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Degeneration (Lumbar)|Percutaneous Facet Fusion|74|Male
Degeneration (Lumbar)|Percutaneous Facet Fusion|74|Male
2016anchordiscogenicfacetInterventional SpinepolyurethaneSIRtitanium
Degenerative Lumbar Stenosis | Percutaneous Vertebroplasty | 64 | Male
Degenerative Lumbar Stenosis | Percutaneous Vertebroplasty | 64 | Male
Rotoscoliosis, Spondyloarthropathy (Asymmetric), Degeneration|Percutaneous Facet Fusion|78|Female
Rotoscoliosis, Spondyloarthropathy (Asymmetric), Degeneration|Percutaneous Facet Fusion|78|Female
2016articularaxialbiomechanicaldevicedilationfacetfixationfluoroscopicimmobilizationInterventional SpineintroducepercutaneousprocedureshrinkageSIRtrocar
Cervical Disc Herniation|Percutaneous Discogel Injection|38|Male
Cervical Disc Herniation|Percutaneous Discogel Injection|38|Male
Vertebral Fracture, Rheumatoid Arthritis|Vertebral Body Replacement|75|Female
Vertebral Fracture, Rheumatoid Arthritis|Vertebral Body Replacement|75|Female
Post-traumatic Ankle Injury|Corticosteroid Injection (Transverse, Fluoroscopic Approach)|40|Female
Post-traumatic Ankle Injury|Corticosteroid Injection (Transverse, Fluoroscopic Approach)|40|Female
Septic Arthritis (Knee) Investigation|Knee Aspiration (Longitudinal, Transverse Approach)|83|Male
Septic Arthritis (Knee) Investigation|Knee Aspiration (Longitudinal, Transverse Approach)|83|Male
Labral Tear|MR Arthrogram (Fluoroscopic Approach)|25|Female
Labral Tear|MR Arthrogram (Fluoroscopic Approach)|25|Female
Hip Arthritis|Corticosteroid Injection|72|Female
Hip Arthritis|Corticosteroid Injection|72|Female
Glenohumoral Arthritis|Corticosteroid Injection|72|Male
Glenohumoral Arthritis|Corticosteroid Injection|72|Male
C4-C5 Arthritis|C4-C5 Facet Joint Infiltration|56|Female
C4-C5 Arthritis|C4-C5 Facet Joint Infiltration|56|Female
Chronic Low Back Pain |PRP, Gelstix |56| Female
Chronic Low Back Pain |PRP, Gelstix |56| Female
2015discGRIBOIherniatedLindare Medical

4 grade of Pfirrmann in L5S1, with discogenic and facet pain, with failure of medical and physical treatment.

And we choose another type of screws, dynamic screws. Not for fixation, but we put the screws under the facet. It's composed by a titanium anchor and a polyurethane stabilizer. The access kit is very similar to previous, but the technical is

a little bit different because we put the access needle, Kirschner wire, dilators, and the tap, and a countersink to create a space for the screws. But when we put the anchor and the stabilizer, we put the screws under the facet. Not to fix them, but to obtain a push up,

a superior push up of the facet and to limit the hyperextension. Then we repeat the procedure on the other pedicle. This is the final position of the implant, and the CT check. We can appreciate

the difference. Here the screws is under the facet not through the facet, as the case before, and the CT check confirms the correct implant of the screws. We also evaluate patient in the study with a two-year follow up.

We had a good reduction of pain evaluated by means of VAS score, and functions by means Oswestry. So we demonstrated that Percudyn system was a good

First case is a 64-years-old male with a neurogenic intermittent claudication, due to degenerative lumbar spinal stenosis confirmed by EMG, and with failure of medical and physical treatment.

We decide to implant a percutaneous interspinous spacer as a stand-alone system, in that case we use Aperius produced by Kyphon Medtronic. And the implant is available in four different size 8, 10, 12 and 14 mm, and it can be introduced by means of four access

Keith needle by corresponding measurements. Procedure, we performed the procedure under fluoroscopic guidance, and with local anesthesia. Subcutaneous Lidocaine, deep ropivacaine and deep sedation with Midazolam and propofol bolus. Patient is in prone position and after we perform the local anesthesia,

we introduce the first 8mm access Keith needle between the two spinous process into the spinous space, interspinous space. And the first accessory was not suitable, and so we moved for the next, 10 mm.

The second was suitable, so we decide to put the corresponding measurement prosthesis. And the prosthesis can be delivered by rotation of the implant, and when we open the wings to keep it in place it can be delivered safely. Here the final results

confirm the good position of the implant, and CT check after the procedure confirm the good position of the interspinous spacer. On the market we can find other three spacers. Lobster is an Italian product by,

thank you so much, [BLANK_AUDIO] Techlamed, and its main characteristics is to be completely removable after its delivering. HeliFix is produced by Alphatec Spine,

and it's a PEEK implant. And In-Space, produced by Johnson & Johnson is a mix, titanium and PEEK. All of them can be introduced by straight access Keith needle. Aperius can be introduced by curved access Keith needle, this is the main difference. We published last year a paper about three-year follow up results

after implant of percutaneous interspinous spacers, evaluating the area of the spinal canal and both neural foramina. And we demonstrate an increasing in a CT check three years after the procedure, and we had a good pain relief demonstrated by mean of VAS score, and the good improvement of functions demonstrated

with Oswestry. So we concluded that Aperius was a good option for a patient with neurogenic intermittent claudication, with failure of medical and physical treatment.

Second case was a 78-years-old female with instability due to rotoscoliosis, with a dilation of left articular space, and shrinkage of right

articular space. So asymmetric spondyloarthropathy with axial back pain, with failure of medical and physical treatment. And we decide to do a percutaneous facet fixation that stabilized the spine, as an aid to fusion through a bilateral immobilization of the facet joint with the screws. The procedure is very simple.

We start with a trocar needle, then we introduce a Kirschner wire under fluoroscopic guidance. Then we introduce the dilators, and then the rasp to create a space for the screws. Then we introduce the screws with, [COUGH] Sorry

about that. [LAUGH] With a screwdriver, and this is the final result when we repeat the procedure on the other pedicle. And the CT check after procedure demonstrates the correct implant of both screws through the facets,

through both the facets. And after one week, we had complete disappearance of symptoms. On the market we have other two device, Bone-Lok produced by Spine Intervention, and Facet Wedge produced by Alphatec Spine. The device is a little bit different because we put the device into

the articular space. And this is a study demonstrating no biomechanical change of one level fixation compared to surgery.

This is an example of a unipedicular approach. You can see the cement has actually gone into the vertebral segment. It's amazing how often even with a half CC of cement, there'll be a plane of plasma sitting in there between the fragments and

the cement will just shoot right across to the other side, and you've got a half CC, you're done. This is another example. You can see in this particular case, you can see that the needle is just immediately above the cortex. Is

that showing there? It's not really showing on the screen for some reason. We can see that the needle is just barely above the inferior cortex of the pedicle.

This is an example of a unipedicular approach. You can see the cement has actually gone into the vertebral segment. It's amazing how often even with a half CC of cement, there'll be a plane of plasma sitting in there between the fragments and

the cement will just shoot right across to the other side, and you've got a half CC, you're done. This is another example. You can see in this particular case, you can see that the needle is just immediately above the cortex. Is

that showing there? It's not really showing on the screen for some reason. We can see that the needle is just barely above the inferior cortex of the pedicle.

This is a 45-year-old construction worker who comes from abroad, he has been operated five years ago abroad. We do not have any history about his operation. He arrived to the hospital with back pain and the Sciatica L5 an AVS score of seven out of ten, and this is his X-ray.

So in the X-ray you can see there's a metallic object right here but something was put there in the operation probably this is a marker of some kind of disc implant but we do not have any other information. So the simple thing is since the operation has been done after 2000, we ask for an MRI, this is MRI.

So this is not a good MRI and of course it's not a non-diagnostic MRI, so what can you do? Well in this case, you can do nothing and go directly for surgery, conservative treatment, injections based on clinical findings, surgery, we prefer to do

a myelogram or an epidurogram depending on which technique you'd like. So in this case, you stick a needle and inject your contrast media in the space and actually you can see the metal artifact it's just irritating the L5 route coming out there. So now you have a pretty precise conception of why it is irritating, this technique is very useful specifically when you have [UNKNOWN] sessions

or surgery in the area that creates metallic artefacts for MRIs and it can help your CT myelo to give you more information.

This is 38-year-old interventional radiologist inside this room who had a neck and shoulder numb pain with a minor moderate deficit so this time we do not have the precious time waiting period because he has a C6 and C7 left root numbness and you can see the compression

there you can see there is some [UNKNOWN] starting to grow inside the code and we don't have waiting time so either it's surgery or percutanous and since he is in IR, he wants a percutaneous instead of a surgery approach.

So we went there and did a percutaneous approach and this is the percutaneous approach inside the disk, followed afterwards with the injection of material which is called disc gel which acts like an alcohol gel, I don't think it's in the US, but you can

inject that and actually what it creates is an ethyl cellulose alcohol gel which actually shrinks the disk. And you inject that and this is the follow up at 19 months and the disk has completely resorbed and we had a good outcome, this is how we started and this is how it ended.

We published the paper a few years ago showing exactly that when you do percutaneous approaches you get the same results as you would do for medical management and you have the advantage that you have a more long term result. Usually when you do a medical management, the patients will come

back a year later with the same symptoms probably it was hernia. So sometimes you have to wait, but if the waiting does not work, then you have to go for a percutanous approach.

rate. There's a 45 year old radiology tech with a back pain and a sciatica of L5 S1 and an AVS of six out of ten. And this is his MRI. Okay, you can see the disc protrusion,

what are we going to do? Nothing? Make him work? Conservative, injectates, percutaneous disc. Well the first thing you should always try is conservative management. This is the first and foremost way of treating for these patients

so conservative management is the first thing one should try. This is one year later, you can see that the hernia has completely disappeared and has completely retracted because the disc has a natural history of resorbing itself. 17 to 19 of all persons will experience low back pain at some point

in their lives, and 80 to 90 will recover by themselves within three months, just physiotherapy, exercise and changing diet. Again disc herniation in time in the cervical level, you can see that's for an MRI and one year later where is that hernia? So the disc can resorb itself given enough time.

The question is if we have this time?

So last case for a 75-year-old patient with a rheumatoid arthritis and a cancer of the bladder treated by chemo falls on her back,

this is her fracture. You can see the fracture here and the question we have to answer is first what kind of fracture is that? What kind of Magerl is it A1, A2, or A3? Why is that important,

because you should care because if you do not choose the right type of fracture like the A1 fractures for a vertebroplasty and do not do something more complicated like KIVA or stent or something which is a bigger augmentation, you risk that, and this is destruction. Cement is not good enough for

very severe fractures they risk to break, and this has been already published and in this case for example you can do a peek implant and put the peek impant inside and actually [UNKNOWN] the fracture before injecting the cement and this will hold better and have less risk of having a secondary fracture in the area.

The future of treatments is real time, non invasive, bone implants with different things, the purpose of all this is to go from paliation to local regional tumor control. If I give you a small algorithm,

radio therapy still is the gold standard as initial treatment. Whether it will be replaced by pharmacol/g ultrasound for metastasic diseases is something that we will see in the technology of the future but those are not always effective, 60% will react and about

40% will not be effective. So then you have to choose whether you have a weight bearing or a non weight bearing area. And if you have a weight bearing area, you need stabilization definitely, if you have a non weight bearing area,

then you can go just for ablation. Where do you put embolization? When you want to go for tumor control. When you want to go for tumor control you need stabilization, embolization,

and ablation because you are going for local region tumor control. And of cause there are still other questions to answer like with performance status, patient compliance and analgesic drugs or surgery. So I'll stop here thank you very much, I went a little bit over


For our last joint we'll talk about the ankle, this is a 40 year old female with left ankle pain there's a subtle finding on this radiograph that the MRI will kinda help us see, and then the green circle will make sorta everyone sees it.

Healing osteochondritis dissecans, this patient had a car accident and had trauma and had ongoing chronic ankle pain so requesting that a therapeutic injection into this left ankle. So again starting off with ultrasound you can look at it transverse and longitudinally, the patient just supine relaxed on the table there.

We'll look at the relevant anatomy here. So overlying we've got extensor tendons, tibialis anterior, extensor hallucis longus, the neurovascular bundle there, anterior tibial artery/[UNKNOWN] depending what level you're imaging it at, and in the transverse

you should see a nice, flat, tailor [UNKNOWN] there. Longitudinally is a nice way to lay out the anatomy, you see the tibia superiorly, the talus inferiorly, but often times as you can see here there's a

tendon or an artery in the path when you approach it from a longitudinal view. This patient has quite a bit of chronic synovitis. You can see a lot of hypercoag thickening around there and that's just synovial proliferation in this patient who had this ongoing long post traumatic ankle.

So on the top there you can see this was a longitudinal approach, I prefer, I've come to really prefer this transverse approach and will kinda talk about why. So with the transverse approach all the targets that you wanna avoid are really out of the way. You can see them, you can steer clear of them from a medial to lateral

approach. You have to be comfortable seeing the needle just anterior to that flat aspect of the talus and then will turn longitudinally to confirm it's where you think it is. So there longitudinally you can see that right there. The longitudinal pictures look nice because you can see the needle

the whole way going right to where you want it to go but often times just like I said the overlying tendons and neurovascular bundle preclude that approach. [BLANK_AUDIO] For a fluoroscopic approach patient's gonna be supine on the table, you wanna palpate the artery,

mark that, you do toes to the nose, palpate the tendons and pick a gap between them. Here we can see fluoroscopic approach and one thing to keep in mind is you're not quite vertical, you can have slight [UNKNOWN] angulation as demonstrated with this lateral approach here.

Free flow of contrast. Now this is a post traumatic ankle, so there's not a lot of space there. This is often what we'll see in these damaged ankles. That wraps up approach to these major joints here with ultrasound and fluoroscopy.

Thank you for your attention, happy to answer any questions.

Moving along we've got an 83 year old male, he's got a infected right hip and he has new painful right knee joint and there is concern for an additional site of infections so we're asked to aspirate this right knee.

So again initial ultrasound scan. I should mention that all the photographs are photographs of fellows, residents or myself, not of the patients so we can get him in here. So often times that image might not correspond with what we're seeing with the ultrasound or the x-ray images so these are all volunteers in the photographs, but position like this and you

wanna identify the patella as well as the femur, and we'll look at the relative anatomy here. So overlying you should see the Quadriceps tendon longitudinally, and then superficial layer of course we'll have fat and skin. Due to that you have the patella and the femur and really what you

wanna look for is that Quadriceps fat pad which is highlighted there as well as the Prefemoral fat pad. And between that space is where fluid would be, sometimes it's salivary physiological fluid and sometimes it's our big joint of fusion. You can really accentuate that by increasing flexion a little bit

or putting a little just manual pressure around the knee, kinda milking fluid up in there whether it's inferiorly, medially or laterally. That can

really accentuate that. There's where you're gonna be looking, so this is just an initial scan to kinda give a lay of the land to figure out is there a lot of fluid, is there not much fluid? Then I'd like to try and transverse and look at that superior lateral

recess. It's important to use light transducer pressure here cause you can really pretty easily obliterate that if you're pushing too hard, and this is a real nice approach for accessing the knee joint when there's fluid present because really you go through skin,

subcutaneous fat and maybe a little bit of the vastus lateralis. But it's really very well tolerated for an approach. Another, and there's like this, looking at our anatomy there. If we move inferiorly,

same basic position but just a little more inferiorly where we're bring the patella into view there. You can see the patella medially, the femur as well as that little lateral recess to the joint. And this is an approach that we'll employ when there's not enough

fluid distending that superior lateral recess. This is another great way to get into the joint. However, you will go through a little more of the joint capsule here so this is a little more painful. If

you're gonna be doing an aspiration. [BLANK_AUDIO] So one of the considerations for aspiration we'll give local anesthetic to the skin and a little bit deeper. But we really avoid putting much local anesthetic right at the joint capsule.

Because of the potential to interfere with the sample we're retrieving. The local anesthetic is often bacteria static and that can interfere with cultures. And also if you get just increase fluid and then that can dilute the sample for a cell count, so two of the most important reasons we'd be aspirating this joint can be confounded.

So we just kinda coach patients you might feel a brief pinch as we enter the joint and then you should do very well with that. We do this in-plane lateral to medial. The same approach can be used for knee injections. If there is a jointed fusion. Often there is a joint effusion in patient's knees we're being asked

to inject. So that the superior lateral recess. If there's not an effusion again you just move inferiorly where you can see the patella like that. Now the advantage to an injection is we don't have a sample we are worried about interfering with so

you can be a lot more liberal with local anesthetic at the capsule there and those patients do very well with this approach. So here is an example of an injection gone without approach. Even if there is no fluid which really I rarely encounter but if you have this view and there is really no fluid you can still put the needle behind the patella and once you've crossed through there

then you know you are on the knee joint, and then again you should have nice free flow of fluid. Also prior to knee injections I'll always look for and effusion in a longitudinal view and then following any knee injection, I'll get that longitudinal view again and I like to see that has been distended there just proving that even if I use this approach, that

I have shown that the fluid has gone where I planned it to. So accessing the knee, under fluoroscopy we can go medial or lateral. The patient is gonna be supine, the leg is gonna be extended and important that quadriceps is relaxed and you wanna just jiggle

the patella around a little bit, make sure it's nice and mobile and often times you have to kind of remind the patient throughout just relax that leg. This will contact cartilage, either patella or femoral cartilage because it's hard to make sure you are perfectly in line when you are advancing and again contrast should not be administered prior

to aspiration to exclude infection for those reasons we already discussed. So here we've got an image, pick that superior third at the patella, either approach is fine. This image on the right kinda reminds us that if we're gonna come laterally, you're basically horizontal,

and if you're gonna come medially, you're about 30, 45 degrees, so quite different approach than for shoulders and hips where you're essentially vertical. And however you approach it then you should see a nice free flow of contrast through there.

So here we have a nice confirmation that we're in that knee joint. So diagnostic aspirations, typically we'll use a 20 gauge or larger needle. This is case dependent, if we're using ultrasound and we see it's

a real complex collection we'll sometimes even put in a 5 French UA catheter. It's a great way to get really thick pus out or if it's a hematoma, can aspirate those nicely. As mentioned we wanna avoid injection of local anesthetic or iodinated contrast prior to obtaining fluid.

Commonly ordered tests. Don't forget cell count, cell count, cell count. Often times cultures gets ordered but they forget the cell count. Cell count really is how we make the diagnosis of these and so it should almost always be included.

Of course crystals are important and then Grams stain has variable positivity rates with these. With our lab set up we need about 1 to 2 mls to perform all those. It does vary based on labs so kinda knowing your pathology lab and knowing what they need can be very helpful. Cause often times you're getting very little fluid out of some of

these joints. Here's just a reference side looking at what the cell count tells us. Normal, non inflammatory, inflammatory, septic and hemorrhagic, and then partnering that with cultures.

So here is our companion case demonstrating a fluoroscopic approach to the hip. This is a 25 year old female and she's gonna get an arthrogram to evaluate for labral pathology. And the target here is gonna be superolateral aspect of the head-neck junction.

Patients can be positioned supine, internal rotation and again a little sandbag outside the foot there can kinda help keep the patient in that position. Here we can see a 22 gauge spinal needle has been advanced pretty much vertically to that target location and we use this anterior

approach, for this will work great for your aspirations or injections. For a fluoroscopy, important to palpate the femoral artery, mark it and make sure you stay lateral from that and you should see nice free flow of contrast like this surrounding that hip joint. You've got images from the MRI for arthrogram here demonstrating

a nicely distended hip joint capsule there. So arthrograms, this is for an example the formula that we use. But that's gonna vary based upon the concentration of gadolinium we're using and the preference that your musculoskeletal radiologists have. But again, we're gonna be careful to avoid any air installation

and listed some typical joint volumes. For shoulder 10 to 12 ml, hip 10 to 15, knee 15 to 20. Now that's a reference range that's gonna be guided based on the resistance you feel with the needle whether you're using ultrasound or fluoroscopy, the patient will start to tell you, yeah, I'm kinda feeling this

tendon, I'm having pain. And then you will go and tell you really feel like you're close to rupturing that capsule as long as you're within these appropriate ranges. Other things, if we're doing knees or hips we don't let the patient walk, afterwards we keep them on the table because that joint is

gonna be very distended so we wanna transport them to the MR scanner on a gurney so they don't potentially rupture that capsule or they don't force any of that to inject it out through the hole that we just created in the joint there. The same thing was seated position,

that can disrupt the hip joint so we don't even let them sit. Occasionally we'll get a request to mix a steroid in with that little cocktail. We don't do that. There's a theoretical consideration for gadolinium may disassociate

when mixed with a steroid. So we don't do that. We will add local anesthetics because commonly local injection into this joints is part of the clinical workout when you're looking at labral pathology, particularly in these young people with hip

pain. So fairly routinely we'll have a local anesthetic, just to see is that the patient's pain generator?

administration. Moving on to the hip, we have a 72 year old female here with a right hip pain. They requested a therapeutic right hip joint injection.

[BLANK_AUDIO] So again, we'll start with an ultrasound approach here. We're gonna use an oblique approach, winding up with that head-neck junction of the femur.

Relevant anatomy here, you'll identify the femoral head femoral neck. You can see acetabular and superiorly there. Overlying the femoral head are iliopsoas tendon, rectus femoris tendon which we try to avoid.

Sometimes if those do get poked in a procedure, patient will have transient leg weakness when they're walking out. It does resolve but it can explain sometimes why patients have a little bit of weakness when they're walking out of a procedure like this.

Other thing to identify is the lateral femoral circumflex artery. It's almost always right in the path that you'd like to take with ultrasound. Usually going superior to it works fine but sometimes we go inferior as well. In the green highlight there you can see the joint capsule,

and it's really got a nice inferior extent which makes targeting that hip joint really nice either with ultrasound or fluoroscopy. Now the femoral vessels that we worry so much about with the fluoroscopic approach usually are quite medial for ultrasound because of the approach we take so you really don't see those.

So here we've got a scenic clip playing it will be playing as I'm talking. And then once you've put the needle on the joint you should start to see fluid flowing over the femoral head real nicely there and you can just kinda see that distending with the hypoechoic and echoic fluid, and at the end you're gonna see something hypoechoic kinda shoot across there,

a little bit of gas there at the end of the syringe there. And sometimes that's just a nice way to show that oh, I was where I thought I was. Now for doing an arthrogram you wanna avoid any gas being injected

in there but just for a therapeutic injection and a couple molecules of gas is not gonna be a problem at all. The same approach can be used for hip aspiration under ultrasound

with a 72 year old male, he's got a painful right shoulder. You can see from the radiograph he's got pretty extensive glenohumeral arthritis there.

And they're requesting therapeutic right shoulder joint injection. So first we'll demonstrate how we look at the shoulder joint with ultrasound. We look at the shoulders posteriorly because it allows really unfettered access to that glenohumeral joint. If you're not familiar with scanning shoulders with ultrasound a

lot, it's really easy to identify the humerus in a transverse plain and then just scan superiorly and tell you hit that humeral head. The other landmark there is gonna be the glenoid. A little bit of passive abduction and adduction can really bring out that glenohumeral joint, which is gonna be your target.

So we'll look at the relevant anatomy for our shoulder, aspiration or injection with ultrasound. You can see the humeral head, the bony glenoid, and then the hypercore structure there at the labrum, and your needle target it's gonna be right short of that labrum there in the joint space.

Often times you'll see hypercore cartilage or anticore cartilage right over the humeral head. In this case there really is none as you could tell from that radiograph there was such degenerative arthritis, so there's no real articular cartilage in this target here. Overlying the joint you can see the infraspinatus, the myotendinous

junction there, the hypercoag part is that tendon and you've got the muscle on both sides. In superficial you're gonna of course have deltoid and subcutaneous fat. So for an injection, we like to have the patients in a decubitus

position. You can do it seated like I was showing on that scan there but really, any time we put a needle in someone we like to have the supine, decubitus, making some contact with the bed just in case they start to feel faint. We'll anaesthetize the skin,

we'll anesthetize the deeper tissues and then this was a 25 gauge needle so you can't, kinda hard to see the needle there. But the needle tip target there's going to be a right between that labrum and humeral head.

Now if we confirm one of the joint, one by watching it going and two by a nice easy test injection and injectation flow very smoothly through there. If you are not getting nice slow resistance flow and it looks like you are in the right spot often times you might

be contacting that labrum or maybe articular cartilage so just withdrawing a millimeter or two and then trying again will often yield good results. Patients will often let you know too if you're contacting the labrum or the cartilage because they are quite sensitive, so sometimes that's not even a mystery.

So if you're gonna access this joint under a fluoroscopy. We do it with the patient's supine. We'll talk about two approaches, two great approaches, The Schneider approach as well as The Rotate Interval approach after that. Both these approaches the patient is gonna be supine and externally

rotated, sometimes a sand/g bag and the palm, can help keep people in that position remember because they don't migrate out of that position. For this you're gonna wanna pick the inferior medial margin of the humeral head and basically a vertical approach there until

you contact that humeral head. Now this approach you may transverse the subscapularis tendon, the portion of the labrum or the inferior glenohumeral ligament which can be painful but also can cause some trauma and edema to the area.

So if you're gonna be sending this patient for an MRI arthrogram that can be confounding. And so we use this approach, really only for aspiration under fluoroscopy, not for injection, just because of that reason. And here you see an example where we've advanced the needle and

see a nice flow of contrast throughout that glenohumeral joint there. Here's a an approach where the Rotate Interval Approach and so that is a reminder between the subscapularis tendons, supraspinatus and then base of coracoid, same position supine,

external rotation and you wanna identify that coracoid and draw kind of imaginary horizontal line across, and once you reach the humeral head that will be your target there. You advance until you hit the humeral head and then again nice free

flow of contrast there. Now this approach is used for injections and it's great for arthograms but it's not a good approach for aspiration because there's a potential that you're not sampling the fluid. The chance of falsing negative dry tap really increases with this approach versus that first axillary recess or schneider approach

so we don't use this for trying aspirations under fluoroscopy. So just some few comments on joint injections. We typically do them with a 22 gauge needle, sometimes larger, sometimes smaller. Kinda depends on what we're using,

if we are gonna be using viscossupplementation going a little larger really helps because it just flows through there a little easier. When we are aspirating, I guess we'll talk to aspirating next, our typical injectate we use about five ml in any one of these major

joints, they can call it quite a bit more as we'll see when we talk about arthrograms, but here is an example where you use one milliliter of betamethasone at a six milligram to ml concentration and ropivacaine. We switched the ropivacaine

from bupivacaine a few years ago just because the theoretical risk of cartilage toxicity with bupivacaine and similar analogues. Here's a companion case kinda highlighting the utility of ultrasound. So this was a female who was scheduled to have her contralateral shoulder operated on and decided to get a flu shot injection just to get

kind of tuned up for surgery, and then she presented with a really painful right shoulder. So clinically, there were concerns for a septic arthritis they send her to us for a glenohumeral joint aspiration.

We put the ultrasound probe down and saw a large subacromial subdeltoid bursal effusion, looked at the glenohumeral joints and there was no fluid there. So we aspirated this, this was culture negative but full of inflammatory cells, so this was actually a SIRVA or we call it a shoulder injury

related to vaccine administration. So what they'd done is they'd gone through the deltoid and deposited the whole vaccine into the subacromial subdeltoid bursa and she had an inflammatory response to that. Sometimes those get deposited in the tendon, other non-target locations

and this is a case where if we had just perhaps used fluoroscopy and put a needle on the joint we wouldn't have accessed this fluid collection and this would have gone undiagnosed here. This is also why I watch very carefully whenever I get a flu shot any more but typically it's women with very little fat and very

So we have a 56-year-old female patient and things are not always that simple. So the question why is she in pain? She has cervical back pain, three successive surgeries, you can see here the implants,

the screws, no change, we try a C3, C4 root infiltration you can see the interior fixation with a disc and there's again another operation with fusion here, no change after the infiltration. So how can you find out what exactly is in pain from all of it?

Well, one solution is to do nothing. The other is go conservatively, new injections and pre myelography but there's another tool you might use, PET. And we tried PET and we saw very interesting results because PET

actually can show you because of the high metabolic effect, the inflammation for specific area. So in this patient we were able to discover a C4,C5 Arthritis. It's an expensive

way I agree, but it's a very functional way, and with a PET we were able to see facet joint infiltration at that level, and that was a successful pain treatment for 6 months which was followed by a second infiltration

iii to me iii point eight post six weeks there is 1.5 26 months

0.5 and you'll see here the disc and the iii into the disc I don't see it here because it's somewhere, sorry I have to go back sorry this also room bottom, no not on show previous okay here we go back back back yeah that's a hydrogel/g here.

Have to look closer because I don't see it from the distance here and here. Okay, that's the hydrogel/g and the disc here and here. You can see it actually. The here, it even dislocated a little bit, and here.

That's why you should not put it in your herniated disc. If there's, that's contrary indication,

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