Official Proceedings - AIUM

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013Results—Of the 47 patients, 12 (25.53%) had a carotid arterystenosis percentage diagnosed by ultrasound that agreed with the advancedimaging modality. Fifteen (31.91%) patients likely would have had alternatetreatment based on their advanced imaging studies. Based on the acceptedcurrent treatment, carotid endarterectomy for a symptomatic patientwith >70% stenosis by ultrasound, 3 patients would have undergone an unnecessarycarotid endarterectomy. Additionally, 12 patients would havemet criteria for carotid endarterectomy and not received one.Conclusions—Clinicians must consider that many patients mayreceive inappropriate treatment of carotid artery stenosis if ultrasound isthe sole modality used for diagnosis. Eighty percent of endarterectomiesare performed based on ultrasound alone in the United States, meaning alarge impact on American health care overall. While more research isneeded, alternate imaging and close monitoring may be required with atypicalor symptomatic patients before medical management or carotid endarterectomyis chosen as treatment.1536948 Efficacy of Ultrasound-Guided Injection of the SternoclavicularJoint SpaceYisrael Katz,* Oliver Joseph, Oleg Uryasev, John McNamara,Apostolos Dallas Virginia Tech Carilion School of Medicine,Roanoke, Virginia USAObjectives—The sternoclavicular joint (SCJ) space can be affectedby various osteoarthropathies, including degenerative, crystal deposition,and inflammatory. Like other osteoarthropathies, corticosteroidinjections could likely provide therapeutic relief to individuals with SCJosteoarthropathy. While the literature discusses the success of computedtomography (CT)-guided injection, we hypothesize that ultrasound (US)can be used to guide SCJ intra-articular injection without exposing patientsto unnecessary radiation.Methods—This study serves as a pilot study. The SCJ was injectedbilaterally on 4 nonembalmed cadaveric models. The anatomy forall cadavers was within normal limits, with the exception of 1, which hadmarked musculoskeletal deformity of the lower limbs; an identical procedurewas followed, and pathologic anatomy did not affect data collection.A 10–5-MHz small linear array transducer (L38n) was used. The SCJwas palpated, and the transducer was aligned parallel to the angle of theSCJ. Using a short-axis approach, US-guided injection was performed. A1.5-in 22-gauge needle with 0.25 mL of 0.5% methylene blue was used.Incisions were made parallel and perpendicular to the SCJ. The joint capsulewas dissected to visualize the dye as confirmation. Attempts wereclassified according to accuracy and precision. Accuracy measured if thejoint space was stained with dye; precision measured if the injection waslocalized without damage to adjacent anatomy.Results—Bilateral injections on all 4 cadavers were accurateand precise.Conclusions—US is inexpensive, quick, and minimally invasivecompared to CT. Given that CT-guided intra-articular SCJ injection with acorticosteroid and anesthetic has provided symptomatic relief to patientswith SCJ pain, the analogous procedure can be performed under US guidance.Future phases of this study will expand the current data set and investigatethe efficacy of US-guided SCJ injection in patients with SCJ arthralgia.1536971 Efficacy of Ultrasonographically Guided AnteriorInterosseus Nerve Perineural Injection at Its BifurcationFrom the Median NerveElizabeth Glazier,* Oleg Uryasev, Oliver Joseph, JohnMcNamara, Apostolos Dallas Virginia Tech Carilion Schoolof Medicine, Roanoke, Virginia USAObjectives—Compression of the anterior interosseus nerve(AIN) immediately distal to its bifurcation from the median nerve (MN)results in Kiloh-Nevin syndrome. Like other nerve compression syndromes,corticosteroid injections are a potential therapeutic modality. Wehypothesize that one can effectively inject the AIN perineural space at itsbifurcation from the MN.Methods—This study serves as a pilot study. The AIN perineuralspace was injected bilaterally on 4 cadaveric models. Cadavericanatomy was unremarkable with the exception of 1, which had markedmusculoskeletal deformity that did not affect the upper extremities. Anidentical procedure was followed, and pathologic anatomy did not affectdata collection. A 10–5-MHz linear array transducer was used. The transducerwas placed transversely through the antecubital fossa. The MN wasidentified proximally as it coursed over the supracondylar eminence. Itappeared spindle shaped with alternating hyperechoic and hypoechoicbands. The MN was traced inferolateral to the origin of the pronator teresmuscle, where the AIN bifurcation was visualized. Ultrasonographically(US) guided injections were achieved with a long-axis, medial-to-lateralapproach with a 22-gauge syringe and 0.35 mL of 0.5% methylene blue.Anatomic dissection and dye visualization allowed for confirmation.Attempts were classified according to accuracy and precision. Accuracymeasured nerve staining; precision measured localized injection withoutdamage to adjacent structures.Results—Six of 8 (75%) injections were accurate, while 4 of 8(50%) were precise.Conclusions—AIN perineural injection at its bifurcation fromthe MN is significant. Such ability can likely provide symptomatic reliefwith corticosteroid administration to patients with Kiloh-Nevin syndrome.US is inexpensive, quick, and minimally invasive. Future phases of thisstudy will expand on our current data set and, pending such results, investigateefficacy of US-guided AIN perineural corticosteroid injectionsin patients with Kiloh-Nevin syndrome.1536975 Efficacy of Ultrasonographically Guided Injection of theUlnar Nerve Perineural Space at the Guyon CanalJeffrey Heimiller,* Oliver Joseph, Oleg Uryasev, JohnMcNamara, Apostolos Dallas Virginia Tech Carilion Schoolof Medicine, Roanoke, Virginia USAObjectives—The ulnar nerve (UN) can become compressed asit passes through the Guyon canal (GC). Like other nerve compressionsyndromes, corticosteroid injection is a therapeutic modality. We thereforehypothesize that ultrasonographic (US) guidance can aid in effectiveUN perineural injections in the GC at the level of the pisiform.Methods—This is a pilot study to explore the feasibility of USguidedinjections of the UN perineural space in the GC at the level of thepisiform. Injections were performed on 4 unembalmed cadavers, 1 ofwhich had marked musculoskeletal deformity that did not affect the upperextremities. The GC was imaged in the transverse plane at the level of thepisiform, and 0.25 mL of 0.5% methylene blue dye was injected into theUN perineural space using a long-axis approach from the medial end ofthe probe, just superficial to the pisiform. Anatomic dissection was performedsubsequently to evaluate injection accuracy and precision: accuracyrefers to nerve staining, while precision denotes that adjacentstructures were not damaged.Results—Six of 8 (75%) were accurate. All injections were precise.Conclusions—This study was able to demonstrate an effectivemeans of visualizing and injecting the UN perineural space at the GCunder US guidance. Inaccuracies were primarily operator dependent. Theoperator for most injections was a second-year medical student with noprior experience performing perineural injections. Initial attempts establishedan effective protocol. In the method described here, the operatordiscovered and consistently visualized a narrow window immediately superficialto the pisiform that allowed for repeatedly accurate and preciseinjections. Despite the initial learning curve, the operator was overall successfulwith accuracy of 75% and precision of 100%. US is a viable meansof increasing the accuracy and precision, and therefore effectiveness, ofUN perineural injections into the GC, but it must be combined with aworking knowledge of superficial landmarks and target anatomy.S94