Hurdle, Mark Friedrich B.

Objectives Ultrasound‐guided percutaneous needle fenestration (UPNF) and percutaneous needle tenotomy (UPNT) are minimally invasive procedures commonly used to treat chronic tendinopathies. However, these techniques can be painful, potentially limiting patient tolerance, satisfaction, and procedural feasibility. Although local anesthetics (LAs) provide analgesia, their potential inhibitory effects on tenocyte activity and the efficacy of orthobiologics raise concerns regarding their impact on tendon healing. The objectives of this study is to propose a practical, anatomy‐based approach for the use of ultrasound‐guided peripheral nerve blocks (USG‐PNBs) as a strategy to reduce pain and improve patient comfort during UPNF and UPNT, with or without orthobiologic adjuncts. Methods We reviewed commonly affected anatomical sites in chronic tendinopathies and identified corresponding peripheral nerve targets that can be reliably and safely blocked under ultrasound guidance. For each condition, we outline appropriate nerve block techniques, anatomical landmarks, and recommended patient positioning to optimize procedural analgesia. Results A set of targeted USG‐PNBs was defined for commonly treated tendinopathies, including supraspinatus tendinopathy, lateral and medial epicondylitis, gluteus medius and/or minimus tendinopathy, patellar tendinopathy, Achilles tendinopathy, and plantar fasciopathy. Conclusion Ultrasound‐guided peripheral nerve blocks represent a practical and effective approach to manage pain during percutaneous procedures for chronic tendinopathies. By reducing procedural discomfort and avoiding the potential drawbacks of peritendinous LAs, these techniques may enhance patient tolerance, procedural success, and overall clinical outcomes.

Background and Objectives: Peripheral nerve stimulation (PNS) may provide analgesia for neuropathic pain syndromes in that nerve distribution. PNS electrode placement using ultrasound (US) guidance for upper extremity pain syndromes has not been reported. Existing anchoring technology may allow permanent implantation without significant migration. Methods: Three cadaver midhumeral fresh frozen upper extremity specimens were studied. US scanning was performed, targeting electrode placement at the radial, ulnar, and median nerves. Leads were anchored in the superficial fascia. The targeted nerves were exposed by careful dissection. Visual inspection for gross nerve damage, and electrode proximity to the nerve was performed. After confirmation of adequate lead placement, 2 extremities were sutured and placed in a continuous passive motion (CPM) machine for 21 hours to simulate activity. Each electrode was assessed for migration. Results: Acceptable locations for US-guided electrode placement were: radial nerve approximately 10-14 cm superior to the lateral epicondyle; median nerve approximately 6 cm below the antecubital fossa; and ulnar nerve approximately 9 to 13 cm above the medial epicondyle. One electrode was placed at each site without difficulty. After careful exposure, visual inspection showed no gross nerve damage. Each electrode had at least 2 electrical contacts within 2 mm of the nerve sheath. At CPM termination, only the median nerve electrode on 1 cadaver extremity had migrated significantly. Conclusions: This new minimally invasive approach to lead placement requires further study to determine implantation criteria, optimal locations, anchoring techniques, and electrode design to define best clinical practice.

AbstractIntroductionPersistent pain following breast surgery is common and may be challenging to treat. In patients refractory to conservative treatments, ultrasound‐guided fascial plane blocks of thoracic nerves can be a useful option.ResultsThis type of neuro blockade technique provides advantages in terms of safety and efficacy that are convenient for physicians managing refractory and complex cases of post‐breast surgery syndrome.ConclusionThis technical review aims to present an up‐to‐date summary of the most common ultrasound‐guided fascial plane blocks for chronic pain in post‐breast surgery patients, provide a detailed technical description of each intervention, and propose preferred injections based on the anatomical location of the pain.

Abstract Objectives To describe and assess the feasibility of an ultrasound-guided technique for intra-articular injection of the costovertebral joints, in an unembalmed cadaveric specimen, utilizing fluoroscopy and cone beam computerized tomography for confirmation of contrast spread and needle tip position, respectively. Methodology A single unembalmed cadaveric specimen was obtained. A single interventionist performed the placement of the needles under ultrasound guidance. Contrast dye was then injected through each of the needles under real-time fluoroscopy. Finally, the specimen was submitted to a cone beam computerized tomography with 3-dimensional acquisition and multiplanar reformatting to assess final needle tip position relative to the costovertebral joints. Results In total, 18 spinal needles were placed under ultrasound guidance. Fluoroscopy showed 4 distinct patterns of contrast spread: intra-articular in the costovertebral joint (13 levels in total), epidural (1 level), intra-articular in the facet joint of the target level (3 levels), and undetermined (1 level). Cone-beam computerized tomography confirmed 13 out of 18 needles to be adequately placed in the costovertebral joints (72% of the total) and 5 out of the 18 needles to be misplaced: 3 needles were placed in the facet joint of the target level, and 2 needles were placed in the epidural space. Conclusions This study suggests that, when performed by experienced interventionists, this technique has an accuracy rate of 72%. Further studies are warranted before these results can be extrapolated to daily clinical practice.

Brachial plexus avulsion injuries result in permanent motor and sensory deficits, leading to debilitating symptoms. We report the case of a 25-year-old man with chronic pain following right-sided C5-T1 nerve root avulsion without evidence of peripheral nerve injury. His pain was recalcitrant to medical and neurosurgical interventions. However, he experienced substantial (>70%) pain relief with peripheral nerve stimulation targeting the median nerve. These results agree with data suggesting collateral sprouting of sensory nerves occurs following a brachial plexus injury. Further study is needed if we are to understand the mechanisms of the peripheral nerve stimulator as a treatment option.