Clendenen, Steven R.

Abstract Introduction Greater trochanteric pain syndrome may often mimic pain generated from other sources. However, it is most commonly caused by gluteus medius and gluteus minimus tendinopathy or tear. The purpose of this technical report was to: 1) describe the ultrasound-guided fascial plane block technique targeting the superior gluteal nerve in the plane between gluteus medius/gluteus minimus to treat moderate-to-severe, chronic, refractory greater trochanteric pain syndrome; 2) anatomically correlate the procedure with cadaveric dissections demonstrating the structures being imaged and the tissues along the needle trajectory; 3) demonstrate the feasibility of the technique with serial dissection of one cadaveric specimen following injection with color dye. Technique description The ultrasound-guided fascial plane block targeting the superior gluteal nerve to treat moderate-to-severe, chronic, refractory greater trochanteric pain syndrome has been outlined with supporting ultrasound scans and anatomical dissections. The cadaveric dissections are correlated to the ultrasound scans of a healthy volunteer and provide visualization of the tissues in the needle trajectory. The feasibility study in a cadaveric specimen showed adequate stain of the superior gluteal nerve without spread to the piriformis muscle belly, the sciatic nerve, or the inferior gluteal nerve. Conclusions This ultrasound-guided fascial plane block is a feasible option for blocking the superior gluteal nerve without inadvertent involvement of the sciatic and inferior gluteal nerves. Further randomized controlled clinical trials are necessary to assess the clinical efficacy of the gluteus medius/gluteus minimus fascial plane block to treat moderate-to-severe, chronic, refractory greater trochanteric pain syndrome.

Piriformis syndrome is a pain syndrome originating in the buttock and is attributed to 6% – 8% of patients referred for the treatment of back and leg pain. The treatment for piriformis syndrome using fluoroscopy, computed tomography (CT), electromyography (EMG), and ultrasound (US) has become standard practice. The treatment of Piriformis Syndrome has evolved to include fluoroscopy and EMG with CT guidance. We present a case study of 5 successful piriformis injections using 3-D computer-assisted electromagnet needle tracking coupled with ultrasound. A 6-degree of freedom electromagnetic position tracker was attached to the ultrasound probe that allowed the system to detect the position and orientation of the probe in the magnetic field. The tracked ultrasound probe was used to find the posterior superior iliac spine. Subsequently, 3 points were captured to register the ultrasound image with the CT or magnetic resonance image scan. Moreover, after the registration was obtained, the navigation system visualized the tracked needle relative to the CT scan in real-time using 2 orthogonal multi-planar reconstructions centered at the tracked needle tip. Conversely, a recent study revealed that fluoroscopically guided injections had 30% accuracy compared to ultrasound guided injections, which tripled the accuracy percentage. This novel technique exhibited an accurate needle guidance injection precision of 98% while advancing to the piriformis muscle and avoiding the sciatic nerve. The mean (± SD) procedure time was 19.08 (± 4.9) minutes. This technique allows for electromagnetic instrument tip tracking with realtime 3-D guidance to the selected target. As with any new technique, a learning curve is expected; however, this technique could offer an alternative, minimizing radiation exposure. Key words: Piriformis, electromagnetic, ultrasound, fluoroscopy, injection, 3-D imaging.

Over the last two decades, the clinical applications of diagnostic and interventional ultrasound have expanded rapidly. When analyzing the chest wall and thoracic region, ultrasound has previously been shown to reliably identify chest wall pathologies like rib fracture and slipping rib syndrome, as well as having fundamentally changed perioperative management and patient outcomes after the emergence of point-of-care ultrasound. In addition, ultrasound guidance has recently become more popular for multiple blocks in the field of regional anesthesia and pain medicine. In this technical report, we systematize an ultrasound-guided protocol for counting ribs and thoracic levels for both posterior and anterior approaches, which does not require level confirmation by fluoroscopy. With this protocol, we hope to create an effective educational resource to support physicians from any specialty background as they engage in point-of-care ultrasound applications in the thoracic region.

The use of intraoperative epicardial ultrasound in order to aid physicians and surgeons in open cardiac surgery has been established for quite some time. Recently, the development of ultra-high frequency ultrasound (UFHUS) technology has resulted in high-resolution imaging capabilities previously unavailable for clinical use. This report is the first to describe the use of intraoperative UFHUS epicoronary scanning to assess coronary anatomy and visualize cardioplegia flow within native coronary vessels.

AbstractIntroductionRadiologically inserted gastrostomy (RIG) placement in patients with amyotrophic lateral sclerosis (ALS) carries risks related to periprocedural sedation and analgesia. To minimize these risks, we used a paravertebral block (PVB) technique for RIG placement.MethodsWe retrospectively reviewed patients with ALS undergoing RIG placement under PVB between 2013 and 2017.ResultsNinety‐nine patients with ALS underwent RIG placement under PVB. Median (range) age was 66 (28 to 86) years, ALS Functional Rating Scale—Revised score was 27 (6 to 45), and forced vital capacity was 47% (8%–79%) at time of RIG placement. Eighty‐five (85.9%) patients underwent RIG placement as outpatients, with a mean postanesthesia care unit stay of 2.3 hours. The readmission rate was 4% at both 1 and 30 days postprocedure.DiscussionPVB for RIG placement has a low rate of adverse events and provides effective periprocedural analgesia in patients with ALS, the majority of whom can be treated as outpatients.