1. 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)

2. 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

3. 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

4. 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

5. US guided Visualization of MSK injury: Trigger Point  Trigger Point (initial)  Big mangled mass of muscle tissue

6. US guided Visualization of MSK injury: Intervertebral Disc  US lumbar spine at L5-S1

7. 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

8. 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

9. 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

10. 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

11. Injectional Treatment: Scar Tissue/Bone Spurs http://www.chiropractorspringfield.com/doctor/chiropractor/10 12L/springfield-chiropractor/nova-chiropractic-and-wellness- center.htm

12. Injectional Treatment: Scar Tissue/Bone Spurs  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

13. Injectional Treatment: Scar Tissue/Bone Spurs 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

14. Injectional Treatment: Scar Tissue/Bone Spurs  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.

15. Injectional Treatment: Scar Tissue/Bone Spurs  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)

16. Injectional Treatment: Scar Tissue/Bone Spurs  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

17. Injectional Treatment: Scar Tissue/Bone Spurs  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

18. 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

19. 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

20. Injectional Treatment: Scar Tissue/Bone Spurs  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

21. Injectional Treatment: Scar Tissue/Bone Spurs  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)

22. 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

23. US guided injection of neuromas  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

24. US guided injection of neuromas  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

25. US guided injection of neuromas

26. 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

27. 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%.

28. Puncture at L4-L5 performed under CT guidance.

29. 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.

30. 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.”

31. US guided injection of an Intervertebral Disc MRI-L4-5 disc herniation US L4-5 disc herniation

32. 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