Chapter 59 Interventional Techniques for Pain Management Flashcards
Interventional management of musculoskeletal and joint
pain may include
injection either into the joint space
(intra-articular), around the joint space (periarticular)
or within specific soft tissue structures
Injections may be with
corticosteroid, local
anesthetics, or viscoelastic supplementation.
Shoulder pain defined as chronic when
it has been present for longer than 6 months.
Common conditions that
can result in chronic shoulder pain include
rotator cuff disorders,
adhesive capsulitis, shoulder instability, and shoulder
arthritis.
Persistent shoulder pain can also result from
bursitis, tendonitis, impingement syndromes, avascular necrosis,
other causes of degenerative joint disease, or traumatic injury.
Joint injection
should be considered after
failure of conservative interventions
such as nonsteroidal anti-inflammatory drugs and
physical therapy
Imaging studies
plain radiographs,
magnetic resonance imaging, ultrasonography, and
computed tomography scans may be indicated either when
the etiology is unclear or if findings would change the management.
The glenohumeral joint
multiaxial ball-and-socket
synovial joint
glenohumeral joint relatively unstable
the humeral head is larger than the
glenoid fossa, only part of the humeral head can be in articulation with the glenoid fossa at any given joint position
glenoid labrum
a rim of fibrocartilaginous tissue that surrounds the glenoid fossa thereby deepening the articular cavity. Additionally, it protects the bony edges and provides
lubrication to the joint
strengthen the labrum
The tendons of the long head of the biceps brachii and triceps brachii muscles
The glenohumeral joint itself is surrounded by
thin loosely fitting capsule that attaches medially to the
margin of the glenoid fossa beyond the labrum and laterally to the anatomical neck extending slightly below the shaft of the humerus.
vital to the maintenance of structural integrity of
the glenohumeral joint.
the capsule contributes little
to the overall stability of the joint, it is the ligaments and
the attachment of the muscle tendons of the rotator cuff.
glenohumeral joint is supported by
Superiorly, the joint is supported by the capsule in conjunction with the coracohumeral ligament, anteriorly, by the glenohumeral ligaments and the attachment of the subscapularis tendon and posteriorly, by the attachment
of the teres minor and infraspinatus tendons. Inferiorly, however, the capsule is thin and weak and contributes
little to the stability of the joint
The inferior part of the glenoid capsule is subjected to considerable strain
as it is stretched tightly across the head of the humerus when the arm is elevated
The tendon of the long head of the biceps brachii muscle is situated in the
intertubercular groove, and then becomes intracapsular. It is particularly prone to injury at the point where it arches over the humeral head and at the junction of bony cortex with
articular cartilage
Indications for glenohumeral joint injection
osteoarthritis, adhesive capsulitis, and rheumatoid arthritis.
Patients with glenohumeral osteoarthritis present
with
gradual onset of pain and loss of motion.
Adhesive capsulitis, also known as frozen shoulder
typically occurs after prolonged immobility of the arm. Clinical presentation
includes diffuse shoulder pain with the inability to abduct at the shoulder more than just a few degrees in any direction. Shoulder examination reveals diffuse pain with palpation and reduced active and passive range of motion in all planes. Remarkably, findings
on radiography will often be normal.
Adhesive capsulitis can be associated with
diabetes and thyroid disorders
The glenohumeral joint can be injected from
an
anterior or posterior approach.
modified anterior approach for glenohumeral joint injection
injection into the
rotator cuff interval has been described to avoid injury to
the subcoracoid bursa, subscapularis muscle and tendon
or the inferior glenohumeral ligament
Patient’s Positioning for glenohumeral joint injection
it is recommended that for easy access of the joint the patient be comfortably seated with his arm at the side, and the shoulder externally rotated for the anterior approach (i.e., palm facing out or forward). By
externally rotating the arm, more anterior articular surface
of the humeral head is exposed. Additionally, it ensures that the long head of the biceps tendon is removed
from the injection tract. On the contrary, internal rotation
of shoulder is preferred in posterior approach with
the forearm across the body and the ipsilateral hand
touching the contralateral elbow.
Blind Anterior Approach for glenohumeral joint injection
The needle should be placed
just medial to the head of the humerus and 1 cm lateral to
the coracoid process. The needle is directed posteriorly
and slightly superiorly and laterally to avoid the cephalic
vein, brachial plexus and axillary artery located medial to the coracoid. When the needle hits the bone (humeral
head), it should be withdrawn slightly into the joint space
Blind Posterior Approach for glenohumeral joint injection
The needle should be inserted
1 to 2 cm inferior and medial to the posterolateral corner
of the acromion and directed anteriorly in the direction of
the coracoid process.
Fluoroscopically Guided Anterior Approach for glenohumeral joint injection
The injection is
performed with the patient supine and the shoulder slightly externally rotated. After the skin is prepped and draped, the injection site is infiltrated with local anesthetic. A 22-gauge
needle is directed in the AP view under fluoroscopic control at the junction of the middle and lower thirds of the medial part of the humeral head. Contrast material
may be injected to confirm intraarticular placement with
spread of contrast between the glenoid and the humerus.
If resistance to injection is encountered during Fluoroscopically Guided Anterior Approach for glenohumeral joint injection
the needle tip is most likely in the cartilage and should be redirected by rotating or slightly withdrawing it away from the humerus. The needle should not be withdrawn more than few millimeters, otherwise the needle tip will be in the subacromial-subdeltoid bursa. If needle manipulation
does not yield the desired result, the needle should
be gently directed medially, while exercising caution not to
advance the needle into the glenoid labrum.
rotator cuff interval
described as a triangular
space on the superomedial aspect of the humeral head. It
is a right triangle, the base of which is formed by the superior
border of the subscapularis muscle up to the anterior
border of the glenohumeral joint, the height is formed by
the lateral border of the coracoid process from the superior border of the subscapularis tendon to the edge of the supraspinatus
tendon, and the hypotenuse is formed by the inferior border of the supraspinatus tendon. The apex of the triangle is at the intersection of the base, and the hypotenuse is represented by the bicipital groove.
Within this triangle of the rotator cuff interval
biceps tendon, glenohumeral capsule, coracohumeral
ligament, and glenohumeral ligament. Therefore this triangle serves as a site for glenohumeral joint injection.
injection into the rotator cuff interval External rotation of the humerus may avoid
injection into the long head of the biceps tendon.
Fluoroscopically guided injection into the rotator cuff interval
The fluoroscopy tube is positioned perpendicular to the table, and the point of entry is marked over the upper medial quadrant of the humeral head close to the articular joint line. With intermittent fluoroscopy,
we then advance the needle parallel to the x-ray beam or
with a slight medial angulation until it came in contact with
the humeral head. Injection of contrast may be used to
confirm the intra-articular position of the needle.
Fluoroscopically Guided Posterior Approach
The injection is performed in prone position with the symptomatic shoulder slightly raised until the glenohumeral joint is seen tangentially. After the skin is sterilely prepped and draped, the injection site is infiltrated with local anesthetic. With the shoulder in a neutral position or slightly internally rotated, the needle is aimed at the inferomedial quadrant of the humeral head and advanced vertically under fluoroscopic guidance to the cartilage of the humeral head.
Ultrasound-Guided Posterior Approach positioning
The patient is
positioned either lying obliquely prone on the contralateral shoulder or sitting upright with the back to the physician and the ipsilateral hand on the contralateral shoulder there
by internally rotating the shoulder. The injection may be
performed with a 7.5- to 14-MHz linear array transducer.
Ultrasound-Guided Posterior Approach
After the skin and transducer are sterilely prepared and
drape, the injection site is infiltrated with local anesthetic.
The probe is positioned at the myotendinous junction of the
infraspinatus muscle inferior to the spine of the scapula.
The larger size and the superior location of the infraspinatus muscle and its longer tendon differentiates it from the teres minor muscle. The lateral humeral head, posterior glenoid rim and medial triangular shaped labrum should be identified as hyperechoic areas. The needle is inserted in-plane, advanced in the joint between the
humeral head and the posterior glenoid labrum.
Ultrasound-Guided Rotator Cuff Interval Approach (Modified Anterior Approach):
The transducer is placed cephalad to the greater and lesser tuberosities of the humerus with visualization of the intra-articular course of the biceps tendon between the supraspinatus and subscapularis tendons. The superior glenohumeral ligament is visualized between the biceps and subscapularis tendon while the coracohumeral ligament is between the biceps and supraspinatus tendons. The needle is advanced in-plane between the biceps tendon and the subscapularis tendon.
The acromioclavicular joint
a synovial joint between the
small, convex oval facet on the lateral end of the clavicle and a concave area on the anterior part of the medial border of the acromion process of the scapula
The acromioclavicular joint articular surfaces are
the joint line is oblique and slightly curved. This joint curvature permits the acromion, and thus
the scapula, to glide forward or backward over the lateral
end of the clavicle. This movement of the scapula keeps the glenoid fossa continually facing the humeral head.
The acromioclavicular joint contributes to
total arm movement in addition to transmitting forces between the clavicle and the acromion.
The acromioclavicular joint has
a capsule and the upper
aspect of the joint is strengthened by the superior acromioclavicular ligament.
The major ligamentous structure stabilizing acromioclavicular joint and binding the clavicle to the scapula is
the coracoclavicular ligament
Indications for injection of the acromioclavicular joint include
osteolysis of the distal clavicle and osteoarthritis
Osteolysis of the distal clavicle
a degenerative process that
results in chronic pain, particularly with adduction movements of the shoulder and is typically seen secondary to traumatic injury or in persons who perform repetitive weight training involving the shoulder.
Osteoarthritis also may develop in the acromioclavicular joint and typically develops secondary to
previous trauma or injury
diagnosis of osteolysis of the distal clavicle or osteoarthritis
History and physical examination are important. On physical examination, there is tenderness to palpation of
the acromioclavicular joint, and pain with active or passive
adduction (reaching the arm across the body) of the shoulder. Pain can be exacerbated by having the patient hold the opposite shoulder and pushing the elbow toward the ceiling
against resistance
Radiographs of the acromioclavicular joint
will confirm the diagnosis of osteolysis or osteoarthritis
Acromioclavicular joint injections can be used for
diagnostic or therapeutic purposes. As a diagnostic tool, a local anesthetic is injected into the joint to confirm the origin of pain.
Acromioclavicular joint injections Blind Approach
Patients are placed in the supine or seated position with the affected arm resting comfortably at their side. To identify the acromioclavicular joint, palpate the clavicle distally to its termination at which point a slight depression can be felt at the joint articulation. The needle
is inserted from the superior and anterior approach into the
acromioclavicular joint and directed inferiorly. Injection of
the acromioclavicular joint should be carried out by
positioning the needle almost perpendicular to the joint.
Acromioclavicular joint injections
Fluoroscopic Approach
With fluoroscopy the patient is
positioned supine and the image intensifier should be
placed in an anteroposterior direction and the needle is
advanced with intermittent fluoroscopy.
Acromioclavicular joint injections
Ultrasound Approach:
The acromioclavicular joint can be visualized using a high frequency linear ultrasound transducer. The transducer should be placed vertically over the superior aspect of the acromioclavicular joint area and adjusted until the joint space is visualized.
Using an in-plane technique, a needle is advanced into the
joint space. After injection, the intra-articular placement
may be verified by noting widening of the joint space.
The most common cause of hip pain in people over the age of 50 is
osteoarthritis of the hip joint. Other causes of hip pain include inflammatory arthritides such as rheumatoid arthritis and psoriatic arthritis, and trauma, infection, and avascular necrosis.
True intra-articular hip
pathology typically presents as
pain localized to the groin,
exacerbated by internal rotation.
Evaluation of hip pain is particularly challenging as the
hip joint cannot be palpated and it is important to be aware
of referred pain from a
hernia, back (spinal stenosis), or from trochanteric bursitis
Therapeutic joint
injections typically with a combination of
local anesthetic and corticosteroids are used to provide analgesia and improve functionality
The hip is a
ball-and-socket joint that exhibits a wide range
of motion in all directions. The femoral head articulates
with the pelvis to form the hip joint
functions as sites for muscle attachment at the hip
The greater and lesser
trochanters of the femur
The spherical acetabular socket
covers most of the
femoral head except for the acetabular notch inferomedially
where it is deficient. This deficient portion of the acetabulum is transversed by the acetabular ligament.
The anatomic relationship between the femur and the acetabulum
the acetabular cup oriented anterolaterally relative to the
pelvis and the femoral neck directed posteriorly, contributes
to the overall stability of the joint
allow for smooth movement of the joint
A thin layer of hyaline
cartilage covers the surfaces of both the femoral head as well as the acetabulum
the hip labrum
a circular layer of cartilage
that surrounds the outer part of the acetabulum. This deepens
the socket, thereby providing more stability
The hip joint capsule
is a thick ligamentous structure with circular and longitudinal fibers that surround the entire joint and is lined by a synovial membrane. The head of the femur fits into the acetabulum, where it is held firmly by a thick capsule, which
is divided into thickened layers forming the iliofemoral,
pubofemoral, and ischiofemoral ligaments.
iliofemoral ligament
connects the pelvis to the femur in the front of the
joint. It is Y-shaped and stabilizes the hip by limiting hyperextension
pubofemoral ligament
connects the pubis to the femur while the ischiofemoral ligament strengthens the posterior aspect of the capsule by attaching to the ischium and between the two trochanters of the femur.
muscles that attach to or cover
the hip joint including
gluteals, quadriceps, hamstrings,
iliopsoas, and the groin muscles
Intra-articular hip injections are performed for
diagnostic and therapeutic purposes. Arthrocentesis of the hip is performed to diagnose the presence or absence of pyarthrosis. Intraarticular injection of the hip is used to determine the likelihood of achieving pain relief after hip arthroplasty. Therapeutic hip injections are usually indicated for the treatment of arthritic symptoms in patients who are not considered good surgical candidates.
Intra-articular hip injections are challenging because
the joint cannot be easily palpated as well as its proximity
to the femoral nerve, artery, and veins anteriorly.
in Intra-articular hip injections
the anterior approach resulted in greater likelihood of injury to both the
femoral artery and the lateral femoral cutaneous nerve than the lateral approach. Thus
image guidance is typically recommended either with
fluoroscopy or with ultrasonography.
Intra-articular hip injections
Fluoroscopic Anterior Approach
Fluoroscopy is used to
visualize anatomical landmarks including the anterior superior iliac spine and the pubis. The femoral artery is palpated half-way between these points and the femoral nerve is about 1 cm lateral to the artery. The needle entry site is lateral to this point to avoid femoral nerve injury. Skin is prepped and draped and local anesthetic infiltrated into skin. The needle is advanced toward the junction of
the femoral head and neck just inferior to the acetabular lip. An arthrogram is then performed to confirm the
placement of the needle inside the hip joint.
Intra-articular hip injections
Ultrasound Approach
Patient is positioned supine with the hip neutral or slightly internally rotated. The anterior–superior iliac spine (ASIS) is
palpated, and the transducer is oriented in a sagittal plane
with the superior end just medial to the ASIS. While
maintaining this orientation, the transducer is moved medially until the femoral head is visualized as a hyperechoic
rounded surface. The transducer is then rotated into the transverse plane and moved medially to visualize the femoral nerve and vessels. After confirming the position of the neurovascular structures, the transducer is moved back to the anterior hip joint in the sagittal plane. The inferior end
of the transducer is then rotated laterally while maintaining the superior portion on the femoral head to obtain a long-axis femoral head-neck view. The skin at the inferior end of the transducer is marked and the area is prepared in the usual sterile manner, and local anesthesia is injected.
Intra-articular hip injections
Ultrasound Approach
Needle advancement
A 22-gauge spinal needle is advanced under direct ultrasound visualization to the junction of the femoral head and neck. A slight increase in resistance is appreciated as the needle reaches the iliofemoral ligament. A “pop” is felt as the needle passes through the ligament to enter the joint. Intraarticular placement is verified by visualizing the needle tip and injecting 1 to 2 ml of local anesthetic while observing the capsular distention with ultrasound
Greater trochanteric pain syndrome (GTPS), previously
known as greater trochanteric bursitis
resulting in pain over the greater trochanter. Symptoms include pain in the lateral hip radiating along the lateral aspect of the thigh to the knee and occasionally below the knee. Physical examination reveals point tenderness over the greater trochanter.
Greater trochanteric pain syndrome treatment
self-limited with conservative measures, such as physical
therapy, weight loss, and nonsteroidal anti-inflammatory
drugs. Other treatment modalities include bursa or lateral hip injections performed with corticosteroid and local anesthetic.
The trochanteric bursa is located
over the lateral prominence
of the greater trochanter of the femur.
Three bursas (two major and one minor) surround the greater trochanter
Major bursas are the subgluteus medius bursa (posterior and superior to the proximal edge of the greater trochanter) and the subgluteus maximus bursa (lateral to the greater trochanter). The minor bursa is the subgluteus minimus bursa (above and slightly anterior to the superior surface of the greater trochanter).
Indications for greater trochanteric bursa injection
acute and chronic inflammation associated with osteoarthritis, rheumatoid arthritis, repetitive use, and other
traumatic injuries to the area
pain of Greater trochanteric pain syndrome can be from
Imaging studies indicate
that the pain can be from gluteus minimus or medius
injury or inflammation of the bursa itself. It is often
idiopathic but may result from running, local trauma, and gait disturbances
pain of Greater trochanteric pain syndrome
The pain can be severe, radiate to the buttock or anterior thigh, and be exacerbated by standing
or sleeping on the affected side. Patients often describe
“hip” pain; however, true intra-articular hip pain usually
radiates to the groin. On examination, palpation over the
greater trochanter reproduces the pain
Greater trochanteric Injection
Blind Approach
The patient should be in the lateral decubitus position with the affected side up. It is recommended to flex the hip 30 to 50 degrees and flex the knee 60 to 90 degrees to improve patient comfort as well as for stabilization of the hip. The greater trochanter is identified by palpating the femur proximally from the midshaft until the bony protrusion is felt. The point of
maximal tenderness or swelling is identified and marked. A 22- or 25-gauge, 3.5-inch spinal needle is inserted perpendicular
to the skin.
Greater trochanteric Injection
Fluoroscopic Approach
The patient is placed in the lateral position with the affected side up. The most painful area is marked over the anticipated site of the bursa. Using fluoroscopy, a 22-gauge 3.5-inch spinal needle should be advanced into the bursa over the greater trochanter. 0.5 to 1 ml of contrast may be injected to confirm intrabursal spread
The knee joint
largest joint in the body and consists of four bones, namely the femur, the tibia, the fibula, and the patella, and an extensive network of ligaments and muscles.
The knee joint is made up of two functional joints
the femoral-tibial and the femoral-patellar joint
The main movements of the knee joint occur among the
femur, patella, and tibia, which are each covered by articular
cartilage designed to decrease the frictional forces
as movement occurs between the bones.
The patella lies in the
intercondylar groove at the distal end of the femur
surrounds the entire knee joint
A thick ligamentous joint capsule lined by synovial membrane, which secretes
synovial fluid to reduce friction and facilitate movement. The frictional forces are additionally reduced by the
infrapatellar fat pad and bursae
The primary stabilizers of
the knee are the
anterior and posterior cruciate ligaments, the medial and lateral collateral ligaments, and the capsular ligaments. The cruciate ligaments are so called because they form a
cross in the middle of the knee joint
The medial collateral ligament
a band that runs between the inner surfaces of the femur and the tibia. It resists valgus forces acting from the outer surface
of the knee
The lateral collateral ligament
traverses from
the outer surface of the femur to the head of the fibula and
resists varus forces from the inner surface of the knee
The anterior cruciate
ligament (ACL)
travels from the anterior of the tibia to the posterior the femur and prevents the tibia moving
forward. It is one of the most important structures in the knee, and is most commonly injured in twisting movements. Injury to it may require extensive surgery and rehabilitation.
The posterior cruciate ligament (PCL)
travels from the posterior surface of the tibia to the
anterior surface of the femur and in doing so wraps
around the ACL.
menisci
Each knee joint has two crescent-shaped cartilage menisci. These lie on the medial and lateral borders of the upper surface of the tibia and are essential components, acting as shock absorbers for the knee as well as allowing for correct weight distribution between the tibia and the femur.
Indications for knee joint injection include
delivery of viscoelastic supplementation for advanced osteoarthritis as well as corticosteroid for other noninfectious inflammatory
arthritides such as rheumatoid arthritis, gout, or calcium pyrophosphate deposition disease
intra-articular knee injections
Midpatellar Approach:
The patient is positioned supine with the knee extended and a pillow or roll beneath the popliteal fossa. For the lateral midpatellar approach, lines are drawn along the lateral and proximal borders of the patella. The needle is inserted into the soft tissue between the patella and femur near the intersection point of the lines, and directed at a 45-degree angle toward the middle of the medial side of the joint. Medial midpatellar
approach; the needle enters the medial side of the knee
under the middle of the patella (midpole) and is directed
toward the opposite patellar midpole.
intra-articular knee injections Anterior Approach (Infrapatellar):
The knee is flexed 60 to
90 degrees, and the needle is directed either medially or
laterally to the inferior patellar tendon and cephalad to the
infrapatellar fat pad. This technique is useful when the knee cannot be extended. Also, it avoids injury to the articular cartilage
intra-articular knee injections
Suprapatellar Approach:
This approach is more common in large effusion as the suprapatellar pouch will be
expanded. However, it is rarely done nowadays especially with the introduction of ultrasound-guided suprapatellar recess injection
intra-articular knee injections
Fluoroscopic Approach
Fluoroscopic guidance may be
indicated in obese patients or when it is expected to have
difficulty accessing the intra-articular space.
intra-articular knee injections
Ultrasound Suprapatellar Approach
Patient is positioned
supine with the knee flexed 20 to 30 degrees and is supported by a pillow in the popliteal space. A linear-array
high-resolution transducer is placed longitudinally such that
it is parallel to the tendon of quadriceps femoris muscle.
The distal femur, the superior pole of the patella, suprapatellar fat pad and the suprapatellar recess can be visualized. Minimal pressure should be applied on the transducer to avoid compressing the suprapatellar bursa. The transducer is then rotated to the axial plane, and tendon of quadriceps femoris, suprapatellar fat pad, and the suprapatellar bursa should be reidentified. The largest dimension of the synovial
recess is identified and is the target for the injection. After the skin is sterilely prepped and draped, a 22-gauge,
3.5-inch spinal needle is advanced in-plane to the suprapatellar recess. Aspiration of synovial fluid confirms proper needle placement. During the injection, a fluid jet may be
visualized distending the suprapatellar recess.
Infection, the most serious complication, is extremely
rare.
it is strongly recommended
to follow strict aseptic technique and avoiding
injections in patients with suspected cellulitis, infectious
arthritis or bursitis, bacteremia, or in severely immunocompromised
patients
corticosteroid preparations use
risk of hyperglycemia in patients
with diabetes is also very small and transient
Risk of hemarthrosis
is
small even in those taking antiplatelet or anticoagulation
agents, although it is recommended that these
agents be discontinued prior to elective injection
Postinjection inflammation is caused by
intra-articular injection of corticosteroid crystals causing
synovitis and can mimic septic arthritis, however, septic
arthritis usually differs in timing and duration, occurring
later than postinjection inflammation and lasting much
longer. It is a rare complication that begins shortly after the injection and usually subsides within a few hours, rarely continuing for 2 to 3 days. Treatment is conservative and
includes ice at the site of injection and oral analgesics until the reaction abates.
Capsular (periarticular) calcifications
at the site of the injection have been reported in rare cases on radiographs taken after treatment. They usually disappear spontaneously
and have no clinical significance. Careful technique
and avoiding leakage of the steroid suspension from
the needle track to the skin surface prevent or minimize
these problems.
