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In the past 10 years, ultrasound (US) has become increasingly popular to image both peripheral musculoskeletal and axial structures. Presently, US is often used to guide interventions such as aspiration, hydrodissection, tenotomy, as well as diagnostic or therapeutic injections (e.g., epidural, facet joint, intra-articular, sacroiliac joint, subtalar joint, trigger point and viscosupplement injections). This clinical policy bulletin describes some of the medically necessary as well as experimental/investigational indications associated with the use of US guidance.
Manickam et al (2009) noted that saphenous nerve (SN) block can be technically challenging because it is a small and exclusively sensory nerve. Traditional techniques using surface landmarks and nerve stimulations are limited by inconsistent success rates. In a prospective study, these researchers examined the feasibility of performing an ultrasound (US)-guided SN block in the distal thigh. After the research ethics board's approval and written informed consent, a total of 20 patients undergoing ankle or foot surgery underwent ultrasonography of the medial aspect of the thigh to identify the SN in the adductor canal, as it lies adjacent to the femoral artery (FA), deep to the sartorius muscle. An insulated needle was advanced in plane under real-time guidance toward the nerve. After attempting to elicit paresthesia with nerve stimulation, 2 % lidocaine with 1:200,000 epinephrine (5 ml) and 0.5 % bupivacaine (5 ml) were injected around the SN. The SN was identified in all patients, most frequently in an antero-medial position relative to the FA, at a depth of 2.7 +/- 0.6 cm and 12.7 +/- 2.2 cm proximal to the knee joint. Complete anesthesia in the SN distribution developed in all patients by 25 mins after injection. The authors concluded that in this small, descriptive study, US-guided SN block in the adductor canal was technically simple and reliable, providing consistent nerve identification and block success.
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Messeha (2016) stated that lumbar plexus block, combined with a sciatic nerve block, is an effective loco-regional anesthetic technique for analgesia and anesthesia of the lower extremity. These researchers compared the clinical results outcome of the adductor canal block versus the psoas compartment block combined with sciatic nerve block using real time US guidance in patients undergoing elective laparoscopic knee surgeries. A total of 90 patients who were undergoing elective laparoscopic knee surgeries were randomly allocated to receive a sciatic nerve block in addition to lumbar plexus block using either an adductor canal block (ACB) or a posterior psoas compartment approach (PCB) using 25-ml of bupivacaine 0.5 % with adrenaline 1:400,000 injection over 2 to 3 mins while observing the distribution of the local anesthetic in real time. Successful nerve block was defined as a complete loss of pinprick sensation in the region that is supplied by the 3 nerves along with adequate motor block, 30 mins after injection. The degree of motor block was evaluated 30 mins after the block procedure. The results of the present study showed that the real time US guidance of PCB is more effective than ACB approach. Although the sensory blockade of the femoral nerve achieved equally by both techniques, the LFC and OBT nerves were faster and more effectively blocked with PCB technique. Furthermore, PCB group showed significant complete sensory block without need for general anesthesia, significant decrease in the post-operative visual analog scale (VAS) and significant increase time of 1st analgesic requirement as compared to the ACB group. The authors concluded that the findings of this study showed that blockade of lumber plexus by psoas compartment block was more effective in complete sensory block without general anesthesia supplementation in addition to decrease post-operative analgesic requirement than adductor canal block. The subjects in this study underwent laparoscopic knee surgeries, not ankle surgeries.
The authors stated that this study had several drawbacks. The exclusion of obese patients led to that the incidence of success in patients with body mass index (BMI) of greater than 35 kg/m2 could not be determined, as US visibility of the lumbar paravertebral structures in obese patients was poorer than that observed in patients with low BMI. Another limitation was the wide range of age group and changes in musculoskeletal structures, especially in the elderly patients (greater than 65 years of age) that could reduce the contrast between a peripheral nerve and its surrounding muscles and could adversely affect the quality of US images. Furthermore, patients with abnormal spinal anatomy, due to either spinal deformity or history of previous back or spine surgery also demonstrated poor image quality.
Klaastad and co-workers (2009) noted that many of the reports concluded that US guidance may provide a higher success rate for brachial plexus blocks than guidance by nerve stimulator. However, the studies were not large enough to conclude that US will reduce the risk of nerve injury, local anesthetic toxicity or pneumothorax. Ultrasound may reveal anatomical variations of importance for performing brachial plexus blocks. For post-operative analgesia, 5 ml of ropivacaine 0.5 % has been sufficient for an US-guided interscalene block. For peri-operative anesthesia, as much as 42 ml of a local anesthetic mixture was calculated to be appropriate for an US-guided supraclavicular method. For the future, these investigators noticed that 3D- and 4D-US technology may facilitate visualizing the needle, the nerves and the local anesthetic distribution. Impedance measurements may be helpful for nerve blocks not guided by US. The authors concluded that the literature gave a sufficient basis to recommend the use of US for guidance of brachial plexus blocks.
Nadeau and associates (2013) reviewed the main US-guided approaches used for regional anesthesia of the upper limb. The anatomical configuration of the upper limb, with nerves often bundled around an artery, makes regional anesthesia of the arm both accessible and reliable. In-depth knowledge of upper limb anatomy is needed to match the blocked territory with the surgical area. The interscalene block is the approach most commonly used for shoulder surgery. Supra-clavicular, infra-clavicular, and axillary blocks are indicated for elbow and forearm surgery. Puncture techniques have evolved dramatically with US guidance. Instead of targeting the nerves directly, it is now recommended to look for diffusion areas. Typically, local anesthetics are deposited around vessels, often as a single injection. Phrenic nerve block can occur with the interscalene and supra-clavicular approaches. Ulnar nerve blockade is almost never achieved with the interscalene approach and not always present with a supra-clavicular block. If US guidance is used, the risk for pneumothorax with a supra-clavicular approach is reduced significantly. Nerve damage and vascular puncture are possible with all approaches. If an axillary approach is chosen, the consequences of vascular puncture can be minimized because this site is compressible. The authors concluded that upper limb regional anesthesia has gained in popularity because of its safety profile and effectiveness associated with US-guided techniques.
Shin et al (2011) stated that continuous interscalene block has been known to improve post-operative analgesia after arthroscopic shoulder surgery. In a prospective study, these investigators examined the US-guided posterior approach for placement of an interscalene catheter, clinical efficacy and complications after placement of the catheter. A total of 42 patients undergoing elective arthroscopic shoulder surgery were included in this study and an interscalene catheter was inserted under the guidance of US with posterior approach. With the in-plane approach, the 17-G Tuohy needle was advanced until the tip was placed between the C5 and C6 nerve roots. After a bolus injection of 20-ml of 0.2 % ropivacaine, a catheter was threaded and secured. A continuous infusion of ropivacaine 0.2 % 4 ml/hour with patient-controlled 5-ml boluses every hour was used over 2 days. Difficulties in placement of the catheter, clinical efficacy of analgesia and complications were recorded. All patients were monitored for 48 hours and examined by the surgeon for complications within 2 weeks of hospital discharge. Easy placement of the catheter was achieved in 100 % of the patients and the success rate of catheter placement during the 48-hour period was 92.9 %. Post-operative analgesia was effective in 88.1 % of the patients in the post anesthetic care unit (PACU). The major complications included nausea (7.1 %), vomiting (4.8 %), dyspnea (4.8 %) and unintended vascular punctures (2.4 %). Other complications such as neurologic deficits and local infection around the puncture site did not occur. The authors concluded that US-guided interscalene block with a posterior approach was associated with a success high rate in placement of the interscalene catheter and a low rate of complications; however, the small sample size limited these researchers to draw definite conclusions; thus, a well-designed randomized controlled trial (RCT) is needed to confirm these preliminary findings.
Finlayson et al (2014) stated that US guidance offers an alternative to fluoroscopy for medial branch blocks of the upper cervical spine; however, it may be less accurate for blocks at the C5 and C6 levels. These researchers hypothesized that a modified technique using biplanar US imaging would facilitate level identification and provide greater accuracy for the lower cervical spine. A total of 40 patients with chronic neck pain underwent US-guided blocks of the C5 and C6 medial branches. For each level, 0.3-ml of a local anesthetic/iodinated contrast mixture was injected. Postero-lateral in-plane needle placement was performed in a transverse view, and the position of the needle tip was verified in the coronal plane using the C7 transverse process as a sonographic landmark. Contrast distribution, as assessed by a blinded observer on antero-posterior and lateral x-ray views, constituted the primary outcome. Secondary outcomes were performance time and pain relief 30 mins after the blocks; 100 % and 97.5 % of C5 and C6 levels, respectively, demonstrated appropriate contrast distribution. The C7 transverse process was readily identified in the coronal plane in all but 2 subjects. Performance time was 248.8 82.7 seconds; the mean percentage of relief provided by the blocks was 76.9 % 25.5 %. In 30 % of patients, a blood vessel was visualized crossing the C6 articular pillar and successfully avoided during needle insertion. The authors concluded that US guidance using a biplanar approach was a reliable imaging modality for C5 and C6 medial branch blocks.
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