Chapter 25

1. Chapter25 Peripheral Joint, Soft Tissue & Spinal Injection Alireza Ashraf, M.D. Associate Professor of Physical Medicine & Rehabilitation Shiraz Medical school

2. 1901 Cathelin----epidural with cocain 1951 Hollander-----------------------hydrocortisone 1957 Lievre------------------------------------------------------------------------epidural with corticosteroid Robecchi& Capra---------------------S1

3. Pain sources within joints: capsule, tendons, ligaments, synovium and periosteum. Common spine pain : facet joint, sacroiliac joint, nerve root (spinal nerve) and intervertebral disk.

4. Rheumatoid arthritis,Osteoarthritis Spondyloarthropathies,Gout, Pseudogout,Bursitis,Adhesive capsulitis,Tendonitis,Axial spine pain,Sympathetic-mediated disorders andRadiculopathy.

5. INJECTION MATERIALS

6. .The mechanism that allows local anesthetics to provide pain relief is the reversible neural blockade… • blocking sodium channels…….

7. Local anesthetics • Local anesthetics can have side effects locally or systemically • seizures,respiratory arrest,convulsions,confusion,death ,tremor,sluggishness,twitches, drowsiness,blurred vision,incoherent speech,light-headedness,cardiac depression,malignant hypertension, and anaphylaxis.

8. Corticosteroid • Corticosteroids have two mechanisms: antiinfiammatory & immunosuppressive.

9. Corticosteroids have been utilized for treatment of musculoskeletal pain because of their antiinflammatory properties………………………………………………. • They have also been reported to have a direct membrane-stabilizing effect, which leads to decreased afferent ectopic discharges at the neural membrane…………..

10. There is a reversible inhibition of nociceptive C-fiber transmission with local application of corticosteroids.there has been no demonstration of AorB fiber transmission interruption……………….. • Corticosteroids have a modulation effect on spinal cord……………………….

11. Betamethasone, Dexamethasone, Hydrocortisone, Methylprednisolone, Prednisolone and Triamcinolone.

12. Adverse corticosteroid reactions Skin hypopigmentation,subcutaneous fat atrophy,tendon rupture,fluid retention, flushing,hyperglycemia,change in taste, insomnia,malaise and dyspepsia………………………………………… Systemic suppression of the adrenal glands can happen after a local injection of corticosteroids into any structure……… Repeated injections of corticosteroids can lead to a cushingoid appearance…………….

13. Non-ionic contrast agents include metrizamide(Amnipaque), iopamidol(Isovue), andiohexol(Omnipaque)……………. • These are used in conjunction with fluoroscopy for needle tip localization in performing spinal injection procedures and some peripheral joint injections……………….. • The use of contrast significantly reduces the risk of an unintended injection into a vascular area, blood vessel or subarachnoid space………………

14. The adverse effects that can result from the use of contrast agents are due to local tissue toxicity and to anaphylaxis…………………………………………………….. • Greater than 90% of adverse reactions occur within the first 15 min……………………………………………………. • other side effects :nausea, headache, and emesis….. • Pretreatment is recommended with steroids and antihistamines 12 h, and again at 2 h, prior to the procedure in patients with an allergic reaction history……………….

15. Gadolinium is a viable alternative for patients with contrast material allergies, and provides adequate visualization for spinal injection procedures………………………

18. GENERAL CONSIDERATIONS • Answer all questions. provide the patient with a clear explanation of the risks and benefits……………………………………………… • Caution should always be used to avoid the risk of bleeding. Patients using aspirin should discontinue it for at least 7 days. If patients cannot tolerate being off aspirin, a non-selective NSAID can be substituted for at least the 3 days prior to any injection… • Women who are pregnant or suspected to be pregnant should avoid radiation exposure from fluoroscopy………………….

19. The patient is properly positioned on the procedure table before beginning the injection………………………………………………… • Prepare and drape the injection site in a sterile manner with povidone-iodine (Betadine), chlorhexidine gluconate (Hibiclens), and/or isopropyl alcohol…………. • Sterile gloves are worn during the injection procedure…………………………………. • Gown, cap, and mask are used when performing myelography and diskography….

20. Intravenous or oral antibiotics are used when performing injection procedures in patients with implanted prosthetic devices or with a history of mitral valve prolapse……. • The injection site can be anesthetized for patient comfort with a vapocoolant spray OR anesthetic creamprior to injection………………….

21. The needle is always aspirated via the syringe before the injection to avoid an intravascular or, in the case of some spinal procedures, an intrathecal injection………… • Avoid injecting into a ligament, a tendon, or the periosteum. This means repositioning the needle if there is significant resistance……………………………… • Avoid needle contact with articular cartilage surfaces during joint injections…………………………………………..

22. The injection is given slowly, with steady pressure………….. • A dressing is applied to the injection site after the injection is completed………. • The patient is encouraged to rest the area after the injection for several days, especially if it is a major weight-bearing joint…………… • All patients should be driven home and should not drive for the next…………

23. CONTRAINDICATIONS • Absolute contraindications Bacteremia*** Joint infection*** Cellulitis*** Skin ulcerations*** Osteomyelitis*** Infectious arthritis*** Epidural abscess*** Joint injections requiring fluoroscopy in the pregnant patien**********************

24. Relative contraindications Chronic infection distant from the injection** Allergy to the injection solution ** Latex allergy ** Diabetes mellitus ** Allergy to contrast agents for fluoroscopically ** Altered anatomy( surgery or congenital ) **

25. Tendons and ligaments can be ruptured if corticosteroids are injected directly into them (this is estimated to occur in less than1%of such cases)…………………………..

26. Patients requiring anticoagulation medication or with a known bleeding diathesis should be approached with a great deal of caution………………………….. • Coagulation parameters should be evaluated in these cases, including : prothrombin time,,,,activated partial thromboplastin time,,,, international normalized ratio (INR) and platelet level count……

27. Injections should be avoided with prolonged bleeding times, an INR greater than 1.2 and a platelet count of less than 100 000 per ml…….

28. EFFICACY • Improvement in rheumatoid synovitis has been seen to last for as long as 3 months after injecting glucocorticoids, with improvement in pain and in knee extensor strength…………………………………….

29. intraarticular injections of hyaluronan(hyaluronic acid,,,,,, hyaluronate) were more effective than placebo in reducing pain and improving joint function from osteoarthritis of the knee……………

30. A small randomized controlled trial found no significant difference between intraarticular injections of methylprednisolone plus lidocaine (lignocaine) versus lidocaine alone for the treatment of shoulder pain, although there was a small improvement in pain and range of motion in both groups at 24 weeks……………………………….

31. Acromioclavicular joint • The injection is performed with the patient in the seated position with the upper limb resting comfortably………………………………. The acromioclavicular joint is located at a depressed and soft region distal to the end of the clavicle……………………………………..

32. The injection site is anterior and superior to acromioclavicular joint ……………………………………… The needle is then advanced inferiorly into the joint……………..

34. Glenohumeral joint • The glenohumeral joint is typically injected from either an anterior or a posterior approach……………………… • In the anterior approach, a needle is inserted lateral to the coracoid process while avoiding the thoracoacromial artery .The needle is then directed dorsally and medially into the joint space…………

35. The posterior approach is set up by placing the patient's hand across the chest on the opposite shoulder. The needle is inserted 2-3 cm below the posterolateral aspect of the acromion. The needle is then advanced toward the coracoid process in an anterior and medial direction into the joint.

37. Subacromial bursa • The subacromial bursa lies above the supraspinatus tendon and under the acromion…………………………………………….. • A posterolateral approach is used to place the needle into the subacromial space.The needle is inserted underneath the palpable posterolateral cornerof the acromion and advanced toward the coracoid process,which places the needle tip under the acromion………………………….

39. Ulnohumeral(elbow)joint • The elbow joint consists of three articulations between the humerus, ulna and radius, with the true elbow joint formed by the humerus and ulna…………. • Injection of the ulnohumeral joint is accomplished from a posterolateral or posterior approach with the elbow flexed between 50 and 90°…………………..

40. In posterolateral approach, the needle is inserted in the posterolateral triangle formed by the palpable olecranon, lateral epicondyle and radial head ………………………………………………… • The needle is directed medially away from the ulnar nerve and proximally toward the head of the radius. A lack of resistance indicates entry of the needle tip into the joint………………………………….

41. The posterior approach to the elbow joint involves inserting the needle in between the posterior olecranon and lateral epicondyle, advancing the needle until there is a loss of tissue resistance (indicating that the needle tip is within the joint)………………………….

43. Medial and lateral epicondyle • Medial epicondylitis or 'golfer's elbow', results from tendonosis or degenerative changes at the tendon attachment of the wrist flexor and pronator muscle groups. The elbow is positioned in abduction,with the forearm in supination.A needle is inserted at the site of tenderness along the medial epicondyle and advanced until there is contact with the periosteum.The needle is slightly withdrawn before the injection……………

44. Lateral epicondylitis or 'tennis elbow', is a tendonosis from repetitive wrist extension and forearm supination. The elbow is flexed to 45° and the forearm is placed in pronation. A needle is inserted at the point of tenderness along the lateral epicondyle and advanced to the periosteum………..

46. Olecranon bursa • Olecranon bursitis or 'draftsman's elbow', occurs in RA, crystal arthropathies, and repetitive trauma. The needle is directed toward the olecranon bursa, which is superficial to the olecranon and external to the elbow joint …………………. • Injection of the olecranon bursa should be preceded with aspiration and no corticosteroids should be injected if there is a purulent discharge……………….

48. Carpal tunnel • Injection of the carpal tunnel can be approached inulnar orradial orientation, based on positioning relative to the palmaris longus tendon………………………………………….. • The ulnarapproach is preferred. it is less likely to injure the median nerve during the injection. The wrist can be flexed to increase the prominence of the palmaris longus tendon…………….

49. A needle is inserted with the wrist in a neutral position at a 30° angle ulnar to the palmaris longus tendon at the distal wrist crease .The needle is then advanced in a distal and radial direction underneath the transverse carpal ligament. The needle is withdrawn if paresthesias are experienced during the insertion, and redirected within the tunnel……..