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Ultrasound use in the management of intrathecal delivery systems
Michael Saulino, MD PhD
Physiatrist
MossRehab Elkins Park
Disclosures
• Speaker’s bureau and clinical investigator for Jazz Pharmaceuticals
• Speaker’s bureau and clinical investigator for Medtronic, Inc
• Clinical investigator for Mallinckrodt
• Consultant for SPR therapeutics
• NANS Board of Directors
Objectives
• Understand the basic underpinnings of diagnostic ultrasound
• Recognize the potential utility of using ultrasound in the management of intrathecal therapy systems
Advantages of ultrasound • More accurate than palpation techniques
• More precise needle placement
• Potentially less risk for inadvertent trauma
• Can view soft tissues better than x-ray
• “Affordable”
• More portable than fluoroscopy
Advantages of ultrasound • Doppler mode visualization of flow
• No radiation exposure
• Decreased associated expense of upkeep
• Billable procedure 76942 (Caveat emptor)
• Potentially svoids the dreaded pocket fill
• Diagnoses the flipped pump
Disadvantages of ultrasound • Needle visualization has to be in-plane with
transducer
• 2d representation of 3d structure
• Poor penetration > 4-5 cm, unusable after 15cm
• Deeper views have poorer resolution
Disadvantages of ultrasound • Artifact from air and other density changes
• Anatomic variations
• Limited field of view
• Sometimes need an extra pair of hands
Practical considerations
“Thanksgiving – 8 hours of preparation for 10 minutes of eating”
Sarah Saulino – Mike’s Mom
Ultrasound refills can be the same way
Practical considerations
• Know pump anatomy
• Know the refill procedure – intrathecal delivery systems were not designed for ultrasound guidance
• Use ultrasound as an adjunct
• Consider patient positioning – can be creative here (standing, side lying, beach chair)
• Know the machine
Practical considerations
• Consider ergonomics
• Lighting can can make a world of difference
• Have all of materials within arms reach
• No such thing as too much gel
• Watch the screen, not the patient
• Use hydro dissection
• Need to retain an image for billing
Ultrasound: applied reflectivity
• Transducer is both a speaker and microphone
• Piezoelectric crystal emits a sonic frequency in the 3-40 MHz range
• Human hearing stops at 20 kHz, canine hearing stops 60 kHz, dolphins use echolocation up to 150 kHz
• Microphone picks up reflected signals
• Computer decodes the reflections to create an image
Ultrasound is applied reflectivity
• Air reflects nothing
• Soft tissue sort of reflect
• Bone and metal reflect a lot
Ultrasound is applied reflectivity
• Higher frequency means higher resolution but lower penetration
• Lower frequency means lower resolution and higher penetration
• Most transducers have a range of frequencies
Depth
• Ultrasound can be set to penetrate a certain distance
• Set the depth a little deep to begin so you don’t waste time looking for your target
• When you have your bearings, set the depth so it is enough to cover your area of interest
• Excessive depth will degrade the picture unnecessarily
Gain
• Gain is the volume control of ultrasound
• Not enough is too dark (soft)
• Too much is too bright (loud)
• Similar to equalizer in audio systems, gain can be adjusted at different frequencies
Visualization of current systems
• “Not-for-human-use” pumps were obtained from all three device manufacturers: SynchroMed II (Medtronic), MedStream (Codman) and Prometra (Flowonix).
• Each pump was placed in 3-inch deep baking tray and covered with an ultrasound phantom gel
Methods
• The anterior surface of each pump was then scanned with 50 mm high-frequency linear transducer HFL50 attached to the portable ultrasound machine MTurbo.
• The sonographic features of each pump was then observed and recorded.
Conclusions
• All reservoir ports can be readily identified by portable sonography
• Potentially, the dome-shaped configuration of reservoir access ports for the Prometra and MedStream systems make the access easier, when compared to SynchroMed system.
• Each of the 3 systems has a unique sonographic appearance which allows for prompt identification