Atlas of Ultrasound-Guided Procedures in Interventional Pain Management

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Atlas of Ultrasound-Guided Procedures in Interventional Pain Management

In 1941, Dr. Karl Theodore Dussik of Austria introduced the idea of using ultrasound waves as a diagnostic tool. Over the next few decades he, along with others like Professor Ian Donald of Scotland, developed the practical technology.

And applications of ultrasound in the field of medicine Since then, ultrasound (US) has become progressively more useful across a wide range of medical specialties, for both diagnostic and therapeutic procedures. US is quickly becoming the imaging modality of choice to guide practitioners in pain management and musculoskeletal interventions. Although fluoroscopy has long been a mainstay in image-guidance for such procedures, US provides an attractive alternative given its superior soft tissue resolution, allowance of real-time needle guidance, absence of iodinated contrast and lack of ionizing radiation

The Atlas of Ultrasound-Guided Procedures in Interventional Pain Management by Narouze et al. is a comprehensive review of the principles of US-guidance as an aid in current pain management practices. It is divided into six parts and 30 chapters arranged by system and discipline. Leading experts in each discipline have contributed to this body of work, providing an extensive literature review encompassing each chapter. This text is meant to serve as a user-friendly manual, covering the anatomy, treatment rationale, and technical aspects of US-guided interventional pain management procedures.

Imaging in Interventional Pain Management and Basics of Ultrasonography

The introductory section of the text reviews the imaging modalities currently utilized in interventional pain management. These include fluoroscopy, computed tomography (CT) and ultrasound. The accuracy, precision, safety and diagnostic benefits gained by the use of image-guided modalities make them more attractive than using surface landmarks. A brief risk to benefit analysis highlights the strengths and weaknesses of each modality in various scenarios.

The section includes a discussion of the utility of ultrasound in intra-articular injections, trigger point and muscular injections, zygapophyseal and medial branch blocks, epidural blocks, sympathetic blocks, and the combination use of ultrasound and CT/fluoroscopy.

A concise yet satisfactory review of the basics of US imaging is provided as background for the sections to follow. The principles of US pulse generation, wavelength, frequency and US-tissue interaction are outlined and reinforced with helpful diagrams, tables and images. The essential knobology for US-guided regional anesthesia and interventional pain management provide a user-friendly guide to optimize the image obtained from US machine operation. The last chapter of the section guides the reader through the process of improving needle visibility for US-aided procedures. Inadequate needle visualization during a procedure may lead to inadvertent vascular, neural or visceral injury. Vascular puncture injuries have been decreased by 30% with the use of real-time visualization via US. This chapter is quite thorough in exploring the multitude of factors that impact needle placement. An emphasis is placed on the importance of proper training with adequate mentorship and the use of high-fidelity simulation in the mastery of the described techniques. The factors discussed include but are not limited to needle type (echogenic), insertion site and angle, the US device, needle-probe alignment, “in-plane” and “out-of-plane” needle approaches as well as ergonomics. Side-by-side clinical images with corresponding US images provide a realistic illustration of techniques described. Overall, Part I of the text provides a high-quality introduction to the subject matter and a step-by-step guide to the general principles of US-guided procedures which sets the stage for a more detailed discussion and description of this modality on an anatomical basis.

Spine Sonoanatomy and Ultrasound-Guided Spine Injections:

The second section focuses on sonographic exploration and interventions involving the spine. A review of the cervical, thoracic, lumbar and sacral spine is provided and supported by labeled gross anatomical photographs. Although an extremely useful method of identifying and protecting delicate structures from damage during procedures, US continues to have important limitations which are appropriately addressed. Perhaps most notable is the distinction between the superficial and deep anatomy. Generally speaking, more superficial structures such as bony contours, synovial joint capsules or entrances are more consistently visualized with greater image quality as compared to deeper structures. Working with deep articular cavities of zygapophyseal and sacroiliac joints, vertebral canal, epidural space, intervertebral foramina, paravertebral space and nerve roots as well as sacral foramina and vertebral arteries tends to be more challenging. Detailed sonoanatomy of the entire spine divided into the four anatomical regions is presented in a clear and comprehensive manner. Emphasis is placed on the distinction between the superficial and deep anatomy as figures display anatomical models, cadaveric dissections and US imaging to demonstrate various correlations.

US-guided blockade of the third occipital and cervical medial branch nerves are discussed starting with the indications for both. The authors cite the relevant literature and as well as their own clinical experience in the treatment rationale outlining the advantages and limitations of US methods. The primary advantage of US over CT or fluoroscopy is the ability to visualize the cervical medial branch for local anesthetic injection. However, the quality of visualization is dependent on patient body habitus and thus presents a limitation. Step-by-step explanations of the related techniques are included with clinical photographs that demonstrate US probe placement and proper needle location. The section goes on to cover cervical zygapophyseal (facet) intra-articular injections describing both lateral and medial approaches. Additionally, a thorough description of US-guided thoracic paravertebral, lumbar zygapophyseal nerve and neuraxial blocks as well as lumbar nerve, caudal, ganglion impar and sacroiliac joint injections is provided. Many of the sources cited underscore the benefit US-guidance in interventional spinal procedures. The ability to identify vital neurological and vascular anatomy allows practitioners to effectively execute diagnostic and therapeutic procedures while protecting these structures.

Transversus abdominis plane block aided by US is a proven management option for chronic pancreatitis, post-operative pain, and various other causes of abdominal pain. The classic or “double-pop” approach originally described by Rafi and McDonell is reviewed and followed by a description of the US-guided technique and its benefits. Celiac plexus blockade and neurolysis has been widely accepted in the management of malignant and nonmalignant pain conditions in the pancreas, liver, gall bladder, mesentery, omentum and portions of the gastrointestinal tract from the lower esophagus to the transverse colon. The advantages and limitations of the use of US-guidance in common approaches are evaluated including related diagrams and sonographic images.

Lastly, management of chronic pelvic pain is addressed. This phenomenon is complex as potential etiologies may stem from the viscera, neuromuscular system or the gynecological system. Operative and traumatic damage to ilioinguinal, iliohypogastric and genitofemoral nerves are relatively common causes of pelvic pain. Additionally, piriformis syndrome and pudendal neuralgia are outlined and sonoanatomy with US-guided blockade techniques are illustrated. Moreover, an extensive literature review references data that validates the use of US for the identification of the target structures associated with chronic pelvic pain.

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