Sheath Injection Research Articles

Accuracy of Palpating the Long Head of the Biceps Tendon: An Ultrasonographic Study

To determine the accuracy of palpating the long head of the biceps tendon (LHBT) within the intertubercular groove with the use of ultrasonographic localization as a gold standard. Prospective, single-blinded pilot study. Sports medicine clinic at a tertiary care academic institution. Twenty-five male and female asymptomatic volunteers ages 24-41 years (mean, 30.9 ± 4.3 years) with body mass indices of 19.3 to 36.3 kg/m(2) (23.84 ± 4.8 kg/m(2)). Three examiners of differing experience (a sports medicine board-certified staff physician, a sports medicine fellow, and a physical medicine and rehabilitation resident) identified the LHBT location in the intertubercular groove via palpation on a subject in the supine position and marked its location by taping an 18-gauge Tuohy needle to the skin overlying the groove. The examiner order was randomized. A fourth examiner who was blinded to the palpation order assessed the previous examiner's palpation accuracy by comparing the needle position to the sonographically determined tendon position. Needle placement in relation to the intertubercular groove was graded as being within the groove, medial to the groove, or lateral to the groove. In the latter 2 cases, the distance from the needle to the closest groove edge was recorded. Overall accuracy rate was 5.3% (4/75), ranging from 0% (0/25) for the resident to 12% (3/25) for the fellow (P ≤ .007 for interexaminer differences). All missed palpations were localized medial to the intertubercular groove by an average of 1.4 ± 0.5 cm (range, 0.3 for the fellow to 3.5 cm for the resident). Based on the current methodology, clinicians have a tendency to localize the intertubercular groove medial to its actual location. Consequently, clinicians should exercise caution when relying on clinical palpation to either diagnose a biceps tendon disorder or perform a bicipital tendon sheath injection. When clinically indicated, sonographic guidance can be used to accurately identify the LBHT within the intertubercular groove.

Sonographically Guided Tendon Sheath Injections Are More Accurate Than Blind Injections

Trigger finger is frequently treated with tendon sheath injections. This cadaveric study evaluated the accuracy and safety of blind and sonographically guided tendon sheath injections. To our knowledge, a study that precisely mapped the locations of material injected into the tendon sheath has not been reported previously. A total of 40 fingers (excluding thumbs) of 5 fresh cadavers were used. Methylene blue dye was injected into the flexor tendon sheath using either a blind or sonographically guided injection technique (20 fingers for each technique). The location of the dye was then determined via dissection. Dye was observed only in the tendon sheath (ie, optimal outcome) in 70% of sonographically guided injections and 15% of blind injections (P = .001). Dye was observed in the tendon proper (ie, unsafe outcome) in 30% of blind injections and 0% of sonographically guided injections (P = .02). We found that sonographically guided tendon sheath injections were more accurate and may be potentially safer than blind injections. These findings suggest that sonographically guided injections should be considered over blind injections when treating trigger finger.

Sonographically Guided Popliteus Tendon Sheath Injection

The purpose of this investigation was to describe two sonographically guided popliteus tendon sheath injection techniques and determine their accuracy in a cadaveric model. A single experienced operator completed 24 sonographically guided popliteus tendon sheath injections, 12 using a longitudinal approach and 12 using a transverse approach relative to the tendon. The injection order was randomized, and all injections were completed with diluted colored latex. Coinvestigators blinded to the injection technique dissected each specimen and graded the colored latex location as accurate (in the sheath), accurate with overflow (within the sheath but also in other regions), or inaccurate (no latex in the sheath). All 12 sonographically guided popliteus sheath injections using the longitudinal approach placed latex into the sheath. Eight of these injections (67%) also resulted in overflow into the knee joint. Ten of 12 transverse approach injections placed latex into the sheath (83%), with 7 of these (70%) also producing overflow into the knee joint. Two of 12 transverse injections (17%) placed latex only into the knee joint and were therefore inaccurate. Sonographic guidance can be used to inject the popliteus tendon sheath with a high degree of accuracy. Although the longitudinal approach is potentially more accurate, both approaches may result in injectate overflow into the knee joint, likely through the popliteus hiatus.

Sonographic Evaluation and Sonographic-Guided Therapeutic Options of Lateral Ankle Pain: Peroneal Tendon Pathology Associated with the Presence of an Os Peroneum

Clinical implications of acute injuries of the os peroneum have been described, with the recommendation in some cases being the excision of the bone fragments. We describe the spectrum of sonographic appearances associated with pain in the region of the os peroneum, document associated peroneal tendon pathology, and describe the use of sonography to direct and guide therapeutic and/or diagnostic injections. All sonographic examinations in our ultrasound database from Jan 1, 2001-Jan 30, 2007 with the words "os peroneum" were reviewed. Patients were cross-referenced in our radiology database to find relevant foot or ankle radiographs for correlation. There were 47 patients (18 men and 29 women, age range 16 to 83) referred for sonographic evaluation of lateral foot and/or ankle pain who had an os peroneum identified during the sonographic evaluation. Eighteen patients were referred specifically for targeted injection of the lateral ankle, including peroneal tendon sheath injections (N = 10), calcaneocuboid joint injections (N = 1), and injections around symptomatic os peroneum (N = 7). All 47 patients had tendinosis of the peroneus longus, in varying degrees of severity. Radiographs were available for correlation in 28 patients. The causes of lateral ankle pain with a co-existent os peroneum are multifactorial and may not directly relate to the presence of an os peroneum. Ultrasound can be of value in separating out the specific etiology for pain, as well as provide a method for problem solving by the performance of targeted diagnostic or therapeutic injections in the lateral ankle.

Procedure-Oriented Sectional Anatomy of the Shoulder

This is the first in a series of papers on procedure-oriented joint anatomy. This paper will review anatomy of the shoulder joint and focus on non-imaging-guided procedures. Needle procedures of the shoulder include glenohumeral, subacromial, and acromioclavicular joint injections; electromyography; trigger point and other intramuscular injections; bicipital tendon sheath injection; suprascapular nerve blocks; and botulinum toxin injections. The accuracy of these non-imaging-guided procedures is reviewed. Complications of these procedures include infection, damage to tendon, and local or systemic response to medication. This paper provides anatomically accurate schematics of the shoulder anatomy relevant to needle procedures. Cross-sectional schematics of the shoulder were drawn as they appear on axial and sagittal projections. Superficial and deep landmarks are highlighted and sources of potential complications. The schematics allow for safer and more accurate non-image-guided needle procedures in the shoulder region.

Flexor Tendon Sheath as a Source of Pain in Lesser Metatarsal Overload

Lesser metatarsal overload may lead to pathologic conditions ranging from plantar metatarsophalangeal joint pain to dislocation. The flexor tendon sheath lies directly plantar to the joint. The increased pressure associated with lesser metatarsal overload may lead to synovitis and pain of the flexor tendon sheath. Fifteen consecutive patients with lesser metatarsal overload had visual analog scale scores determined at three metatarsophalangeal joint areas to determine the source of pain. The patients underwent seven maneuvers to determine the pain scale score: single-leg heel raise and palpation of the second and third metatarsophalangeal joints on the plantar proximal, plantar distal, and dorsal aspects. The patients were then injected with 0.5 mL of lidocaine, 2%, into the second and third flexor tendon sheaths, and the maneuvers were repeated. Before the injection, the second metatarsophalangeal joint had a significantly greater visual analog scale score plantar than dorsal (6.9 and 2.6, P < or = .01). The flexor tendon sheath injection significantly improved all seven pain scale scores. Patients with lesser metatarsal overload experienced significantly greater visual analog scale pain scores on the plantar than the dorsal aspect of the second metatarsophalangeal joint. The scores significantly improved after diagnostic injection in the flexor tendon sheaths. The flexor tendon sheaths are probably involved in patients with primarily plantar pain.

The ECU Synergy Test: An Aid to Diagnose ECU Tendonitis

Chronic dorsal ulnar-sided wrist pain challenges even the most experienced physicians. The close anatomic proximity and the possibility of coexistent injuries can render physical examination maneuvers ambiguous, making it difficult to discern between intra-articular and extra-articular pathology. Using the principle of synergism, we describe the extensor carpi ulnaris (ECU) synergy test as a novel means for diagnosing ECU tendonitis and document its benefit in the clinical setting. A retrospective chart review was performed, identifying adult patients experiencing greater than 4 months of dorsal ulnar-sided wrist pain. Physical examination findings, results of magnetic resonance imaging (MRI) and/or wrist arthroscopy, and clinical outcomes were compiled. Fifty-five patients met inclusion criteria. Twenty-one patients (group 1) had no pain with the synergy test but had exams suggesting ulnar-sided intra-articular pathology. All had ulnar-sided intra-articular pathology on MRI and/or arthroscopy. Eleven patients (group 2) had positive synergy tests and no pain with the remainder of the exam. All had greater than 90% pain relief after ECU tendon sheath injection; 5 patients remained pain free. Six patients experienced temporary improvement and had MRI evaluation, confirming the diagnosis of isolated ECU tendonitis in 5 of the 6 patients. The remaining 22 patients (group 3) had positive synergy tests and exams that suggested concomitant ulnar-sided intra-articular pathology. After ECU sheath injection, 5 patients had persistent discomfort with either lunotriquetral ballottement or triangular fibrocartilage complex compression. All 5 patients had ulnar-sided intra-articular pathology confirmed by MRI and/or arthroscopy. Seventeen patients had greater than 90% pain relief after injection. Of these, 7 patients remained asymptomatic at latest follow-up, confirming the diagnosis of ECU tendonitis. Ten patients had recurrent symptoms, of which 6 patients demonstrated ulnocarpal pathology by MRI and/or wrist arthroscopy. By differentiating between intra-articular and extra-articular pathology, the ECU synergy test composes part of a clinical algorithm that minimizes the need for wrist MRI and diagnostic arthroscopy. Diagnostic II.

Comparison of MRI and Local Anesthetic Tendon Sheath Injection in the Diagnosis of Posterior Tibial Tendon Tenosynovitis

Comparison of MRI and Local Anesthetic Tendon Sheath Injection in the Diagnosis of Posterior Tibial Tendon Tenosynovitis

Comparison of MRI and Local Anesthetic Tendon Sheath Injection in the Diagnosis of Posterior Tibial Tendon Tenosynovitis

The modalities currently available to clinicians to confirm the clinical suspicion of posterior tibial tendinitis include MRI, CT, sonography, tenography, and local anesthetic tendon sheath injections. There are no reports in the literature comparing local anesthetic tendon sheath injection to MRI as tools for diagnosing posterior tibial tenosynovitis. The authors reviewed the records of all patients with stage 1 posterior tibial tendon dysfunction between the dates of September 1, 2001, to November 21, 2004. Fifteen patients (17 ankles) had a local anesthetic injection into the posterior tibial tendon sheath and MRI for clinically suspected tenosynovitis of the posterior tibial tendon. Seventeen (100%) of 17 ankles had complete relief of symptoms after the local anesthetic tendon sheath injections. Fifteen (88%) of 17 ankles had abnormally increased fluid signal within the posterior tibial tendon sheath seen on MRI. Two of two ankles (100%), after having negative MRI findings, had complete relief with a local anesthetic tendon sheath injection. In addition, conservative treatment failed in these two patients, and they subsequently had tenosynovectomy with gross confirmation at surgery of inflammatory changes within the tendon sheath. These two patients had complete symptom relief after tenosynovectomy. Local tendon sheath injections and MRI are both reliable diagnostic tools. Injection of the posterior tibial tendon is an accurate, safe, and sensitive modality useful in patients in whom MRI studies are negative in the face of continued clinical suspicion.

Continuous dielectrophoretic cell separation microfluidic device

We present a prototype microfluidic device developed for the continuous dielectrophoretic (DEP) fractionation and purification of sample suspensions of biological cells. The device integrates three fully functional and distinct units consisting of an injector, a fractionation region, and two outlets. In the sheath and sample injection ports, the cell sample are hydrodynamically focused into a stream of controlled width; in the DEP fractionation region, a specially shaped nonuniform (isomotive) electric field is synthesized and employed to facilitate the separation, and the sorted cells are then delivered to two sample collection ports. The microfluidic behavior of the injector region was simulated and then experimentally verified. The operation and performance of the device was evaluated using yeast cells as model biological particles. Issues relating to the fabrication and operation of the device are discussed in detail. Such a device takes a significant step towards an integrated lab-on-a-chip device, which could interface/integrate to a number of other on-chip components for the device to undertake the whole laboratory procedure.

PR_136: Piriformis Injection Using Ultrasound Guidance: Description and Validation of Technique

Setting: Tertiary care medical center. Program: Ultrasound-guided piriformis injection. Program Description: Piriformis syndrome is a painful condition consisting of gluteal, hip, and variable leg pain similar in presentation to lumbosacral radiculopathy. Piriformis syndrome may be responsible for up to 6% to 8% of low back pain and sciatica. Due to lack of a criterion standard, diagnosis can be difficult and is often one of exclusion. Piriformis muscle and/or sheath injections are often used diagnostically (anesthetic) and/or therapeutically (eg, corticosteroid, botulinum toxin). Although “blind” piriformis muscle injections are performed, guidance is recommended for accurate localization. Techniques utilizing magnetic resonance imaging, computed tomography, fluoroscopy, electromyography, and nerve stimulator guidance have been well described. Ultrasound (US) offers an alternative means for accurate placement of piriformis injections, with several distinct advantages over traditional guidance techniques. We present an easy to learn method using US guidance to inject the piriformis, with fluoroscopic validation. Assessment/Results: We utilized office-based US equipment to reliably identify the piriformis using bony acoustic landmarks. Piriformis muscle and/or sheath injections could be precisely placed while avoiding adjacent neurovascular structures, as confirmed by fluoroscopic imaging of contrast injected with US placement. Discussion: Successful piriformis injection is important for diagnostic and therapeutic purposes in patients with presumed piriformis syndrome. US identifies relevant bony and soft tissue structures and provides guidance for accurate piriformis injection. Furthermore, US provides several distinct advantages over traditional guidance techniques. Conclusions: Piriformis injection under US guidance provides a highly accurate, real-time, cost-effective technique with no radiation exposure that can be performed by the physiatrist in an office setting.

Study to outline the efficacy and illustrate techniques for steroid injection for trigger finger and thumb

Aim: To outline the efficacy of a steroid injection in treating trigger finger. Our study defines the anatomy of the A1 pulley, and suggests methods for simple and safe flexor...

Brainstem anaesthesia after retrobulbar block: A rare cause of coma presenting to the emergency department

Local anaesthesia, in particular retrobulbar block, is commonly used to perform cataract surgery. Known complications of retrobulbar block include cranial nerve palsies, seizures and cardiorespiratory arrest. We report a case of brainstem anaesthesia causing apnoea and loss of consciousness in a man who received retrobulbar block. The likely mechanism is inadvertent dural puncture of the optic nerve sheath and local anaesthetic injection into the cerebrospinal fluid space. As in this case, the literature reports a short-lived period of anaesthesia with usually no long-term sequelae. Although rare, it is a life-threatening complication if the patient is not appropriately resuscitated. This case highlights the need for trained personnel, with suitable monitoring and adequate resuscitation facilities in order to perform this technique.

Musculoskeletal ultrasound

Over the last few years a sonographic revolution has occurred in rheumatology. Ultrasonography has been shown to be capable of substantially changing the traditional approach to most clinical problems in daily rheumatological practice because of its ability to allow a quick, safe and inexpensive access to otherwise undetectable anatomical information on the early targets of most rheumatic diseases. Ultrasonography completes the physical examination in a rapid and accurate manner and allows the detection of a wide spectrum of pathological findings involving different anatomical structures in the musculoskeletal system. Guidance for intervention (joint aspiration, synovial or soft tissue biopsy, joint or tendon sheath injection) is a major application of ultrasonography. Sonographic guidance is particularly useful when fluid collections are very small or when the inflammatory process is adjacent to anatomical structures that could be seriously damaged by the injection.

PSOAS SHEATH INJECTION AND PELVIC STABILISATION IN BACK PAIN. LONG TERM OUTCOMES

Methods: Anonymous patient questionnaires with reply paid addressed envelopes and separate reply paid consent slip were sent to 134 patients confirmed to have had a psoas sheath injection over six months previously by data base search and then manual confirmation of records. Pain was rated using a 10 point VAS for pain pre procedure and at time of reply. Area of main and secondary pain was recorded. Results: Average length of time in pain was 43 months. At average 14 month follow up: 72% of patients with primary low back pain were good or excellent 69% of patients with primary groin were good or excellent 72% of patients with upper AND lower leg pain were good or excellent The worst responding group were those with lateral hip pain, which is in keeping with labral tears of the hip. 10% of patients were worse on VAS of pain. Those with an excellent response had the following distribution of pain: Main area of pain: LBP 58%, Groin 23%, Upper leg 8% Discussion: Psoas dysfunction is defined as: Low back & or groin pain Tight & tender psoas muscle belly. L23 & L34 facet joint dysfunction. Groin pain in “thomas test” position Positive hip quadrant ± abdominal discomfort The commonest cause is pelvic instability. Others are: Psoas dysfunction and insufficiency syndrome Hip labral tears True back pathology Gross pelvic instability Tumours Conclusion: Psoas sheath injection followed by transversus abdominus retraining appears to have a place in the treatment of back and groin pain. More work needs to be done on identifying those in the good and excellent groups.

Diagnostic and therapeutic ankle tenography: outcomes and complications.

The purpose of our study was to evaluate tenography complications and outcomes in a large series. Of 144 tenograms obtained consecutively from May 5, 1995, to March 17, 1997, 111 were located for at least a 6-month follow-up; 65 were posterior tibial, 39 peroneal, two anterior tibial, three flexor digitorum longus, and two flexor hallucis longus tenograms. Tenography was performed fluoroscopically with contrast material and anesthetic followed by steroid placement into tendon sheaths. Of 65 patients undergoing posterior tibial tenography, 31 (48%) had complete or near-complete symptom resolution; 17 (26%) had no relief. Seventeen patients (26%) had initial relief with the subsequent return of pain to the pretenography level. Of 39 patients undergoing peroneal tenography, 18 (46%) had complete or near-complete symptom resolution; 10 (26%) had no and 11 (28%) had initial relief with subsequent pretenography pain return. Of three patients undergoing flexor digitorum longus tenography, one had complete, one had no, and one had initial relief with complete pretenography pain return. One of two patients who underwent flexor hallucis longus tenography had no relief; the other had initial relief with complete pain return. Two patients who underwent anterior tibial tenography had complete pain relief. We found no correlation between degree of tenosynovitis shown radiographically and therapeutic improvement with anesthetic and steroid injection. Tenography complications included one posterior tibial tendon rupture (0.89%) and 14 patients with skin discoloration at the tendon sheath injection site. Forty-seven percent of surgical candidates whose condition was refractory to conservative therapy had complete or near-complete prolonged symptom relief after tenography. In appropriate patients, tenography is excellent therapy for tenosynovitis. Certain precautions make complications rare.

Efficacité des infiltrations péridurales de corticoïdes par voie périradiculaire ou interépineuse dans le traitement des sciatiques discales. Étude pilote prospective, randomisée, et à double insu

Study objectives. Pilot study comparing the short-term efficacy on pain and functional impairment of nerve root sheath versus interspinous glucocorticoid injections in patients admitted to a French rheumatology department for disk-related sciatica or femoral neuralgia. Patients and methods. Thirty patients with refractory nerve root pain (sciatica, n = 29; femoral neuralgia, n = 1) for a mean of four months were randomized to nerve root injection ( n = 17) or interspinous injection ( n = 13) of the same mixture of 0.10 g of lidocaine hydrochloride and 3.75 mg of cortivazol. Both injection methods were performed under analgesia and benzodiazepine sedation to maintain double blinding. Each patient was evaluated daily during the first seven days of bed rest in the hospital, then after discharge on postinjection day 28. Results. Prompt pain relief was obtained in both groups. On day 1, the mean pain scale score (0–100) fell from 70 ± 3.9 to 26 ± 5.6 in the nerve root group and from 63 ± 4 to 23 ± 4.7 in the interspinous group. These results were sustained on D7 and D28. Conclusions. The unusually high level of efficacy of glucocorticoid injection in our study may be ascribable in part to strong placebo and Hawthorne effects and in part to the intrinsic effects of the injections. Whether nerve root injection is superior over interspinous injection remains unproven.

Extradural sensory rhizotomy in the management of chronic lumbar radiculopathy: a minimum 2-year follow-up study.

Fifty-one consecutive patients who underwent extradural sensory rhizotomy for chronic radiculopathy after lumbar surgery were reviewed retrospectively. To determine the effectiveness of sensory rhizotomy in the management of chronic radiculopathy in patients selected by extensive imaging techniques and selective nerve root sheath injections. Results of more central ablative procedures for chronic benign pain problems have been disappointing, with variable reports of pain relief. Fifty-one patients were reviewed. All patients underwent extensive evaluation to exclude reversible structural lesions, and all had the diagnosis of chronic radiculopathy confirmed by results of clinical and electrophysiologic examination. Selective nerve root sheath injections under fluoroscopic guidance confirmed the symptomatic nature of the segments. All blocks were repeated at least once. All patients underwent selective sensory rhizotomy or, in some cases, complete rhizotomy. After rhizotomy, 37 patients were available to be observed at selected time intervals for a minimum of 2 years. Clinical results were determined by the presence or absence of pain relief (visual analog scale), sensory and motor deficits, narcotic analgesic usage, and the patient's estimation of the effectiveness of the procedure. At 6 months after surgery, all 51 patients and the outcomes of their surgery were available for review. Fifty-five percent of patients rated were believed to have good or excellent outcomes, whereas the remainder had poor or failed outcomes. For the minimum 2-year follow-up period (range, 2-4.2 years), 37 patients were available for review. At final follow-up examination only 19% of the patients maintained good or excellent outcomes. The results of the rhizotomy procedures deteriorated over time. Possible reasons for the failure, other than temporal deterioration, were anatomic factors and lack of specificity of diagnostic techniques, specifically selective nerve root sheath injection. At this point rhizotomy cannot be recommended with any confidence whatsoever in the setting of chronic lumbar radiculopathy after lumbar surgery.

Effect of a plasma sheath and ion injection on axial particle and energy confinement in a collisional mirror plasma

Continual scattering of particles into the loss cone of a simple magnetic mirror used to confine a collisional, fully Maxwellian plasma results in exceedingly large particle and energy loss rates. However, a considerable increase in confinement is found when a material wall is placed at the high field side of the mirror. A plasma sheath forms which reflects a large fraction of the electrons which pass through the mirror. Further, the sheath potential can be increased by axial ion injection. With optimized axial ion injection, the energy loss rate for a deuterium–tritium plasma decreases to 1.5% of its value without sheath reflection and near perfect electron confinement is obtained.

External spermatic sheath injection for vasal nerve block

The Family Planning Scientific Research Institute in Chongqing China developed a painless and atraumatic technique for external spermatic sheath injection for vasal nerve block (the no-scalpel method) for vasectomy. As of early 1992 this technique has been used to perform 10 million vasectomies in China. Physicians at Cornell Medical Center and the Population Council in New York City have used it for >500 vasectomies. Physicians from both China and the US have not observed any complications from this method. The procedure involves 1st locating the middle-upper 3rds of the median raphe of the scrotum. Using the 3-finger technique the physician then needs to locate and secure the vas deferens under the skin and separate it from the internal spermatic vessels. After placing a 1.5 inch 25-27 gauge needle into a 1-1.5 cm skin wheal in the dermis over the vas deferens midway between the thumb and index finger the needle is advanced all the way in the direction of the external inguinal ring adjacent and parallel to the vas deferens. The syringe is lightly aspirated to verify that the needle is not in a blood vessel. 2-5 ml of 1-2% plain lidocaine is injected gently within the external spermatic fascial sheath. The same procedure is followed for the other vas deferens. After removal of the needle the skin wheal is pinched for several seconds to reduce swelling in the area over the vasectomy site. Lidocaine acts quickly (5 seconds) and works for up to 1 hour. It is safer than bupivacaine and procaine. Thus lidocaine should be the anesthesia of choice.