On the Therapeutic Viability of Peripheral Nerve Stimulation for Ilioinguinal Neuralgia: Putative Mechanisms and Possible Utility

▪ Abstract:   Injury to the ilioinguinal nerve commonly follows during lower abdominal and pelvic surgery, especially with inguinal hernia repair, appendectomy, and hysterectomy. Other potential causes include low abdominal blunt trauma, iliac crest bone graft, psoas abscess, Pott's disease, and prolonged wearing of abdominally constrictive clothing. The actual incidence of ilioinguinal neuralgia is uncertain, as reported percentage ranges between 12% and 62%. Prompt and accurate diagnosis is critical, and appropritate treatments range from conservative pharmacologic management with nonopioid (eg, gabapentin, topiramate) as well as opioid agents, to surgical neurectomy of the proximal portion of the ilioinguinal nerve. Pharmacological treatment is frequently unsuccessful (particularly if delayed) and while surgery is successful in approximately 73% of cases, it can result in problematic paresthesias, and pain may continue to persist in some patients. Thus, minimally invasive techniques, such as peripheral nerve stimulation, may be viable in those patients who are refractory to pharmacological management, as an option to surgery, and who have not gained satisfactory pain relief through surgical intervention. We present three cases of successful pain control of ilioinguinal neuralgia with peripheral nerve stimulation. These cases demonstrate the potential benefits of neurostimulation including durable effective pain relief and decreased use of medication. Putative mechanisms of effect(s) and caveats for continued research to inform prudent employment of this technique are presented. ▪     

Ilioinguinal pain syndrome

Chronic pain may occur in the ilioinguinal nerve distribution spontaneously or following herniorrhaphy or other surgery. Primary ilioinguinal neuropathy may also cause abdominal muscle motor weakness resulting in direct hernia. We describe 12 patients with ilioinguinal nerve disorders and discuss therapeutic alternatives and results of treatment.     

Minimally invasive management of 14.5-week abdominal pregnancy without laparotomy: a novel approach using percutaneous sonographically guided feticide and systemic methotrexate.

OBJECTIVE: To evaluate the possible role of a novel, minimally invasive approach to the management of abdominal pregnancy. METHODS: We hypothesized that sonographically guided feticide without subsequent laparotomy for removal of the fetus and placenta could minimize potential blood loss and would be a reasonable approach in the care of a patient who had a viable 14.5-week abdominal pregnancy with placental implantation directly over the bifurcation of the left common iliac artery. An extensive MEDLINE literature review revealed 1 case of sonographically guided feticide followed 10 days later by uneventful laparotomy for removal of the fetus and placenta. Thus, we used sonographically guided feticide without subsequent laparotomy for removal of the products of conception. RESULTS: The sonographically guided feticide was uneventful, and the patient had no major postprocedure morbidity; a mild ileus was treated conservatively without the need for nasogastric suctioning. No major postprocedure bleeding was encountered. Human chorionic gonadotropin levels dropped precipitously. During the 1.5 years of postprocedure follow-up, the patient reported no major complications. The gestational sac involuted very slowly; amniotic fluid volume appeared normal at 6 months after the procedure but was diminished at the 9-month postprocedure examination. CONCLUSIONS: In cases of previable intra-abdominal pregnancy, sonographically guided feticide may lessen the risk of extensive hemorrhage that can be associated with exploratory laparotomy. Sonographically guided feticide without subsequent exploratory laparotomy can result in a gradual resorption of the products of conception and an uncomplicated recovery. This treatment option should be considered in the management of this potentially life-threatening condition.     

超声引导下的神经阻滞术临床应用进展

传统的神经阻滞与临床经验密切相关,成功率低、安全性较差。近年来,随着超声技术的快速发展,超声引导下的神经阻滞技术得到了广泛应用与飞速发展。超声引导下的神经阻滞技术的出现已使临床神经阻滞的方式发生了根本性变革。临床医师可以通过超声显像观察外周神经及其周围结构,并在超声实时、动态引导下穿刺到目标神经周围,实施精准地神经阻滞,避免了对周围重要组织结构的损伤,提高了操作的成功率,减少了并发症,并大大提高了阻滞效率。本文将综述超声引导下的神经阻滞术临床应用进展。     

Real-time sonographic imaging for periradicular injections in the lumbar spine: a sonographic anatomic study of a new technique.

OBJECTIVE: We conducted this study to develop a sonographically guided approach to the spinal nerve of the lumbar spine and to assess its feasibility and accuracy by means of computed tomography (CT). METHODS: Fifty sonographically guided approaches at 5 levels (L1-S1) were performed on 5 embalmed cadavers, which were positioned prone. The spinal nerves of the lumbar spine were shown under sonographic guidance. In 1 cadaver, the most lateral aspect of the roof of the intervertebral foramen was defined as a reference point. Its position was computed as a distance from the tip of the spinal process (A), the midline (B), and the intervertebral disk (C). Subsequently, axial transverse CT scans were made to verify these distances. In a second part of the experiment, a spinal needle was advanced under sonographic guidance to the spinal nerves for each lumbar spinal level on 1 embalmed cadaver. The exact placement of the needle tips was checked with the help of CT. RESULTS: This technique for a sonographically guided approach to the periradicular area proved to be feasible and accurate. Sonography and CT provided the same mean measurements of 4.0, 2.5, and 1.4 cm for distances A, B, and C, respectively. The Pearson correlation coefficient was 0.99 (P < .001) between sonography and CT. In the experimental study, all 10 needle tips were placed periradicular to the spinal nerves. CONCLUSIONS: Sonographic guidance is a useful adjunct to increase the safety and efficacy of periradicular injections in the lumbar spine.     

Sacroiliac joint injections performed with sonographic guidance.

OBJECTIVE: To investigate the feasibility and effectiveness of sonographic guidance for therapeutic intra-articular sacroiliac joint injections in patients with sacroiliitis. METHODS: Thirty-four consecutive patients with sacroiliitis were enrolled in this study. The synovial portions of 60 sacroiliac joints received injections under sonographic guidance. For treatment, a mixture of a corticosteroid and a local anesthetic was injected intra-articularly. Fluoroscopic spot images were obtained to assess the accuracy of the sonographically guided technique. RESULTS: Of the 60 sonographically guided injections, 46 (76.7%) were successful (i.e., intra-articular), and 14 (23.3%) were missed. The successful intra-articular injection rate was 60% in the first 30 injections, and it gradually improved, reaching 93.5% in the last 30 injections. The mean procedure time was 9 minutes. CONCLUSIONS: Our initial experience suggests that sonographically guided therapeutic injections to sacroiliac joints could be valuable alternatives to other guidance modalities in patients with sacroiliitis. In the hands of experienced radiologists, this technique is safe, rapid, and reproducible.     

Sonographically Guided Carpal Tunnel Injections

Objective. The purpose of this report is to describe a new sonographically guided technique for carpal tunnel injections using an ulnar approach. Methods. Previously published sonographically guided techniques for carpal tunnel injections were reviewed. Described approaches were noted to be technically challenging because of the need to perform long‐axis imaging of the carpal tunnel, short‐axis (out‐of‐plane) imaging of the needle, or both. Results. We developed and herein describe the ulnar approach for sonographically guided carpal tunnel injections. Advantages of this approach include transverse imaging of the carpal tunnel, long‐axis (in‐plane) imaging of the needle, and versatility in targeting structures within the carpal tunnel. Conclusions. Clinicians should consider the ulnar‐sided approach when performing sonographically guided carpal tunnel injections.     

Sonographic diagnosis and treatment of ganglion cysts causing suprascapular nerve entrapment.

One cause of shoulder pain is suprascapular nerve entrapment resulting from compression by a ganglion cyst. We discuss the sonographic diagnosis and treatment of these ganglion cysts and the use of sonographically guided aspiration of these cysts. Previous authors have described CT or MR imaging diagnosis and CT guided aspiration of ganglion cysts. Sonographically guided aspiration appears to be an equally effective but less expensive method to treat these cysts.     

Tibial Nerve Block Using an Ultrasound‐Guided Inframalleolar Medial Plantar Nerve Perineural Injection: A Technical Note

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. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45 :134–137, 2017     

Sonographically Guided Percutaneous First Annular Pulley Release

Objective. The purpose of this study was to assess the safety of sonographically guided percutaneous finger and thumb first annular (A1) pulley releases performed using needle and hook knife techniques in an unembalmed cadaveric model. Methods. A single operator completed 50 (40 fingers and 10 thumbs) sonographically guided percutaneous A1 pulley releases in unembalmed cadavers using previously described needle and hook knife techniques and simulated local anesthesia. Half of the fingers and thumbs were completed with each technique. An experienced observer blinded to the technique dissected each specimen and assessed for neurovascular, flexor tendon, and A2 pulley injury. Completeness of release was also recorded as a secondary outcome. Results. No neurovascular or A2 pulley injury occurred in any digit, regardless of technique. No significant flexor tendon injury was seen in any digit, although minor surface scratches were visualized in 3 cases (6%; 2 knife and 1 needle). The hook knife technique was significantly more likely to result in a complete pulley release compared to the needle technique (22 of 25 [88%] versus 8 of 25 [32%]; P < .001). Conclusions. Sonographically guided percutaneous A1 pulley releases can be performed safely using previously described needle and hook knife techniques. The safety margin for thumb releases is less than that for finger releases, particularly with respect to the radial digital nerve. These cadaveric data support recently published clinical investigations recommending consideration of sonographically guided percutaneous A1 pulley release in the management of patients with a disabling trigger finger.     

Sonographically guided infraclavicular brachial plexus block in adults: a retrospective analysis of 1146 cases.

OBJECTIVE: The aim of this study was to analyze our experience in 1146 cases of sonographically guided infraclavicular brachial plexus block (ICBPB) performed over 32 months. METHODS: Anesthetic records of 1146 cases of sonographically guided ICBPB performed by our staff were studied retrospectively with the use of a database created by an automated anesthesia record-keeping system. The rates of successful blocks, failed blocks necessitating conversion to general anesthesia or requiring supplementation with local anesthetics, those requiring larger-than-usual doses of sedation, and complications were determined. Analysis included an attempt to determine the possible causes of inadequate blocks and complications. RESULTS: In 1138 patients (99.3%), the block was successful. Six patients had incomplete blocks requiring general anesthesia, and another 2 patients needed local anesthetic supplementation by the surgeons. Ninety-seven percent of the blocks were performed by residents directly supervised by an attending anesthesiologist who held the ultrasound probe. The mean age+/-SD of the patients was 39+/-15 years; the mean duration of surgery was 165+/-114 minutes; and the male-female ratio was 4:1. More than 50% of patients were obese. There were no reported cases of nerve injury, pneumothorax, or local anesthetic toxicity. Arterial punctures occurred in 8 (0.7%) patients, but all were inconsequential. CONCLUSIONS: The data from this retrospective study suggest that sonographic guidance provides a high success rate (99.3%) and improved safety for ICBPB. The increased operator team experience virtually eliminates failure and complications.     

Suprascapular nerve block for pain relief in adhesive capsulitis: comparison of 2 different techniques

OBJECTIVE: To evaluate the clinical effectiveness of 2 suprascapular nerve block techniques in adhesive capsulitis. DESIGN: A single-blinded, randomized, comparative clinical trial. SETTING: Physical medicine and rehabilitation department of a university hospital in Turkey. PARTICIPANTS: Forty-one patients with adhesive capsulitis. INTERVENTIONS: Suprascapular nerve block with patients randomly divided into 2 groups: group A, needle tip guided by superficial bony landmarks, or group B, near-nerve electromyographically guided technique. MAIN OUTCOME MEASURES: Visual analog scale (VAS) score for pain severity and range of motion (ROM) were assessed before the injection and at 10 and 60 minutes after it. RESULTS: Active and passive ROM changes and VAS score changes from baseline were statistically significant for each group (P<.05). Passive ROM changes within time after the injection were statistically significant between the 2 groups in all planes except glenohumeral abduction. Achieved VAS score changes in the groups within time were significantly different from each other (P=.001). The VAS score difference after the suprascapular nerve block was more prominent in the near-nerve electromyography group. CONCLUSION: The near-nerve electromyography technique for suprascapular nerve block was more successful in providing and maintaining pain relief for up to 60 minutes.     

Pseudolymphoma of the liver: Sonographic findings and review of the literature

We report a case of hepatic pseudolymphoma in a 67-year-old woman that was detected during an abdominal sonography screening. The lesion was further evaluated using CT, MRI, angiography, and contrast-enhanced sonography. The imaging features of this tumor are discussed herein. The diagnosis of pseudolymphoma was achieved via sonographically guided biopsy. The lesion regressed completely within 1 year.     

CT引导内脏与腹腔神经丛阻滞治疗上腹癌痛的比较

目的：观察CT引导下内脏与腹腔神经丛毁损性阻滞对上腹癌痛的镇痛效果比较。方法：48例顽固性上腹部癌症重度疼痛患者，随机分两组，在CT引导下分别行腹腔神经丛（Ｆ组）或内脏神经丛（Ｎ组）无水乙醇毁损阻滞治疗。观察两组镇痛效果、疼痛缓解程度及不良反应。结果：治疗后即刻全部患者疼痛减轻或消失。在治疗后第3、7、15、30、60、90天，患者的疼痛评分、疼痛程度均明显改善，两组间无显著差异，治疗过程中和治疗后未发生严重并发症。结论：内脏神经丛阻滞可取得与腹腔神经丛阻滞一致的效应，操作方便、疗效确切、安全性高，可供临床选择。     

Sonographically guided core needle biopsy of cervical lymphadenopathy in patients without known malignancy.

OBJECTIVE: The purpose of this study was to retrospectively evaluate the efficacy of sonographically guided core needle biopsy (core biopsy) for diagnosing the causes of cervical lymphadenopathy in patients without known malignancy. METHODS: One hundred fifty-five sonographically guided core biopsies performed in 155 patients with cervical lymphadenopathy were retrospectively evaluated. None of the 155 patients had any known primary malignancy. Final diagnoses were determined by the histologic examination from excision biopsy when performed or by the clinical and sonographic follow-up for more than 12 months. When a lymph node diagnosed as benign by sonographically guided core biopsy regressed spontaneously or by subsequent management, the diagnosis made by the sonographically guided core biopsy was considered correct. When a lymph node diagnosed as benign by sonographically guided core biopsy was unchanged or increased in size with subsequent management, excision biopsy was performed. Diagnostic yield, sensitivity, specificity, accuracy, and complications of core biopsy were evaluated. RESULTS: Histologic diagnosis could be made by sonographically guided core biopsy in 146 (94%) of the 155 patients. The histologic diagnoses were reactive hyperplasia in 44 patients, tuberculosis in 37, Kikuchi disease in 25, metastasis in 16, lymphoma in 16, normal in 7, and toxoplasmosis in 1. Sensitivity, specificity, and accuracy of sonographically guided core biopsy were 97.9%, 99.1%, and 97.9%, respectively. There were no procedure-related complications. CONCLUSIONS: Sonographically guided core biopsy is a safe and efficient tool for diagnosing the cause of cervical lymphadenopathy in patients without known malignancy and may obviate unnecessary excisional biopsy.     

Feasibility of an infraclavicular block with a reduced volume of lidocaine with sonographic guidance.

OBJECTIVE: A successful brachial plexus block requires a large volume of a local anesthetic. Sonography allows reliable deposition of the anesthetic around the cords of the brachial plexus, potentially lowering the anesthetic requirement. METHODS: Fifteen sonographically guided infraclavicular blocks were performed in 14 patients with 2% carbonated lidocaine with epinephrine through a 17-gauge Tuohy needle. The amount of lidocaine injected at several points around each cord was based on satisfactory spread observed sonographically. A 19-gauge catheter was then placed with its tip between the posterior cord and axillary artery, and tip position was confirmed by observing the spread of 1 to 2 mL of injected air. Lidocaine was injected through the catheter if necessary to prolong the blocks. RESULTS: Surgery was performed in all patients without general anesthesia, rescue blocks, or infiltration. A heroin user was given an additional 50 microg of fentanyl before the block. One patient required 5 mL of lidocaine through the catheter for an incomplete radial nerve block 5 minutes after initial injection. Seven patients received additional midazolam (mean, 2.5 mg) for alleviation of anxiety despite excellent blocks. The mean +/- SD volume of lidocaine for the initial block was 16.1 +/- 1.9 mL (4.2 +/- 0.9 mg/kg). In 4 patients, additional lidocaine 1 hour after an initial successful block increased the total volume to 19.5 +/- 7.1 mL (5 +/- 1.9 mg/kg). The mean times to perform the block, onset of the block, and achieving surgical anesthesia and the duration of surgery were 10.8 +/- 3.3, 2 +/- 1.3, 5.9 +/- 2.6, and 92.7 +/- 54.4 minutes, respectively. CONCLUSIONS: A successful infraclavicular block in adults with 14 mL of lidocaine is feasible with the use of sonography. The reduced volume does not seem to affect the onset but shortens the duration of the block.     

神经阻滞技术与周围神经痛

介绍三叉神经痛、舌咽神经痛、枕神经痛、颈椎性神经根痛、肋间神经痛、坐骨神经痛、股神经痛、股外侧皮神经痛、髂腹股沟及髂腹下神经痛等10种周围神经痛的病因和发病机制、临床症状、诊断以及治疗方法。神经阻滞(nerveblock,NB)技术治疗这些疾病是来源于麻醉学的一种独特的方法。当药物疗法或其他方法不见效时改用这种技术可获显著效果,于是详述眶上NB,眶下NB,上颌NB,下颌NB,颏NB,半月神经节乙醇、甘油、热凝NB,舌咽NB,枕NB,肋间NB,腰大肌肌沟阻滞,股NB,股外侧皮NB,髂腹股沟及髂腹下NB等18种NB技术的实施方法。     

Sonographically guided hydrostatic reduction of intussusception in children

PURPOSE: The aim of this study was to assess the efficacy of sonographically guided hydrostatic enema in therapeutic reduction of intussusception in children and to determine whether certain factors may predict the outcome of this technique. METHODS: We retrospectively reviewed the medical records and sonographic examinations of 83 consecutive children sonographically diagnosed with 101 cases of intussusception over a 40-month period. In 99 cases, sonographically guided hydrostatic reduction was attempted. The presence of free peritoneal fluid, the presence of fluid inside the intussusception, and the initial location of the intussusception, as confirmed by sonography, along with the level of experience of the radiologist who performed the reduction were statistically analyzed to determine their effect on outcome. A p value less than 0.05 was considered significant. RESULTS: In 88 (89%) of the 99 cases, hydrostatic reduction was successful. No complications during or after hydrostatic enema were noted. The success rate was significantly lower among patients whose intussusception was located in the left side of the abdomen (p < 0.01) or contained entrapped fluid (p < 0.02) or those in whom hydrostatic reduction was not performed by an experienced sonologist (p < 0.01). The presence of free peritoneal fluid was not a predictor of outcome (p > 0.1). No complications during or after hydrostatic enema were noted. CONCLUSIONS: Sonographically guided hydrostatic reduction of intussusception is safe and effective. We recommend that this method be attempted before surgery is considered, even in cases in which the intussusception contains entrapped fluid or is located in the left side of the abdomen. The level of experience of the radiologist who performs the reduction significantly affects the results of this procedure and should be carefully considered, particularly in cases in which initial sonography reveals the presence of risk factors.     

Accuracy of Sonographically Guided Posterior Subtalar Joint Injections

Objective. The primary purpose of this investigation was to determine the accuracy of 3 different sonographically guided posterior subtalar joint (PSTJ) injection techniques in an unembalmed cadaveric model. Methods. A single experienced examiner injected the PSTJs of 12 unembalmed cadaveric ankle‐foot specimens using the anterolateral, posterolateral, and posteromedial approaches. The injection order for each specimen was randomized, and each technique was completed with a different‐color diluted latex solution. Coinvestigators blinded to the injection technique dissected each specimen and graded the colored latex location as accurate (in the PSTJ), accurate with overflow (within the PSTJ but also in other regions), or inaccurate (no latex in the joint). Results. All 3 sonographically guided PSTJ injection approaches accurately placed latex into the PSTJ (100% accuracy). Latex was also found in adjacent regions in 19.4% (7 of 36) of injections: 8.3% (3 of 36) within the tibiotalar joint, 8.3% (3 of 36) in the peroneal (fibularis) tendon sheath, and 2.8% (1 of 36) in the flexor hallucis longus tendon sheath. The anterolateral approach placed latex outside the PSTJ 25% of the time (3 of 12 injections: 1 tibiotalar and 2 peroneal [fibularis] sheath), the posterolateral approach 25% of the time (3 of 12 injections: 1 tibiotalar, 1 peroneal [fibularis] sheath, and 1 flexor hallucis longus tendon sheath), and the posteromedial approach 8.3% of the time (1 tibiotalar). Conclusions. This cadaveric investigation suggests that all 3 sonographically guided PSTJ techniques may be used to access the PSTJ with a high degree of accuracy. Clinicians should consider sonographically guided PSTJ injections as a favorable alternative to fluoroscopy and computed tomographic guidance when diagnostic or therapeutic image‐guided PSTJ injections are indicated.