shawn jorgensen, md albany medical center aapm&r annual assembly october 2015

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ULTRASOUND GUIDANCE NEW STANDARD OF CARE OR BILLING GIMMICK? Shawn Jorgensen, MD Albany Medical Center AAPM&R Annual Assembly October 2015

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ULTRASOUND GUIDANCENEW STANDARD OF CARE OR BILLING GIMMICK?

Shawn Jorgensen, MDAlbany Medical CenterAAPM&R Annual AssemblyOctober 2015

Goals

Review evidence for use of ultrasound guidance in four major groups of injections

Conclude (if possible) if ultrasound guidance (USG) should be used at this point instead of landmark guided (LMG)

NOT teach how to do the injections

Should we use US?

Is there evidence that US makes these injections better? Are they safer? Are they more accurate? Do they work better? If better, is it worth the extra cost?

Disclosures

None

Perineural injections

Not discussing nerve blocks for anesthesia

Usually local anesthetic and corticosteroid

Perineural injections

Carpal tunnel injections – USG vs LMG Safety

Makhlouf 2014 No complications in blind or US guided

groups (77 patients total) Ustun 2013

No difference in side effects (p>0.05)

Perineural injections

Carpal tunnel injections – USG vs LMG Accuracy

No studies looking specifically at this

Perineural injections

Carpal tunnel injections – USG vs LMG Efficacy

Lee 2014 Diagnosed with CTS by () 75 hands (44 patients) randomized to in-plane,

out-of-plane, or blind injections Outcomes measured by Boston Carpal Tunnel

Questionaire (BCTQ), EDX, US parameters Patients receiving in-plane injections had

significantly improved BCTQ, EDX, US at 4 and 12 weeks

Perineural injections

Carpal tunnel injections – USG vs LMG Efficacy

Makhlouf 2014 77 hands randomized to USG or LMG Primary outcome is pain US guidance led to significant improvements

in: 77.1% decrease in injection pain (p<0.01) 63.3% decrease in pain at outcome (p<0.014) 93.5% increase in responder rate (p<0.001) 71% increase in therapeutic duration

(p<0.001)

Perineural injections

Carpal tunnel injections – USG vs. LMG Efficacy

Ustun 2013 46 hands randomized to US-guided or blind

injections Primary end-point was BCTQ US guided had better improvement on BCTQ

than blind at 12 weeks (p<0.05) and time to relief was significantly shorter (p<0.05)

Perineural injections

Carpal tunnel injections – USG vs. LMG Cost-effectiveness

Makhlouf 2014 Cost per patient per year

Blind $146 US guided $263 (p=0.001)

Cost per responder per year Blind $307 US guided $286 (p=0.39)

Perineural injections

Carpal tunnel injections – USG vs. LMG Summary

Limited evidence, but most and best of any US guided perineural injections

Suggests: SAFETY Same (both are safe) PAIN Less ACCURACY No data EFFICACY Better (consistently in all studies,

quicker, longer and stronger) COST EFFECTIVE ? ( more in responders in one

study)

Perineural injections

Ulnar nerve at the elbow – USG vs. LMG No studies comparing USG vs. LMG Only studies comparing USG vs. no

injection or placebo

Perineural injections

Ulnar nerve at the elbow Safety

Choi 2015 No side effects reported in 10 patients

Rampen 2011 1/7 had an increase in sx

Alblas 2012 1/9 had worsening but not after the injection

Perineural injections

Ulnar nerve at the elbow Accuracy

No studies looking specifically at this

Perineural injections

Ulnar nerve at the elbow Efficacy

Choi 2015 10 patients dx with UNE clinically/EDX All given USG injections Primary end-points were VAS, self-

administered questionnaire of the ulnar neuropathy at the elbow (SQUNE), CSA by US and CV/block by EDX at 1 and 4 weeks post injection

Improvements in VAS (p<0.05) and CV/block at 1 and 4 weeks (p<0.05)

Perineural injections

Ulnar nerve at the elbow Efficacy

vanVeen 2014 55 patients with UNE randomized to USG

injection or USG placebo injection Primary outcome change in sx at 3 months;

secondary outcomes change in EDX and US No change in sx or EDX; US showed a

significantly improved decrease in CSA

Perineural injections

Ulnar nerve at the elbow Evidence for efficacy

Rampen 2011 7 patients dx with UNE were given USG

injection At 6 weeks, 4 improved, 2 had no change, 1

had worse sx

Perineural injections

Ulnar nerve at the elbow Summary

No comparisons of USG vs LMG Studies on USG injections

SAFETY ? (some worsening sx)

ACCURACY No data EFFICACY ? (most improve,

but no better than placebo in one trial)

COST EFFECTIVENESS No data

Perineural injections

Suprascapular nerve – USG vs. LMG Safety

Gorthi 2010 25 patients with US guidance had no

complications 25 patients in control (blind) group had 2

arterial punctures, 3 cases of nerve injury with deficit for 2 months

Perineural injections

Suprascapular nerve – USG vs. LMG Accuracy

No studies looking specifically at this

Perineural injections

Suprascapular nerve – USG vs. LMG Efficacy

Gorthi 2010 50 patients with perishoulder pain randomized

into USG suprascapular nerve block (25) or blind (25)

Primary end points VAS and Constant shoulder score (CSS) immediately following the procedure and 1 month post procedure

Both groups improved in both measures immediately post-procedure (p<0.05)

At one month USG group had significantly better VAS and CSS (p<0.05)

Perineural injections

Suprascapular nerve – USG vs. LMG Summary

Limited evidence SAFETY Better

(significantly) ACCURACY No data EFFICACY Better COST-EFFECTIVENESS No data

Perineural injections

Overall summary – USG vs. LMG Carpal tunnel injections

Best but still limited data Not safer, less pain, better effect (quicker,

stronger, longer), more cost effective Ulnar neuropathy at the elbow

Limited data, no USG vs. LMG, only vs. placebo or no treatment

? Safety, ?efficacy Suprascapular nerve

Very limited data Safer, more effective

Perineural injections

Overall summary – USG vs. LMG Limited data Some USG injections are safer, less

painful, more effective, and could be more cost effective

Improvements are in disease severity and sx in many cases

Thank you!

Bibliography

Alblas CL, van Kasteel V, Jellema K. Injection with corticosteroids (ultrasound guided) in patients with an ulnar neuropathy at the elbow, feasibility study. Eur J Neurol 2012;19(12):1582-1584.

Chavez-Chiang NR, Sibbitt WL, Band PA, DeLea SL, et al.  The outcomes and cost-effectiveness of intra-articular injection of the rheumatoid knee.  Rheumatol Int 2012;32:513-518.

 Choi CK, Lee HS, Kwon JY, Lee WJ. Clinical implications of real-time visualized ultrasound-guided injection for the treatment of ulnar neuropathy at the elbow: a pilot study. Ann Rehabil Med 2015;39(2):176-182.

Gorthi V, Moon YL, Kang JH. The effectiveness of ultrasonography-guided suprascapular nerve block for perishoulder pain. Orthopedics 2010;33(4):

Lee JY, Park Y, Park KD, Lee JK, Lim OK. Effectiveness of ultrasound-guided carpal tunnel injection using in-plan ulnar approach: a prospective, randomized, single-blinded study. Medicine (Baltimore) 2014;93(29):e350.

Makhlouf T, Emil NS, Sibitt WL Jr, Fields RA, Bankhurst AD. Outcomes and cost-effectiveness of carpal tunnel injections using sonographic needle guidance. Clin Rheumatol 204;33(6):849-858.

Rampen AJ, Wirtz PW, Tavy DL. Ultrasound-guided steroid injection to treat mild ulnar neuropathy at the elbow. Muscle Nerve 2011;44(1):128-130.

Ustun N, Tok F, Yaqz AE, Kizil N, Kormaz L, Karazincir S, Okuyucu E, Turhanoglu AD. Ultrasound-guided vs. blind steroid injections in carpal tunnel syndrome: A single-blind randomized prospective study. Am J Phys Med Rehabil 203:92(11):999-1004.

vanVeen KE, Alblas KC, Alons IM, Kerklaan JP, Siegersma MC, Wesstein M, Visser LH, Vankasteel V, Jellama K. Corticosteroid injection in patients with ulnar neuropathy at the elbow: A randomized double-blind, placebo-controlled trial. Muscle Nerve 2014; Dec