Guided Interventions in Musculoskeletal Ultrasound

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    Review

    Guided interventions in musculoskeletal ultrasound:whats the evidence?

    J. Davidson*, S. Jayaraman

    St Richards Hospital, Spitalfield Lane, Chichester, West Sussex, UK

    a r t i c l e i n f o r m a t i o n

    Article history:

    Received 2 March 2010

    Received in revised form

    13 August 2010

    Accepted 21 September 2010

    Increasing histological and radiological understanding of the processes involved in soft-tissue

    injury is leading to novel targeted treatments. A number of reviews have recommended that

    these treatments should be performed with image guidance. This review describes current

    ultrasound-guided interventions and injections, together with the level of evidence for these.

    Discussion of guided interventions will include; percutaneous lavage (barbotage), brisement,

    dry needling, electrocoagulation, and of guided injections; corticosteroids, autologous

    substances (blood and platelet rich plasma), sclerosants, and prolotherapy (hyperosmolar

    dextrose). Representative imaging illustrating some of these techniques is included for

    correlation with the methods described. As these procedures are often performed in sports-

    people, it is essential that the radiologist is aware of prohibited substances and methods

    outlined in an annual publication from the World Anti-Doping Association (WADA). Finally,

    future directions, including the use of autologous substances, mesenchymal and stem cells will

    be discussed.

    2010 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

    Introduction

    Ultrasound is essential in soft-tissue injury diagnosis andtreatment, including tendon, muscle, and nerve patholo-gies. Ultrasound-guided interventions straddle conserva-

    tive and surgical management and improve patientsquality of life in those unsuitable for surgery.

    Ultrasound-guided procedures allow assessment of

    lesions and evaluation of procedure tolerance. Radiologistsmust remember that they are clinicians and hone theircommunication skills to improve the patient experience.

    Ultrasoundallows real-timeaccurateplacement of treatment.Recent government initiatives to increase physical

    activity will probably increase activity-related injury. There

    is an increasing body of evidence from non-radiologyspecialties performing these techniques, both blind and alsounder ultrasound-guidance. Radiologists must lead evalu-

    ation of these techniques to ensure they are evidence-basedand performed safely.

    Informed consent is essential, assisted by the referring

    clinician explaining the procedure in clinic. We routinelysend an information leaflet with the appointment letter.

    Patients can generally perform activities of daily living butshould refrain from strenuous exercise for 72 h. Anaphy-laxis is rare but should be considered. A high frequency(7e12 Hz) linear probe should be used.

    There is surprisingly little evidence in the literatureregarding the efficacy of the methods used for infection

    prophylaxis.1 Our practice is to clean the puncture site with

    an alcohol solution. The probe is cleaned and sterile salineused as a coupling agent. Our audited injection rates arezero in over 2000 injections with this technique. Readers

    should be aware that using alcohol directly on the probe

    * Guarantor and correspondent: J. Davidson, 34 The Avenue, South-

    ampton, Hampshire SO17 1XN, UK. Tel.: 44 7894 076 939.

    E-mail address: jdavidson@doctors.org.uk (J. Davidson).

    Contents lists available at ScienceDirect

    Clinical Radiology

    j o u r n a l h o m e p a g e : w w w . e l s e v i e r h e a l t h . c o m / j o u r n a l s / c r a d

    0009-9260/$ e see front matter 2010 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

    doi:10.1016/j.crad.2010.09.006

    Clinical Radiology 66 (2011) 140e152

    mailto:jdavidson@doctors.org.ukhttp://www.sciencedirect.com/science/journal/00099260http://www.elsevierhealth.com/journals/cradhttp://dx.doi.org/10.1016/j.crad.2010.09.006http://dx.doi.org/10.1016/j.crad.2010.09.006http://dx.doi.org/10.1016/j.crad.2010.09.006http://dx.doi.org/10.1016/j.crad.2010.09.006http://dx.doi.org/10.1016/j.crad.2010.09.006http://dx.doi.org/10.1016/j.crad.2010.09.006http://www.elsevierhealth.com/journals/cradhttp://www.sciencedirect.com/science/journal/00099260mailto:jdavidson@doctors.org.uk
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    may invalidate the warranty. Full draping and probe coversis reserved for deep injections.

    This is an extensive topic; therefore, biopsy, joint aspi-

    ration, and foreign body removal have not been included.The studies cited refer to adult patients only. Almostexclusively published papers have been referenced.

    We will describe these techniques and the evidence for

    guided interventions and injections of therapeuticsubstances. Table 1 lists the included techniques, Table 2

    summarizes the current evidence, Table 3 lists thekey studies and Table 4 lists information pertaining toregulations of the World Anti-Doping Association

    (WADA),52 which governs the use of prohibited substances

    and methods of administration in many sporting bodies.

    Guided interventions

    Dry needling

    This technique involves needle insertion into the lesionsite, then repeated puncture aiming to stimulate aninflammatory healing response (Fig. 1). Disruption of

    collagen fibres at the lesion causes local haemorrhage. Thehypothesis is that inflammation leads to granulation tissueformation and tendon strength.2 Indications include:

    patellar tendinosis,2 lateral epicondylitis,3 medial epi-condylitis,4 and plantar fasciitis.5 There is anecdotalevidence in Achilles tendinosis and adductor insertion

    tendinopathy.To our knowledge, there are no studies in the literature

    that purely use dry needling, although studies exist that

    combine dry needling with autologous blood injection.2e4

    Further work is needed.

    Brisement/percutaneous hydrostatic decompression

    This has been described under different terms, includingbrisement and high-volume image-guided injections. It is

    suitable for use in Achilles tendinopathy as there is notendon sheath, surrounded by connective tissue, the para-

    tenon. The development of abnormally oriented vessels andnerves, is felt to contribute to pain.6,7 Therefore, a physicalmethod of disrupting these neurovascular structures is

    thought to reduce pain. Surgical management of Achillestendinopathy includes: open or percutaneous tenotomy,peritenon and tendon debridement.7

    The review by Cormick8 describes a method using 20 mlof cold 0.9% saline with celestone (betamethasone) andlocal anaesthetic, which is injected to strip the paratenon off

    the tendon. No prospective results are available with regard

    to short- or long-term pain relief. The use of steroids, in thecontext of abnormal tendon, is not advised because of thepotential risk of rupture from inadvertent intratendinous

    injection.9

    However, peritendinous steroid injections have not beenshown to be associated with an increased risk of rupture.10 In

    a retrospective study of 64 patients, one group was givenblind peritendinous or intrabursal injections of 1 ml hydro-cortisone and 1 ml 1% xylocaine with light training. The

    second group underwent physical therapies only. Follow-upwas performed over 1 year. Two ruptures occurred in eachgroup; however, the image-guided injections gaveimproved

    results. A further small study of 28 patients 11 divided into

    twogroups, involved the blind peritendinous administrationof either bupivacaine and prednisolone or bupivacaine

    alone. No tendon ruptures occurred. However, there wasonly a 33% incidence of complete pain relief.

    A study by Chan et al. (2008),12 a prospective study of 30

    patients, with refractory Achilles tendinopathy, underwentan injection of 10 ml 0.5% bupivacaine, 25 mg hydrocorti-sone and 410 ml normal saline, to between the anterior

    aspect of the Achilles tendon and Kagers fat pad. Vascu-larity was assessed with power Doppler and eccentricloading was prescribed. The results from visual analogue

    scores (VAS), showed a significant improvement in pain inthe short term (2 weeks), with a mean change of 50 mm,

    from a mean of 76 mm to a mean of 25 mm (asymptomaticpatients should score a VAS of 0 mm). There was alsoa statistically significant improvement in function with

    a mean gain of 50 mm. The VISA-A (Victorian Institute ofSport Assessment-Achilles tendon)13 scores, reflectingsymptom extent, showed a significant reduction after 30weeks, with a mean VISA-A score pre-procedure of 44.8

    points and 76.2 points post-procedure (an asymptomaticpatient scores 100 points).

    In our institution, this technique is used in refractorymid-Achilles tendinosis.14 After clinical and sonographicassessment of the symptomatic Achilles, ultrasound guidesthe needle between the paratenon and the abnormal

    tendon. Up to 7.5 ml of 0.5% bupivacaine is then injected intothe site over three sessions with the aim of expanding this

    space (Fig. 2). It is important to combine any interventionswith eccentric loading between sessions, as a systematicreview of nine studies by Kingma et al.15 demonstrated a 60%mean pain reduction in the eccentric overloading groups

    compared to 33% reduction in the control groups.

    Electrocoagulation

    This technique treats painful chronic Achilles tendinop-athy. Neovessels and nociceptive fibre formation are

    hypothesized to cause pain. Thi