer test + Dx :
4 Case 1 (1 st ) F/59 Dx : SASD bursitis (impingement) Initial Tx : US guided injection immediate effect : 묵직하게아프다. FU 1 wk : VAS 2 education shoulder ex with ER/IR strengthening
5 Case 1 FU dynamic
6 Case 1 (2 nd ) Revisiting after 6 wks VAS 5 shoulder pain d/t repetitive motion Tx: reinjection After injection response immediate VAS 0 FU 1 wk VAS 0-1
7 M/ 63 Rt. shoulder pain for 1 year recent 2 wks VAS 7 aggravation : side lying 자다가깬다 painfull arc + neer test + Case 2 Dx : SASD bursitis with partial tear in SST Initial Tx : US guided injection
8 Case 2 After injection response immediate VAS 0 FU 1 wk VAS 0 Education shoulder ex with ER/IR strengthening
9 M/ 56 Rt. shoulder pain for 3-4 year intermittent, recent 2 wks VAS 5 aggravation : side lying 육체적, 무리하면심하다 painfull arc + neer test + tenderness Dx : SASD bursitis Case 3 Tx : US guided injection 주사시통증을호소 after injection; immediate VAS 5-6 Long
10 Case 3 ; After Injecton Long Trans
11 Case 3 Before injection Injection Failure ; Myotendinous Junction After injection (dynamic)
12 Cases Discussion
13 Bursa Anatomy Bursa =
14 Anatomy Sacs filled with fluid Misconception Contain only a thin film of viscous fluid serves as a lubricant 1 mm thick, potential space fluid-filled sacs only under pathological condition
15 Bursa of shoulder
16 Nerve supply of Bursa (in shoulder) Free nerve endings Ruffini endings, Pacinian corpuscles, two kinds of unclassified nerve endings were observed. Most of these receptors were observed at the roof side of coracoacromial arch Ide K, Shirai Y, Ito H. J Shoulder Elbow Surg (1996) Dual innervation : articular branches of suprascapular n., lateral pectoral n. 25 fresh human cadavers had dual innervation of the coracoclavicular ligaments, the subacromial bursa, and the acromioclavicular joint. Aszmann OC et al. Clin Orthop Relat Res (1996)
17 Pathology Inflammation causes synovial cells to multiply increases new collagen deposition(formation) fluid production. more permeable capillary membrane allows entrance of high protein fluid. The bursal lining may be replaced by granulation tissue followed by fibrous tissue. Hemorrhage may occur.
18 Pathology Inflammation causes synovial cells to multiply increases new collagen deposition(formation) fluid production. more permeable capillary membrane allows entrance of high protein fluid. The bursal lining may be replaced by granulation tissue followed by fibrous tissue. Hemorrhage may occur.
19 Subacromial subdeltoid bursitis Between the acromion and the rotator cuff - superficial to rotator cuff - deep to acromion and deltoid Repetitive activities with an elevated arm most frequently cause inflammation of the bursae Secondary sign of RC tear A primary process, such as rheumatoid arthritis, gout, or tuberculosis, may lead to bursitis Tender to touch. Painful-arc
20 Subacromial subdeltoid bursitis Hypoechoic thickening of the bursal walls (arrowheads) Small amount of fluid (asterisk) Upper profile of the bursa shows a deep notch (arrow) at the level of the myotendinous junction of the SupraS reflecting the position of the coracoacromial ligament
21 Impingement of SASD bursa
22 Subdeltoid bursitis Long
23 SASD bursitis Long Trans
24 SASD Bursitis Pannus
25 Treatment of SASD Bursitis Injection : - Blind - US guided Solve underlying condition Weakness Balance
26 Blind injection SASD Bursitis Injection
27 US guided injection
28 SASD bursa injection
29 US guided Injection; Arch J PMR 2006 Jan;85(1):31-5. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. Chen MJ, Lew HL et al. Abstract OBJECTIVE: To investigate the treatment effectiveness between ultrasound-guided and blind injection techniques in the treatment of subacromial bursitis. DESIGN: A total of 40 patients with sonographic confirmation of subacromial bursitis were recruited into this study. These patients were divided into blind and ultrasound-guided injection groups. The shoulder abduction range of motion was compared before injections and 1 wk after the completion of injections in both groups. RESULTS: The shoulder abduction range of motion before injection in the blind injection group was / degrees and improved to 100 +/ degrees 1 wk after the injection treatments. However, the improvement did not reveal significant statistical differences (P > 0.05). The shoulder abduction range of motion before injection in the ultrasound-guided injection group was / degrees and improved to / degrees 1 wk after the injection treatments (P < 0.05). CONCLUSIONS: Ultrasound may be used as an adjuvant tool in guiding the needle accurately into the inflamed subacromial bursa. The ultrasoundguided injection technique can result in significant improvement in shoulder abduction range of motion as compared with the blind injection technique in treating patients with subacromial bursitis.
30 Bursal injection (bursitis with fluid) Dominant : roof : tendon surface : medium
31 Injection Responder check a pain score before and 10 min after the injection > 30% improvement in pain True impingement group (bursitis)
32 SASD bursa ; US guided Injection 쉽다? 어렵다? 쉽다 : 점액낭안이든그주위든주사약이들어가기만하면증상이좋아지니까? 어렵다 ; 이유는? 1. 점액낭안에정확히주사를해야만효과가극대화 2. 점액낭주위에주사하면국소부위에과잉되고전체적으로주사양이많아져야한다 3. 주사후통증 (soreness) 이초래 4. 점액낭주위근육근막 (fascia) 힘줄 (tendon) 에불필요한손상초래
33 US guided Injection; J Shoulder Elbow Surg 1997 Mar-Apr;6(2): "Bursal reactions" in rotator cuff tearing, the impingement syndrome, and calcifying tendinitis. Ishii H, Brunet JA, Welsh RP, Uhthoff HK Source Department of Surgery, University of Ottawa. Abstract Subacromial bursal specimens from 63 patients undergoing surgery for rotator cuff tearing (n = 43), the impingement syndrome (n = 14), and calcifying tendinitis n = 6) were studied to characterize the reactions that develop at the tendinopathy "lesional" sites. Intensity of the bursal reactions and production of type III collagen vary considerably, with the highest incidence of both seen in patients with rotator cuff tears. The intensity of bursal reactions correlated with the degree of formation of perivascular new collagen and type III collagen expression. In 22 of the 63 patients the bursal reaction distant to the tendon lesion was also studied. It was minimal and did not correlate to the lesional bursal findings. A strong correlation, however, existed between surgical appearance and histologic grading. The term "localized bursal reaction" as opposed to bursitis more correctly describes bursal involvement. Resection of bursal tissues should be limited to the lesional tissue that interferes with subacromial motion.
34 Synovial thickness; type Dominant : under roof : on tendon surface : medium
35 Synovial thickness; type Dominant : under roof
36 Synovial thickness; type Dominant : on tendon surface
37 : medium Synovial thickness; type
38 SASD bursa injection Long Trans
39 바늘끝을어디에놓을것인가? Long
40 Case above bursa roof
41 Bursa injection ; synovial bursal
42 Bursa injection ; change (long. trans.) Long Trans
43 Bursa dynamic study
44 Bursa dynamic study
45 Recommendation for good Injection US guided evaluation; bursa fluid + - Check needle bevel Lie needle tip in bursal space Small amount fluid in injection evaluate synovial thickness type Confirm adequate position using dynamic motion longitudinal transverse Injection : prn ; Stop and recheck!!! Recheck after injection
US finding of the shoulder (with live demonstration) 인제의대상계백병원 안재기
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