1. Shawn Jorgensen, MD Albany Medical Center AAPM&R Annual Assembly October 2015

2. 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

3. 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?

4. Disclosures  None

5. Perineural injections  Not discussing nerve blocks for anesthesia  Usually local anesthetic and corticosteroid

6. 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)

7. Perineural injections  Carpal tunnel injections – USG vs LMG  Accuracy  No studies looking specifically at this

8. 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

9. 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)

10. 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)

11. 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)

12. Perineural injections  Carpal tunnel injections – USG vs. LMG  Summary  Limited evidence, but most and best of any US guided perineural injections  Suggests:  SAFETYSame (both are safe)  PAINLess  ACCURACYNo data  EFFICACYBetter (consistently in all studies, quicker, longer and stronger)  COST EFFECTIVE ? ( more in responders in one study)

13. 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

14. 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

15. Perineural injections  Ulnar nerve at the elbow  Accuracy  No studies looking specifically at this

16. 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)

17. 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

18. 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

19. Perineural injections  Ulnar nerve at the elbow  Summary  No comparisons of USG vs LMG  Studies on USG injections  SAFETY? (some worsening sx)  ACCURACYNo data  EFFICACY? (most improve, but no better than placebo in one trial)  COST EFFECTIVENESSNo data

20. 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

21. Perineural injections  Suprascapular nerve – USG vs. LMG  Accuracy  No studies looking specifically at this

22. 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)

23. Perineural injections  Suprascapular nerve – USG vs. LMG  Summary  Limited evidence  SAFETYBetter (significantly)  ACCURACYNo data  EFFICACYBetter  COST-EFFECTIVENESSNo data

24. 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

25. 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

26. Thank you!

27. 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