Ebook Atlas of pain medicine procedures: Part 2

Part 2 book “Atlas of pain medicine procedures” has contents: Sphenopalatine ganglion block, occipital nerve blocks, transforaminal epidural steroid injection, sacroiliac joint injections, percutaneous sacroplasty, percutaneous facet fusion, provocative discogram, intradiscal electrothermal therapy,… and other contents.

MUSCULOSKELETAL

INJECTIONS

Corticosteroid injections are frequently used as conservative treatments in themanagement of various conditions, including osteoarthritis, tendonitis, bursitis,and impingement conditions Injectate mixtures typically comprise a localanesthetic and a corticosteroid (triamcinolone or methylprednisolone) Inaddition, patients at higher risk for developing nonsteroidal anti-inflammatorydrug (NSAID)–induced renal dysfunction or gastric and duodenal ulcers arecandidates for intra-articular steroid injections to avoid the potential systemiceffects that occur with oral anti-inflammatory medications However, thedetrimental effects of repeated steroid injections on soft tissue structures likearticular cartilage and tendons have not yet been determined.

The advantages of ultrasound-guided percutaneous interventional procedures

interventional procedures without contrast

Contraindications for injection include:

• Infection, systemic or localized

• Coagulopathy

• Pregnancy for fluoroscopically guided procedures

• Patient refusal

GENERAL IMAGE-GUIDED INTERVENTIONAL PROCEDURE PREOPERATIVE

CONSIDERATIONS

• Informed consent must be obtained and the risks and benefits of the procedureshould be properly explained to the patient or consenting individual

• The area must be examined for infection, skin lesions, and disease extent

• Proper exposure of the targeted area is necessary If clothing is restrictive, thepatient should be requested to change into a gown

• Ideally, the patient should be able to remain in the appropriate position

throughout the procedure

• Intravenous access is not necessary, but may be considered if the patient has ahistory of postprocedural vasovagal or hypotension responses

• The patient must be asked whether he or she takes any anticoagulant

medications (ie, aspirin, NSAIDs, etc) and, if applicable, when these

medications were stopped prior to the procedure If stopping the anticoagulantmedications increases cardiac risks, it is highly recommended to obtain

medical clearance from the patient’s cardiologist

• The physician performing the procedure should have access to fluoroscopy orultrasound

• For fluoroscopically guided procedures, female patients in reproductive ageshould be asked about potential pregnancy and may require a urine pregnancytest

• For fluoroscopically guided shoulder injections, the patient must be askedabout prior allergic reactions to contrast, shellfish, and iodine

BASIC ULTRASONOGRAPHY

Depending on the ultrasound probe and machine used, the shoulder, hip, andelbow regions may be examined with high-frequency (>10 MHz) linear arraytransducers If the patient has a large body habitus, a mid-range frequency

transducer (6-10 MHz) may need to be used to optimize image resolution andfacilitate proper examination An appropriate initial depth is 3 cm Also, thefrequency may be adjusted to visualize deeper structures (ie, glenoid labrum orlabrum of the hip) or shallower ones (ie, acromioclavicular joint [AC] joint).For ultrasound examination, tissues are described by their properties ofechogenicity, echotexture, degree of anisotropy, compressibility, and blood flow

on Doppler examination Blood vessels are not susceptible to anisotropy, butexhibit compressibility and presence of blood flow on Doppler examination Inthe shoulder, rotator cuff tendons display a high degree of anisotropy, which isparticularly pronounced at the musculotendinous junction

Tissue echogenicity is characterized as hyperechoic, hypoechoic, anechoic, orisoechoic Due to lack of echoes, anechoic structures have a black appearance.Isoechogenic tissues have similar brightness in comparison with surroundingtissues Hyperechoic structures (ie, normal tendons and ligaments) appearbrighter than adjacent tissues In contrast, hypoechoic structures appear darkerthan surrounding structures Both muscles and nerves have mixed echogenicitypatterns Blood vessels either appear to be hypoechoic or anechoic

Echotexture refers to the internal pattern of echoes and may vary based on theaxis used to assess the structure Both tendons and ligaments have “broom end”appearance when viewed in the transverse axis and a fibrillar pattern whenviewed in the longitudinal axis Nerves have a “honeycomb” appearance ontransverse imaging and a fascicular pattern on longitudinal imaging Muscleshave a “starry night” appearance on a transverse axis and a pennate or “featherlike” pattern on a longitudinal axis [7, 9]

BASIC POSTPROCEDURE FOLLOW-UP

The patient should be contacted via telephone on the day following theinterventional procedure to determine pain relief achieved from the localanesthetic and if there were any complications If the patient received acorticosteroid injection, the patient should be reminded that the anti-inflammatory property has a variable onset and may take up to 2 to 3 weeks toachieve symptomatic improvement The primary postinjection concern isinfection Therefore, the patient should monitor the injection site for erythema,warmth, increased swelling or systemic features of an infection, including feverand chills If the patient develops any complications, he or she should be advised

to contact the injectionist for further guidance For severe procedurally relatedadverse events, ie, fever >101°F, weakness, dyspnea, severe pain exacerbation,

etc, the patient should be recommended to seek immediate emergency medicalservices and to notify the injectionist All adverse reactions should be properlydocumented in the patient’s chart.

• Body habitus may influence the image-guided approach used In obese

patients, fluoroscopy may be used to improve visualization of deeper

anatomic structures that would be more difficult to visualize under ultrasoundguidance Conversely, in leaner patients, use of ultrasound guidance

eliminates radiation exposure and usually most anatomic structures can beeasily identified

• Success of image-guided procedures is dependent on numerous factors, whichinclude target localization through use of anatomic landmarks, patient

on soft tissue structures, ie, articular cartilage and tendons have not yet beendetermined

The large and round head of the humerus articulates with the relatively flatglenoid fossa of the scapula to form the glenohumeral (GH) joint The articularsurface is covered with hyaline cartilage Due to the relative incongruence ofthese surfaces, the glenohumeral joint is susceptible to degenerative changes andinstability The glenoid labrum is a fibrocarti-laginous layer, which envelops therim of the glenoid fossa With humeral dislocation and subluxation, the glenoidlabrum is exposed and has an increased risk for trauma The glenohumeral joint

is encompassed by a lax capsule that permits a wide range of motion of the joint.However, this laxity compromises joint stability The glenohumeral joint is lined

by a synovial membrane, which attaches to the articular cartilage and formssynovial tendon sheaths and bursae These synovial structures are particularlyvulnerable to inflammation The glenohumeral joint are innervated by the

The glenohumeral, transverse humeral, and cora-cohumeral ligaments are themajor ligaments of the shoulder joint The rotator cuff muscles that surround theshoulder joint are the supraspinatus, infraspinatus, teres minor, and subscapularismuscles The rotator cuff musculature and ligaments provide strength to thejoint However, due to misuse and overuse injuries, the rotator cuff muscles andtheir tendons are susceptible to trauma and inflammation

The key to successfully locating the glenohumeral joint from a posteriorapproach is identifying the following structures (Figure 50-1):

• Humeral head, which is the primary bony landmark for locating the GH joint

• Posterior labrum

• Infraspinatus muscle and tendon

• Tendon sheath of the bicipital tendon

Preoperative Considerations for GH Joint Injections

• For the ultrasound-guided approaches to the glenohumeral joint, the patientmust be able to sit upright for the procedure duration Preferably, the patientwill be able to sit upright on a stool with a rotating seat, but without wheels

• Alternatively, the patient may lie prone or supine on the examination table for,respectively, ultrasound-guided posterior and anterior approaches to the

glenohumeral joint However, assessment and procedural efficiency wouldlikely be sacrificed

• For most fluoroscopic interventional procedures, the patient should be able tomaintain his or her position for the length of the procedure For glenohumeraljoint injections utilizing the posterior approach, the patient must be able to lieprone For the anterior approach, the patient must be able to supine

Selection of Needles, Medication, and Equipment

Needles

• 22-gauge 3.5-in spinal needle or, for ultrasound-guided injections, a 22-gaugeechogenic needle, which will be connected to extension tubing

• 22-gauge 1.5-in needle to prepare the injectate medication

• 25-gauge 1.5-in needle for local anesthetic

• Transducer repositioning may be used to differentiate anisotropy from otherpathological conditions Great care should be taken to identify the other

primary landmark, the glenoid labrum

• The infraspinatus muscle and glenoid labrum are located superior to the

glenohumeral joint Whereas, the humeral head is located slightly inferolateral

to the glenohumeral joint Prior to needle entry site demarcation, the intendedtarget should be viewed in 2 orthogonal planes, which are the long and short

• Scan the area for the presence of a glenohumeral joint effusion to aspirate.The bicipital tendon sheath directly communicates with the glenohumeraljoint and may have fluid due to either an extension of the glenohumeral jointeffusion or a local tenosynovitis

• Orient the ultrasound probe in the long axis view of the glenohumeral jointwith the glenohumeral joint centered on the screen

Ultrasound-Guided Injection Techniques

Primarily, the anterior and posterior approaches have been described for needlepassage to gain access to the glenohumeral joint Due to the increased risk ofneurovascular injury to the brachial plexus with the anterior approach, weadvocate the posterior approach to the glenohumeral joint Contributing to thispreference, other rationales include heightened patient anxiety with direct needlevisualization and enhanced sensitivity of flexor surfaces compared with extensorsurfaces

• When inspecting the target area, the depth and gain may be adjusted to

optimize structure visualization [9]

• Scan the area for glenohumeral joint effusion to aspirate

• To relieve the pressure from teres minor and infraspinatus muscles against theposterior capsule or to increase the amount of fluid in the posterior recess ofthe glenohumeral joint and facilitate ultrasound-guided arthrocentesis, thetargeted upper limb may be externally rotated

• Orient the ultrasound probe in the long axis view of the glenohumeral jointwith the glenohumeral joint centered on the screen and the needle entry pointshould be clearly demarcated approximately 1 cm from the medial transduceredge (Figure 50-2)

long axis of the glenohumeral joint in the posterior view The needle entry point

• The skin overlying the demarcated needle entry site and the glenohumeraljoint should be prepared using aseptic technique

• 5 cc of 1% lidocaine is infiltrated into the skin and surrounding soft tissues toensure appropriate local analgesia using a 25-gauge 1.5-in needle

• Using the 22-gauge 1.5-in needle, the 1% lidocaine/triamcinolone injectatemixture is drawn up into a 6-cc syringe Depending on the patient’s bodyhabitus, the amount of 1% lidocaine will range from 2 to 4 cc and the amount

of triamcinolone will range from 40 to 80 mg The total injectate volumeshould range from 3 to 6 cc

• Invert and revert the injectate syringe several times to ensure adequate mixing

of the medications

gauge 3.5-in spinal needle and primed

• The injectate syringe should be attached to the connector tubing with the 22-• The 22-gauge 3.5-in spinal needle is inserted at the demarcated needle entrypoint and directed toward the glenohumeral joint In the long axis view, theneedle should appear as a hyperechoic and linear structure

• Throughout the entire procedure, the needle tip position should be visualized

To enhance need conspicuity, the needle should be maintained as parallel aspossible to the ultrasound probe and may be gently moved without

advancement, which is termed jiggling

• The needle should take an oblique course from medial to lateral, which

facilitates the gliding of the spinal needle above the humeral head and belowthe posterior labrum and the infraspinatus tendon

• As the needle is advanced, the needle path should be adjusted to access theposterior recess of the glenohumeral joint, which lies deep to the free margin

of the labrum and tangential to the curve of the humeral head

• With proper intra-articular needle positioning at the posterior recess of theglenohumeral joint, the needle tip should be located beneath the infraspinatustendon and glenoid labrum and adjacent to the hyaline cartilage of the

humeral head (Figure 50-3) The hyaline cartilage should appear hypoechoicagainst the hyperechoic humeral head [4]

tendon and glenoid and adjacent to the hyaline cartilage of the humeral head inthe glenohumeral joint The image on the right is an illustration of the ultrasoundimage

• The needle is aspirated to ensure that the needle is not located intravascularly

• With real-time ultrasound, the 1% lidocaine/triamcinolone mixture is slowlyinjected into the posterior recess of the glenohumeral joint

• Correct intra-articular positioning is confirmed by the dynamic and visualexpansion of the posterior recess with injectate mixture fluid and

needle would be visualized in the longitudinal view The 22-gauge spinal needlewould be inserted on the anterior surface between the coracoid process and thelesser tuberosity of the humerus Then, the needle would be aimed in theposterolateral direction toward the spine of the scapula and the medial border ofthe humeral head The needle tip should be positioned at the glenohumeral joint.Due to the increased risk of neurovascular injury, the area should be assessed forthe presence of nerves, which appear as honeycombed structures on transverseviews and fascicular patterns on longitudinal views Also, vascular structuresmay be evaluated with power Doppler imaging.

Fluoroscopic Views

• Start with an anterior-posterior (AP) image of the glenohumeral joint in view.Diligently mark the center or inferolateral quadrant of the humeral head as theneedle entry site to ensure a medial approach to access the glenohumeralhead

• A lateral view may be helpful to determine needle depth

Fluoroscopy-Guided Injection Techniques

As with ultrasound-guided glenohumeral joint injections, the anterior andposterior approaches have been described for needle passage to gain access tothe glenohumeral joint Again, due to increased potential complicationsincluding neurovascular injury, patient anxiety, and sensitivity of dorsal surfaces,

we advocate the posterior approach to the glenohumeral joint

Our Preferred Fluoro-Guided Technique: The Posterior Approach to the GH Joint

• The patient is positioned in the prone position with the arm on the side of thesymptomatic shoulder in either a neutral or slightly internally rotated position

• Starting in the AP view, the symptomatic shoulder should be elevated until theglenohumeral joint is visualized tangentially

• A radio-opaque marker is utilized to localize the center or the inferolateralquadrant of the humeral head and, consequently, the skin overlying this areashould be clearly demarcated

• The skin overlying the demarcated needle entry site and the glenohumeraljoint should be prepared in a typical sterile fashion

• 3 cc of contrast should be drawn up into a 3-cc syringe Then, the extensionconnector tubing with a 21-gauge 3.5-in spinal needle should be attached andprimed

• Using a 22-gauge 1.5-in needle, the 1% lidocaine/triamcinolone injectatemixture is drawn up into a 6-cc syringe Depending on the patient’s bodyhabitus, the amount of 1% lidocaine will range from 2 to 4 cc and the amount

of triamcinolone will range from 40 to 80 mg Including contrast, the totalinjectate volume should range from 5 to 8 cc The injectate syringe should beinverted and reverted several times to ensure adequate mixing of the

medications

• The 22-gauge 3.5-in spinal needle is inserted at the demarcated needle entrypoint and directed toward the cartilage of the humeral head and the

glenohumeral joint (Figure 50-4)

the 22-guage spinal needle directed towards the center of the humeral head andthe glenohumeral joint in the AP view Image on the right demonstrates theglenohumeral joint arthrogram with capsular distension achieved with injectediodinated contrast media

• With fluoroscopic guidance, needle is advanced vertically in the oblique view

to the cartilage of the humeral head

to a spinal needle via the connector

• The needle is aspirated to ensure that the needle is not located intravascularly

• With real-time live fluoroscopy, the iodinated contrast media is injected toobtain an arthrogram (Figure 50-4) If this isn’t observed, rotate the bevel ofthe needle 90 to 180 degrees, maintain contact with the humeral head andrepeat

• Careful examination should be made to ensure that the contrast spread

remains confined to the glenohumeral joint and that no intravascular uptakeoccurred

• Once proper needle placement has been confirmed, the 5-cc syringe

containing the iodinated contrast is removed and the 5-cc syringe containingthe injectate mixture is attached to the extension tubing

• Prior to pushing the injectate mixture, the needle should be aspirated again toensure that the needle is not located intravascularly

• The needle injectate should be pushed slowly

• With repeat fluoroscopic imaging, contrast spread throughout the GH jointand “washing out” of the contrast dye adjacent to the needle tip should bevisualized

be demarcated for the inferolateral border or center of the humeral head Aftersterile skin preparation and local anesthetic infiltration, a 22-gauge spinal needleshould be directed toward the glenohumeral joint and the inferolateral quadrant

or center of the humeral head under fluoroscopic guidance Consequently,iodinated contrast media is injected to confirm intra-articular needle position.With the anterior fluoroscopically guided anterior approach to the GH joint, it isparticularly important to aspirate prior to injection, inject iodinated contrastmedia, and obtain an arthrogram

Although image-guided interventional procedures of the glenohumeral jointoffers the advantages of real-time assessment, needle visualization, andguidance, various obstacles may be encountered In patients with a history ofprior shoulder surgeries, history of prior shoulder trauma, abnormal orcomplicated anatomy, and calcifications of the rotator cuff tendons and bicipitaltendon, all of these approaches may be challenging to the injectionist Withfluoroscopy, these procedures may be a particular concern for elderly patientsand those exposed to radiation in other body regions Patients should becautioned that corticosteroid injections to the GH joint may not completelyalleviate the pain and may be potentially ineffective Other potentialcomplications include:

is nonresponsive to more conservative measures (eg, oral medications such asNSAIDs, physical therapy, activity modifications and other lifestyle changes)

Image guidance has been recommended for many years for specific anatomicreasons related to the hip joint; including the deep location of the joint and theclose proximity of the anterior hip joint to the femoral artery, vein, and nerve(Figure 50-5) Therefore, image guidance can improve the accuracy of properneedle placement, and theoretically improve the safety profile of the injectionwith less risk of neurovascular injury [23].

bundle, including the femoral vein, femoral artery, and femoral nerve

A thorough understanding of intra-articular and extra-articular structures of thehip is absolutely necessary in the management of various hip conditions For thepurposes of intra-articular hip injections, a solid understanding of the surfaceanatomy of the hip and the bony anatomy of the proximal femur is mostimportant This will provide the clinician with the ability to locate the site ofentry and then allow for proper navigation of the needle into the joint space Inaddition, to avoid complications, the location of the femoral neurovascularbundle (femoral nerve, artery, and vein) must be understood since they are inclose proximity to the anterior hip joint

The key to successfully locating the hip joint from an anterior approach isidentifying the following structures (Figure 50-6):

attachments, including the iliofemoral ligament to intertrochanteric line of thefemur and the pubofemoral ligament to the lesser tuberosity of the femur On theright, a posterior view of the hip capsule and ischiofemoral ligament is

illustrated

• The acetabulum and its bony anatomy with labrum

Preoperative Considerations for Intra-Articular Hip Injections

• For the image-guided approaches to the intra-articular hip joint, the patientmust be able to lie supine for the procedure, which should take approximately

• Total injectate volume: 3 to 10 cc

Two primary techniques have been described for intra-articular hip injections:

1 Anterior approach (patient supine, hip in full extension and neutral rotation)

2 Go from medial to lateral in order to avoid hitting vital structures Lateralapproach (patient supine with the hip in full extension)

The anterior approach with fluoroscopic or ultrasound guidance, with thepatient supine and the hip in full extension with neutral rotation is commonlyutilized by clinicians The advantages includes the ability to palpate keylandmarks, easy positioning of tools for image guidance (C-arm or ultrasoundprobe) and most importantly avoidance of important intra-articular structures(eg, articular cartilage, acetabular labrum) because the target is either the middle

of the femoral neck on AP fluoroscopic image or the femoral head-neck junction

on ultrasound image The primary disadvantage includes the potential forneurovascular injury to the femoral nerve, artery, or vein; even injury to thelateral femoral cutaneous nerve is possible

The lateral approach, with the patient supine and the hip full extension, isanother approach commonly utilized by clinicians The primary advantage overthe anterior approach may be improved accuracy if image guidance isn’t utilized.The primary disadvantage includes injury to intra-articular structures, such asarticular cartilage and/or acetabular labrum

We advocate this approach for many reasons This technique allows forcomfortable positioning of the patient, confirmation of intra-articular placementvia ultrasound visualization of the needle tip and injectate filling pattern, and thepatient and operator is able to avoid ionizing radiation and the use of contrastagents which theoretically decrease the risk of allergic reactions In ourexperience, this approach is tolerated very well by the patient and is an accurate

• The patient is placed in a supine position with the hip in full extension andneutral rotation, slight internal rotation may be utilized to obtain a better

image of the femoral head-neck junction

• The ultrasound probe is then used to mark the location of the femoral nerveand vessels, then the probe is placed longitudinal to the femoral neck andpositioned to obtain a long axis view of the femoral head-neck junction

• The site of needle entry is marked with a pen on the skin just distal

(approximately 2-3 cm) to the probe

• The injection site is then prepared in a sterile fashion and a sterile cover isapplied to the ultrasound probe

• Up to 3 cc of 1% lidocaine is then infiltrated into the skin overlying the site ofthe injection to provide adequate skin analgesia using a 25-gauge 1.5-in

needle

• The injectate is drawn up using a 10-cc syringe which consists of 40 to 80 mg

of either triamcinolone or methylprednisolone and 2 to 4 cc of 1% lidocainewith the option to include additional 2 cc of 0.25% bupivacaine

• The 22-gauge 3.5-in spinal needle with this 10-cc syringe attached is thenadvanced at approximately a 45-degree angle, in the plane of the ultrasoundbeam to allow real time visualization of the needle tip and shaft

• The trajectory of the needle is adjusted to visualize the needle tip at the

femoral head neck junction Expect a slight increase in resistance as the

needle pierces the iliofemoral ligament and anterior capsule In our

experience, passing the needle through these tissues produces anterior hippain for the patient, and warning them prior to this may be helpful

• Once the needle tip contacts the femoral neck and can be visualized on

ultrasound, aspiration is performed and if negative for blood, a test injection

of 1 to 2 mL is used to confirm filling along the femoral head-neck junctionalong with anterior capsular distension (Figure 50-8) If this isn’t observed,rotate the bevel of the needle 90 to 180 degrees and maintain contact with thefemoral neck and repeat

with anterior capsular distension along the femoral head-neck junction Theimage on the right is an illustration of the ultrasound image

• The remainder of the solution is injected under real time visualization to

continue to confirm filling pattern along the femoral head-neck junction alongwith anterior capsular distension

• At the conclusion of the procedure, the needle is clearly withdrawn and steriledressings are used to apply pressure

• The area is cleansed with alcohol solution, dried, and a dressing is appliedover the site of the injection

Fluoroscopic Views

• Start with an AP view of the pelvis, center the femoral neck, and magnify the

image Mark the middle of the femoral neck (Figure 50-9).

posterior approach with the 22-guage spinal needle directed toward the femoralneck in the AP view Image on the top right demonstrates the injection iodinatedcontrast media into the right intra-articular hip joint The bottom image

demonstrates filling of a left hip capsule with contrast media

Fluoroscopically Guided Technique

• The patient is placed in a supine position on the table, with the hip in fullextension and neutral rotation

• An AP view of the pelvis is obtained, then femoral neck on the side of theinjection is centered

• The site of needle entry is marked with a pen on the skin at the center of thefemoral neck

• The injection site is then prepared in a sterile fashion

• Up to 3 cc of 1% lidocaine is then infiltrated into the skin overlying the site ofthe injection to provide adequate skin analgesia using the 25-gauge 1.5-inneedle

• The injectate is drawn up using a 10-cc syringe, which consists of 40 to 80 mg

of either triamcinolone or methylprednisolone and 2 to 4 cc of 1% lidocaine+/1 an additional 2 cc of 0.25% bupivacaine

• A 22-gauge 3.5-in spinal needle is directed down to the femoral neck underfluoroscopic guidance

• The trajectory is perpendicular to the femoral neck, in the beam of the

fluoroscope, attempting to obtain a hub view Expect a slight increase in

resistance as the needle pierces the iliofemoral ligament and anterior capsule

In our experience, passing the needle through these tissues produces anteriorhip pain for the patient, and warning them prior to this may be helpful

• Once the needle tip contacts the femoral neck and is visualized

fluoroscopically (still using an AP image), aspiration is performed and ifnegative, the extension tubing is connected to the spinal needle and contrastdye is injected to obtain an arthrogram (Figure 50-9) If this isn’t observed,rotate the bevel of the needle 90 to 180 degrees and maintain contact with thefemoral neck and repeat

• Once a good arthrogram is obtained, indicating a capsular filling pattern,syringes are switched and now the steroid and anesthetic is injected

• The area is cleansed with alcohol solution, dried, and a dressing is appliedover the site of the injection

EXTENSOR CARPI RADIALIS BREVIS MUSCLE AND THE COMMON EXTENSOR TENDON

Indications

Lateral epicondylitis, which is more commonly known as tennis elbow, is caused

by overuse injuries and chronic repetitive microtrauma to the forearm extensortendons The most common area of pain is located at the origin of the extensorcarpi radialis brevis tendon at the lateral epicondyle of the elbow Rarely, lateralepicondylitis pain may originate at a more distal site, which is where the ECRBoverlies the radial head With chronic overuse or misuse of the forearmextensors, the inflammatory response may spread to adjacent tissues With lateralepicondylitis, the abnormality consists primarily of degeneration, tendinosis, andpotential tendon tear The primary indication for extensor carpi radialis brevismuscle and common extensor tendon injection is lateral epicondylitis

Relevant Anatomy

The extensor carpi radialis brevis muscle extends the wrist with radial deviation.The origin of the extensor carpi radialis brevis muscle is located at the lateralepicondyle via the common extensor tendon, the radial collateral ligament, andthe antebrachial fascia The distal insertion is located at the base of the thirdmetacarpal The extensor carpi radialis brevis muscle is innervated by the deepbranch of the radial nerve Overuse and misuse injuries of the extensor carpiradialis brevis muscle are associated with the development of lateralepicondylitis

The common extensor tendon is located at the lateral elbow in the posteriorcompartment The lateral collateral ligament lies immediately deep to thecommon extensor tendon The radial head lies beneath the lateral collateralligament The deep fibers primarily contain contributions from the extensor carpiradialis brevis The superficial tendon receives fibers from the extensor carpiradialis brevis, extensor carpi ulnaris, extensor digitorum, and extensor digitminimi muscles

The key to successfully locating the ECRB muscle and common extensortendon is identifying the following structures (Figure 50-10):

Figure 50-10 Illustration of the lateral view of the elbow, highlighting the

location of the lateral epicondyle, common extensor tendon, and extensor carpiradialis brevis muscle to nearby anatomical structures

• Lateral epicondyle

• Radial head

lateral collateral ligament, which is immediately deep to the common extensortendon, should be identified (Figure 50-11).

The patient should lie supine with the arm adducted at the patient’s side and the

• Alternatively, the patient may be seated with the arm resting on the table andthe elbow flexed to 70 to 80 degrees In this position, the wrist should bepronated

• For the elbow and forearm, a high-frequency (17-5 MHz) ultrasound

transducer is an appropriate ultrasound probe to select and ultrasound gelshould be applied to the transducer

• Structures of interest in the lateral elbow include the common extensor

tendon, lateral epicondyle, the lateral collateral ligament complex, the radialhead, annular recess, capitulum, extensor carpi radialis, extensor digitorum,extensor carpi ulnaris, and extensor digiti minimi While performing the

sonographic examination, the wrist and finger extensor musculature may beidentified by having the patient move their wrist or finger(s) accordingly

• The ultrasound transducer is aligned in the long axis view of the attachmentsite of the extensor carpi radialis brevis muscle to the common extensor

tendon (Figure 50-11) To guide the examination, the lateral epicondyle,

lateral collateral ligament, and the radial head, which lie deep to the commonextensor tendon and ECRB muscle, should be identified and examined in alongitudinal plane To aid in ECRB identification, the patient may be asked toextend and radially deviate the wrist The common extensor tendon origin has

a uniform hyperechoic triangular configuration, which is seen traversing theradiocapitellar joint

• Scan the area for neurovascular structures, including the deep branch of theradial nerve The deep branch of the radial nerve should appear to have a

“honeycomb” appearance on a transverse view and a fasicular appearance onlongitudinal view

• When inspecting the target area, the depth and gain may be adjusted to

optimize structure visualization

• Once the ECRB muscle and common extensor tendon are identified, thesestructures should be evaluated in 2 orthogonal planes, which are

longitudinally (long axis) and transversely (short axis)

• The extensor carpi radialis brevis component of the common extensor tendon

is most commonly affected in lateral epicondylitis Sonographically,

tendinosis appears as thick and hypoechoic Also, there may be concomitantswelling of the involved tendon with possible hyperechoic calcification with

inflammation Superimposed partial-thickness tears appear as hypoechoic oranechoic clefts and incomplete fiber discontinuity with linear [33]

• Orient the ultrasound probe in the long axis view of the ECRB muscle and itsattachment to the common extensor tendon centered on the screen The needleentry point should be clearly demarcated approximately 1 cm from the

proximal transducer edge (Figure 50-11) With the long-axis approach, theneedle tip and shaft are positioned collinearly with the long axis of the

ultrasound probe This optimizes the needle visualization approach to thetarget

• Following sterile preparation of the skin overlying the posterolateral aspect ofthe joint, the lateral epicondyle is identified

• Using the 22-gauge 1.5-in needle, the 1% lidocaine/triamcinolone injectatemixture is drawn up into a 5-cc syringe

• The 22-gauge 1.5-in needle is inserted at the demarcated needle entry pointand directed toward the centered ECRB muscle attachment to the commonextensor tendon In the long axis view, the needle should appear as a

hyperechoic and linear structure Throughout the entire procedure, the needletip position should be visualized To enhance need conspicuity, the needleshould be maintained as parallel as possible to the ultrasound probe Also, theneedle may be gently moved without advancement, which is termed jiggling

• The needle should take a longitudinal course from proximal to distal

• With proper needle positioning at the ECRB muscle attachment to the

common extensor tendon, the needle tip should be located adjacent to thetarget area (Figure 50-12) Care must be taken to ensure that the commonextensor tendon is not directly injected to avoid tendon rupture

junction of the extensor carpi radialis brevis and the common extensor tendon.The image on the right is an illustration of the ultrasound image

• The needle is aspirated to ensure that the needle is not located intravascularly

• With real-time ultrasound, the 1% lidocaine/triamcinolone mixture is slowlyinjected into the area adjacent to the musculotendinous junction of the ECRBmuscle Correct positioning is confirmed by the dynamic and visual expansion

of the area with fluid and hydrodissection, which should appear relativelyhyperechoic on ultrasound