Ultrasound Guided Injectional Treatment of Scar Tissue...

Ultrasound Guided Injectional Treatment of Scar Tissue, Bone Spurs, and

Neuromas

Dr. John C. Hughes, D.O.

February 17-18, 2012

AAOT Conference

(Dallas, Texas)

Ultrasound Guided Injectional Treatment of Scar Tissue, Bone Spurs, and Neuromas

Injection Treatment Background:

US guided injectional treatment for MSK injury

US Images

US guidance Benefits

US guided Injectional Treatment: Scar Tissue/Bone

Spurs

US guided Injectional Treatment: Neuromas

US guided Injectional Treatment: Intervertebral Discs

US guided Visualization of MSK injury

Creating a proper neuromuscular ultrasound image

takes years of training

Visualization and understanding these images also

requires extensive work

Download to a pdf can compromise some image

quality

Injection of a substance such as a liquid or gas into

the view significantly

It is all still better than going at it blindly

US guided Visualization of MSK injury: R Shoulder

Notice the supraspinatus tendon

The tendon widens from 0.75mm to 2.03 mm

The area of widening is the area of laxity

The US guided the prolotherapy injection with

precision

US guided Visualization of MSK injury: Trigger Point

Trigger Point (initial)

Big mangled mass of muscle tissue

US guided Visualization of MSK injury: Intervertebral Disc

US lumbar spine at L5-S1

Ultrasound Benefits for MSK Injury

Noninvasive; Real Time

Easy to Use; Easy to Transport

No DNA damage, No cutaneous burns

Accurate placement of needle guided injections

Able to see immediate results

Cost-effective

Done at major universities such as Johns Hopkins as an

initial diagnosis instead of MRI

Injectional Treatment: Scar Tissue/Bone Spurs

Scar Tissue (aka Fibrosis, Tendonosis, etc.):

Fibrosis is the formation of scar tissue due to injury or

long-term inflammation. Fibrosis tissues form a web

around the injured area in an attempt to support the

muscle while it heals itself. (http://www.wisegeek.com/what-causes-muscle-scar-

tissue.htm)

http://www.parkwayphysiotherapy.ca/article.php?aid=245

Normal Tendon with distinct elongated,

parallel fibers

Scar tissue (fibrosis) early: disorganized

collagen, fibroblasts infiltrate: loose and pale

appearance

Histology of Scar Tissue in Tendons Adapted from The Journal of Bone and Joint Surgery

http://www.jbjs.org/article.aspx?Volume=81&page=259

Electron micrograph of normal area of

tendon: collagen with small and large

bundles, parallel arrangement

Electron micrograph of short fragments of

collagen in scar tissue that completely lack

organization

Histology of Scar Tissue in Tendons Adapted from The Journal of Bone and Joint Surgery

http://www.jbjs.org/article.aspx?Volume=81&page=259


http://www.chiropractorspringfield.com/doctor/chiropractor/10

12L/springfield-chiropractor/nova-chiropractic-and-wellness-

center.htm


Bone Spurs (aka Osteophytes or Enthesophytes):

Definition: Bone spurs, or osteophytes, are bony

projections that form along joints, and are often seen in

conditions such as arthritis. Bone spurs are largely

responsible for limitations in joint motion and can cause

pain. (http://orthopedics.about.com/cs/arthritis/g/bonespur.htm)

Enthesophytes are bony projections which form at the

attachment of a tendon or ligament. http://en.wikipedia.org/wiki/Osteophyte


http://physioindia.blogspot.com/2011/05/radiological-interpretation-of-joint.html

http://www.rad.washington.edu/academics/academic-sections/msk/teaching-materials/online-musculoskeletal-radiology-book/appendicular-arthritis

http://orthopedics.about.com/cs/arthritis/g/bonespur.htm


Basics of US guided MSK injections

Diagnosis often aided by Xray, MRI, CT

Palpatory diagnosis critical for interpretation of US

image

Patient history also critical: how the injury occur, prior

surgeries, etc.


Injection Technique

Key: To determine what is scar tissue/bone spur versus

healthy tissue

Bone spurs: With a needle, spurs feel like barnacles

next to a ship hull (healthy bone)

Scar Tissue (Fibrosis, Tendonosis): With a needle, scar

tissue feels like thick, crusty spider webs versus tender

chicken legs (healthy tendons and ligaments)


Injection Technique

Technique: Involves gentle needling and sometimes

chiseling for bone spurs all guided by ultrasound

Goal: to free up the ligament, joint, tendon that may

overlap the spur and bring healthy blood flow and O2 to

the area to encourage fibroblastic resorpion and

prevent reattachment

Following injection of scar tissue/bone spur, a second

injection (of a proliferant) is used to tighten the ligament

or tendon or joint


Injection Components:

Injection solution is often simply a local anesthetic

(lidocaine, procaine, marcaine) may also include other

trace agents that improve fibroblastic resorpion (eg.

Trace amounts of HCl, MgSO4, Phosphatidyl choline,

Ascorbate) followed by O3 at 20ug/cc

Post Injection Visualization by Ultrasound:

Should demonstrate a “clean”, integrous, smooth bone

surface with elongated, parallel fibers in adjacent

ligaments or tendons

Injectional Treatment: Ligament/Scar Tissue/Bone Spurs

L MCL ligament laxity (aka chronic sprain) with bone spur

Pre-Injection: Notice the spur in the central part of the

ligament at the joint space(initial); the spur is partly

visible as a white and partially hidden (due to

shadowing by the US)

Post-Injection: Notice the absence of the spur (now in

pieces floating in the ECM) and the tightening of the

MCL ligament

Injectional Treatment: Ligament/Scar Tissue/Bone Spurs

L LCL ligament laxity (aka chronic sprain)

Pre-Injection: Notice the extreme edema and

inflammation and laxity in the ligament

Post-Injection: Note the decrease in the fluid and the

tightening of the ligament


L ACL laxity (aka acute sprain with partial tear), minimal

scar tissue

Pre-Injection: Note the thickness of ACL and its more

horizontal position

Post-Injection: Note the tightening of the ACL and its

more vertical position


Side effects of Injectional Treatment of Ligament/Scar

Tissue and Bone Spurs

Pain-often acute, during the injection, even with local anesthesia;

it is difficult to anesthetize the nerve fibers imbedded in the scar

tissue and bone spur (Patients are given Valium or pain-killer)

Pain-after the injection--usually for 1-3 days; secondary to the

proliferative activity

Inflammation-can last 1-2 months; often seen in patients with

hyperactive immune systems, chronic inflammatory conditions

(such as arthritis, food allergies, genetic disorder)

US guided injection of neuromas

What is a neuroma?

Morton’s Neuroma: The thickening, or

enlargement of a nerve leading to compression

and irritation of the nerve. Usually located

between the 3rd and 4th metatarsals http://www.footphysicians.com/footankleinfo/mortons-neuroma.htm

What does a neuroma hurt?

It is largely due to sodium channels, which are

upregulated in neuromas http://www.ncbi.nlm.nih.gov/pubmed/12181690


Accumulation of PN1 and PN3 sodium channels

in painful human neuroma-evidence from

immunocytochemistry. Kretschmer T, Happel LT, England JD, Nguyen DH, Tiel RL, Beuerman RW, Kline DG.

Department of Neurosurgery University of Ulm, BKH Neurochirurgie, Günzburg,

Germany.

Conclusions: Both, PN1 and PN3 seem to be involved in

hyperexcitability induced pain. Thus, in order to

therapeutically control hyperexcitability induced neuropathic

pain, it is necessary to selectively block different sodium

channel subtypes and subunits http://www.ncbi.nlm.nih.gov/pubmed/12181690


So what’s the treatment?

Downregulate the sodium channels with small

injection of 1.8% to 2% sterile saline (Normal

Saline is 0.9%). Injection is done at least one time

per week x 3-4 weeks. US guidance allows for

precise visualization and demonstrates reduction

in size of the neuroma after each injection

Use good orthotic to avoid compression and

reoccurence of the neuroma

Intervertebral O3 injections--Italian Study

http://www.ajnr.org/cgi/content/full/24/5/996/F2

(American Journal of Neuroradiology)

From 1999 to 2001, 600 patients aged 20–80

years treated with a single dose of oxygen-ozone

therapy. (All done in Italian hospitals).

Three hundred patients (group A, received an

intradiscal (4 mL) and periganglionic (8 mL)

injection of an oxygen-ozone mixture with an

ozone concentration of 27 µg/mL

Ozone (O3)-Italian Study

The other 300 patients (group B,) received

identical oxygen-ozone injections, followed by a

periganglionic injection of corticosteroid (1 mL of

Depo-Medrone 40 mg and anesthetic (2 mL of

Marcain 0.5%

The L4–5 level was the most frequently treated

(61.8%); L1–2, 0.7%; L2–3, 1.2%; L3–4, 8.7%;

L5-S1, 27.6%.

Puncture at L4-L5 performed under CT guidance.

FIG 3. Therapeutic outcome 6 months after oxygen-ozone therapy. Light gray bars indicate group A (n=300); dark gray bars, group B (n=300). Numbers at top of bars are percentages.

Ozone Study MetaAnalysis

From June 2000 to December 2006, the Muto

group performed the oxygen/ozone procedure on

2900 patients with lumbar disc herniation.

Dr. Murphy, professor of interventional radiology

at the University of Toronto states,

“When you have 79.7% of patients with a

herniated disc getting improvement from this

procedure, that's pretty cool."

US guided injection of an Intervertebral Disc

MRI-L4-5 disc herniation US L4-5 disc herniation

US Guided Disc Injections-Final Words

The question is no longer, “Can we visualize the

Intervertebral Disc Herniation using Ultrasound?”

But rather, “Are you skilled enough to visualize

the area and perform the procedure?”

And finally, “If an ultrasound-guided lumbar disc

shot is not performed perfectly, will it still benefit

the patient?”

KEY: Horseshoes, Hand Grenades, and Ozone

Ultrasound Guided Injectional Treatment of Scar Tissue...

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