Ultrasound-guided Injection of the Levator Scapulae Muscle in a Cadaver Model

BACKGROUND

Despite the advantages of ultrasound and previous anatomical data on neuromuscular junction locations, to the best of our knowledge, the feasibility and accuracy of precise ultrasound-guided injection techniques into the proposed injection site of botulinum neurotoxin for the levator scapulae muscle have not been assessed in any publication.

OBJECTIVE

In the present cadaver-based study, the ultrasound-guided injection technique in the middle and distal portions of the levator scapulae muscle was evaluated to determine whether this method distributes injections properly to the target muscle in fresh cadavers.

STUDY DESIGN

Cadaveric study.

SETTING

A cadaver laboratory.

METHODS

Twenty fresh cadavers were used. Real-time B-mode ultrasound scanning was performed interfaced with a linear array transducer. A mixture of 0.5 mL of dye and yellow filler was injected transverse in-plane with a 6 cm 21-G. needle. Each specimen was dissected to determine whether the dye was correctly targeted to the middle and distal portions of the levator scapulae muscle and to evaluate the accuracy of the injections and any complications.

RESULTS

All 40 injections were successfully injected within the middle and distal portions of the levator scapulae muscle. When dissecting the cadavers, the dye spread was evenly distributed along the muscle fiber.

LIMITATION

Despite successful injection into the middle and distal portions of the levator scapulae muscle, the usefulness of this technique was not verified in clinical practice.

CONCLUSIONS

The ultrasound-guided injection technique presented in this study might facilitate precise visualization and localization of the levator scapulae muscle, thereby enhancing the effectiveness and safety of botulinum neurotoxin treatment in cervical dystonia.

Point-of-care ultrasound in general practice: an exploratory study in rural South Australia

INTRODUCTION

Access to ultrasound imaging services is limited in rural areas and point-of-care ultrasound (POCUS) has the potential to address this gap. We aimed to examine how POCUS is utilised by doctors in contemporary Australian rural general practice.

METHODS

A portable ultrasound machine and access to a training course were provided to four general practices in rural South Australia, and the type and frequency of POCUS scans were recorded, along with user information, between July 2020 and June 2021. Participating general practitioners (GPs) completed a survey at the commencement of the study regarding their previous experience and confidence in using POCUS for specific assessments and procedures.

RESULTS

Of the 472 scans recorded, most (95%) were for clinical indications, 3% for teaching activities and 2% for self-learning. Overall, 69% were obstetric scans, followed by abdominal (12%), gynaecological procedures (10%), other procedural (7%) and thoracic exams (1.5%). Users reported higher confidence for lower complexity POCUS.

CONCLUSION

Although POCUS has diverse potential applications in rural practice, GPs reported limited confidence for certain scans and used POCUS predominantly for obstetric indications. Further studies should examine the barriers to POCUS utilisation, with particular attention to training requirements, reimbursement for use and access to machines.

Comparing the quality of analgesia with ultrasound-guided pectoral nerve block and serratus anterior plane block II in patients undergoing modified radical mastectomy: a randomised clinical trial

INTRODUCTION

Despite the recent use of serratus anterior plane (SAP) and pectoral nerve (PECS) blocks for pain management following breast surgery, there are insufficient data comparing their analgesic benefits. This study aimed to compare the quality of analgesia for PECS and SAP blocks in patients having modified radical mastectomy (MRM).

MATERIAL AND METHODS

This trial enrolled 50 adult female patients scheduled for MRM under anaesthesia. Patients were randomly allocated to two groups. After induction of anaesthesia, 25 patients received US-guided PECS II block, and 25 patients received US-guided SAP block. The primary outcome was the time to first analgesic request. Secondary outcomes included the total analgesic consumption and postoperative pain during the first 24 hours as well as the total time to perform the block, surgeon satisfaction, haemodynamic parameters, and postoperative nausea and vomiting.

RESULTS

Time to first analgesic request was significantly longer in the SAP group than in the PECS II block group (95% CI: 90.2-574.5, P = 0.009). The SAP block significantly lowered the total analgesics consumption, the 24 hours patient's need for analgesia, and the VAS scores immediately, as well as at 2, 8, 20, 22, and 24 hours postoperatively ( P < 0.005). Although it required a longer preparation time than PECS II block, the SAP block had comparable surgeons' satisfaction, haemodynamic parameters, and post-operative nausea and vomiting to PECS II block.

CONCLUSIONS

Following MRM, US-guided SAP block provided a delayed time to first rescue analgesia with better acute pain control and lower total analgesic consumption compared to the PECS II block.

Comparative Efficacy of Rotator Interval Versus Posterior Capsule Approach Intraarticular Corticosteroid Injections for Primary Frozen Shoulder: A Single-blind, Randomized Trial

BACKGROUND

Intraarticular (IA) corticosteroid injection is commonly performed in patients with primary frozen shoulder (PFS). However, the best administration site remains controversial.

OBJECTIVES

To compare the efficacy of rotator interval (RI) vs posterior capsule (PC) approach for ultrasound-guided corticosteroid injections into the glenohumeral joint of patients with PFS.

STUDY DESIGN

A randomized, exploratory, prospective study.

SETTING

A single fellowship training institution in Daegu, Republic of Korea.

METHODS

This study was approved by the Institutional Review Board (2019-04-047-001).  Ninety patients with PFS were randomly assigned to either RI approach (RI group, n = 43) or PC approach (PC group, n = 45) for ultrasound-guided IA corticosteroid injection. Fluoroscopic images to assess the accuracy of the injection were obtained immediately after injection by a shoulder specialist. Visual Analog Scale for pain, the American Shoulder and Elbow Surgeons score, the subjective shoulder value, and range of motion (ROM) were used to assess clinical outcomes for all patients at the time of presentation, and at 3, 6, and 12 weeks after injection.

RESULTS

The accuracy of injection was 76.7% (33/43) and 93.3% (42/45) in the RI and PC groups, respectively; the between-group difference was statistically significant (P = .028). Significant improvements were observed in both groups in terms of all clinical scores and ROMs throughout follow-up until 12 weeks after the injection (all P < .001). At 12 weeks, better improvements in forward flexion and abduction (P = .049 and .044) were observed in the RI group than in the PC group. No adverse effect related to injection was observed in either group.

LIMITATIONS

This study had no control group receiving placebo injections and limited follow-up time.

CONCLUSIONS

Both groups showed significant pain reduction and functional improvement until 12 weeks after injection. Although no significant differences were observed in pain and functional scores between the 2 groups, the RI group showed better improvement of ROM than the PC group. These results indicate that the RI and anterior structures are a major site in the pathogenesis and treatment target of PFS.

Predicting Epidural Space Spread Using Ultrasound Color Doppler Imaging in Interlaminar Epidural Steroid Injection: A Prospective Observational Study

BACKGROUND

While the use of fluoroscopy-guided transforaminal epidural steroid injection (TFESI) to help spread the injectate toward the ventral side has increased, this procedure has a radiation risk. Recently, ultrasound has been widely used in the medical field; among ultrasound methods, color Doppler is useful for predicting the direction of the injectate.

OBJECTIVE

This study describes a novel technique employing color Doppler to help predict epidural space spread in interlaminar epidural steroid injection (ILESI).

STUDY DESIGN

Prospective observational study.

SETTING

The study took place at a single pain clinic within a medical center in Jeonju, Republic of Korea.

METHODS

We enrolled 35 patients scheduled for lumbar epidural steroid injection (ESI).  Ultrasound-guided epidural lateral parasagittal interlaminar injection was performed and real-time images using color Doppler were recorded during injections of 5 mL of 0.1% ropivacaine containing contrast dye with dexamethasone 5 mg (1 mL). Fluoroscopy-guided TFESI was performed if it was difficult to perform the procedure based on ultrasound images.

RESULTS

The analysis included 30 images from 30 patients. The observed sensitivity, specificity, positive predictive value, and negative predictive values of the ultrasound color Doppler were 100%, 89.5%, 84.6%, and 100%, respectively. The agreement with ultrasound color Doppler was 93.3%.

LIMITATIONS

The sample size was relatively small.

CONCLUSION

The main advantage of ultrasound-guided ILESI is the lack of radiation exposure and contrast medium requirement. Color Doppler may be a reliable imaging modality to predict epidural space spread during ultrasound-guided ILESI. It is worth predicting the spread in the anterior epidural space (AES) by first attempting ultrasound-guided ESI. If the injectate has not spread to the AES, fluoroscopy-guided TFESI may be a good option after confirming improvement of the patient's symptoms.

[Predictive value of comprehensive preoperative evaluation for the outcome of TURP]

Objective

To evaluate preoperative comprehensive examinations of the IPSS-voiding to storage subscore ratio (IPSS-V/S), maximum urinary flow rate (Qmax), intravesical prostatic protrusion (IPP) and postvoid residual urine volume (PVR) in predicting the outcome of transurethral resection of the prostate (TURP) for BPH.

METHODS

This retrospective study included 103 cases of BPH treated by TURP in Yixing People's Hospital from December 2018 to December 2019. The patients averaged 71.92 ± 7.73 years of age, with a mean prostate volume of (58.34 ± 15.59) ml, preoperative IPSS of 23.38 ± 3.36, voiding score of 14.38 ± 2.69, storage score of 9 (8－10), V/S ratio of 1.67 (1.43－1.88), Qmax of 7 (5－8) ml/s, IPP of 4 (0－5) mm, and PVR of (117.03 ± 20.51) ml. The TURP operations were completed by the same surgeon, with mean operation time of (83.65 ± 14.31) min and intraoperative blood loss of (55.32 ± 18.92) ml. The patients were followed up for 3 months after surgery for evaluation of the outcomes based on the IPSS and quality of life (QOL) scores.

RESULTS

The postoperative IPSS was significantly improved in all the patients compared with the baseline (5.36 ± 1.95 vs 23.38 ± 3.36, P < 0.05). Based on the criteria of IPSS < 7 and general satisfaction with QOL, satisfactory results were achieved in 71 (68.93%) of the patients (aged 71.04 ± 7.23 years, prostate volume: ［59.68 ± 15.79］ ml, IPSS: 23.87 ± 3.42, voiding score: 14.87 ± 2.34, storage score: 9 ［8－10］, V/S ratio: 1.67 ［1.47－1.86］, Qmax: 6 ［4－7］ ml/s, IPP: 5 ［0－6］ mm, PVR: 110.53 ± 17.69 ml, operation time ［85.37 ± 12.28］ min, intraoperative blood loss: ［58.08 ± 14.61］ ml), and unsatisfactory results in the other 32 (31.07%) (aged 76.91 ± 8.25 years, prostate volume: ［55.38 ± 14.73］ ml, IPSS: 22.53 ± 3.25, voiding score: 13.53 ± 3.21, storage score: 9 ［8－12］, V/S ratio: 1.36 ［1.03－1.95］, Qmax: 8 ［7－9］ ml/s, IPP: 0 ［0－5］ mm, PVR: ［129.61 ± 20.62］ ml, operation time: ［78.85 ± 10.04］ min, intraoperative blood loss: 48.76 ± 12.19 ml).

CONCLUSIONS

TURP yields better results in younger BPH patients, with baseline IPSS dominantly in urinary symptoms, greater IPP, lower PVR, and lower Qmax.

Evaluation of Increased Intracranial Pressure with the Optic Nerve Sheath Diameter by Ultrasound in Epiduroscopic Neural Laser Discectomy Procedures

BACKGROUND

In order to clarify the camera image and open the adhesions mechanically during epiduroscopy, saline is injected continuously in the epidural area. As a result, an increase in intracranial pressure is to be expected in theory. Increased intracranial pressure can be evaluated by measuring by optic nerve sheath diameter.

OBJECTIVES

This study was designed to evaluate the relationship between optic nerve sheath diameter measurements and intracranial pressure, after injecting fluid to the epidural area during epiduroscopy procedures performed in our clinic.

STUDY DESIGN

Retrospective study.

SETTING

Sakarya University Training and Research Hospital.

METHODS

During the epiduroscopy procedure, pre and postoperative bilateral optic nerve sheath diameters were measured with an ultrasonography probe. With the patients' eyelids closed, the probe was placed on the orbita in the sagittal plane, measuring 3 mm posterior of the papilla.

RESULTS

While there was a statistically significant difference between pre- and post-operative optic nerve sheath diameter measurements, there was no significant correlation with processing time, amount of fluid delivered, or fluid delivery rates.

LIMITATIONS

One of the limitations of this study is the retrospective collection of data. A second limitation is that repetitive measurements were not performed, instead of a single postoperative measurement.

CONCLUSION

We think more prospective randomized controlled studies are required to examine the increase in the diameter of the optic nerve sheath, which is an indirect indicator of increased intracranial pressure after epiduroscopy applications, in order to determine whether the pressure increase is associated with the rate of fluid delivery, the total fluid amount, or the processing time.

[Ultrasonographic and clinical features of common testicular germ cell tumors in children]

OBJECTIVE

To study the ultrasonographic manifestations and clinical features of common pediatric testicular germ cell tumors (TGCT) in children.

METHODS

We retrospectively analyzed the laboratory, ultrasonographic and clinical data on 92 children with TGCT diagnosed in Shanghai Children's Hospital from March 2013 to January 2019, and investigated the values of the serum alpha-fetoprotein (AFP) level and maximum diameter of tumors in the diagnosis of benign and malignant tumors using the ROC curve.

RESULTS

Of the 92 cases of pediatric TGCT, 64 (69.6%) were pathologically confirmed as benign tumors, including 40 cases of teratoma (62.5%), 18 cases of epidermoid cyst (28.1%) and 6 cases of dermoid cyst (9.4%), and the other 28 (30.4%) as malignant neoplasms, including 26 cases of yolk sac tumor (YST, 92.9%) and 2 cases of mixed germ cell tumor (MGCT, 7.1%). Ultrasonography showed that 62.5% of the teratomas were cystic-solid mixed (25/40) and 32.5% solid masses (12/40), that 33.3% of the epidermoid cysts exhibited a typical sign of "onion ring" (6/18) and 22.2% that of capsular calcification (4/18), and that 42.3% of the YSTs displayed isoechoic (11/26), 30.9% hypoechoic (8/26) solid masses without calcium and 26.9% cystic anechoic lesions (7/26). Color Doppler blood flow imaging manifested abundant blood flow signals in most of the YSTs (25/26, 96.2%) but none in either the epidermoid or the dermoid cysts. The area under the ROC curve (AUC) of the serum AFP value was 0.985, with an optimal cutoff value of 124.2 ng/ml, and the sensitivity and specificity of AFP in the diagnosis of benign and malignant tumors were 92.9% and 93.7%, respectively. The AUC of the maximum diameter of the tumors was 0.796, with an optimal cutoff value of 2.7 cm, and the sensitivity and specificity of the maximum diameter of the tumors in the diagnosis of benign and malignant neoplasms were 57.1% and 93.7%, respectively.

CONCLUSIONS

Ultrasonographic images have different characteristic manifestations for different pathological types of pediatric TGCT. Pediatric TGCT has a good prognosis and radical orchiectomy should be considered for the treatment of the tumors with serum AFP ≥ 124.2 ng/ml and a diameter ≥ 2.7 cm.

[16-gauge vs 18-gauge puncture needle for transrectal ultrasound-guided prostate biopsy in the diagnosis of prostate cancer: Effect and complications]

OBJECTIVE

To compare the efficiency and complications of transrectal ultrasound (TRUS)-guided prostate biopsy with a 16-gauge (16G) or an 18G puncture needle in the diagnosis of PCa.

METHODS

This prospective randomized controlled study included 142 male patients undergoing TRUS-guided prostate biopsy in our hospital, 71 with the 16G and the other 71 with the 18G puncture needle. We compared the post-puncture incidence rates of hematuria, bleeding and infection between the two groups of patients and classified the complications according to the Clavien-Dindo scores.

RESULTS

The detection rate of PCa was significantly lower in the 18G than in the 16G group (12.68% vs 36.62%, χ2 = 10.958, P = 0.001), even with f/tPSA ≤ 0.15 (8.51% vs 44.44%, χ2 = 12.617, P = 0.001), but showed no statistically significant difference between the two groups with f/tPSA > 0.15 (P<0.05). No post-puncture infection was observed in any of the patients. There were no statistically significant differences between the 18G and 16G groups in the incidence rates of rectal bleeding (21.13% vs 15.49%, χ2 = 0.753, P = 0.385) and urethral bleeding (18.31% vs 16.90%, χ2 = 0.049, P = 0.826), nor in Clavien-Dindo grades (26 vs 20 cases of grade I; no grade II in either group; 2 vs 3 cases of grade III ; Z = －0.698, P = 0.458).

CONCLUSIONS

The 16G puncture needle can achieve a higher detection rate of PCa than the 18G needle in TRUS-guided prostate biopsy without increasing the incidence of complications.

[Laparoscopic percutaneous extraperitoneal closure does not affect vas deferens orientation or testicular volume and perfusion]

OBJECTIVE

To investigate the influence of single-port laparoscopic percutaneous extraperitoneal closure (LPEC) on the orientation of the vas deferens and the volume and perfusion of the testis in pediatric patients undergoing inguinal hernia repair.

METHODS

A total of 92 consecutively enrolled boys diagnosed with unilateral inguinal hernia underwent single-port LPEC between June 2013 and June 2014. The orientation of the vas deferens and the testicular volume and perfusion of the patients were ultrasonographically assessed preoperatively and at 1 and 6 months after surgery.

RESULTS

All the surgical procedures were performed successfully without conversion or serious perioperative complications. Ultrasonography showed no angulation or distortion of the vas deferens on the surgical side during a six-month follow-up period. Similarly, no obvious changes were observed in the testicular volume or perfusion.

CONCLUSIONS

Single-port LPEC is safe and effective in the treatment of pediatric inguinal hernia and does not affect the orientation of the vas deferens or testicular volume and perfusion.