Faculty Bibliography

Purpose: Assess the impact of MR pelvic and lumbosacral neuorgraphy on ultrasound-guided pelvic perineural injections. Materials and Methods: A retrospective review of all ultrasound-guided pelvic perineural injections with prior MR pelvic and/or lumbosacral neurographic imaging over a 5-year period was performed. Demographics, presence of structural pathology on imaging, and immediate and interval pain relief was recorded. Results: 30 total injections were performed among 20 patients accounting for multiple injections in a single visit or multiple visits [mean age at injection: 52.03 (range 23-77), female (n= 24, 80%) male (n=6; 20%)]. In 24 cases a combination of steroid and anesthetic solution was administered. In the remaining 6 cases, only anesthetic solution was administered. Most commonly, injections involved the sciatic nerve (n = 21; 70%). Other injections in our series include pudendal (n=5, 16.7%), genitofemoral (n=2; 6.7%), lateral femoral cutaneous (n=1, 3.3%) and ilioinguinal (n= 1, 3.3%) nerves. Concurrent therapeutic procedures were performed in 10 cases (33%). Pre-procedure MR imaging revealed structural abnormality of the nerve or adjacent soft tissues in 11 of 22 MRIs performed amongst the 20 patients (50%). Pre-procedure ultrasound revealed structural abnormalities associated with the nerve in 9 cases of 19 cases that had complete documentation (47%). Of 26 injections with complete documentation, immediate improvement of symptoms was reported in 22 cases (85%). The remaining 4 cases either began with no pain (n=3), or reported no change in symptoms (n=1). Variable degrees of long-term symptom relief was achieved in 4 injections out of 11 steroid injections for which follow-up was available (37%). Conclusion: Ultrasound-guided perineural injections can be performed for treatment of a variety of pelvic neuropathies. MR imaging prior to sonographic intervention demonstrated an abnormality in nearly half of cases, and is a useful tool to appropriately target perineural injections

Purpose: To correlate quantitative shear wave velocities (SWV) in the supraspinatus muscle (SSM) with that of the tendon (SST), and to evaluate whether SSM SWV changes precede morphologic fatty atrophy. Materials and Methods: An IRB-approved, HIPAA-compliant study of 45 patients (22 men, 23 women) with mean age of 59 (range 39-84) was conducted. Grayscale ultrasound and shear wave elastography images of the SST and SSM were performed with a 9MHz linear transducer on a Siemens S3000 scanner with VTIQ software (Siemens). Sample volume SWV values were obtained of the proximal (PSST) and distal tendon (DSST). Mean SSM SWV was reported from the software region of interest or calculated from sample volumes. Exclusion criteria included history of rotator cuff repair and non-target measurements on bone or peribursal fat. Qualitative tendon pathology grading was as follows: 1=normal or mild tendinosis without tear, 2=moderate or severe tendinosis without tear or mild tendinosis with low-grade partial tear, 3=partial tear with at least moderate tendinosis, and 4=full-thickness tear. All patients demonstrated normal grayscale appearance of the SSM, without evidence of fatty atrophy. Pearson and Spearman rank correlations were used for statistical analysis. Results: No statistically significant correlation was found between mean SSM SWV and mean PSST, DSST, or overall tendon SWV (R=0.14, p=0.396; R=0.04, p=0.832; R=0.06, p=0.731, respectively). There was no statistically significant correlation between SSM SWV and tendon grade (R=0.13, p=0.435). Mean PSST, DSST, and overall tendon SWV demonstrated weak negative correlation with qualitative tendon grade (R=-0.22, p=0.183; R=-0.32, p=0.054; R=-0.30, p=0.045, respectively). Conclusion: Supraspinatus muscle SWV does not appear to vary with quantitative tendon SWVor qualitative tendon grading. Aweak negative correlation between supraspinatus tendon SWV and qualitative tendon grade is compatible with tendon softening with progressive tendinopathy

We describe an easily constructed, customizable phantom for magnetic resonance imaging-ultrasound fusion imaging and demonstrate its role as a learning tool to initiate clinical use of this emerging modality. Magnetic resonance imaging-ultrasound fusion can prove unwieldy to integrate into routine practice. We demonstrate real-time fusion with single-sequence magnetic resonance imaging uploaded to the ultrasound console. Phantom training sessions allow radiologists and sonographers to practice fiducial marker selection and improve efficiency with the fusion hardware and software interfaces. Such a tool is useful when the modality is first introduced to a practice and in settings of sporadic use, in which intermittent training may be useful.

The aim of this study was to assess changes in shear wave velocity within the pronator quadratus muscle in patients following volar plate fixation for distal radial fractures compared to the contralateral nonoperated side. Shear wave velocity values were obtained in the short and long axis of the pronator quadratus muscle, which were analyzed separately. Patients were also stratified by age below or above 66 years. Statistical analysis was performed using paired sample Wilcoxon signed rank and t tests. Pearson and Spearman rank correlations were also used. Seventeen patients (nine women and eigth men; age range 33-82, mean 62.4 years) were prospectively assessed following open reduction volar plate fixation of distal radial fracture. A statistically significant reduction in the velocities of the treated versus the nontreated side was observed in the long axis of the muscle (3.29 versus 3.59 m/second; t test p = 0.035). The data provide evidence for shear wave elastography as a quantitative measure to assess postoperative changes in muscle and a potential tool to monitor the efficacy of rehabilitation.

PURPOSE: To correlate shoulder ultrasound and radiography with F-FDG PET-CT to establish FDG uptake and therefore range of metabolic activity, as defined by SUV analysis, in various symptomatic shoulder pathologies. METHODS: Retrospective database query was performed for shoulder ultrasound and PET-CT scans between January 2012 and January 2017. Patients who had both studies within 1 year were included. Age- and sex-matched control patients with PET-CT scans only were also included. Retrospective image review determined shoulder pathology, and F-FDG SUVmax was measured using regions of interest placed at the glenohumeral joint, rotator cuff/bursa, and bicipital groove. Glenohumeral and acromioclavicular osteoarthrosis was assessed by radiography using the Kellgren-Lawrence classification system. RESULTS: Thirty-three patients had both imaging studies within 1 year. Ten patients (11 cases) were included, ranging in age from 56 to 90 years (mean, 67.9 years). Control subjects were selected among patients receiving PET-CT within 1 week of symptomatic patients. Glenohumeral osteoarthrosis was mild in 3 (27%), moderate in 2 (18%), and severe in 2 (18%). Six full-thickness rotator cuff tears (55%) were identified. SUVmax means were compared between the pathologic and control groups and were significantly higher in the former: glenohumeral joint (1.96 vs 1.32; P = 0.016), rotator cuff/bursa (2.80 vs 2.0; P = 0.005), and bicipital groove (2.19 vs 1.48; P = 0.007). The highest values were seen in full-thickness rotator cuff tear and severe biceps tenosynovitis. CONCLUSIONS: Increased metabolic activity about the shoulder is associated with a spectrum of rotator cuff, glenohumeral joint, and other soft tissue pathology that can be correlated with diagnostic ultrasound findings.

PURPOSE: Injury to the anterolateral ligament (ALL) of the knee has recently received attention as a potential risk factor for failure of anterior cruciate ligament reconstruction. However, evaluation of the anterolateral ligament is currently difficult, and radiologic data are sparse with regard to the normal appearance of this ligament. The purpose of the present study was to determine whether the ALL could be identified and visualized using ultrasonography. METHODS: Ten non-paired, fresh-frozen cadaveric knees underwent ultrasound by an experienced musculoskeletal radiologist using a Siemens S2000 Acuson Ultrasound machine with a 14-MHz linear transducer. After first identifying anatomical landmarks by palpation, a thin band of tissue originating in the vicinity of the fibular collateral ligament (FCL) origin was identified and followed up distally. The tibia was held at 30 degrees of flexion and internally rotated to verify tightening of the structure. Under ultrasound guidance, 25-gauge hypodermic needles were placed at what were sonographically determined to be the origin and insertion points of the ligament. One-tenth of a CC of aniline blue dye was injected. The specimens were then dissected to confirm the presence and location of the ALL. If an ALL was found, distances between the epicentre of the injected dye and the actual origin and insertion points were calculated. Additionally, ligament length based on dissection images and ultrasound images was calculated. RESULTS: Eight of ten specimens had an anterolateral structure that originated from the lateral femoral epicondyle just posterior and superior to the origin of the FCL and inserted on the lateral plateau approximately halfway between Gerdy's tubercle and the fibular head. The average length based on ultrasound was 3.8 cm (+/-.7; range 3.1-4.7) and 4.1 cm (+/-1.1; range 2.6-6.1) based on dissection. Length based on dissection and ultrasound had minimal agreement (ICC = .308; 95 % confidence interval .257-.382, p = .265). The average width of the structure on dissection was .8 cm (+/-.24; range .5-1.2). The mean distance from ultrasound-determined origin and insertion points to anatomical origin and insertion based on dissection was 10.9 mm (+/-2.9, range 7.0-15.8) and 12.5 mm (+/-5.7 range 3.2-19.3), respectively. Inter-observer reliability was excellent for all measurements based on dissection and ultrasound. CONCLUSION: Ultrasound was unable to reliably identify the anterolateral structure from its femoral to tibial attachment sites. Distinguishing it from the posterior IT band and anterolateral capsule was challenging, and it is possible that the structure is a thickened band of fascia rather than a true ligament. As a clinical diagnostic tool, ultrasound likely offers little utility in the evaluation of the ALL for injury. LEVEL OF EVIDENCE: IV.

OBJECTIVE: To describe a 4-year clinical experience with ultrasound-guided therapeutic perineural injections of peripheral nerves about the foot and ankle. MATERIALS AND METHODS: Retrospective analysis of foot and ankle perineural injections performed between January 2012 and August 2016. Demographics, clinical indications, presence of structural pathology, immediate and interval pain relief, as well as complications were recorded. RESULTS: Fifty-nine therapeutic injections were performed among 46 patients, accounting for multiple injections in a single visit or multiple visits [mean age = 43 years (range 18-75), 31 female (67%) and 15 male (33%)]. Most commonly, perineural injections involved the hallux branch of the medial plantar nerve (n = 17, 22%). Least commonly, perineural injections involved the saphenous nerve (n = 3, 4%). Other injections in our series include sural (10), superficial (11) and deep (7) peroneal, medial (5) and lateral (3) plantar nerves, and the posterior tibial nerve (3). Ultrasound evaluation revealed structural abnormality associated with the nerve in 30 cases (51%)-most commonly thickening with perineural scarring (n = 14). Of 45 injections with complete documentation, immediate relief of symptoms was reported in 43 (96%) cases. Interval symptom relief was achieved in 23 injections [short term (n = 12), intermediate (n = 6), and long term (n = 5)] out of 38 for which follow-up was available (61%). Complications are rare, occurring in only one case. CONCLUSION: Ultrasound-guided perineural injections about the foot and ankle are safe and provide lasting symptomatic relief for many indications. Concomitant sonographic evaluation identifies structural abnormalities that may contribute to neuropathic symptoms, allowing targeting of injection or clinical therapy.

Sonographic-guided tibial nerve block allows for rapid anesthetization of the heel and plantar regions of the foot. We describe a variant technique for tibial nerve regional anesthesia utilizing perineural injection of the medial plantar nerve proximal to the sustentaculum tali where the nerve is superficial and readily accessed, with resultant retrograde flow of local anesthetic proximally. Perineural injection of the medial plantar nerve at the inframalleolar level provides a simple, safe, and effective alternative method to achieve tibial nerve block for regional anesthesia in a variety of procedures. (c) 2017 Wiley Periodicals, Inc. J Clin Ultrasound, 2017.

We sought to assess the potential use of an application allowing real-time ultrasound spatial registration with previously acquired magnetic resonance imaging in musculoskeletal procedures. The ultrasound fusion application was used to perform a range of outpatient procedures including piriformis, sacroiliac joint, pudendal and intercostal nerve perineurial injections, hamstring-origin calcific tendonopathy barbotage, and 2 soft tissue biopsies at our institution in 2015. The application was used in a total of 7 procedures in 7 patients, all of which were technically successful. The ages of patients ranged from 19 to 86 years. Particular use of the fusion application compared to sonography alone was noted in the biopsy of certain soft tissue lesions and in perineurial therapeutic injections.

OBJECTIVES: (1) Assess the association between the B-mode morphologic appearance and elasticity in the rotator cuff tendon using shear wave elastography (SWE). (2) Assess the association between SWE and symptoms. METHODS: Institutional Review Board approval and informed consent were obtained. A retrospective review identified 21 studies in 19 eligible patients for whom SWE was performed during routine sonographic evaluations for shoulder pain. Evaluations were compared with 55 studies from 16 asymptomatic volunteers and 6 patients with asymptomatic contralateral shoulders. Repeated studies were accounted for by resampling. Proximal and distal tendon morphologic characteristics were graded from 1 to 4 (normal to full-thickness tear), and average shear wave velocity (SWV) measurements were obtained at both locations. In 68 examinations, deltoid muscle SWV measurements were available for post hoc analysis. RESULTS: The morphologic grade and SWV showed weak-to-moderate negative correlations in the proximal (P < .001) and distal (P = .002) rotator cuff tendon. A weakly significant SWV decrease was found in the proximal tendon in symptomatic patients (P = .049); no significant difference was seen in the distal tendon. The deltoid muscle SWV showed weak-to-moderate negative correlations with the morphologic grade in the proximal (P = .004) and distal (P = .007) tendon; the deltoid SWV was also significantly lower in symptomatic shoulders (P = .001). CONCLUSIONS: Shear wave elastography shows tendon softening in rotator cuff disease. It captures information not obtained by a morphologic evaluation alone; however, a poor correlation with symptoms suggests that SWE will be less useful in workups for shoulder pain than for preoperative assessments of tendon quality. Deltoid muscle softening seen in morphologically abnormal and symptomatic patients requires further exploration.