Ebook Atlas of pain medicine procedures: Part 2

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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. SECTIONV MUSCULOSKELETAL INJECTIONS CHAPTER50 FluoroscopyandUltrasound-Guided JointInjections JenniferSolomon,ChristineRoque-Dang,andJamesWyss IMAGE-GUIDEDPERIPHERALJOINT INJECTIONINDICATIONS The most common clinical indication for an image-guided interventional procedureispaininthetargetedanatomiclocation,whichhaseitherfailedother conservativetreatmentsorasanadjunctivetreatment Theprimaryadvantageof image-guided interventional procedures over blind injections includes needle placement confirmation and the ability to view the targeted area and relevant anatomy Corticosteroidinjectionsarefrequentlyusedasconservativetreatmentsinthe management of various conditions, including osteoarthritis, tendonitis, bursitis, and impingement conditions Injectate mixtures typically comprise a local anesthetic and a corticosteroid (triamcinolone or methylprednisolone) In addition, patients at higher risk for developing nonsteroidal anti-inflammatory drug (NSAID)–induced renal dysfunction or gastric and duodenal ulcers are candidates for intra-articular steroid injections to avoid the potential systemic effects that occur with oral anti-inflammatory medications However, the detrimental effects of repeated steroid injections on soft tissue structures like articularcartilageandtendonshavenotyetbeendetermined The advantages of ultrasound-guided percutaneous interventional procedures areasfollows: • Real-timeassessment • Guidance,andcontinuousneedlevisualization • Lackofradiationexposure • Technologicalportability • Relativelylowcost • Improvedaccessibility Fluoroscopic guidance also allows real-time needle visualization and the acquisitionofimagingframesthroughouttheinjectioncourse Thevisualization occurs at different C-arm angles The primary disadvantage of fluoroscopy is radiationexposuretoboththepatientandphysician BASICCONCERNSANDCONTRAINDICATIONS With therapeutic interventions, the benefits and risks of the procedure must be considered Generally,peripheraljointcorticosteroidinjectionsareconsideredto be safe and conservative treatments However, each patient’s risk factors for complicationsmustbecarefullyconsideredpriortoundergoingtheprocedure Somebasicconcernsforinjectionarefollowing: • Patientswithprimaryormetastatictumorsinthetargetarea • Immunocompromisedpatients,whoareatincreasedriskforinfection • Patientswiththrombocytopenia • Patientswhomaybeunabletotoleratepositioning • Patientswithallodyniaorcomplexregionalpainsyndrome(CRPS),whowill beunabletotoleratetheprocedure • Patientsonanticoagulantmedications,whohavebeenunabletostopthese medicationsatanappropriatetimeinterval • Forfluoroscopicallyguidedprocedureswiththeuseofcontrastdye,patients withallergiestocontrast,shellfish,oriodinemaybeconsideredfor interventionalprocedureswithoutcontrast Contraindicationsforinjectioninclude: • Infection,systemicorlocalized • Coagulopathy • Distortedorcomplicatedanatomy • Pregnancyforfluoroscopicallyguidedprocedures • Patientrefusal GENERALIMAGE-GUIDEDINTERVENTIONAL PROCEDUREPREOPERATIVE CONSIDERATIONS • Informedconsentmustbeobtainedandtherisksandbenefitsoftheprocedure shouldbeproperlyexplainedtothepatientorconsentingindividual • Theareamustbeexaminedforinfection,skinlesions,anddiseaseextent • Properexposureofthetargetedareaisnecessary Ifclothingisrestrictive,the patientshouldberequestedtochangeintoagown • Ideally,thepatientshouldbeabletoremainintheappropriateposition throughouttheprocedure • Intravenousaccessisnotnecessary,butmaybeconsideredifthepatienthasa historyofpostproceduralvasovagalorhypotensionresponses • Thepatientmustbeaskedwhetherheorshetakesanyanticoagulant medications(ie,aspirin,NSAIDs,etc)and,ifapplicable,whenthese medicationswerestoppedpriortotheprocedure Ifstoppingtheanticoagulant medicationsincreasescardiacrisks,itishighlyrecommendedtoobtain medicalclearancefromthepatient’scardiologist • Thephysicianperformingtheprocedureshouldhaveaccesstofluoroscopyor ultrasound • Forfluoroscopicallyguidedprocedures,femalepatientsinreproductiveage shouldbeaskedaboutpotentialpregnancyandmayrequireaurinepregnancy test • Forfluoroscopicallyguidedshoulderinjections,thepatientmustbeasked aboutpriorallergicreactionstocontrast,shellfish,andiodine BASICULTRASONOGRAPHY Depending on the ultrasound probe and machine used, the shoulder, hip, and elbow regions may be examined with high-frequency (>10 MHz) linear array transducers 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 and facilitate proper examination An appropriate initial depth is cm Also, the frequencymaybeadjustedtovisualizedeeperstructures(ie,glenoidlabrumor labrumofthehip)orshallowerones(ie,acromioclavicularjoint[AC]joint) For ultrasound examination, tissues are described by their properties of echogenicity,echotexture,degreeofanisotropy,compressibility,andbloodflow on Doppler examination Blood vessels are not susceptible to anisotropy, but exhibitcompressibilityandpresenceofbloodflowonDopplerexamination In theshoulder,rotatorcufftendonsdisplayahighdegreeofanisotropy,whichis particularlypronouncedatthemusculotendinousjunction Tissueechogenicityischaracterizedashyperechoic,hypoechoic,anechoic,or isoechoic Duetolack of echoes, anechoicstructureshaveablackappearance Isoechogenic tissues have similar brightness in comparison with surrounding tissues Hyperechoic structures (ie, normal tendons and ligaments) appear brighter than adjacent tissues In contrast, hypoechoic structures appear darker thansurroundingstructures Bothmusclesandnerveshavemixedechogenicity patterns Bloodvesselseitherappeartobehypoechoicoranechoic Echotexturereferstotheinternalpatternofechoesandmayvarybasedonthe axisusedtoassessthestructure Bothtendonsandligamentshave“broomend” appearance when viewed in the transverse axis and a fibrillar pattern when viewed in the longitudinal axis Nerves have a “honeycomb” appearance on transverse imaging and a fascicular pattern on longitudinal imaging Muscles havea“starrynight”appearanceonatransverseaxisandapennateor“feather like”patternonalongitudinalaxis[7,9] BASICPOSTPROCEDUREFOLLOW-UP The patient should be contacted via telephone on the day following the interventional procedure to determine pain relief achieved from the local anesthetic and if there were any complications If the patient received a corticosteroid injection, the patient should be reminded that the antiinflammatorypropertyhasavariableonsetandmaytakeupto2to3weeksto achieve symptomatic improvement The primary postinjection concern is infection Therefore,thepatientshouldmonitortheinjectionsiteforerythema, warmth,increasedswellingorsystemicfeaturesofaninfection,includingfever andchills Ifthepatientdevelopsanycomplications,heorsheshouldbeadvised to contact the injectionist for further guidance For severe procedurally related adverseevents,ie,fever>101°F,weakness,dyspnea,severepainexacerbation, etc, the patient should be recommended to seek immediate emergency medical servicesandtonotifytheinjectionist Alladversereactionsshouldbeproperly documentedinthepatient’schart ClinicalPearls • Image-guidedinterventionalproceduresarepowerfuldiagnosticand therapeutictoolstoaidinthediagnosisandmanagementofvarious musculoskeletaldisorders • Thedurationofbenefitisvariable,butsteroidinjectionstendtoproduce substantialshort-termreliefofsymptoms(eg,pain,swelling)withvariable durationofrelief(1-3months) • Bodyhabitusmayinfluencetheimage-guidedapproachused Inobese patients,fluoroscopymaybeusedtoimprovevisualizationofdeeper anatomicstructuresthatwouldbemoredifficulttovisualizeunderultrasound guidance Conversely,inleanerpatients,useofultrasoundguidance eliminatesradiationexposureandusuallymostanatomicstructurescanbe easilyidentified • Successofimage-guidedproceduresisdependentonnumerousfactors,which includetargetlocalizationthroughuseofanatomiclandmarks,patient cooperation,andtheexperienceofthephysicianwithimage-guided interventions • Image-guidedinjectionsarewelltoleratedandhaveanexcellentsafety profile • Theseprocedurescanberepeatedtomanagerecurrentsymptoms,butpatients shouldbecautionedthatthedetrimentaleffectsofrepeatedsteroidinjections onsofttissuestructures,ie,articularcartilageandtendonshavenotyetbeen determined THEGLENOHUMERAL(GH)JOINTOFTHE SHOULDER Indications The glenohumeral joint of the shoulder is susceptible to premature arthritic development from various conditions that may damage the joint cartilage Of these conditions, glenohumeral osteoarthritis is the most common form of arthritisthatresultsinshoulderjointpain Theindicationsinclude: • Glenohumeralosteoarthritis • Rotatorcuffarthropathy • Post-traumaticosteoarthritis • Acuteandchronicadhesivecapsulitis • Rheumatoidarthritis • Collagenvasculardiseases Oftentimes,patientspresentwithgeneralizedshoulderandupperarmpainand it may be difficult to localize the primary pain generator intra-articular glenohumeral joint injections are excellent diagnostic tools, which can aid in elucidating the primary pain generator Therapeutically, intra-articular glenohumeral joint corticosteroid injections are relatively safe interventional procedures These procedures may be performed if shoulder pain remains refractory to more conservative measures such as occupational therapy, pharmacologic intervention, and activity modification Accuracy of blind glenohumeraljointinjectionshasbeenfoundtobeextremelyvariable,ranging from 25% to 95% accuracy Image-guided intra-articular glenohumeral joint injection enables dynamic real-time visualization of the process, improves needle visualization, augments target accuracy, reduces damage to surrounding structures, ie, glenoid labrum, and decreases the risk of neurovascular injury, particularlytothebrachialplexus RelevantAnatomy The large and round head of the humerus articulates with the relatively flat glenoidfossaofthescapulatoformtheglenohumeral(GH)joint Thearticular surface is covered with hyaline cartilage Due to the relative incongruence of thesesurfaces,theglenohumeraljointissusceptibletodegenerativechangesand instability Theglenoidlabrumisafibrocarti-laginouslayer,whichenvelopsthe rimoftheglenoidfossa Withhumeraldislocationandsubluxation,theglenoid labrumisexposedandhasanincreasedriskfortrauma Theglenohumeraljoint isencompassedbyalaxcapsulethatpermitsawiderangeofmotionofthejoint However,thislaxitycompromisesjointstability Theglenohumeraljointislined by a synovial membrane, which attaches to the articular cartilage and forms synovial tendon sheaths and bursae These synovial structures are particularly vulnerable to inflammation The glenohumeral joint are innervated by the axillaryandsuprascapularnerves Theglenohumeral,transversehumeral,andcora-cohumeralligamentsarethe majorligamentsoftheshoulderjoint Therotatorcuffmusclesthatsurroundthe shoulderjointarethesupraspinatus,infraspinatus,teresminor,andsubscapularis muscles The rotator cuff musculature and ligaments provide strength to the joint However,duetomisuseandoveruseinjuries,therotatorcuffmusclesand theirtendonsaresusceptibletotraumaandinflammation The key to successfully locating the glenohumeral joint from a posterior approachisidentifyingthefollowingstructures(Figure50-1): • Humeralhead,whichistheprimarybonylandmarkforlocatingtheGHjoint • Posteriorlabrum • Infraspinatusmuscleandtendon • Tendonsheathofthebicipitaltendon Figure50-1 Illustrationsoftheposterior(left)andanterior(right)viewsofthe rightglenohumeraljointwithrelationtonearbyanatomicalstructures From an anterior approach, the following structures should be identified (Figure50-1): • Lessertubercleofthehumerus • Coracoidprocess • Tendonsheathofthebicipitaltendon Other relevant anatomy that should be taken into consideration while performingtheseinjectionsis: • Brachialplexus,whichisatincreasedriskforneurovascularinjuryfromthe anteriorapproach • Calcificationsoftherotatorcuffmuscleandbicipitaltendons PreoperativeConsiderationsforGHJointInjections • Fortheultrasound-guidedapproachestotheglenohumeraljoint,thepatient mustbeabletosituprightfortheprocedureduration Preferably,thepatient willbeabletosituprightonastoolwitharotatingseat,butwithoutwheels • Alternatively,thepatientmaylieproneorsupineontheexaminationtablefor, respectively,ultrasound-guidedposteriorandanteriorapproachestothe glenohumeraljoint However,assessmentandproceduralefficiencywould likelybesacrificed • Formostfluoroscopicinterventionalprocedures,thepatientshouldbeableto maintainhisorherpositionforthelengthoftheprocedure Forglenohumeral jointinjectionsutilizingtheposteriorapproach,thepatientmustbeabletolie prone Fortheanteriorapproach,thepatientmustbeabletosupine SelectionofNeedles,Medication,andEquipment Needles • 22-gauge3.5-inspinalneedleor,forultrasound-guidedinjections,a22-gauge echogenicneedle,whichwillbeconnectedtoextensiontubing • 22-gauge1.5-inneedletopreparetheinjectatemedication • 25-gauge1.5-inneedleforlocalanesthetic Stellateganglionblock anatomyin carotidandvertebralarteriesin,341–342 cervicalsympatheticchainand,lyingoverlonguscollimuscle,336,338f cervicothoracic(stellate)ganglion,336,337f anteriorparatracheal(classic)approach,340,341f contraindicationsto,336 equipmentfor,338 fluoroscopicviewsinanteroposterior approach,337,339f obliqueapproach,337,339f indicationsfor,336 medicationsfor,338 needlesandsupplies,337–338 obliqueapproachto anteroposteriorviewofinjectate,340,340f APviewin,339,339f fluoroscopicobliqueviewin,339,340f injectionofanestheticorsteroid,340,340f injectionofcontrastin,339–340,340f needleplacementin,339 patientpreparationfor,338–339 patientpositioningfor,337 posteriorapproach,342 postprocedureconsiderations,341 preoperativeconsiderations patienteducationinpostproceduraleffects,336–337 previousneckorthyroidsurgery,336 Subarachnoidneurolysis agentsusedfor,680–681,681t withalcohol,intraoperativesteps,682–683 withphenol,intraoperativesteps,683 Sufentanil non-FDA-approvedforintrathecaluse,566 Superiorhypogastricplexusneurolysis anatomyin,676 complicationsof,677,679 contraindicationsto,676 described,675–676 fluoroscopicviews,676 anterior-posterior,675f lateral,675f intraoperativestepsin advancementofneedle,677 injectionofcontrast,677 injectionofphenolinglycerin,677 patientpositioning,677 scoutfilmoflumbarspine,677 patientpositionfor,676 selectionofneedles,medications,andequipmentfor,676 Supraclavicularnerveblock anatomyin brachialplexus,495–496 relationshipofbrachialplexustrunkstosubclavianartery,495f relationshipofsubclavianarteryandveinin,496,496f indicationsfor,495 nervestimulatortechnique landmarksfor,496,497f ultrasoundtechnique anatomyforsupraclavicularbrachialplexusblock,498f probein,497 probepositionin,497,498f setupofprobeandneedlein,499,499f Supraorbitalnerve peripheralnervestimulationtrial,641,641f,642f permanentimplant,642–643 Supraorbitalnervecryoneuroablation anatomyin,695 supratrochlearnerve,695,695f indicationsfor,694–695 patientpositionfor,695 technique,696f closed,695 openoperative,695 Supraorbitalneuralgia,694–695 Suprascapularnerveblock anatomyin importanttoperformanceofblock,538 motornervestosupraspinatusandinfraspinatusmuscle,537 sensorynervebranches,537 suprascapularartery,538 suprascapularnerveinrelationtomusclesandvasculature,538f suprascapularnotch,537–538 supraspinousfossa,537 classicapproach(Wertheim),539–540,539f,540f Dangoisse-modifiedmethod,540,540f fluoroscopicimageof,540f equipmentfor inblindapproach,538 influoroscopicprocedure,539 inultrasoundblock,538 fluoroscopy-guided,541,541f historicalperspectiveon,537 indicationsfor,537 medicationsfor,539 pneumothoraxriskwith,540,541 preoperativeconsiderations,538 suprascapularnervedescribed,537 ultrasound-guided,541 Supraspinous/interspinousligaments anatomyof,477–478,478f injectionof,482–483,483f Syringes,specialized,40,40f T Tendinopathy/tendonosis tendoninjectionfor,476,477f Tendoninjection(s) anatomyin bicipitaltendonitis/tendonosis,476,477f distalpiriformis,478–479,478f iliolumbarligament,479,479f lateralepicondylosis/epidondylitis,477,478f levatorscapula,477,477f supraspinous/interspinousligaments,477–478,478f ofbicipitaltendon,480,480f,481f complicationsof,485 contraindicationsto,476 ofdistalpiriformis,484–485,484f equipmentandmedications,480 fluoroscopic/ultrasoundviews,479–480 ofiliolumbarligament,483,484f indicationsfor,476 intraoperativestepsin,480–485 oflateralepicondyle,481–482,482f oflevatorscapula,481,481f postoperativeconsiderations,485 preoperativeconsiderations,479 ofsupraspinous/interspinousligament,482–483,483f Tenniselbow extensorcarpiradialisbrevismuscleandcommonextensortendoninjections for,415 Tetracainemetabolismanduniqueproperties,61–62 Thermalrhizotomy,fortrigeminalganglionblock,126,128 Thoracicdiscanatomy,234 Thoracicdiscogram SeealsoProvocativediscogram injectionofcontrastin,237 needleadvancementtomiddleofdiscunderfluoroscopicguidance,237 patientpositionin,237 ThoracicDRGblock fluoroscopicviews oblique,197,197f patientpositionfor,197,197f preferredtechnique digitalsubtractionfluoroscopyin,197 needlepositionin,197,197f pulsed-doselow-frequencyin,198 sensoryandmotorstimulationin,198 Thoracic(T2-3)ganglionblock anatomyand autonomicnervoussystem,344 radiologiclandmarksforobliquetechnique,345,345f sympathetictrunkand,344f thoracicganglia,344–345 basicconcerns riskofpneumothorax,345,347 complicationsof pneumothorax,349 equipmentfor,345 indicationsfor,343t painsyndromes,343 vascularinsufficiency,344 intercostalobliqueapproachtosympatheticganglia APfluoroscopicviewand,347,348f “gunsight”viewofneedleandtargetin,347,348f lasersightingdeviceand,347 needleinsertionin,347,348f needlepositionin,347,349f patientpositioningfor,347 ribsandtheirarticulationsin,346f,347 medicationsfor,345 neurolyticprocedure phenolin,349 radiofrequencyablationin,349 obliquetechnique,345,345f advantagesof,345 paraspinousapproach anatomy,346f needleinsertionin,346 radiofrequencylesioningin,346–347 postprocedurefollow-up,349 Thoracicinterlaminarepiduralsteroidinjections SeealsoInterlaminarepidural steroidinjection paramedianapproach,158,159f positioningfor,158 Thoracicoutletsyndrome anteriorscalenemuscleinjectionwithlocalanestheticfor,443 scalenemuscleinjectionsfor,442 Thoracolumbarspineinterventions,vascularcomplicationsin,319–320 Ticlid(ticlopidine),anticoagulationguidelinesfor,82 Ticlopidine(Ticlid),anticoagulationguidelinesfor,82 Touhyneedle,37,38f withflexibleintroducercannula,38,38f Transducers inportableultrasoundmachine frequencyrangesin,20–21 typesof,20,21f–22f Transforaminalepiduralsteroidinjection(TFESI) advantagesof,162 cervicalspine,327–331 safeperformanceof,Kambinvs “safetriangle”approachfor,324–325,324f, 325f techniqueinKambintriangle finalneedleposition,325,326f,327f injectionofdyefollowing,327f obliqueapproach,325,325f skinentrysite,325,325f thoracolumbar,319 vascularcomplicationsof,324–325,324f,325f Triamcinoloneacetonide,depot adrenalsuppressionwith,45t Trigeminalganglion anatomyof externallandmarks,123 mandibulardivision,122 maxillarydivision,122 Meckelcavityand,122 ophthalmicdivision,122 radiographic,122 Trigeminalganglionnerveblock chemicalrhizotomy,126 complicationsof,127 contraindicationsto,123 equipmentfor,123–124 fluoroscopicviewsof AP,123,123f lateral,123,124f oblique,123,124f,125 submental,123,124f indicationsfor,122 medicationsfor,124 preoperativeconsiderationsin anticoagulation,123 conscioussedation,123 pulsedradiofrequency,126–127 technique advanceneedlethroughforamenovale,125,125f aspirate,125–126 injectcontrastandlocalanesthetic,125 insertblockneedle,125,125f obliqueimageintensifier,125,125f patientpreparation,124 thermalrhizotomy lesioningin,126 lesioningofophthalmicdivision,128 radiofrequencyneedlein,126 Trigeminalnervedivisionblocks mandibularnerveblock complicationsof,128 maxillarynerveblock,127 intraorbital,127 maxillary,128 radiofrequency,128 ophthalmic forsupraorbitalnerve,127 forsupratrochlearnerve,127 Trigeminalneuralgia ballooncompressionfor,661 characterizationof,656 diagnosisof,656 glycerolinfusionfor,661 medicaltherapyfor,657 problemswith,657 microvasculardecompressionfor,657–658 complicationsof,658–659 procedurein,658,659f ofsuperiorcerebellarartery,658,658f motorcortexstimulationfor,662 neuromodulationtherapiesfor,661–662 versusotherfacialpaindisorders,656 pathophysiologyof,656–657 percutaneouslesioningatgasserianganglionfor,659 anatomyin,660f biplanefluoroscopyin,659,660f radiofrequencythermocoagulationlesioning,659 recurrenceratewith,660 stepsin,659–660 peripheralfacialstimulation advantagesof,662 localizationofelectrodefor,662,663f nonapproved,662 usesof,663 stereotacticradiosurgeryfor,661 surgicaltherapyfor,657 Trigeminalneurolysis complicationsof,670 CT-guided advancingneedletipinrelationshiptoforamenovale,668f,669f,670 contrastinMeckelcave,669f,670 injectionofabsolutealcohol,670 needleplacementin,668f needletipenteringforamenovale,668f patientpositionin,668f,670 postoperativeconsiderations,670 Triggerpointinjections,434 basicconcerns,434 complicationsof,429 contraindicationsto,434 defined,428,434 equipmentandmedicationsfor,435 equipmentandsuppliesfor,428–429,429f exampleof,430f goalof,428 indicationsfor,428 marktriggerpointswithreferencezonemarked,429,430f needleinsertionin,429,430f patientpositioningfor,429,429f physicalexaminationfor,428 postinjectioninstructions,429 preoperativeconsiderationsin,435 technique,435 triggerpointsand,434 U Ultrasound advantagesof,20t basicphysicsof acousticimpedance,19 attenuation,19 commonproceduresperformedwith,20t principlesof inmedicalimaging,20 scatteringin,20 specularreflectionin,20 transducersin,20 Ultrasoundimaging advancesin echogenicneedlescoatedwithnanoparticles,28,28f needleoptimizationtechnology,29,29f three-dimensional,28,28f artifactsin anisotropy,28–29 comettail,27,27f enhancement,26,27f mirrorimages,26f,27 reverberation,27,27f ergonomicsduring,27–28 limitationsof,26,26f recommendationsfor,29 Ultrasoundportablemachine imageoptimizationduringscanning,26t imageoptimizationfunctions depth,22,23f focus,22 gain,22,23f tissueharmonicimaging,23–24 zoom,23 transducersin frequencyrangesin,20–21 typesof,20,21f–22f troubleshootingifneedlenotvisualized,25–26 Ultrasoundsonopathology,26,26f Upperextremity electromyographyof,88f,92,94f V Vascularcomplicationsofspinalinterventions anatomyand arteryofAdamkiewicz,321,322f,323–324 radiculomedullaryarteries,321,321f,322–323,322f “safetriangle“in,321f incervicalspine,319–320,327–329 embolismtheoriesofvascularinjury,330 othermechanismsof,330 intravascularuptake techniquemodificationstodetect,330–331,332f intravascularuptakeprevention epimedblunt-tippedneedle,332f interlaminarapproachwithsteerablecatheter,332,332f techniquemodificationsfor,330–332,333 useofnonparticulatesteroid,331–332 radiculomedullaryarteries,322,322f inlumbarspine,322 nervoussystembranches,323 spinalcanalbranches,323 inthoracicspine,322 spinalcordinjury fromlumbartransforaminalprocedures,320,321f fromvascularischemia,320–321 sympatheticblocksorneurolyticprocedures insympatheticblocksorneurolyticprocedures,325–326,327f obliqueapproach,326 transdiscalapproach,326,327f inthoracolumbarspine,319–320 indicationsforinterventionalproceduresin,320 proceduresandprocedure-relatedcomplications,320 intransforaminalepiduralsteroidinjections,324–325,324f,325f vascularinjury,theoriesof,321 vascularsupplyofspinalcord arteryofAdamkiewicz,321,322f radiculomedullaryarteries,321f,322,433f vascularuptakeofdyeandsteroid,protectivestrategiesagainst,324 Vertebralaugmentation SeealsoKyphoplasty;Vertebroplasty anatomyin,299 contraindicationsto,299 historicalperspectiveon,298 indicationsfor,299 kyphoplastyfor,306f,307–308 forosteoporoticvertebralcompressionfracture,298–299 goalof,299 vertebroplastyfor,299–306 Vertebralcompressionfracture,298,299 Vertebroplasty SeealsoKyphoplasty;Vertebralaugmentation complicationsof aorticembolism,309,311f cementembolizationintolungsandcerebralcirculation,309 cementextravasationin,308,308f,309 cementextrusion,308 intraduralleakage,310f nerverootsevered,309,311f pediclefracture,309,311f posteriorleakage,309,310f transientradiculopathy,308 needleplacementin APandlateralviewsforcorrect,312,312f guidefor,312,312f needletrajectories,unsafe,312,313f parapedicularapproach needleinsertionin,306,306f inthoracicspineaboveT8,306 preoperativeconsiderationsin C-armfluoroscopy,301f CTguidance,299 fluoroscopy,301,302f imagingin,300 real-timeimagingin,299,300 spinalneedleentryintovertebralbody,300f transpedicularapproach dangerzonein,305,305f injectionofcement,303,305,305f safedepositofcementin,303 “Scottiedog”viewofvertebralbodyin,301,303f unipedicularversusbipedicularneedlein,303,305f viewsofvertebroplastyneedleinpedicle,301–302,303f Viscosupplement FDAapprovalof,419 intra-articularinjectioninknee,423f,424–425,424f complicationsof,425 injectionsitepreparationfor,423f,424 markinganatomicallandmarks,423f,424 needledirectedtoenterjointcapsule,424–425,424f needlesandequipmentfor,424 patellatiltfor,424f,425 positioningfor,422–423,423f postprocedurefollow-up,425 manufacturerandbrandinformation,419t W Warfarin(Coumadin),anticoagulationguidelinesfor,79–80 X X-rays fluoroscopicimageanalogoustophotographicnegative,3,3f physicsof,2–3 plainradiography,chest,analogoustophotograph,4f Z Ziconotide,intrathecalforneuropathicpain,565 Ziconotidetrialing bolustrials,singleormultipleinjections,572 continuousintrathecalinfusion,570–571 equipmentforneedleplacement,566,567f procedurefor,571–572 psychosisassideeffectof,570–571 single-shottrialprocedure,572–583 limiteddurationtrials,571 single-shottrialprocedure,572 post-trialconsiderations,572–573 ... Theinjectateisdrawnupusinga10-ccsyringewhichconsists of 40to80mg of eithertriamcinoloneormethylprednisoloneand 2 to4cc of 1%lidocaine withtheoptiontoincludeadditional 2 cc of 0 .25 %bupivacaine • The 22 -gauge3.5-inspinalneedlewiththis10-ccsyringeattachedisthen... attachments,includingtheiliofemoralligamenttointertrochantericline of the femurandthepubofemoralligamenttothelessertuberosity of thefemur Onthe right,aposteriorview of thehipcapsuleandischiofemoralligamentis... the suspected source of pain For therapeutic purposes,intra-articularsteroidinjectionsareoftenconsideredasthenextstep of treatmentforintra-articularsources of hip pain (eg,OAorlabralpathology)that
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