Principles of SonographicNeedle Guidance
Gurjit S Kaeley MRCP, RhMSUSProfessor and Division Chief,
Rheumatology Fellowship Director,Director of Musculoskeletal Ultrasound,
Chair IRB03 University of Florida College of Medicine, Jacksonville
CRUS/SURC Ultrasound Guided Interventions For Rheumatologists with Cadaver Hands on Training.
Montreal, QC. March 2ND - 3RD 2019
DisclosuresGurjit S Kaeley MRCP--None
ObjectivesAfter completing this activity attendees should be able to• Summarize the evidence for sonographic
guidance for joint injections• Describe approaches to visualize the needle• List best practices for workflow
Why Use Sonographic Guidance For Injections?
• Comfort• Accuracy
– Intra-articular• Conventional joints, small joints, “difficult joints”, • Obese patients
– Synovial Sheath– Neurovascular Tunnels
• Aspiration– Joint Effusions– Diagnostic aspiration of suspicious areas
Blind injections. Do we hit the target?
5Courtesy Juhani Koski MD PhD
Accuracy of Palpation Guided Injections
• 29-100%– Jones 1993, BMJ– Eustace 1997, ARD– Partington 1998, J Shoulder Elbow Surg– Bliddal 1999, ARD– Yamakado 2002, Arthroscopy– Jackson 2002, J Bone Joint Surg Am.– Esenyel 2003, Acta Orthop Traumatol Turc.– Bisbinas 2006, Knee Surg Sports Traumatol Arthrosc– Koski JM 2006, Clin Exp Rheumatol– Lopes 2008, Rheumatology
Chen et al – 1993 – accuracy of blind injections tested by contrast instillation in 109 injections
1/3 knee and ankle injections were extra-articular. Less than half wrist injections were intra-articular Less accuracy for shoulder injections Aspiration of synovial fluid not perfect – half of injections that were performed
after aspiration were extra-articular
US vs Palpation Injection Accuracy
US is Better• Hand; Raza, 2003• Knee; Balint, 2002• Knee; Im, 2009• Tarsometatarsal; Khosla, 2009• Mtp, ankle, Achilles paratenon, flex.
hall. long., tibialis post tendon, subtalar; Reach, 2009
• Multiple joints; Cunnington, 2010
US and Palpation are Same• Knee; Wiler, 2008• SASD-bursa; Rutten, 2007• Wrist; Luz, 2008• Subtalar and ankle; Khosla, 2009
Less Pain with US Guidance• Wiler et al – less pain on US guided parapatellar
aspirations than landmark guided knee aspiration. • Sibbitt et al – less procedural pain with sonographic
guidance than anatomically guided procedures• Less Procedural Pain may be due to
– Avoiding periosteal contact – US allows injection just under the joint capsule
– Distraction effect of using sonographic equipmentSibbitt et al Journal Rheumatology. 2009;36:9 1892-1902Wiler, J. L et al . J Emerg Med. (2008).
Verify – Diagnosis- Clinical Need
Basic Principles
What would you inject? CMC/Comp1 ?
Sonographic Diagnosis• Identify Target BY SONOGRAPHY• Selection of injectate
• Depomedrol• Lidocaine
• Verify depth and calibre & length of needle needed
General GuidelinesJoint: Small Intermediate Large
Needle 1 – 1.5 inch22 – 27 G
1.5 – 2.0 inch22 – 25 G
1.5 – 5.0 inch22 – 25 G(Longer needles use 22 G)
Depomedroldose
5-10 mg 10-40 mg 40 – 80mg
Wittich et al Mayo Clin Proc. 2009;84(9):831-837
Large amounts of intra-articular bupivicane have been associated with cartilage damage
General GuidelinesJoint: Small Intermediate Large
Needle 1 – 1.5 inch22 – 27 G
1.5 – 2.0 inch22 – 25 G
1.5 – 5.0 inch22 – 25 G(Longer needles use 22 G)
Depomedroldose
5-10 mg 10-40 mg 40 – 80mg
Wittich et al Mayo Clin Proc. 2009;84(9):831-837
Kaeley GS, Thway M, Dodani S. Injectable Corticosteroid Use in Musculoskeletal Care Specialties [abstract]. Arthritis Rheumatol. 2016; 68 (suppl 10).
How Injectable Steroids Were Used by MSK Specialists in 2014
Verify – Diagnosis- Clinical Need
Sonographic Diagnosis• Identify Target BY SONOGRAPHY• Selection of injectate
• Depomedrol• Lidocaine
• Verify depth and calibre & length of needle needed
Basic Principles
Select approach• Indirect• Direct
• In plane / out of plane
Concept: Just Need To Get Needle Under the Capsule!
Palpation Guided
USGuided
What is the Target?
Indirect vs Direct Visualization
•Mark injection site after sonographic exam•Needle not visualized•Depth difficult to gauge
•Real time visualization of needle•Adjustment for depth and target•Need to learn to visualize tip at all times
INDIRECT DIRECT
In Plane Out of PlaneDirect Visualization
Verify – Diagnosis- Clinical Need
Basic Principles
Sonographic Diagnosis• Identify Target BY SONOGRAPHY• Selection of injectate
• Depomedrol• Lidocaine
• Verify depth and calibre & length of needle needed
Needle Visualization: Finding Your Needle• Optimize probe placement• Verify route of needle• Use of beam steering if available• Use of trapezoid view if available
Select approach• Indirect• Direct
• In plane / out of plane
Where Do You Expect to See the Needle?
Needle is Best Visualized When it is Parallel to the Probe
Long Axis
Beam Steering
Where Do You Expect to See the Needle?
Short Axis – Keeping Probe in Step With the Needle Tip
Needle not in plane Needle seen but tip distal
Needle tip visualized within
target
Verify – Diagnosis- Clinical Need
Puncture Point• Close or distant to probe?• Will you need a sterile probe cover or gel?
Basic Principles
Sonographic Diagnosis• Identify Target BY SONOGRAPHY• Selection of injectate
• Depomedrol• Lidocaine
• Verify depth and calibre & length of needle needed
Needle Visualization: Finding Your Needle• Optimize probe placement• Verify route of needle• Use of beam steering if available• Use of trapezoid view if available
Select approach• Indirect• Direct
• In plane / out of plane
Puncture Point Depends on Size of Joint
Small Targets – Sterile Gel StandoffLarge Joints – Puncture Point Away From Probe
Verify – Diagnosis- Clinical Need
Puncture Point• Close or distant to probe?• Will you need a sterile probe cover or gel?
Site Preparation• Use of chloroprep and isopropyl alcohol• Cryo anesthesia versus lidocaine
Documentation• Record sonographic exam• Record needle placement• Procedure note
Basic Principles
Sonographic Diagnosis• Identify Target BY SONOGRAPHY• Selection of injectate
• Depomedrol• Lidocaine
• Verify depth and calibre & length of needle needed
Needle Visualization: Finding Your Needle• Optimize probe placement• Verify route of needle• Use of beam steering if available• Use of trapezoid view if available
Select approach• Indirect• Direct
• In plane / out of plane
Aseptic techniques• Skin Cleaning
– Alcohol or Chlorhexidine - Chlorhexidine is more effective than iodine• For peripheral single stick injection when probe is far from puncture
point– Non-sterile gloves– Non-sheathed probe– Non-touch technique– If draining a lot of fluid consider 3 way stopcock
• For puncture point in close proximity to probe– Sterile probe cover and gel– If able to use non-touch technique, non-sterile gloves are sufficient
Tips for needle insertion• Ensure patient and injector comfort!• Screen should ideally be in front – avoid looking
sideways• Anchor transducer to avoid sliding• Learn to scan with non-dominant hand • Penetrate skin and insert needle for about 1cm• Find and advance needle with attention to
needle tip• Never move needle and transducer together
Provider Sits Where Camera Is
Tips For Documenting InjectateUse Doppler To Show Jet Use Air as Contrast
Koski – “Gas Graphy”
Disadvantage: If you are in the wrong place, you may not be able to see the target anymore
Distension of Anatomic Compartment
Verify – Diagnosis- Clinical Need
Puncture Point• Close or distant to probe?• Will you need a sterile probe cover or gel?
Site Preparation• Use of chloroprep and isopropyl alcohol• Cryo anesthesia versus lidocaine
Documentation• Record sonographic exam• Record needle placement• Procedure note
Basic Principles
Sonographic Diagnosis• Identify Target BY SONOGRAPHY• Selection of injectate
• Depomedrol• Lidocaine
• Verify depth and calibre & length of needle needed
Needle Visualization: Finding Your Needle• Optimize probe placement• Verify route of needle• Use of beam steering if available• Use of trapezoid view if available
Select approach• Indirect• Direct
• In plane / out of plane
Documentation• Consent documentation/form• Record sonographic exam
– Still and or video loop • Record needle placement (preferred)• Key elements of procedure (preferred) • Before and after injection images
• Procedure note– Can employ standard templates to streamline
documentation
And finally – does it make any difference – palpation vs sonographically guided?
The Problem With Outcome Studies• Sparse• Majority – reason for injection is clinical and not sonographic• Heterogeneous populations even for same anatomic sites• US vs Palpation guidance – level of experience not always matched• Non-standardization of
– Anesthetic agent– Corticosteroid preparation (Use of too large/low dose may obliterate differences between
groups)– Contrast for accuracy assessment (which may be an irritant by itself)– Injection technique including use of sham US– Outcome tools (telephone follow up in some studies)
• Relevance of outcome clinically unclear eg difference of VAS of 1 at 6 months
Outcomes of Accurate Needle Placement
Improved Outcomes Equivocal With US GuidanceMultiple Joints: Sibbitt et al – Less procedural pain and better short term pain outcomes
Multiple Joints: Cunnington et al (US guided more accurate, trend to less pain)
Hand: MCP, PIP: Raza et al 2003de Quervains: Zingas et al 1998Wrist: Koski et al 2001
Shoulder : SASD, GH – Eustace et al, Naredo et al, Chen et al, Ucuncu et al
Knee: Sibbitt et al – Less pain, more fluid aspirated Knee: Wiler et al – no increase in fluid (but issues with technique)
Plantar Fasciitis: Chen et al, Tsai et al ,Cunane et al 1996 Plantar Fasciitis: Ball et al, Kane et al, Yucel et al
Li Z, et al Ultrasound- versus palpation-guided injection of corticosteroid for plantar fasciitis: a meta-analysis. PloSone. 2014;9(3):e92671.
SASD Injection: Evidence for AccuracyVerification Outcome
Dogu et al(46 Patients)
MRI Palpation with US Sham (Physiatry) vs US guided (Radiology)US Accuracy 65%, Palpation guided 70% (US injection description poor)
Henkus et al 2006(33 Patients)
MRI Palpation guided SASD injection:Posterior Approach 76% accuracy, Anteromedial approach 69% accuracy
Eustace et al 1997(38 Shoulders)
Xray contrast Palpation guided injections:29% Accuracy for SASD, 42% accuracy for glenohumeral jointMore accurate injections – better outcome
Dogu et al Am. J. Phys. Med. Rehabil. & Vol. 91, No. 8, August 2012; Henkus et al, Arthroscopy: Vol 22, No 3 (March), 2006: pp 277-282; Eustace et al Annals of the Rheumatic Diseases 1997;56:59–63
SASD Injection: Summary of EvidenceStudy Population Guidance
(Target Selection)Accuracy
Outcome
Zufferey et al 2012
7mg Betametasone
Acute Shoulder Pain30 –US30 – Landmark
US: Target selection based on US findings. Palpation guided: SASD
NotAssessed
67 of 70 completed study(US: 14 “Ant Recess”, 14 Bursa, 1 calcification, 3 tendinitis) 2,12 wk phone FU.US>Palp at 2 wks, not at 12 wks
Ekeberg et al 2009
Local: Bursa: 20mg Triam+5ml lidocaine, IM 4 cc Lido to glutealSystemic: 5ml to bursa and 20ml Triam + 2 cc Lido to gluteal
Rotator Cuff Pain – clinical criteria
53 – Local Injection53 – Systemic injection + bursal lidocaine
Crass positionSASD Anteriorly
(Clinical based target)
Not Assessed Shoulder pain and disability index similar in two groups at 2 and 6 weeks
Ucuncu et al 2009
40mg Triam + 1ml 1% Lidocaine
Shoulder pain, multiple etiologies30 – Landmark30 – US guided
US “Lesional +perilesional”Position not described
Landmark – lateral bursa
Not Assessed Shoulder pain better and ROM better in US guided group
Chen et al 2006
1ml betamethasone + 1 ml lidocaine
40 SASD Bursitis
20 US, 20 Palpation
Crass position, lateral. Not Assessed At one week shoulder abduction was greater in US group
Naredo et al 2004
21G needle20mg triamcinolone
41 Shoulder Pain20 US, 21 Palpation
Position not specified. SASD targeted Not Assessed At 6 weeks greater pain relief and better shoulder function in US group
Zufferey et al Joint Bone Spine 79 (2012) 166–169; Ucuncu et al Clin J Pain 2009;25:786–789; Ekeberg et al BMJ 2009;338:a3112; Chen et al Am journal of physical medicine & rehabilitation. 2006;85(1):31-5.; Naredo et al. J Rheumatol. 2004;31(2):308-14.