Ultrasound Guided Chronic Pain Interventions (Part I) Ultrason Eşliğinde Kronik Ağrı Girişimleri (1

Agri 2016;28(1):1–8

doi: 10.5505/agri.2015.27879 A RI PAIN

R E V I E W

Ultrasound guided chronic pain interventions (Part I) Ultrason eşliğinde kronik ağrı girişimleri (1. bölüm)

Taylan Akkaya, Alp Alptekin, Derya Özkan

Summary Recently, ultrasonography (US) is an indispensible imaging technique in regional anesthesia practice. With the guidance of US, various invasive interventions in chronic pain pathologies of the musculoskeletal system, peripheral and neuroaxial pathologies has become possible. The management includes diagnostic blocks as weel as radiofrequency ablation and institution of neurolythic agents. During these algologic interventions we are able to see the target tissue, the dispersion of the drug and all nearby vascular structures. Besides these the US also protects the team from ionic radiation that one encounters when using flouroscopy or computed tomography. Latest publications in this field show that applicability of US in chronic pain syndromes is rapidly expanding with a good future. The additional equipment (echogenic needles, 3-D US etc.) will also expand its applications in algology practice. This review highlights different applications of US in chronic pain conditions. Keywords: Chronic pain; nerve blocks; ultrasound.

Özet Son zamanlarda rejyonal anestezi pratiğinde ultrasonografi (US) vazgeçilmez görüntüleme tekniği olarak yerini almıştır. Ultra- sonografi ile kas/iskelet, periferik ve nöraksial bölgelerin kronik ağrılı patolojilerde çeşitli invaziv girişimler yapmak olasıdır. Bu girişimler diagnostik bloklar, radyofrekans uygulamaları ve nörolitik ajanların uygulamaları olarak özetlenebilirler. Algolojik gi- rişimler esnasında US; hedef dokuların görüntülenmesinde, uygulanan ilacın yayılımında, çevredeki vasküler yapıların görün- tülenmesinde büyük kolaylıklar sağlar. Ayrıca US ile floroskopi veya bilgisayarlı tomografi uygulamaları esnasındaki radyasyon yayılımı söz konusu değildir. Kronik ağrı girişimlerinde US ile yayınlanan klinik çalışmalar umut vericidir. Ayrıca son yıllarda bu alandaki gelişmeler (ekojen iğneler, üç boyutlu US cihazları vd.) US’nin algoloji pratiğindeki kullanımının daha da yaygınlaşaca- ğını düşündürmektedir. Bu derlemenin amacı, US eşliğinde yapılan çeşitli kronik ağrı girişimlerini gözden geçirmektir. Anahtar sözcükler: Kronik ağrı; sinir blokları; ultrason.

Introduction create minimal echoes (hypoechoic), whereas tis- Ultrasonography (US) has been performed in various sues that transmit less of these sound waves (like fields of medicine for a long time, recently it has be- fat and bone) create intense echoes (hyperechoic). come available for various interventions of regional Hypoechoic areas are visualized black and hyper- anesthesia. However, it has not made into routine echoic areas are visualized white on the screen. B use in algology practices yet. mode, M mode and Doppler modes are commonly used in routine pain practice. B mode (brightness) US is an imaging device which utilizes sound waves enables real-time visualization of tissues. M mode between 2–22 MHz frequency; the sound reflects (motion) is used for visualization of mobile struc- from parts of the tissue and these echoes are re- tures (heart, valve, vascular structures, diaphragm corded and displayed as an image.[1,2] Tissues that motion). Doppler mode is used for evaluation of transmit these sound waves easily (fluid or blood) blood flow.[3,4]

Department of Anesthesiology, Pain Service, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey Submitted: 12.06.2015 Accepted after revision: 29.09.2015 Correspondence: Dr. Taylan Akkaya. Dışkapı Yıldırım Beyazıt Eğitim ve Araştırma Hastanesi, Anesteziyoloji Kliniği, Ağrı Servisi, Ankara, Turkey. Tel: +90 - 312 - 596 25 51 e-mail: [email protected] © 2016 Turkish Society of Algology

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Compared to conventional anatomical landmark increases. However, it takes time to gain sufficient method, fluoroscopy and CT techniques, US applica- experience. In addition, US practice necessitates de- tions have many advantages. The biggest advantage tailed sonoanatomy knowledge, which requires a is that while visualizing blockage needle, target tis- serious anatomy education. In the recent years, ESRA sue and the injected material in real-time, patient is (European Society of Regional Anesthesia) and ASRA not subjected to harmful effects of radiation. Addi- (American Society of Regional Anesthesia) have pub- tionally, use of contrast material during radiological lished recommendations related to education on US imaging poses some risks to the patient. Easy iden- applications in regional anesthesia.[10] tification of the target tissue especially during nerve blockade reduces application time and time for initia- There is particularly not enough experience related tion of block; therefore it increases both the patient’s to US practice in permanent interventions like abla- and provider’s satisfaction.[5] Additionally, US allows tion, phenol and alcohol application among chronic repeat imaging non-invasively. Thus, it enables de- pain interventions. On the other hand, pulsed RF ap- termination of typical and atypical anatomical and plications seem promising in US utilization, since it is structural anomalies that stem from individual differ- less invasive and can be repeated as required. ences, and allows planning prior to intervention.[6,7] Although no absolute contraindications for US use Hence US can readily be performed at the point of have been reported, it is thought that ultrasound en- care, it has increasingly been favored by the provid- ergy results in tissue heating, and small gas pockets er, progressively increasing its use in daily practice. (cavitation) may form in tissues due to this reason. For pain clinics where fluoroscopy has essentially However, long-term clinical effects of tissue heating been used as the imaging device, US provides a new and cavitation is not known yet.[11] perspective. Despite known limitations of fluoroscopy (weight, radiation exposure, requirement for a In pain treatment, US is used in interventions per- technician, etc.), it also has advantages like visualiza- formed on peripheral nerves, neuroaxial structures tion of bone structures in particular. and musculoskeletal structures. These common interventions are listed below: US can be more advantageous compared to fluoroscopy especially during peripheral nerve blockade Musculoskeletal interventions: Joint injections, Liga- owing to direct visualization of muscle, tendon, liga- ments, Peritendinous injections, Intramuscular Bo- ment, vascular and bone structures. Introduction of tox injection, Bursa injection, Lavage. echogenic block needles into practice has strength- ened its place in this field. In addition, US enables Peripheral interventions: Greater occipital nerve dynamic measurements, allowing “real time” posi- block, intercostal nerve block, Suprascapular and ax- tioning of target tissue. Thus, target tissue can be vi- illary nerve blocks, Iliohypogastric/ilioinguinal nerve sualized from different angles, and the intervention block, Lateral femoral cutaneous nerve block, Pu- can be made in the most appropriate position. Ad- dendal nerve block, saphenous nerve block. ditionally, the ability to differentiate various tissues (vessel, diaphragm, etc.) by US may prevent compli- Neuroaxial interventions: Stellate ganglion block, cations such as intravascular injection and pneumo- Cervical and lumbar spine procedures (nerve root, thorax during nerve blockade.[8] facet periarticular, medial branch), Thoracic paraver- tebral block, Caudal epidural, Ganglion impar block, Although US applications have remarkable advantag- sacroiliac joint injections. es, there are some limitations of its utilization. For ex- ample, acoustic shadows of bone structures may pre- Musculoskeletal interventions in chronic pain vent visualization of structures behind,[9] or, though In musculoskeletal interventions, the performer deep structures can be visualized with convex probe, should have a through understanding of normal and image resolution may be compromised. These limi- abnormal sonographic appearances of the anatomi- tations may be alleviated as performer’s experience cal structures. These structures can often be differen-

2 JANUARY 2016 Ultrasound guided chronic pain interventions tiated by their echogenicity, compressibility, anisot- the third cervical nerve. It supplies sensory innerva- ropy and Doppler flow characteristics.[12] In chronic tion to the medial portion of the posterior scalp as pain treatment musculoskeletal interventions that far anterior as the vertex. GON blockade is used in are frequently performed under US guidance in- various type of headaches like migraine, occipital clude calcific tendinitis lavage, pulsed radiofrequen- neuralgia, servicogenic headache, postdural punc- cy, botulinum toxin or sclerosing agent injection, ture headache (PDPH) with generally favorable clini- trigger point injections. cal outcomes.[19,20] For a long time, GON blockade has been performed by classical approach using ana- US is used for diagnostic purposes in conditions re- tomical landmarks (Figure 1). In one related study, lated to shoulder such as bursitis, calcific tendonitis, 10 patients who received GON pulsed radiofrequen- septic arthritis and impingement syndrome. Addi- cy (PRF) by classical landmark technique due to oc- tionally, during intraarticular injections to subacro- cipital neuralgia were followed up for 7.5 months on mial bursa or glenohumeral joint for treatment pur- average, and their pain scores decreased to 0.8 after [21] poses, US increases the chance to apply it to target PRF from 6.9. Additionally 80% of the patients dis- area precisely by 94%.[13] continued their analgesic use.

For elbow, US is commonly used for diagnosis of lat- In our clinic, we prefer GON blockade technique eral and medial epicondylitis, synovitis, triceps ten- described by Greher et al. using new anatomical [22] don injury, septic arthritis, effusions or entrapment landmark (Figure 2). This new proximal technique neuropathies and for effusion aspiration.[14] For wrist, has some important advantages over the classical US has been used for diagnosis of anatomical anomalies like bifid median nerve and for therapeutic interventions.[15]

US has been found quite useful in trochanteric pain during interventions in hip joint, in interventions related to knee joint and plantar fascia.[16]

For interventions in knee joint, US has limited use due to limited visualization of cruciate ligament, me- niscopathy and fractures.[14] For interventions related to ankle, US has been used in interventions to lesions such as Morton ganglioma and plantar fasciitis.[17]

Figure 1. Greater occipital nerve and artery. Peripheral interventions Blockade of trigeminal ganglion and its branches: To- day fluoroscopy is still commonly used in orofacial pain interventions. However, lateral pterygoid plate, maxillary artery and pterygopalatine fossa can readily be visualized with US. Nader et al. performed trigeminal nerve blockade in 15 patients with US (4 mL of bupivacaine 0.25%, one mL of steroids were injected).[18] In all patients, pain subsided after 5 minutes following blockade. Analgesic period was described to last for up to 15 months.

Greater occipital nerve blockade: Greater occipital nerve (GON) arises from the dorsal primary ramus of the second cervical nerve with contribution from Figure 2. GON blockade (New approach).

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Figure 3. Anatomic landmarks for suprascapular nerve blockade. Figure 5. Intercostal nerve blockade.

tial during suprascapular nerve blockade. Supra- scapular notch can show quite different anatomical variations.[24] Blockade can be performed with suc- cess by visualization of superior transverse scapular ligament, suprascapular artery and nerve. Blockade of axillary nerve together with suprascapular nerve under guidance of US yields good patient satisfaction and postoperative analgesia in rotator cuff operations.[25] Axillary nerve blockade is particularly very effective in pathologies of proximal humerus. There are successful reports of suprascapular nerve PRF in various shoulder pathologies; however, clinical stud- ies related to axillary nerve is limited.[26] During US Figure 4. Anatomic landmarks for axillary nerve blockade (H: guided axillary nerve blockade, posterior circumflex Humerus; CA: Circumflex artery; PDM: Posterior part of the del- toid muscle; AN: Axillary nerve). humeral artery can be used as a landmark (Figure 4).

Intercostal nerve blockade: The intercostal nerves one. Greater occipital nerve is located deeper, just supply skin and musculature of chest and abdomi- superior to obliquus inferior capitis muscle, addi- nal wall. Intercostal nerves are mixed sensory-motor tionally spinous process of C2 vertebrae can easily nerves. Apart from various acute pain conditions, in- be visualized. Pain caused by irritation of the bone tercostal blockade is also effective in many chronic during classical technique is not encountered with pain situations (Intercostal neuralgia, Post-mastec- this approach. In this proximal technique, the nerve tomy Syndrome, Post-thoracotomy Syndrome, Post- can easily be visualized. Additionally, greater occipi- herpetic neuralgia). Bhatia et al. compared anatomi- tal artery and vertebral artery can also be visualized cal landmark and US guided intercostal blockade with Doppler technique. techniques in cadavers.[27] They reported it is possible to perform more successful blockade using less Suprascapular and axillary nerve blockades: In painful volume of dye with US. During intercostal blockade clinical conditions like frozen shoulder, shoulder os- with US, costae, pleura, internal and external inter- teoarthritis, malignancy of upper lobe of lung (Pan- costal muscles can easily be visualized (Figure 5). Ad- coast tumor), suprascapular nerve blockade yields ditionally, intercostal artery can easily be visualized highly successful outcomes. Suprascapular and axil- with Doppler, which provides great convenience. In lary nerves supply major innervation of the shoulder. various pain syndromes intercostal pulsed RF appli- These two nerves can readily be visualized with US[23] cations can provide successful analgesia that lasts (Figure 3). Visualizing suprascapular notch is essen- for approximately 6 months.[28]

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Ilioinguinal and Iliohypogastric nerve blockades: These nerves originate from Th12 and L1. Following lower abdominal operations and particularly inguinal her- nia operations, intractable neuropathic pain may de- velop along the trace of these nerves. Possibly more than one mechanism are responsible for these pain, like direct nerve trauma also accompanied by neu- roma and scar tissues. Trace of ilioinginal (ILI) and iliohypogastric (ILH) nerves may show important anatomical variations. Failure rates in classical anatomical landmark techniques are 10-45%.[29] Wrong guidance of blockade needle can result in femoral nerve blockade, pelvic hematoma and bowel perfo- Figure 6. Ilioinguinal and iliohypogastric nerve blockade (ILHY: ration. During visualization of these nerves with US, Iliohypogastric nerve; ILIO: Ilioinguinal nerve; A: Artery). external, internal oblique (EO, IO) and transverse abdominal (TA) muscles can easily be seen. ILI and ILH various ultrasonographic patterns (hyperechoic, hy- nerves trace along the fascial plane between IO and poechoic or mixed type) along its trace that shows TA muscles (Figure 6). great variations (under or through the inguinal ligament or over the iliac crest). Genitofemoral nerve blockade: The genitofemoral nerve (GF) arises from L1 and L2 nerve roots. GF nerve Piriformis muscle injection: Piriformis muscle origi- divides into genital and femoral branches above the nates from the level of S2–S4 and exits the pelvis via level of the inguinal ligament. The point of division is the greater sciatic foramen, inserting into the greater variable. GF nerve mainly provides cutaneous innerva- trochanter. Piriformis muscle is an abductor and ex- tion. It provides motor innervation only for cremasteric ternal rotator of hip, and also provides slight flexion muscle. Genitofemoral neuralgia is an iatrogenic injury to hip during walking. Piriformis Syndrome is an un- usually observed following operation to the inguinal common cause of pain in the buttock and leg. Some region. Genitofemoral neuralgia is a neuropathic pain authors call Piriformis Syndrome as “Pseudo-sciatal- syndrome manifested as scrotal pain in men and pain gia”. It may clinically be confused with other patholo- [30] in labium major and mons pubis in women. It is not gies of this area. US guided injection into piriformis easy to visualize the genital branch with US when it muscle was virtually a revolution because, successful is in inguinal canal. In men, genital branch may trace piriformis injection rate was 30% with fluoroscopy, inside or outside spermatic cord. It is possible to visu- but this rate has reached up to 95% with US.[33] Dur- alize the femoral branch easily just over mons pubis. ing US guided Piriformis muscle injection, posterior Lateral Femoral Cutaneous Nerve Block: Lateral femo- superior iliac spine, ileum, gluteus maximus muscle ral cutaneous nerve (LFCN) provides sensory inner- can be used as a landmark in the patient when ly- vation to the antero-lateral part of leg up to the knee. ing in prone position (Figure 7). Confirmation of the Complex of pain, numbness, tingling and paresthe- piriformis muscle can be made by having an assis- sia symptoms observed in this area is described as tant rotating the hip externally and internally with Meralgia Paresthetica. In one cadaveric study, LFCN the knee flexed. Anatomical relation of sciatic nerve blockade was performed at high rate as 84.2% using and piriformis muscle can show great variation. For US guidance, however this rate was 5.3% with clas- this reason, it has been recommended to use nerve sical landmark technique.[31] Fowler et al. performed stimulator during piriformis injection in order to pre- US guided PRF (42°C, 2x120 second) in a patient di- vent damage to sciatic nerve. agnosed with Meralgia Paresthetica who was unre- sponsive to various treatments.[32] They reported ex- Pudendal nerve blockade: The pudendal nerve arises cellent pain relief in controls at 1.5th and 3rd month. from S2 to S4, and passes through the greater sci- Authors report US provides great convenience in atic notch and interligamentous plane to enter the identification of LFCN. LFCN can be visualized in pelvis through Alcock’s canal. There are three termi-

JANUARY 2016 5 A RI PAIN nal branches; the dorsal nerve of the penis (clitoris), same time. During 6 months follow up period, good inferior rectal nerve, and perineal nerve. Pudendal analgesia and improvement in knee functions were nerve plays important role in the etiology of chronic observed. Knee has quite complex sensorial innerva- perineal pain. Apart from pathologies related to the tion, and no interventional method has been prov- anatomical trace of the nerve (Pudendal Entrap- en to be effective for the treatment of pathologies ment Syndrome), complex perineal pain syndromes of knee with chronic pain. During saphenous nerve can also be observed, such as Pudendal Neuralgia in blockade with US, anatomical landmarks are sartori- which etiology is not very clear.[34] In addition, many us muscle, femoral artery, vastus medialis muscle and pelvic interventions can cause injury to this nerve. adductor magnus muscle.[40] Chronic pain observed Various approaches have been described for puden- in middle part of the knee following total knee pros- dal nerve blockade (S2-S4 blockade, transgluteal thesis has neuropathic character. Adhesion and scars approach, transvaginal approach).[35–37] It is possible developing around infrapatellar nerve at postopera- to visualize pudendal nerve with US in extrapelvic tive period are the cause of this type of pain. Up to 6 localization. In patients undergoing TUR-P, it was re- months pain-free period has been reported by local ported that postoperative analgesia was better in US anesthetic + cortisone mixture administered around guided pudendal nerve blockade performed with infrapatellar nerve that is exposed by applying hy- transperineal approach.[38] During pudendal nerve drodissection at interfascial plane with US.[41] blockade with transperineal approach, ischiadicum tuberculum, sacrotuberous ligament and pudendal Genicular nerve blockade: In the first genicular nerve artery can be used as landmarks (Figure 8). The nerve RF study performed on older patients with osteo- can be reached with block needle under sacrotu- arthritis, 50% reduction in pain complaints was berous ligament. This approach can yield successful achieved for approximately 12 weeks.[42] Also, re- outcomes in patients with chronic pelvic pain due to markable improvement was reported in Oxford Knee various etiologies. scores. Application was done with fluoroscopy gui- dence. In another study using US, Vas et al. performed Saphenous nerve blockade: Saphenous nerve is the blockade on saphenous nerve, peripatellar, subsar- most important sensory branch of the femoral nerve. torial and popliteal plexus along with the genicular In chronic pain of anteromedial area of the knee like nerve.[43] PRF was applied on these predetermined saphenous neuralgia, saphenous nerve blockade is nerves and plexus for 8 minutes at 42°C. Remarkable an effective analgesic option. Vas et al. performed US improvement was observed in patient’s pain at rest guided PRF in two patients who had chronic postsur- and during activities for 6 months time. Additionally, gical pain after total knee replacement (TKR).[39] PRF there was also remarkable improvement in standing, was applied to saphenous, tibial, common peroneal walking and climbing step functions. nerves and peripatellar, subsartorial and popliteal plexus. Dry needling was performed with US at the Obturator nerve blockade: Advanced coxarthrosis

Figure 7. Piriformis muscle injection. Figure 8. Pudendal nerve blockade (New approach).

6 JANUARY 2016 Ultrasound guided chronic pain interventions and various malignancies are the major causes of Antonakakis JG, et al. Clinical sonopathology for the re- chronic hip pain. Hip joint is mainly innervated by gional anesthesiologist: part 2: bone, viscera, subcuta- LFCN, femoral and obturator nerves. US guided fem- neous tissue, and foreign bodies. Reg Anesth Pain Med 2010;35(3):281–9. oral and obturator nerve blockade techniques in pa- 8. Ozkan D, Akkaya T, Karakoyunlu N, Arık E, Ergil J, Koc Z, et tients with coxarthrosis have been first described by al. Effect of ultrasound-guided intercostal nerve block on Kawaguchi et al.[44] Favorable analgesia was achieved postoperative pain after percutaneous nephrolithotomy: in patients with conventional RF (80 seconds, 80°C). prospective randomized controlled study. Anaesthesist Similarly, good analgesia was achieved with US guid- 2013;62(12):988–94. ed conventional RF performed on obturator, femoral 9. Soneji N, Peng PW. Ultrasound-guided pain interventions - a review of techniques for peripheral nerves. Korean J Pain nerves and LFCN in patients who had metastatic hip 2013;26(2):111–24. [45] pain caused by lung cancer. In our pain clinic, US 10. Sites BD, Chan VW, Neal JM, Weller R, Grau T, Koscielniak- guided obturator nerve blockade (diagnostic or with Nielsen ZJ, et al. The American Society of Regional An- ablation techniques) is commonly performed alone esthesia and Pain Medicine and the European Society of or together with blockade of other nerves in obtu- Regional Anaesthesia and Pain Therapy joint committee rator neuralgia, adductor muscle spasm and some recommendations for education and training in ultrasound-guided regional anesthesia. Reg Anesth Pain Med chronic hip and knee pains. 2010;35(2 Suppl):74–80. 11. Shankar H, Pagel PS. Potential adverse ultrasound-relat- Ankle blockade: Foot and ankle are mainly innervated biological effects: a critical review. 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