Hannes Gruber

Ultrasound-Guided Versus Computed Tomography-Controlled Facet Joint Injections in the Lumbar Spine: A Prospective Randomized Clinical Trial

Background and Objectives: Facet joint injections are widely used for alleviation of back pain. Injections are preferentially performed as fluoroscopy or computed tomography (CT)-controlled interventions. Ultrasound provides real-time monitoring, does not produce ionizing radiation, and is broadly available. Methods: We studied feasibility, accuracy, time-savings, radiation doses, and pain relief of ultrasound-guided facet joint injections versus CT-controlled interventions in a prospective randomized clinical trial. Forty adult patients with chronic low back pain were consecutively enrolled and evenly assigned to an ultrasound or a CT- group. Results: Eighteen subjects from the group randomized to ultrasound were judged to be feasible for this type of approach. In 16 of them the facet joints were clearly visible and all of the associated facet joint injections were performed correctly. The duration of procedure and radiation dose was 14.3 ± 6.6 minutes and 14.2 ± 11.7 mGy˙cm in the ultrasound group, and 22.3 ± 6.3 minutes and 364.4 ± 213.7 mGy˙cm in the CT group. Both groups showed a benefit from facet joint injections. Conclusions: The ultrasound approach to the facet joints in the lumbar spine is feasible with minimal risks in a large majority of patients and results in a significant reduction of procedure duration and radiation dose.

The Vascular Nature of Hemorrhoids

The arterial blood supply of the internal hemorrhoidal plexus is commonly believed to be associated with the pathogenesis of hemorrhoids. Ultrasound-supported proctoscopic techniques with Doppler-guided ligature of submucosal rectal arteries have been introduced for the therapy of hemorrhoids. The present investigation focuses on caliber and flow changes of the terminal branches of the superior rectal artery (SRA) supplying the corpus cavernosum recti (CCR) in patients with hemorrhoids. Forty-one outpatients (17 female, 24 male; mean age 48 years) with hemorrhoids of Goligher grades I-IV were compared with 17 healthy volunteers (nine female, eight male; mean age 29 years) by means of transperineal color Doppler ultrasound. The mean caliber of the arterial branches in the study group with hemorrhoids was 1.87±0.68 mm (range, 0.6 to 3.60 mm) and 0.92±0.15 mm (range, 0.6 to 1.2 mm) in the control group (P<0.001). The arterial blood flow was significantly higher in patients with hemorrhoids than in the control group (mean 33.9 vs. 11.9 cm/second, P<0.01). Our findings demonstrate that increased caliber and arterial blood flow of the terminal branches of the SRA are correlated with the appearance of hemorrhoids. We suggest that the hypervascularization of the anorectum contributes to the growth of hemorrhoids rather than being a consequence of hemorrhoids. Transperineal color Doppler ultrasound (CDUS) is an appropriate method to assess these findings in patients with hemorrhoids.

The ultrasonographic appearance of the femoral nerve and cases of iatrogenic impairment.

Objective. To assess the feasibility of ultrasonography of femoral nerves in a cadaveric specimen, healthy volunteers, and patients. Methods. In 1 unembalmed cadaveric specimen (female, 90 years) and 20 healthy volunteers (9 male and 11 female, 18–50 years; n = 40 scans), the topographic features, cross‐sectional shapes (oval or triangular), and cross‐sectional areas of the femoral nerves were evaluated by ultrasonography (5‐ to 12‐MHz broadband linear array). In a subsequent study, 7 consecutive patients with postoperative findings assigned to the femoral nerve were evaluated and assessed by a neurologist. Results. The mean ± SD anteroposterior and mediolateral diameters of the femoral nerves in the volunteers were 3.1 ± 0.8 and 9.8 ± 2.1 mm, respectively, at an average cross‐sectional area of 21.7 ± 5.2 mm2. The cross‐sectional shape was oval in 67.5% superior to the inguinal ligament and in 95% inferior to the ligament. The infrainguinal femoral nerve showed variable distances to the femoral artery. In the subsequent patient study, 5 patients had swelling of the femoral nerve in the affected side. In 1 patient, the nerve had a blurred echo structure due to a hematoma. In 1 patient, major damage of the femoral nerve was ruled out clearly. Conclusions. Ultrasonography allows the depiction and assessment of the femoral nerve from about 10 cm superior to 5 cm inferior to the inguinal ligament. In this region, ultrasonography is helpful in detection of impairments and, therefore, in decisions about planning and even acceleration of further treatment.

High-resolution ultrasound of peripheral neurogenic tumors

Peripheral nerve tumors are not frequent, but due to their association with a nerve they are somewhat special. They may be encountered incidentally during evaluation of a soft-tissue mass or when a nerve lesion is clinically suspected and the recognition of such a lesion and its differential diagnosis is key for successful therapy and patient prognosis. As sonography is often the first line modality in the work-up of a soft-tissue mass, the sonographer should be aware of the typical features of such lesions in order to arrive at the correct diagnosis, and this article tries to give an overview of the histological subtypes of peripheral nerve tumors and their sonographic characteristics.

Ultrasound-guided facet joint injections in the middle to lower cervical spine: a CT-controlled sonoanatomic study.

ObjectivesThe aim of this study was to investigate the efficacy of ultrasound as a guiding tool for simulated cervical facet joint injections in cadavers. MethodsA total of 40 ultrasound examinations at 5 levels (C6-7 to C2-3) were performed on 4 embalmed cadavers. The zygapophyseal joints were located with ultrasound. First, the transverse processes of C6 and C7 were established and the facet joint of C6-7 was demonstrated. The midpoint of this joint space, defined as the middle of its cranio-caudal extension on its lateral surface, was taken as a reference point. Ipsilateral distances (A, B, C, and D) between this point and each one of the 4 facet joints of the cervical spine up to the facet joints C2-3 were then computed. Subsequently, coronal computed tomography (CT) scans were taken to verify these distances. In a second experiment, a spinal needle was advanced under ultrasound guidance to the zygapophyseal joints from C2-3 to C6-7 on both sides of 1 cadaver. The exact placement of the needle tips was again verified by CT. ResultsIn 4 attempts, a depiction of the joint space was not possible. Ultrasound and CT provided the same mean measurements of 1.2±0.2 cm, 2.0±0.3 cm, 3.0±0.2, and 4.0±0.5 cm for distances A, B, C, and D, respectively. All 10 needle tips were located in the joint space during simulated facet joint injections, as also verified by CT. DiscussionThis preclinical study suggests that ultrasound is a useful guiding tool for facet joint injections in the cervical spine.

Ultrasonographic Appearance of Supinator Syndrome

Objective. To describe ultrasonographic findings in 4 patients with supinator syndrome (i.e., deep branch of the radial nerve). Methods. Four patients with weakness and pain in their forearm underwent ultrasonographic examination with subsequent electroneurographic testing and surgical nerve inspection. Normal measurements of the deep branch of the radial nerve in 10 healthy volunteers served as comparison for measurements in the patients. Results. An enlarged deep branch of the radial nerve was found in all 4 patients at the affected side. Electroneurographic testing and surgical inspection confirmed the ultrasonographic findings. The mean transverse diameter was 4.2 mm (range, 3.8–4.5 mm), and the anteroposterior diameter was 3.3 mm (range, 2.5–3.8 mm). In volunteers, the mean transverse diameter was 2.13 mm (range, 1.7–2.6 mm), and the mean anteroposterior diameter was 1.3 mm (range, 1.0–1.5 mm). Conclusions. The deep branch of the radial nerve appears enlarged in patients with supinator syndrome.

Ultrasound-guided periradicular injections in the middle to lower cervical spine : An imaging study of a new approach

Background and Objectives The objective of this study was to show the efficacy of ultrasound in facilitating the performance of a simulated cervical periradicular injection in cadavers. Methods A total of 40 ultrasound-guided examinations at 4 levels (C3 to C7) were performed on 4 embalmed cadavers. The cervical spinal nerves were located with ultrasound. First, the transverse process of each level was taken as a sonoanatomic landmark. The most lateral aspect of the transverse process of the seventh cervical vertebra was then established as the reference point. Ipsilateral distances (A, B, C, and D) between this point and each one of the transverse processes of the cervical spine up to the third vertebra were then computed. Subsequently, coronal computed tomography (CT) scans were taken to verify these distances. In a second part, a spinal needle was advanced under ultrasound guidance to the spinal nerves C5 to C8 on both sides of one cadaver. The exact placement of the needle tips was checked by CT. Results The transverse processes were identified in all cadavers. In 5 attempts, a depiction of the spinal nerves was not possible. Ultrasound and CT provided the same mean measurements of 1.1 cm, 2.1 cm, 3.1 cm, and 4.1 cm for distances A, B, C, and D, respectively. All 8 needle tips were placed within 5 mm dorsal to the spinal nerve and less than 5 mm away from the posterior tubercle of each levels transverse process, as also verified by CT. Conclusions This preclinical study suggests that ultrasound is a useful guiding tool for periradicular injections in the cervical spine.

Ultrasound-guided and CT-navigation-assisted periradicular and facet joint injections in the lumbar and cervical spine: a new teaching tool to recognize the sonoanatomic pattern.

Background and Objectives The aim of this study is to provide a teaching tool to facilitate the acquirement of periradicular and facet-joint infiltration techniques in the cervical and lumbar spine. Methods On 3 fresh cadavers, a computed tomography (CT) of the lumbar and cervical region was obtained. By use of a dedicated image navigation and reconstruction system, sonographic images were generated and fused with the collected CT data set. Results The sonoanatomy can be instantly compared with the correlating CT-images. This new bimodal method allows for simultaneous views of CT and ultrasound images. Multiplanar imaging of ultrasound-guided infiltrations is facilitated. Conclusions This teaching tool provides immediate CT-verification of sonographically identified structures and helps in the identification of bony landmarks, which are necessary for facet-joint and periradicular injections.

Ultrasonography of the accessory nerve: normal and pathologic findings in cadavers and patients with iatrogenic accessory nerve palsy.

Objective. To determine feasibility of ultrasonography in detecting the normal accessory nerve as well as pathologic changes in cases of accessory nerve palsy. Methods. Four patients with accessory nerve palsy were investigated by ultrasonography. Three cases of accessory nerve palsy after lymph node biopsy and neck dissection were primarily diagnosed on the basis of ultrasonography using a 5‐ to 12‐MHz linear transducer. In addition, we performed ultrasonography in 3 cadaveric specimens to show the feasibility of detecting the accessory nerve. Results. Nerve transection (n = 2), scar tissue (n = 1), and atrophy of the trapezius muscle (n = 4) were confirmed by electroneurographic testing and surgical nerve inspection. In 1 case in which a patient had a whiplash injury with accessory nerve palsy, ultrasonography showed atrophy of the trapezius muscle with a normal nerve appearance. Conclusions. Ultrasonography allows visualization of the normal accessory nerve as well as changes after accessory nerve palsy.

Practical Experience with Sonographically Guided Phenol Instillation of Stump Neuroma: Predictors of Effects, Success, and Outcome

OBJECTIVE Phantom limb pain and stump pain frequently occur after limb amputation, and stump neuromas play an important role in generation of the pain. The purpose of this study was to evaluate the effects of a previously described optimized procedure for sclerosis of painful stump neuromas under real-time high-resolution sonographic guidance. SUBJECTS AND METHODS In this prospective study, neurosclerosis was performed on 82 patients by means of high-resolution sonographically guided injection of up to 0.8 mL of 80% phenol solution according to a standardized protocol. RESULTS During treatment all patients had marked improvement in terms of reduction of pain measured with a visual analog scale. Twelve (15%) of the subjects were pain free after one to three treatments, nine of the 12 achieving relief with the initial instillation. At 6-month follow-up evaluation, 52 patients assessed their present pain quantity with a simplified three-step score. Twenty (38%) of the 52 patients reported almost unnoticeable pain, and 33 (64%) reported pain equal to the minimum reached during therapy. In 18 (35%) of the 52 patients, the incidence of painful periods had markedly decreased. The neurosclerosis procedure had a low complication rate (5% rate of minor complications, 1.3% rate of major complications). CONCLUSION The high-resolution sonographically guided neurosclerosis procedure had a significantly better outcome than other documented treatments. Sonographically guided neurosclerosis should be included in the management of chronic phantom limb and stump pain.