Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley...

36
Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor 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 2 ND -3 RD 2019

Transcript of Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley...

Page 1: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 2: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

DisclosuresGurjit S Kaeley MRCP--None

Page 3: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 4: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 5: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

Blind injections. Do we hit the target?

5Courtesy Juhani Koski MD PhD

Page 6: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 7: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 8: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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).

Page 9: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 10: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 11: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 12: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 13: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 14: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

Concept: Just Need To Get Needle Under the Capsule!

Palpation Guided

USGuided

What is the Target?

Page 15: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 16: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

In Plane Out of PlaneDirect Visualization

Page 17: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 18: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

Where Do You Expect to See the Needle?

Page 19: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

Needle is Best Visualized When it is Parallel to the Probe

Long Axis

Page 20: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

Beam Steering

Page 21: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

Where Do You Expect to See the Needle?

Page 22: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

Short Axis – Keeping Probe in Step With the Needle Tip

Needle not in plane Needle seen but tip distal

Needle tip visualized within

target

Page 23: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 24: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

Puncture Point Depends on Size of Joint

Small Targets – Sterile Gel StandoffLarge Joints – Puncture Point Away From Probe

Page 25: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 26: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 27: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 28: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 29: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 30: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 31: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

And finally – does it make any difference – palpation vs sonographically guided?

Page 32: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 33: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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.

Page 34: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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

Page 35: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director

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.

Page 36: Sonographic Needle Guidance - CRUS-SURC...Principles of Sonographic Needle Guidance Gurjit S Kaeley MRCP, RhMSUS Professor and Division Chief, Rheumatology Fellowship Director, Director