Abstract
ObjectivesTo perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton’s neuroma) and provide clinical indications.MethodsWe report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around peripheral nerves in the lower limb (excluding Morton’s neuroma) to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper.ResultsNine statements on image-guided interventional procedures for peripheral nerves of the lower limb have been drafted. All of them received strong consensus. Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia.ConclusionDespite the promising results reported by published papers on image-guided interventional procedures for peripheral nerves of the lower limb, there is still a lack of evidence on the efficacy of most procedures.Key Points• Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications.• US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role.• US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. The volume of local anesthetic affects the size of the blocked sensory area.
Highlights
Over the last few years, increased interest in imaging the peripheral nerves has been supported by novel and highperforming ultrasound (US) transducers
Following a Delphi-based consensus, nine evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures of peripheral nerves of the lower limb were produced by an expert panel of the European Society of Musculoskeletal Radiology (ESSR)
Most published papers on this topic concern interventional procedures on the sciatic nerve and lateral femoral cutaneous nerve; for these nerves, prospective randomized clinical trials have shown that US-guided perineural injection of anesthetics provides good pain improvement in piriformis syndrome and effective post-operative analgesia, respectively
Summary
Over the last few years, increased interest in imaging the peripheral nerves has been supported by novel and highperforming ultrasound (US) transducers. US guidance is the preferred technique for perineural interventional procedures, which mostly consist of peripheral nerve blocks and interventions for entrapment neuropathies [5]. Several image-guided interventional procedures are routinely performed in clinical practice ranging from perineural corticosteroid injections for entrapment neuropathies to hydrodissection, aspiration of ganglia, phenol ablation, injection of botulinum toxin A, or alcohol blocks, and other minimally invasive procedures. There is sparse evidence regarding the clinical value of these procedures and no clear guidelines have been produced to standardize how, when, and why image-guided interventions might be used for treating peripheral neuropathies of the lower limb. As already done for interventional procedures on the nerves of the upper limb [7], an expert board of the European Society of Musculoskeletal Radiology (ESSR) reviewed the evidence in the existing literature to compile evidence-based statements on clinical indications of image-guided procedures of the peripheral nerves of the lower extremities
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