Guidance For Injection Research Articles

Economic Analysis of Accuracy and Cost of Ultrasound-guided Intraarticular Hip Injections

ABSTRACT Background Ultrasonography is an increasingly valuable tool for the diagnosis and treatment of musculoskeletal disorders. In the past, ultrasound has been used for diagnostic purposes, with increasing use of image guidance for joint injections. Hypothesis Ultrasound-guided intraarticular native nontraumatic hip injections are equally as accurate with less cost as other diagnostic imaging modalities including fluoroscopicguided injections. Design This analysis was based on a meta-analysis of the accuracy of the different imaging modalities. Initially a search was performed for intraarticular hip injections in PubMed, EMbasE, and ClinicalTrials.gov. Injection accuracy rates between groups were analyzed via proportional meta-analysis. For the economic analysis, compensation data were determined from estimated charges from Duke University Medical Center. Results Compared with gold standards of accurate injections (such as fluoroscopic and computed tomography-guided injections), ultrasound is 97% as accurate (confidence interval 93%, 99%). based on 2014 reimbursement data, reimbursement for large-joint intraarticular injection averages $61.99 (37.38£, 47.18€) ($49.20–$76.31). Fluoroscopic global reimbursement averages $105.32 (63.51£, 80.13€) ($76.75–$134.72). Ultrasound guidance global reimbursement averages $75.99 (45.86£, 57.83€) ($57.95–$93.15). Conclusion Ultrasound-guided hip injections are an accurate technique for alleviating hip pain at less cost. In an era of increasing concern for health care expenditures, finding an accurate, effective, and cost-friendly alternative has the potential for widespread adaptation and practice. Porras L, boggess b. Economic analysis of accuracy and Cost of Ultrasound-guided Intraarticular Hip Injections. The Duke Orthop J 2016;6(1):35-40.

Effectiveness of Ultrasound Guidance on Intraarticular and Periarticular Joint Injections: Systematic Review and Meta-analysis of Randomized Trials.

The aim of this study was to evaluate the effectiveness and accuracy of ultrasound-guided intraarticular and periarticular joint injections as compared with landmark-guided injections technique. A systematic literature search was performed in Medline, Web of Science, Embase, the Cochrane Central Register of Controlled Trials, reference lists of articles, and other sources. Only randomized controlled trials were included. Two reviewers independently selected and assessed each study for quality and extracted data. Twelve randomized controlled trials were included in the meta-analysis. The results indicated that ultrasound-guided intraarticular and periarticular joint injections were more accurate than the landmark-guided injections (odds ratio, 0.36; 95% confidence interval, 0.22-0.60). Ultrasound-guided joint injections significantly decreased the visual analog scale scores at both 2 wks (mean difference, -9.57; 95% confidence interval, -13.14 to -5.99) (P < 0.00001) and 6 wks (mean difference, -14.21; 95% confidence interval, -18.20 to -10.21) (P < 0.00001) after injection. There was no statistically significant difference in visual analog scale score at 12 wks between ultrasound-guided and landmark-guided intraarticular and periarticular joint injections (mean difference, -4.42; 95% confidence interval, -11.71 to 2.87) (P = 0.23). Intraarticular and periarticular injections using ultrasound guidance significantly improves the accuracy of joint injections, and there is a significant decrease in visual analog scale scores for up to 6 wks after injection. The effect of ultrasound guidance on the long-term outcome of joint injections is inconclusive. The improved accuracy of injections was associated with pain relief. The authors recommend routine ultrasound guidance for intraarticular and periarticular injections.

Poster 367 Ultrasound Guidance for Botox Injections to Avoid Vascular Malformations: A Novel Use for Targeted Therapy. A Case Report

PM&RVolume 7, Issue 9S p. S211-S211 Musculoskeletal and Sports Medicine Poster 367 Ultrasound Guidance for Botox Injections to Avoid Vascular Malformations: A Novel Use for Targeted Therapy. A Case Report Mark Caramore, Mark Caramore University of Virginia, Charlottesville, VA, United StatesSearch for more papers by this author Mark Caramore, Mark Caramore University of Virginia, Charlottesville, VA, United StatesSearch for more papers by this author First published: 08 September 2015 https://doi.org/10.1016/j.pmrj.2015.06.403Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume7, Issue9SSeptember 2015Pages S211-S211 RelatedInformation

Poster 306 Clinical Characteristics of Cervical Dystonia: Differences between Patients Previously Treated with Botulinum Neurotoxin Type A and Naïve Patients

Twenty-one muscles were selected for injection at Visit 1; of these the 5 most commonly injected were splenius capitis (93% of patients), sternocleidomastoid (SCM) (91%), trapezius (63%), levator scapulae (42%), and the semispinalis capitis (27%). Other muscles were injected with a frequency between 0.4e6%. The mean total injected volumes were 1.05 1.16 mL for splenius capitis, 0.68 0.78 mL for SCM, 0.67 0.58 mL for trapezius, 0.42 0.26 mL for levator scapulae and 0.56 0.33 mL for semispinalis capitis. Mean number of injection points were: splenius capitis (2.7 1.5), SCM (2.2 1.2), trapezius (2.7 1.6), levator scapulae (1.5 0.7), and semispinalis capitis (2.0 1.3). At Visit 2 the frequency of muscles injected, the injected volume, and injection points were similar to Visit 1. Injection guidance techniques were used in 37% (SCM) to 57% (levator scapulae) of Visit 1 injections, and this did not change at Visit 2. Analyses by study center revealed that when an injector uses guidance for one muscle, they generally use it for all muscles. Conclusion: In these interim analyses, 5 muscles were identified as being most frequently injected for CD, with other muscles being injected at much lower rates. The muscles and injection method (volume and number of injection points) are in line with recommendations in the literature and did not change between visits.

Development and Evaluation of Ultrasound-Guided Navicular Bursa Injection Using the Palmarodistal Digital Approach in Horses: an Ex Vivo Study

Navicular bursa injections are routinely used in horses with foot pain for diagnostic and therapeutic purposes. Ultrasound-guided injections to the navicular bursa have been proposed as an alternative to traditional techniques. The objective of this study was to develop an ultrasound-guided injection technique to access the navicular bursa using the palmarodistal digital approach and evaluate the success rate, total execution time, number of needle positioning, and ultrasonographic verification of bursal injection compared with contrast radiology. We hypothesized that this technique would be fast and accurate; necessitating few needle repositions and allowing real-time ultrasonographic guidance and verification of bursal injection. Overall success rate was 92.5% (37 of 40). Optimal images presented a success rate of 100% (32 of 32) and suboptimal images of 62.5% (5 of 8). Intrabursal accumulation of radiographic contrast media was correlated in 97.3% (36 of 37) of the limbs to ultrasonographic evidence of fluid and gas in the navicular bursa. Mean total execution time was 16.1 second (±7.84 seconds). Mean number of needle insertions per limb was 1.23 (±0.42). All the needle repositions (9 of 40) were performed within the digital cushion. Our results using cadaver limbs suggest that this approach allows a high injection success rate, high execution speed, accurate confirmation of intrabursal injection, and a low needle reposition rates. Needle repositioning within the digital cushion could minimize the number of unnecessary needle penetrations to the deep digital flexor tendon. Acquisition of suboptimal ultrasound images may preclude the use of this technique because it importantly impacts the injection success rate.

Image-Guided Injections of the Hip

The authors present a technique paper on the utilization of both ultrasound and fluoroscopy guidance for injections about the hip joint.

AB0767 Comparison of Inraarticular and Intracyst Corticosteroid Injections in the Treatment of Baker's Cyst with Ultrasonographic Follow-Up

BackgroundA Baker's cyst is an enlargement of the gastrocnemius-semimembranosus bursa in the knee that usually communicates with the joint. Ultrasonographical examination is important for differentiation of Baker's cyst from other...

OP0013 Treatment of Epicondylitis by Ultrasound-Guided Local Injections of Autologous Conditioned Plasma (ACP®): A Double-Blind Placebo-Controlled Randomized Clinical TRIAL with 1-Year Follow-Up

BackgroundLocal injections of corticosteroid represent a standard of care for epicondylitis, albeit it may adversely impair the healing process (1). Recently, local injections of growth factors-containing platelet-rich plasma (PRP) have...

Ultrasound-Guided Intervention for Pain Management

13 ISSN 1758-1869 10.2217/PMT.13.70 © 2014 Future Medicine Ltd Pain Manage. (2014) 4(1), 13–15 Traditionally, fluoroscopy and computed tomography (CT) have been the two common imaging modalities used for interventional pain procedures. A decade ago, ultrasound emerged as a popular choice for pain intervention, as evident by the rapid growth of literature and workshops in this field [1]. Ultrasound imaging offers many advantages over fluoroscopy and CT because of its affordability, portability, absence of radiation, and independence of infrastructure and facilities. It also allows visualization of target structures, soft tissues and real-time guidance for injection [2]. However, ultrasound has it own limitations: an inability to reveal structures beyond the bone window and poor reliability for deep structure imaging. In general, ultrasound for pain interventions can be divided according to the following target structures: peripheral, axial and musculoskeletal [2]. Examples of these interventions will be discussed below. The most notable example for peripheral structure is cervical sympathetic trunk (CST) block [3]. Commonly described as stellate ganglion block, CST block is typically performed with landmark-based or fluoroscopy-guided techniques. The targets are either the anterior tubercle or transverse process at C6–7 level. There are two reasons why ultrasound has become the technique of choice [1,3]. First, CST is defined by the fascial plane (prevertebral fascia), which ultrasound, not fluoro scopy, can visualize. Second, in older techniques the needle is inserted between the trachea and carotid artery. Recent literature suggested a high prevalence of esophagus and vessels in this region [4,5]. Ultrasound imaging allows the visualization and avoidance of these important structures and enables a ‘lateral’ approach to the CST [3]. Large randomized controlled trials are required to confirm the safety, accuracy and outcome over conventional techniques. Another example is meralgia paresthetica, which is a painful mononeuropathy of the lateral femoral cutaneous nerve. Anesthesiologists are commonly involved in the management of these patients. The success rate of the traditional landmark-based technique is notoriously poor because of the huge anatomical variation of the nerve [6]. Ultrasound allows visualization of the nerve. A comparison

Outcomes and cost-effectiveness of carpal tunnel injections using sonographic needle guidance

This randomized controlled study addressed whether sonographic needle guidance affected the outcomes of corticosteroid injection for symptomatic carpal tunnel syndrome. Seventy-seven symptomatic carpal tunnels were randomized to injection by either (1) conventional anatomic landmark palpation-guided injection or (2) sonographic image-guided injection, each using a two-step technique where 3 ml of 1% lidocaine was first injected to hydrodissect and hydrodisplace critical intra-carpal tunnel structures followed by injection with 80 mg of triamcinolone acetonide (2 ml). Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, total cost, and cost per responder were determined. There were no complications in either treatment group. Relative to conventional anatomic landmark palpation-guided methods, sonographic guidance for injection of the carpal tunnel resulted in 77.1% reduction in injection pain (p<0.01), a 63.3% reduction in pain scores at outcome (p<0.014), 93.5% increase in the responder rate (p<0.001), 84.6% reduction in the non-responder rate (p<0.001), a 71.0% increase in therapeutic duration (p<0.001), and a 59.3% ($150) reduction in cost/responder/year for a hospital outpatient (p<0.001). However, despite improved outcomes, cost per patient per year was significantly increased for an outpatient in a physician's office and was neutral for a hospital outpatient. Sonographic needle guidance significantly improves the performance and clinical outcomes of injection of the carpal tunnel and is cost-effective for a hospital-based practice, but based on current reimbursements, it significantly increases overall costs for medical care delivered in a non-hospital-based physician practice.

Current state of musculoskeletal ultrasound in paediatric rheumatology: results of an international survey

The aim of this study was to investigate the current use of musculoskeletal US (MSUS) and the most relevant areas of interest for this imaging modality in paediatric rheumatology. A questionnaire was developed by the paediatric subgroup of the OMERACT US task force and e-mailed to the members of the main international paediatric rheumatology networks and societies. Responses were entered in an electronic database. Results were analysed quantitatively or summarized qualitatively in the case of open questions. The overall response rate was 36% (262/719). The use of MSUS varied among members of the various networks/societies. MSUS was considered of high relevance for improvement of diagnostic skills, for the guidance of joint injections and for the assessment of specific joints, namely the hip, ankle, midfoot and wrist. It was considered useful for early detection of synovitis and in determining disease activity and disease remission. Although at present MSUS is not widely used by paediatric rheumatologists, there is considerable interest in this imaging technology among members of the international networks. The results of this survey suggest that the next objective in the research agenda should be the standardization of the assessment of joints in healthy children. This will then help differentiate pathological (i.e. synovitic) joints from normal joints. The initial target joints should be the hip, ankle, midfoot and wrist. MSUS training focused on the assessment of paediatric patients might be very important in implementing the use of this technique in clinical practice and research.

First Flight Experiment with the NERVA-1 Inertial Platform

The guidance system of the NERVA small space launcher is based on the six degrees-of-freedom information delivered by an inertial platform. Due to the main scope of the project sponsored by the Romanian Ministry of Education, Research, Youth and Sports to build a cost-effective space launcher, the inertial platform was built with extensive use of on-the-shelf, low cost inertial sensors and equipment. Concerns regarding the behavior and reliability of the sensing block were solved during the first flight experiment in June 2010, on-board the military, unguided drone missile RT-759-01 NERVA-1 and the results are described. The behavior of the electronics under the dynamical loads of the rocket flight, involving overloads of more than 20 g-s and the level of vibration during the real flight was the focus of the flight test, the first ever performed in Romania. The data were broadcast through a eight channel telemetry chain and received on the ground in two different locations for reliability enhancement. The data acquisition performed very well and supplied the basis for further development of the more accurate orbital injection guidance system of the NERVA launcher of small satellites in LEO.

Clinical outcome of ultrasound-guided steroid injections for chronic shoulder pain

To investigate the short- to medium-term effectiveness of ultrasound (US)-guided steroid injections for shoulder pain in patients who previously failed to respond to unguided steroid injections. We examined 60 consecutive patients who had undergone US examination and US-guided steroid injection. Patients were categorised into having had a good response (i.e., good pain relief at time of follow-up), some response (improvement for 2-4weeks) or no response, as documented by their usual rheumatologist in their subsequent routine out-patient review appointments. Average age was 64.4±11.5years and 42 were female. Median interval between US-guided injection and follow-up was four (interquartile range 2-5) months. Thirty-four (56.6%) patients reported a good response, 13 (21.7%) some response and another 13 (21.7%) no response. US guidance of steroid injections may achieve good short- to medium-term benefit in the majority of patients with chronic shoulder pain due to a variety of clinical syndromes.

Advances in imaging

Imaging of inflammatory activity is of increasing importance, and among available modalities, ultrasonography and magnetic resonance imaging (MRI) seem to be of highest impact. The present review includes recent studies describing several aspects of these modalities as well as short descriptions of other promising imaging methods in rheumatoid arthritis (RA). High reliability has been shown for evaluation of ultrasonography still images. Recently excellent reliability was found when an atlas was used as reference for scoring dynamic images with ultrasonography. The optimal number of joints to examine by ultrasonography for follow-up during therapeutic interventions needs to be further explored. Use of ultrasonographic guidance for injections has showed improved clinical results when compared with blind injections. Ultrasonographic pathology, especially power Doppler, was found to be of predictive value in patients with arthritis. Cartilage damage is an important aspect of structural joint damage in RA, and a reliable assessment system of joint space narrowing has been developed for use with conventional MRI, and various biochemical MRI techniques are being developed to visualize cartilage quality, of which delayed gadolinium-enhanced magnetic resonance imaging of cartilage seems to be the most promising method in RA. Novel imaging modalities, especially ultrasonography and MRI, will be of increasing importance to visualize joint inflammation and aid in the diagnosis, treatment and follow-up of patients with RA.

Ultrasonography and color Doppler in juvenile idiopathic arthritis: diagnosis and follow-up of ultrasound-guided steroid injection in the wrist region. A descriptive interventional study

BackgroundThe wrist region is one of the most complex joints of the human body. It is prone to deformity and functional impairment in juvenile idiopathic arthritis (JIA), and is difficult to examine clinically. The aim of this study was to evaluate the role of ultrasonography (US) with Doppler in diagnosis of synovitis, guidance of steroid injections, and follow-up examinations of the wrist in JIA.MethodsIn 11 patients (median age 12.5 years, range 2-16), 15 wrists with clinically active arthritis were assessed clinically by US and color Doppler (Logiq 9, GE, 16-4 MHz linear transducer) prior to and 1 and 4 weeks after US-guided steroid injection.ResultsUS detected synovitis in the radio-carpal joints, the midcarpal joints, and the tendon sheaths in 87%, 53% and 33% of the wrists, respectively. Multiple compartments were involved in 67%. US-guidance allowed accurate placement of steroid in all 21 injected compartments, with a low rate of subcutaneous atrophy. Synovial hypertrophy was normalized in 86% of the wrists, hyperemia in 91%, and clinically active arthritis in 80%.ConclusionsUS enabled detection of synovial inflammation in compartments that are difficult to evaluate clinically and exact guidance of injections, and it was valuable for follow-up examinations. Normalization of synovitis was achieved in most cases, which supports the notion that US is an important tool in management of wrist involvement in JIA.

Musculoskeletal US: examining the joints

Musculoskeletal ultrasound (US) is an excellent tool to diagnose muscle, tendon and ligament injuries, cystic structures and peripheral nerve compression, as well as soft tissue masses, without the risk of ionizing radiation. Musculoskeletal US is now routinely used by a growing number of rheumatology and sports medicine centres throughout UK. In standard clinical practice, US has an extremely useful application in differentiating fluid from soft tissue and identifying the severity of joint inflammation. The work described in this article was carried out to assess patients' feedback regarding the use of US guidance for intra-articular injections and/or the removal of fluid from their inflamed knee joints in a nurse-led clinic. Nineteen patients who had US-guided knee joint injection/aspiration in the clinic were asked to complete a questionnaire regarding their satisfaction with the procedure, and to rate their joint pain and patient global assessment (using numerical visual analogue scale) before the US-guided procedure, and 1 month after. Results revealed a significant improvement (p<0.001) of the joint injection outcome measures and the patients' satisfaction of the US-guided procedure. Therefore, musculoskeletal US can improve two fundamental clinical skills: the clinical diagnosis of joint inflammation, and the accuracy of joint injection/aspiration. This study supports the concept that incorporating musculoskeletal US into clinical practice leads to significant improvements in patient care. It also reveals that US-guided procedures are appreciated by patients.

The trial of ultrasound-Doppler guidance for image-guided injections of temporomandibular joint in rheumatoid arthritis

The trial of ultrasound-Doppler guidance for image-guided injections of temporomandibular joint in rheumatoid arthritis

Clinical utility of ultrasound guidance for intra-articular knee injections: a review

Intra-articular corticosteroid and hyaluronic acid injections provide short-term symptom amelioration for arthritic conditions involving structural damage or degenerative changes in the knee. Conventional palpation-guided anatomical injections frequently result in inaccurate needle placement into extra-articular tissue and adjacent structures. The purpose of this review was to determine the effect of ultrasound guidance on the accuracy of needle placement, clinical outcomes, and cost-effectiveness in comparison with anatomical landmark-guided intra-articular large joint injections, with particular emphasis on the knee. A total of 13 relevant studies were identified; five studied the knee, seven studied the shoulder, one used both the knee and shoulder, and none studied the hip. Ultrasound was used in seven studies; the remaining studies utilized air arthrography, fluoroscopy, magnetic resonance arthrography, or magnetic resonance imaging. Across all studies (using all imaging modalities and all joints), needle placement accuracy ranged from 63% to 100% with ultrasound and from 39% to 100% with conventional anatomical guidance. Imaging guidance improved the accuracy of intra-articular injections of the knee (96.7% versus 81.0%, P < 0.001) and shoulder (97.3% versus 65.4%, P < 0.001). In particular, ultrasound guidance of knee injections resulted in better accuracy than anatomical guidance (95.8% versus 77.8%, P < 0.001), yielding an odds ratio of 6.4 (95% confidence interval 2.9–14). Ultrasound guidance notably improves injection accuracy in the target intra-articular joint space of large joints including the knee. The enhanced injection accuracy achieved with ultrasound needle guidance directly improves patient-reported clinical outcomes and cost-effectiveness.

A Randomized Controlled Trial Evaluating the Cost-Effectiveness of Sonographic Guidance for Intra-Articular Injection of the Osteoarthritic Knee

The present randomized controlled study investigated whether sonographic needle guidance affected the outcomes of intra-articular injection for osteoarthritis of the knee. Ninety-four noneffusive knees with osteoarthritis were randomized to injection by conventional palpation-guided anatomic landmark injection or sonographic image-guided injection enhanced with a 1-handed mechanical (the reciprocating procedure device) syringe. After intra-articular placement and synovial space dilation were confirmed by sonography, a syringe exchange was performed, and 80 mg of triamcinolone acetonide was injected with the second syringe through the indwelling intra-articular needle. Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, reinjection rates, total cost, and cost per responder were determined. Relative to conventional palpation-guided anatomic landmark methods, sonographic guidance for injection of the knee resulted in 48% reduction in procedural pain (P < 0.001), a 42% reduction in pain scores at outcome (P < 0.03), 107% increase in the responder rate (P < 0.001), 52% reduction in the nonresponder rate (P < 0.001), a 36% increase in therapeutic duration (P = 0.01), a 13% reduction ($17) in cost per patient per year, and a 58% ($224) reduction in cost per responder per year for a hospital outpatient (P < 0.001). Sonographic needle guidance reduced procedural pain and improved the clinical outcomes and cost-effectiveness of intra-articular injections of the osteoarthritic knee.

Ultrasound‐Guided FNA of Base of Tongue: A Cadaver Study

Objective: 1) Determine the utility of ultrasound imaging to visualize the anatomy of the tongue base. 2) Demonstrate that ultrasound imaging can guide transcervical needle placement in the tongue base and thus serve as a surrogate for needle biopsy in the patient with a tongue base lesion. Method: Design and subjects: Feasibility study of ultrasound-guided needle placement in the tongue base in 37 adult cadavers. Interventions: Ultrasound imaging of tongue base anatomy and guidance of dye injection into the intrinsic muscles. Outcome Measurements: Tongue base anatomy visualization on ultrasound and placement accuracy of dye injection. Results: Of 37 cadaver heads, 32 were noted to have excellent and identifiable anatomy of the geniohyoid, genioglossus, and intrinsic muscles of the tongue base. The intrinsic muscles were well visualized during methylene blue dye injection on most specimens, with confirmation of the needle tip location and “bloom” of the injection on real-time ultrasound images. After bisection, 25 of 32 (78%) evaluable specimens were found to have accurate placement of dye within the posterior genioglossus and intrinsic tongue base muscles. Neck circumference was similar between those with accurate (mean 37.9 cm) and inaccurate (mean, 37.4 cm) dye placement ( P = .75). Conclusion: This study utilizes a cadaver model to establish that ultrasound visualization of the tongue base provides excellent anatomic detail and demonstrates feasibility of transcervical ultrasound localization of the tongue base for image-guided FNA. This technique has potential applicability to the clinical setting.