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