2013 endoanesthesia peripheral us chronic pain.pptx

8/14/2019 2013 endoanesthesia peripheral US chronic pain.pptx

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Ultrasonography (US) is a recent achievement in the field of regional anesthesia and it

has been increasingly used for its clinical reliability and efficiency. Moreover, US

guidance is nearing to become the standard of care in regional anesthesia and for

postoperative pain management.

Ultrasonographic illustration of the brachial plexus (indicated bywhite arrows) at the supraclavicular level, adjacent to the cervicalPleura (indicated by grey arrows). SA, Subclavian artery.

The sciatic nerve (SN) at the mid-femoral level partly surroundedby local anaesthetic, resulting in a successful block. The homogenoushypoechoic (dark) zone represents the local anaesthetic (LA).

Ultrasonography in Regional Anesthesia


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Application of US in pain medicine is an emerging imaging technique and a

rapidly growing medical field in interventional pain management.

Confronted with uoroscopy, which is one of the main imaging technique used

in pain medicine, US leads to complete elimination of radiation exposure to

patients who often undergo the procedure many times, and nally to the

operator.

What about Ultrasonography in Pain Medicine


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However, US s role in invasive procedures in pain medicine is still

discussed.

The availability of other imaging techniques like flouroscopy, CT and MRI

and lack of familiarization with US imaging are some of the reasons

beneath this discrepancy.

Important steps are being made lately towards the development of safe,

available and clinically efficient US guided techniques for many procedures

especially involving peripheral nerve.

Ultrasonography in Pain Medicine


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Advantages of US guidance both in regional anesthesia and pain medicine:

1. Direct visualization of nerves:

Other methods of nerve localization, such as electrical stimulation or paraesthesia may be replaced

2. Direct visualization of anatomical structures like vessels, muscles, bones, etc. :

This may help assess individual variations in anatomy and facilitate identification of nerves.

3. Real-time control of needle advancement: This may reduce the number of needle passes, shorten the block performance time and lower

the risk of complications caused by a needle e.g., vascular puncture, neuropraxia or pneumothorax

4. Assessment of LA spread around the nerves and immediate supplementary injections

in case of insufficient spread:

This may improve block effectiveness., shorten latency, prolong duration, allow LA dose reduction

and lower the risk of overdose.

Marhofer P, Br J Anesth,2005


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US has a beter safety pro le in percutaneous pain procedures

especially allowing visualization of puncture site, needle tip

advancement through soft tissues and spread of LA and also supplying

real-time image.

especially for diagnostic pain procedures, US allows injecting a very low

dose of a local anesthetic directly near the nerves that supply the assumed

anatomical site of pain origin .

on the other hand , US still lacks acceptable resolution at deep levels, and

it has poor utility for areas hidden by bony structures.


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The application of US in pain medicine

Spinal Pheripheral

Cervical Facet Joint InjectionsCervical Medial-Branch Block

Cervical Nerve Root Block

Lumbar Medial-Branch Block

Lumbar Facet Joint InjectionsLumbar Nerve Root Injection

Sacroiliac Joint Injection

Caudal Epidural Injections

Greater Occipital Nerve BlockStellate Ganglion (Cervical Sympathetic) Block

Suprascapular Nerve Block

Intercostal Nerve Block

Ilioinguinal- Iliohypogastric-Genitofemoral nerve Block

Lateral Femoral Cutaneous Nerve Block

Piriformis Muscle Injection

Pudendal Nerve Injection

Upper and lower extremity Peripheral Nerve blocks

Upper and Lower extremity joints injection


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US GUIDED GREATER OCCIPITAL NERVE BLOCK

is frequently performed either to diagnose orto treat pain mediated by the greater ccipital

nerve (GON) such as occipital neuralgia and

cervicogenic headache.

Unfortunately, no US guided procedures have been described until a

recently completed anatomical study was published.

Greher and coworkers developed an US guided approach to block theGON. In contrast to the standard blind approach of GON block, they

targeted the nerve more proximally where it was usually not divided.


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Their findings confirmed that the GON could be visualized using US both at

the level of the superior nuchal line and C2 .

Ultrasound-guided classical distal block technique at the level of superior nuchal line

Ultrasound-guided new proximal block technique at C2 where it lies superficial to theoblique capitis inferior muscle

This newly described approach superficial to the obliques capitis inferiormuscle has a higher success rate and should allow a more precise blockade ofthe nerve.


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US GUIDED STELLATE GANGLION BLOCK

US allows direct visualization of the local anatomy which are all relevant

anatomical structures of the middle cervical ganglion region at the C6 level,

leading to better safety and block reliability.

may be used in patients suffering fromvascular diseases or sympatheticallymaintained pain of the head or theupper extremity.

So that, clear imaging of the muscles, fasciae, blood vessels, viscera, and bonesurface makes US superior to fluoroscopy for image-guided stellate ganglion block.

Michael Gofeld, Pain Practice, Volu me 8, Issue 4, 2008 226 240


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Ultrasound imaging for stellate ganglion block: direct visualization of puncturesite and local anesthetic spread. A pilot study .

Kapral S, Krafft P, Gosch M, Fleischmann D, Weinstabl C

Kapral and coworkers described a technique first in 1995 and published a

case series. Compared with blind injection, the authors used a lowervolume of local anesthetic (5 mL rather than 8 mL), found no formation of

hematomas (whereas 3 patients in the blind injection group had a

hematoma), and rapid onset of Horner syndrome in US guided stellate

ganglion block.

Reg Anesth1995 Jul-Aug;20(4):323-8.


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Shibata and coworkers suggested that subfascial injection would result in

better spread of the injectate and more reliable sympathetic blockade

Shibata Y, Fujiwara Y, Komatsu T

Anesth Analg 2007 Aug;105(2):550-1

Ultrasound image during C6-stellate ganglion block injection beneath the prevertebral fasicain the longus colli muscle

white arrow indicates the prevertebral fascia distended with local anesthetic


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Gofeld and coworkers attempted to find a pathwayfor needle placement away from vital neck

structures

only the anterior tubercle of the C6 transverse process was visible

adjacent to the projected entry point of the needle, and no visceral orneural elements were situated on the line connecting the entry site and

the lateral surface of the longus colli muscle.

(Reg Anesth Pain Med 2009;34: 475Y479)


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US GUIDED SUPRASCAPULAR NERVE BLOCK

have been used in the management ofa variety of painful shoulder pathologiesby use of several techniques.

(SSN)

In recent years, the technique for suprascapular nerve block under US guidance

was defined, and a few studies using that technique have already been published.

The images shown in those ultrasound-guided SSN injection reports were described

as identifying the SSN within the suprascapular notch and covered by the superior

transverse scapular ligament.

.


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But, fluoroscopic and cadaver dissection

findings as shown in this study suggested

that US image of the SSN block was

actually targeting the nerve on the floor of

the suprascapular spine between the

suprascapular and spinoglenoid notchesrather than the suprascapular notch itself.

Short axis scan of the nerve.Bold arrows=suprascapularnotch

Line arrows =transverse scapularligament

Similar scan with colourDoppler to show thesuprascapular artery(solid arrow), which wasseen underneath thetransverse scapularligament


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Ultrasound-Guided Suprascapular Nerve Block, Description of a NovelSupraclavicular Approach.

Siegenthaler A , Moriggl B , Mlekusch S , Schliessbach J , Haug M , Curatolo M , Eichenberger U .

Reg Anesth Pain Med. 2012 Jan 4.

The authors scanned 60 volunteers with US, both in the supraclavicular and the

classic target area. And then they compared visibility of the SSN in both regions.

They concluded that visualization of the SSN with US is better in the

supraclavicular region as compared with the supraspinous fossa. The anatomic

dissections confirmed that their novel supraclavicular SSN block technique was

accurate.
http://www.ncbi.nlm.nih.gov/pubmed?term=%22Siegenthaler%20A%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Moriggl%20B%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Mlekusch%20S%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Schliessbach%20J%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Haug%20M%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Curatolo%20M%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Eichenberger%20U%22[Author]http://www.ncbi.nlm.nih.gov/pubmed/22222688http://www.ncbi.nlm.nih.gov/pubmed/22222688http://www.ncbi.nlm.nih.gov/pubmed/22222688http://www.ncbi.nlm.nih.gov/pubmed/22222688http://www.ncbi.nlm.nih.gov/pubmed/22222688http://www.ncbi.nlm.nih.gov/pubmed/22222688http://www.ncbi.nlm.nih.gov/pubmed?term=%22Eichenberger%20U%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Eichenberger%20U%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Eichenberger%20U%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Curatolo%20M%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Curatolo%20M%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Curatolo%20M%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Haug%20M%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Haug%20M%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Haug%20M%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Schliessbach%20J%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Schliessbach%20J%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Schliessbach%20J%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Mlekusch%20S%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Mlekusch%20S%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Mlekusch%20S%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Moriggl%20B%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Moriggl%20B%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Moriggl%20B%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Siegenthaler%20A%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Siegenthaler%20A%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Siegenthaler%20A%22[Author]


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Case ReportUltrasound-guided intercostal nerve block for traumaticpneumothorax requiring tube thoracostomy

Stone MB, Carnell J, Fischer JW,Herring A, Nagdev A

American Journal of Emergency Medicine (2011) 29

Stone and coworkers placed probe in a longitudinal

parasagittal orientation to identify the ribs andpleural line.

Then they visualized the needle approaching the

inferior margin of the target ribs, and injected LAsolution into each intercostal space with real-time

ultrasound visualization of local anesthetic spread to

the adjacent pleura


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US GUIDED ILIOINGUINAL, ILIOHYPOGASTRIC, ANDGENITOFEMORAL NERVE BLOCK

Because of the course of the nerves, they are at risk forinjury in lower abdominal surgery or laparoscopic surgery. Asa result, patients may suffer from chronic postsurgicalneuropathic pain due to the nerve injury and will present withgroin pain that may extend to the scrotum or the testicle inmen, the labia majora in women, and the medial aspect ofthe thigh.

The area for optimal scanning of these nerves is

the area posterior and cephalad to the superior

iliac spine. With the probe placed in an

orientation perpendicular to the inguinal

ligament, all the 3 layers of abdominal muscles

(ExtObl, IntObl, and TranAbd), iliac crest, and

peritoneum can be well visualized .


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US GUIDED LATERAL FEMORAL CUTANEOUS NERVE BLOCK

Lateral femoral cutaneous nerve (LFCN) is a

small peripheral nerve, and the scanning

requires experienced personnel with good

knowledge of the anatomy around that

region.

The literature suggests that the LFCN is

best recognized when it courses laterally

over the sartorius muscle, which has a

typical triangular shape.

is used for the diagnosis and conservativemanagement of meralgia paresthetica whichis a mononeuropathy of the LFCN andcharacterized by paresthesia, numbness,and pain in a localized area on theanterolateral aspect of the thigh.


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Bodner and coworkers assessed the feasibility of US in visualizing thelateral femoral cutaneous nerve in a cadaver and 8 volunteers.

They suggested that US enables visualization of the LFCN in a cadaver

and in volunteers


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Pheng and coworkers suggested in this article that the key step for US

guided injection was to align the ultrasound probe in the longitudinal axis of

the piriformis muscle above the ischial spine.

So that they recommended another technique rather than reportedtechnique in the literature:

Scanning was performed in the transverse plane with the probe placed

over posterior superior iliac spine so that the sacroiliac joint can be seen.


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Am J Phys Med Rehabil. 2011 Oct;90(10):871-2

Chen and coworkers recommended the medial-to-lateral approach when

performing the US guided piriformis muscle injection


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US GUIDED PUDENDAL NERVE INJECTION

serves both diagnostic and therapeuticpurposes in pudendal neuralgia which iscommonly presents as chronic debilitatingpain in the penis, scrotum, labia, perineumor anorectal region.

US visualization of the pudendal nerve is limited for several reasons:

The diameter of the pudendal nerve at the level of the ischial

spine is very small (4 to 6 mm) and difficult to detect with an

US at a depth of 5.2 cm.

At the level of the ischial spine, 30% to 40% of pudendal nerves

are 2- or 3-trunked. This reduces the chance of a direct

depiction of the nerve with an US and may also account for the

poor response to the nerve stimulator.

Pheng PWH. et al. , Reg Anesth Pain Med 2009


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New, simple, ultrasound-guided infiltration ofthe pudendal nerve: ultrasonographic technique.

Kovacs P , Gruber H , Piegger J , Bodner G .

Dis Colon Rectum. 2001 Sep;44(9):1381-5.

The authors scanned deep gluteal region in two perpendicular planes aslongitudinal and transverse to the internal pudendal artery.

They founded that in almost one-half of the cases a direct US-guided

infiltration of the pudendal nerve was possible and in the remainingcases the nerve could be detected and blocked indirectly, using the

ischial spine or the internal pudendal artery as a landmark
http://www.ncbi.nlm.nih.gov/pubmed?term=%22Kovacs%20P%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Kovacs%20P%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Gruber%20H%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Piegger%20J%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Bodner%20G%22[Author]http://www.ncbi.nlm.nih.gov/pubmed/11584221http://www.ncbi.nlm.nih.gov/pubmed/11584221http://www.ncbi.nlm.nih.gov/pubmed/11584221http://www.ncbi.nlm.nih.gov/pubmed/11584221http://www.ncbi.nlm.nih.gov/pubmed/11584221http://www.ncbi.nlm.nih.gov/pubmed/11584221http://www.ncbi.nlm.nih.gov/pubmed/11584221http://www.ncbi.nlm.nih.gov/pubmed/11584221http://www.ncbi.nlm.nih.gov/pubmed/11584221http://www.ncbi.nlm.nih.gov/pubmed/11584221http://www.ncbi.nlm.nih.gov/pubmed/11584221http://www.ncbi.nlm.nih.gov/pubmed?term=%22Bodner%20G%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Bodner%20G%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Bodner%20G%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Piegger%20J%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Piegger%20J%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Piegger%20J%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Gruber%20H%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Gruber%20H%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Gruber%20H%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Kovacs%20P%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Kovacs%20P%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Kovacs%20P%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Kovacs%20P%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Kovacs%20P%22[Author]


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Rofaeel and coworkers placed the US probe at the level of the ischial

spine to capture the transverse view of the ischial spine, the sacrospinous

and sacrotuberous ligaments, the internal pudendal artery and

the pudendal nerve.

Their findings were that pudendal nerve block at the ischial spine level

could be reliably performed under real-time ultrasound guidance.

Feasibility of real-time ultrasound for pudendalnerve block in patients with chronic perineal pain.

Rofaeel A , Peng P , Louis I , Chan V

Reg Anesth Pain Med. 2008 Mar-Apr;33(2):139-45

In the literature, only this study describes the feasibility of the US

guided pudental nerve injection technique.
http://www.ncbi.nlm.nih.gov/pubmed?term=%22Rofaeel%20A%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Peng%20P%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Louis%20I%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Chan%20V%22[Author]http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=DetailsSearch&term=rofaeel+a+pudendal+nerve&save_search=truehttp://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=DetailsSearch&term=rofaeel+a+pudendal+nerve&save_search=truehttp://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=DetailsSearch&term=rofaeel+a+pudendal+nerve&save_search=truehttp://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=DetailsSearch&term=rofaeel+a+pudendal+nerve&save_search=truehttp://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=DetailsSearch&term=rofaeel+a+pudendal+nerve&save_search=truehttp://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=DetailsSearch&term=rofaeel+a+pudendal+nerve&save_search=truehttp://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=DetailsSearch&term=rofaeel+a+pudendal+nerve&save_search=truehttp://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=DetailsSearch&term=rofaeel+a+pudendal+nerve&save_search=truehttp://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=DetailsSearch&term=rofaeel+a+pudendal+nerve&save_search=truehttp://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=DetailsSearch&term=rofaeel+a+pudendal+nerve&save_search=truehttp://www.ncbi.nlm.nih.gov/pubmed?term=%22Chan%20V%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Chan%20V%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Chan%20V%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Louis%20I%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Peng%20P%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Peng%20P%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Peng%20P%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Rofaeel%20A%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Rofaeel%20A%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Rofaeel%20A%22[Author]http://www.ncbi.nlm.nih.gov/pubmed?term=%22Rofaeel%20A%22[Author]


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US GUIDED PERIPHERAL NERVE BLOCKS OF THE UPPEREXTREMITY

ISOLATED UPPER EXTREMITY NERVE BLOCK

RADIAL NERVE BLOCKMEDIAN NERVE BLOCKULNAR NERVE BLOCK

US guidance is also very useful for peripheral nerve blocks in the upper

limbs, as it allows the anaesthetist to minimize the dose of local

anaesthetic and to advance the needle to the nerve safely.

It is also possible to follow the anatomical structure of the nerves from

the axilla distally to the wrist. SO THAT anatomical landmarks are no

longer needed to identify nerves.


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US GUIDED MEDIAN NERVE BLOCK

Median nerve can be blocked from the antecubital area of theelbow distally to the wrist.

Used in carpal tunnel syndromeassociated with tenosynovitis of thefinger flexor tendons


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US GUIDED PERIPHERAL NERVE BLOCKS OF THE LOWEREXTREMITY

LUMBOSACRAL PLEXUS BLOCK

FEMORAL NERVE BLOCKOBTURATOE NERVE BLOCKSCIATIC NERVE BLOCK

While peripheral nerve blocks can replace neuraxial techniques, they still

require two punctures. It is therefore useful to minimize the amount of LA

injected by US guidance.

These blocks are useful for surgical anesthesia and postoperative pain but

in interventioanl pain medicine they are olso important especially for

diagnostic as well as for theuropatic blocks.

We usually do these block and put the catheter under US guidance to

manage ischemic pain of lower extremity due to peripheral vascular disease

or diabetes.


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US GUIDED FEMORAL NERVE BLOCKBecause of the proximity to the relatively

large femoral artery, US may reduce the

risk of arterial puncture that often occurswith the use of non-US techniques.

Orientation begins with the identification

of the pulsating femoral artery at thelevel of the inguinal crease.

If it is not recognized, sliding the probe

medially and laterally will bring the vessel

into view. Immediately lateral to thevessel, and deep to the fascia iliaca is

the femoral nerve as a typically

hyperechoic and roughly triangular or oval

in shape.


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US GUIDED SCIATIC BLOCK AT THE POPLITEAL LEVELThe distal branches of the sciatic and femoral

nerves, including the tibial nerve at the popliteal

level and the peroneal nerve distal to the head of

the fibula, can also be selectively visualized

under US guidance.

Figure of four position improves the

visibility of the sciatic nerve in the

popliteal fossa.

Linear probe was applied horizontally on the

posterior thigh 7 cm above the popliteal

crease. In a transverse view, the sciatic

nerve appeared as a round hyperechoic

structure called coin sign.Dufour E,Reg Anesth, 2008


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US-guided injection of the upper and lower extremity joints

With improvements in transducers and image processing software, UShas become an increasingly valuable tool in musculoskeletal diagnostic

imaging and for guiding musculoskeletal interventions.

The main advantage of US-guided joint injection over blind injectionis that the needle position can be confirmed and injection of contrast

medium or medication can be controlled in real-time.

A limitation with regards to US guidance is the presence of anyintervening osteophytes or exostoses which prevent a clear view of

the intended target.


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US GUIDED THE KNEE JOINT INJECTION

in the treatment of anterior knee painsecondary to rheumatoid arthritis andosteoarthritis.

There are several advantages to treat a pathologic knee with the aid

of sonography.

First, US can be used as an extension of the physical examination and

aid in the accurate diagnosis of arthritis.There are few studies examining the outcomes of intraarticular knee

injections using US guidance.


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US for pain procedure remains a very young technique that

needs to be further developed.

Future clinical studies should focus not only on developing and

describing techniques of US-guided procedures, but should

also provide evidence that US is at least equivalent to the

already available imaging techniques or blind approaches interms of effectiveness and safety.

TAKE AWAY MESSAGE


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2013 endoanesthesia peripheral us chronic pain.pptx

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