All right, thank you so much. Thank you again so much. This is fantastic. If anybody has any further questions, please feel free to reach out to her directly on Twitter. If you have any questions about the lecture series at all, you can reach out to me, Sterling Herring, or AAP via those Twitter handles there. If you missed part of this lecture and want to go back and review or if some of your colleagues want to see it that didn't get a chance to, all the links are on that webpage right there, physiatry.org slash webinars. All the videos are there. They can be downloaded. They can be watched there at that website. Like I said, we'll be keeping those and hosting them online at least through the end of this calendar year, knowing that this COVID thing could last a little bit. Again, thank you so much, Dr. Russell. We appreciate you joining us today. For everybody else, we should be getting started here in the next few minutes. We will skip through some of this front matter as we've already gone over this, but we will keep everybody video and audio muted as always. If you have any questions, my name is Sterling Herring. If you click on your participants list, you should see my name up near the top, Sterling Herring. I'm a PGY3 at Vanderbilt. You can double click my name and send me a message and I can ask them to our speaker at appropriate times. If you have any kind of grander questions, suggestions, concerns about this lecture series in general, please feel free to reach out either to me or to Candice Street at aapcstreetphysiatry.org, or you can track her down on Twitter as well. So without further ado, we're excited to have Dr. Michael Schaefer here with us from Case Western. Thank you for joining us, Dr. Schaefer. Thank you, Sterling and Candice. Can everyone hear me okay? Yes, we can hear you great. Okay, great. So I'll share video for just a minute here, but I think we're just showing the slides, right? Either one. You can have your video slides or leave it on. I like to talk with my hands enough that it'll come through. I probably need to share screen here, right? Yes, sir. If you just click that green button, it should ask you if you want to take it away from me. Okay, I think we should be up and running. Okay, that's great. So I'll just introduce myself a little bit more to start with so you know the source here. I'm the new Division Chief for University Hospitals in Cleveland. I was at Mayo Clinic for a short time after residency and fellowship, and then MetroHealth, the home Case Western Reserve residency program, and then to Cleveland Clinic for nine years where I helped start the residency program there, and now at University Hospitals where we also have a new residency program. I didn't really have a role in getting it started, but I'm trying to keep it going here, and we're newly fully accredited for the next 10 years. We also have plans to start a musculoskeletal and spine interventional fellowship, hopefully by next year if the budget comes through, and that's always a big question these days, but just a little shameless plug for a possible new fellowship with University Hospitals. A lot of good things going on in Cleveland for PM&R, and I'm very happy to have been a part of most of it. But today we'll talk about my kind of passion for PM&R outpatient care is ultrasound guided procedures. And I'll go ahead here. I had a big list of objectives and a really ambitious talk. It's got 120 slides or something like that, but I pared it down quite a bit. I can actually do it in two parts, but today we have the very lofty objective of putting the injection in the right place, and that's it. So easier said than done. I plan to go through basics of ultrasound guided procedures, but I would refer you back to Chris Visco's previous lecture from about two weeks ago on the basics of musculoskeletal ultrasound in general where he touched on some physics and a proper imaging optimization and a little bit on procedures, and this lecture will probably build on that. But if you haven't gone back and seen Dr. Visco's lecture, you can view it in the directory. I think it's about 10 lectures down, and I would recommend that. But this lecture can stand on its own, and like I said, I'll touch a little bit on the basics, but we're going to skip all the boring physics stuff. I have a bunch of information on accuracy and some outcomes data, some summary of the literature, but I don't think we'll have time to get to that today, so I actually need to finish up by 1.50 with a hard stop because my daughter is home taking one of her senior year in high school AP examinations, and if she's not logged in and there's any trouble with the connection, she has to reschedule and delay the end of her senior year, so it's pretty important, I figure. Anyway. That'll work. That's pretty good. Good. Yeah. We'll talk about putting the injection in the right place today. I'll talk a little bit about billing and reimbursement, and then we have case examples, kind of the how-to approach, how I do the most common injections, and we can stop anywhere along that list. And like I said, the rest of it could work well in a part two lecture that I'd be happy to go through at a later date. So as most of you know, ultrasound got popular in the early 2000s. I was fortunate enough to be in fellowship at Mayo at the time, and I remember Jay Smith and his wife Diane, who's an orthopedic surgeon, came back from covering the Salt Lake City Olympics, talking about how the European sports docs were using ultrasound in the athlete village or in the medical community right at the bedside, or I guess in there would be at the playing field side, and really excited about it. So I actually had the privilege of being the first fellow at Mayo to really do any ultrasound, but we weren't using it on patients then. We were just experimenting with it in the cadaver lab a little bit, and I think Jay had been to his first course. So he and I were brainstorming a little bit about how we could best use this new technology. We schemed up the idea for echogenic needles to find out they had already been introduced or already had been invented, and we talked about anything from guiding simple injections to things like the current ultrasound guided carpal tunnel release with his Sonex device. So it was an exciting time, but I really didn't see it come to fruition, and I left Mayo and focused on spine injections and just developing general outpatient practice for a few years, but kept in touch and realized it was really taking off. So in about 2007 I went back and took one of their first courses and have gradually developed it since then in my own practice. And this should be kind of reassurance for most of you seniors or even PGY3s looking for careers and looking to graduate, especially the PGY4s now with rotations interrupted, and fellows, if any fellows are listening, that you're realizing that it's a pretty steep learning curve, and to really do it well it takes a lot of repetition. And now with rotations interrupted and electives canceled and things like that, you're probably freaking out a little bit about whether or not you're going to be able to do this. But I can reassure you that still the majority of us doing this, these techniques, learned it on the job, on the fly. You can do a lot with weekend courses and just experimenting on your own, but I would encourage you to still seek out a mentor, have somebody that you can bounce ideas and questions off of on a regular basis. I still get texts and phone calls from previous fellows on a regular basis with just little simple questions like, hey, how'd you do this? So I had this tough case and, you know, it's one of the more rewarding parts of my job and I almost always make time for it. So as I said, don't freak out. You can learn it on the job. Go to courses or online courses these days, but with this ultrasound stuff, you really got to do it hands on. So find somebody in your community who you can practice with and it becomes a mutually beneficial arrangement. You know, it keeps us honest with our own techniques and helps us learn and develop new things. And before we know it, those of us that were the mentors kind of become the student in some ways. So most of you have some experience with ultrasound in residency or fellowship, but I'll be a little bit more basic. It really doesn't take a fancy machine to do guided procedures. The basic laptop units are all you really need, but the most important thing is to know how to optimize the machine that you currently have. So I have a lot of junior residents or some less experienced fellows come through with limited knowledge of really making the picture the best it can be and everybody wants to blame the machine. So I had a former boss that said, a poor carpenter is one who blames his tools, right? So you want to make sure that you know how to use the tools that you have, optimize them before you start complaining about the device you have. That said though, it's important to advocate for yourself if you're about to go out in a new practice, make sure that they equip you with the necessary equipment. Whether it's at least an average laptop type device or portable device, it's important to have multiple transducers at your discretion and you'll be tempted, especially in the current economic climate, to say, well I can do most of my procedures with a basic linear transducer. I probably don't really need a lower frequency, what would you say, for lack of a better term, curve transducer. I probably don't need the hockey stick, that's the small footprint high resolution, because you know most of my procedures, I don't really need that type of thing. But they're really not that high cost of items, you know, $5,000 to $8,000, and for the cases that you really want them, you'll be very glad that you have them. So I would advocate for yourself, get at least a state-of-the-art portable machine with three, four transducers, and then learn how to use it, really learn how to optimize the settings. We'll talk about that in future slides. You have to have some way to back up images, as simple as printing it, the old-fashioned way in scanning, they're putting in the patient's chart, just in case you get audited, the standard is to have some type of ultrasound image. Ideally, I think the best practice would be to have an image prior to the procedure showing pathology and then an image with the needle in the place where the injection is done, but I think as long as you have one image with the needle in it, it's adequate for insurance, audit purposes, documentation. Ideally, you can back it up digitally, not just on the machine or not just on an external storage device, but if you partner with your radiology department, they can usually upload images and save them in their PACS-compatible or DICOM-compatible image archive with the patient information, and then it's backed up and stored perpetually. Otherwise, you need some way of securely storing images, and I would recommend storing a backup copy outside of the machine itself. Most of the machines, especially the portable ones, will have limited memory, so you'll fill that up. If you have a busy practice, you'll probably fill that up in six months or so. It's nice to have a cart so you can position the patient. It's also nice to have a supply cart in the procedure room. This is just kind of my take on things. The machine can be wheeled from room to room, and you can do it right wherever you do the injections, but I think it's usually most time-efficient and effective to have all the supplies you need in one room and move the patient to the room, have a good table that you can set up, use good ergonomics, and have everything right there at your disposal, and then train your support staff to adequately support you, so don't take it upon yourself to be the one that does everything, and that's also going to be a challenge in the current economic environment. People are our most expensive resources, but it's also very inefficient for you to be the one typing the patient's information into the device and making sure it's stored properly. If you train the average medical assistant, especially the younger ones who are very tech-savvy, are able to do this type of thing very easily, and they can even work ahead and pre-populate lists in the machine that you can go down throughout the day. At Cleveland Clinic, as far back as seven, eight years ago, we had a system to import the patient's data from Epic, the EMR, into the ultrasound machine, and that created a space for storage of the image, so look into that. It might be a little expensive to store the images. You might get charged per picture, but when it comes down to an audit and surviving that or protecting your reimbursement, not having to pay back, it's probably worth it, so make sure the images are stored and backed up. And then the actual instrumentation, so I mentioned it's best to learn how to optimize the picture of your own machine regardless of what you're using, and don't get too intimidated by it. You know, there's just a few basic settings that will help get you a lot better image quality and needle visualization, and once you learn how to adjust those, it's the same on every machine, so you can also borrow ultrasound machines. A lot of machines are sitting unused in some back closet or one provider down the hall in a different department uses it one day a week, and that's how I started with Radiation Oncology. They had bought a machine to put in prostate seeds, and we borrowed it just half a day a week and actually used their clinic space. They took technical revenue, and I blocked the whole half a day, and I just did four cases each half a day and had an hour each to really sit and get into it and learn more on the fly. So don't hesitate to set that up, especially if you're heading into practice usually the first year, you're not so productivity biased for reimbursement. Take your time and make sure you learn it properly, and network. So just asking it about it with other specialties, other locations, or the related specialties, neurology, orthopedics, some of the surgical services, just asking about the availability of devices that you can borrow or ways that you can partner is a form of advertising for your practice. So when you're setting up the settings, it's best to choose the most appropriate transducer, and this slide I think pertains more to image optimization for diagnostic purposes. So you want to use a high frequency that allows adequate resolution, the best resolution at the depth that you need. The lower frequency gives better depth penetration, kind of rehashing Dr. Visco's basics lecture here. But for injection purposes, sometimes it's better to use a lower frequency that ensures that you really have enough penetration to see the deeper structures. There's some concern, I don't know the physics very well, but there's some suspicion or I've heard that using lower frequencies, certain transducers have a wider beam, so it's actually easier to visualize the needle. Sometimes the curve transducer is better for procedures because you can actually get the needle underneath it, closer to the area where the sound waves are entering the skin. And it's sometimes easiest to position a hockey stick transducer, the high resolution, small footprint transducer, closer to the needle because it's smaller and a little bit more nimble. It's also lighter, so you get a little bit better ergonomics, less potential for hand cramping or fatigue. And then I think the most important setting, and this is just my opinion, you know, it's not really scientifically based or not really diagnostically based, but in my opinion, turning up the gain is important. It seems like the thing that most people miss because all the machines supposedly have auto gain or a button that you can push for auto, but it almost always, in my opinion, leaves the image too dark. So if you're putting the probe up and trying to see a deeper structure and everything just looks dark, it's usually because the gain is too low. The same gain knob usually in most machines also increases the sensitivity of the Doppler setting, which is important if you're looking for hyperemia or looking for adjacent vascular structures. And then really just as a matter of comedy, the focal zone that they have on a lot of devices, especially the GE devices. These are the hourglass type things that you see on the side. Focal zone is not that important. You could say it kind of sucks, but I know GE has taken the focal zone setting off of their most recent console unit, the most state of the art, and they say it's done automatically. I personally don't think that adjusting it really makes that much difference. So work on the gain, work on the lowest frequency that you can still see enough resolution to see the pathology, and then learn how to use and position the transducer most appropriately. So as I mentioned, it's important to be able to position the patient in a position that both they're comfortable and you're comfortable. So I tell all the trainees that their research shows that we as healthcare providers are most at risk for on-the-job injury. And usually it's not a major trauma, like construction worker or tow truck drivers or things like that that are really, really at risk for major trauma, but healthcare workers are the most at risk for a lost time on-the-job injury. And it's mostly because of nurses, nurses assistant lifting big slippery patients, but also ergonomics are usually terrible when you're reaching over a bedside. So position the patient close to you, close to the edge of the table, use good posture and make sure that you can stabilize or anchor your hand on the skin. You can see this demonstration. This is my fingers on top of the patient's shoulder. Actually, it's one of my colleagues shoulder and to stabilize the transducer, but it also takes the weight off of my limbs so I can rest it there indefinitely without having to hold it up and co-contract all of my shoulders, spine muscles. It's important for diagnostic purposes to use a standardized sequence. I won't talk so much about diagnostic stuff here, but even your injections, there's comfort and quality in using the same techniques over and over. So try to get into a routine and that'll develop with time. But if you need a checklist or if you need a cheat sheet, don't hesitate to have that handy. For a long time, I kept my Jacobson textbook and one of the injection books right there in the ultrasound room also. So it was right there at my fingertips. And there were times I actually pulled the needle out of the patient and said, no, just wait a second, I'm gonna look something up, make sure I'm doing it right. And patients don't mind. Some of them are curious. The ones that are really nervous, I suppose you don't wanna do that right in front of. But take your time, look things up, call for help. So keep in mind limitations with this too. You don't wanna jump in anything that you're not really comfortable with. But as long as you know that the underlying sensitive structures are shielded from your needle or out of the way, I think you can be fairly safe. A lot of times patients are referred for these procedures because of obesity, but keep in mind anything deeper than six or eight centimeters is really difficult to inject accurately. You could probably even bump that back to about four centimeters if you're a novice. Keep in mind you won't see deep to bony structures because the needle can disappear under them and the sound waves are reflected backwards. So that's that acoustic shadowing of bone or dense tissue. Some patients don't like you to press on them, but for a lot of reasons, having the transducer on the skin and the gel and doing scanning and maybe the effect of the ultrasound waves themselves, it actually makes the procedure less painful. And most of the research studies that I'll probably review at some future lecture show that ultrasound guided procedures are less painful than landmark or even fluoroscopic guided procedures. You won't have contrast to look for vascular uptake. And sometimes the ultrasound is time consuming and it's quite operative dependent and that would be for diagnostic procedures. Still very beneficial for injections though. It's a long list of potential applications. I won't go through all of them, but I wanted to emphasize that compared to landmark guided injections, ultrasound is more accurate for sure and probably has better outcomes in most cases, although as long as the needle is appropriately placed with landmark guidance, it's difficult to challenge the outcomes for those techniques. But when we start looking at the cutting edge, the latest things with orthobiologics, prolotherapy, percutaneous debridement and releases, so those things really hinge upon accuracy and I think that's where ultrasound is really important. And it's really the kind of hand-in-hand development of ultrasound along with these other techniques that make them beneficial and make them so effective. So it's important, as you know, or you probably wouldn't be listening in. So with landmark guidance, we wanna always ensure that we have appropriate placement. We're looking for the texture of the tissue as we go through it, whether there's a resistance to actually injecting and if it reproduces pain or if the patient gets pain relief or pain reproduction during the procedures. These are all techniques that you're applying at the same time as you're doing the ultrasound procedures. So I don't want new trainees to lose the landmark guided injection skills. I probably still do about half of my shoulder injections with landmark guidance. Sometimes for efficiency sake, actually most times for efficiency sake, but sometimes just because it puts the patient at ease, gets it over quickly and it's probably more responsible use of healthcare dollar in most cases, although that's debatable also. It depends on your injection skills. I guess I was, you could say fortunate or unfortunate enough to have five or six years worth of experience doing landmark guided procedures before I even started doing ultrasound. But on the flip side, the ultrasound techniques, once you're good at them, I think it makes you better at the landmark guided injections because you have a little better idea of your depth and the angles and the anatomy once you see it with ultrasound guidance. You're a little bit better, I think, at placement with ultrasound with landmark also. So as we know, we should assess the neurovascular structures adjacent to tissues. And we'll talk about two different, the two different common techniques for actually guiding the needle. So the most cases I prefer to do the in-plane or longitudinal technique. I think in-plane is the more in vogue or commonly accepted term. And that just means that the needle shaft is oriented along with the long axis of the transducer. So like you see in the picture here for this subacromial injection. So I'm not actually injecting the patient here. The needle's actually cut in half with a little bit of coffee creamer in the syringe and it's blunt on the end. So it looks like it's denting into Dr. Fox's skin here, but it's not really. So that's why the technique's not fully sterile and you don't see any proper gel or probe cover. We can talk about those things later also. But you can see the needles coming in underneath the skin in-plane with the needle or in-plane with the transducer. And when you really get it lined up well, you'll see reverberation artifact and that's needle shaft here from sonowaves bouncing back off the transducer and then back down and then back up again and then back down. And you can see a little bit deeper at each iteration, a little bit lighter reverberation artifact. And using this technique, you can guide the tip of the needle and you can visualize it usually all the way from near the skin surface all the way down to the target. It's less likely to lose track of it than the out-of-plane technique. So this example of the in-plane technique. And now we'll see, it's kind of moment of truth about my videos playing. There are quite a bit of ultrasound videos in the talk here. We'll see if we can get them to go. They were slow earlier. So this is a baker's fist. You can see it coming in-plane. This is distal to proximal in the plane of the tibia just next to the medial head of the gastroc. I'll replay it so I can get it to go. You can see the bevel of the needle is facing up and that's a good thing to do technique-wise because the inside of the bevel actually reflects some sound waves. And then you can be sure that you're seeing the tip if you see that characteristics hollowed out tip of the needle. You can see turbulence as the fluid is pushed around and then aspirated. I don't advocate doing a lot of baker's fist aspirations. They tend to come right back again. You have to treat the underlying knee arthritis, but it's nice to have. This one often doesn't play. This is an example of a in-plane subacromial injection. So the subacromial bursa is this brighter tissue sometimes with a fluid layer in it, extends deep to the deltoid and over the top of the cuff here. You can see there's a little fluid, even before I started recording the video, a little fluid was injected a little bit too superficially in the deeper layers of the deltoid, maybe caught a little bit of bursa in there. So I advanced the needle a little bit more and you won't see it play because this one is for some reason not playing, but you can see fluid extend within this bright bursal tissue, extending over the greater tuberosity of the humerus. And I guess that's why they call it the subacromial subdeltoid bursa anatomically because it extends all the way down that way. This is another in-plane. This was actually one of the medical assistants in the orthopedic clinic. She had a labral tear and was really trying to avoid surgery. She had had her hip injected before with no benefit and she couldn't really seem to understand why I thought we should try injecting it again, but the hip injections are tricky. So it's worth trying again. And this is actually a variation of hip injection technique where the needle's put deep to the labrum instead of down at the femoral head neck junction. I can tell this is a special needle. We used an echogenic needle to be sure we visualized even though she's a really thin patient. You can see there's a little gap here between the echogenic portions of this echogenic needle. You can see the little bit of a bevel hollowed out here and then the needle's going deep to labral tissue. So this is all bright labral tissue here and just extending deep to it. But I try to avoid scraping the articular cartilage of the femur. I don't do many that way. I still use the injection down at the femoral head neck, but the thin patient, patient where I think I've missed before with the head neck junction, I'll do it that way. I think we'll talk about individual injection techniques later. There's just examples of in-plane for now. This is a cool example though. This is when I try to do a needle over needle technique or a two needle technique to lavage a calcific tendinopathy. And you can see a smaller needle here coming a little bit more proximally injecting inside the calcific lesion. And the calcific lesion isn't very easy to visualize here, but the cool thing is we caught both needles in one view. So both of them are good. And this is a 18 gauge, a little larger bore for aspiration. I don't do them commonly this way. I usually just use a single needle, but it's kind of a neat picture for in-plane procedure. And then the out-of-plane technique, or some people say transverse. Look at the picture here in the lower left. You can see the needle come in more perpendicular to the probe orientation. And there are variations in this depending on the steepness of the needle insertion. So sometimes we'll go more at a 90 degree where you just see the tip of the needle as it comes through in cross-section, really just a little dot as it comes through a cross-section of the ultrasound waves. You can also put it more vertically, kind of parallel with the sound waves. So it follows the sound waves right down to the target. Both techniques are appropriate. They both have their own pros and cons. If you're going straight in to just see it in cross-section, it's better to start superficially and then use what they call a walk-down technique where you go a little deeper. As soon as you see the needle come in the field of view, you withdraw and go steeper, and you'd see it come through here, then withdraw and go steeper, and you'd see it come through here. I don't have a good video of that, but I think the next slide, I have a good video of the needle coming in more parallel with the sound waves straight down to the target, which is what I more or less prefer, but both take some skill and some practice. The approach out of plane, coming more parallel with the sound waves or more straight down, I think you're less likely to overshoot and put the tip of the needle past the plane of the sound waves, kind of behind the probe. So you're less likely to cause trouble that way. The downside is it's harder to visualize the needle when it transverses. So you're really looking for soft tissue to move out of the way here. I think it's coming. So this is a bicep injection, just like it was mocked up in the picture. It's actually next to the bicep in the bicep bone groove. You can see soft tissue being pushed out of the way and the needle's going on the medial side. I'll play it again. The needle's going on the medial side of the bicep bone groove because the ascending branch or the circumflex humeral can come up the lateral side. So there you see needle dropping down. Sometimes you'll see a little bright reflection from the bevel or the adjacent needle. I'll play it once more. You know that sometimes it's tricky and I like to watch it too. I could just sit and watch it over and over again. So this is bicep tendon. There's anisotropy here. That's why it looks dark, but normally it's pretty normal looking tendon. All right, and then a couple slides to talk about needle optimization. So this is an in-plane injection of the hip. You can see there's usually a little turbulence maybe a little bit of air that's mixed in with it. That actually gives you a better visualization. It's kind of like a poor man's contrast to put a little bubble of air in the syringe with the steroid particles and shake it up aggressively. And that probably seeds tiny little bits of air along with the steroid particles to make it more echogenic when you're actually injecting. So it's a subtle technique. I've also used technique where I just put a quarter cc or half cc of air in the syringe and inject the air. There's no harm in it with joints. I know they use it with arthroscopy too for visualization, but the downside of doing that technique, it's great to see where the injectate goes when there's air in it, but the air actually acts as obstruction of sound waves for anything deep to it. So the air effect will actually obstruct your view. So usually only do that for deeper structures. If you're injecting air superficially, it would take. While we have a second, I actually have a question that's relevant to these lectures. Would you guys mind pulling up the chat and telling me if you know when your programs plan to shift back to something akin to a normal clinical schedule? Some may have already transitioned back to a normal clinical schedule, and for others, it may not be clear yet, but this is a conversation that's been ongoing at AAP. We're trying to obviously support the programs in that transition. All right, looks like we might be getting started. Yeah, I'm back on. All right, great. I'll share again. Hopefully I can pick up where I left off. Sorry about that. That's fine. That's home internet in suburban Ohio, I guess. Okay, so I was talking about hip injections, and I think that's where I left off. I was actually talking about ways to optimize in-plane injections here. We'll see. I think it was on this slide. So I was talking about hip injections. I think that's where I left off. Okay. So I was talking about air injectate as a possible contrast medium. You can kind of use for poor man's contrast, and then the importance of injecting up on the femoral head-neck junction. And then I think I've gone on to the next one to show a video. So this is what you might see when things aren't so optimized. So I think I caught this as an example when the resident or fellow was doing the procedure. Might've been me, but the way I remember it anyway, it was a resident fellow, that's the way we do it. A lot of us do it for things that don't look quite right. I'm joking, but there's probably some truth to it. So this is needle superficially. It looks like it's almost in plane, but then you lose the needle deeper. Maybe I can pause it here. You lose the needle deeper, which is common for steep injections. You know, you have to use a pretty steep angle. You're not getting as much sound wave reflecting backward, but I think we had visualized it in the right place, or at least it felt like it was in the right place. And I told the resident to inject just a little bit, you know, to see where the injectate flow, and lo and behold, you can see turbulence here at the femoral head and neck junction in the right place. So you'll see it right here. Little air bubbles deep to the capsule. Looks good, actually. And then this is a little air that was left over in the syringe. You can see it looks like a little air contrast. So what can you do to make this better, right? There are a few different techniques. The most common one I use for steep injections is to heel-toe. So you're trying to point those sound waves back towards the needle. But when you're first starting, the most important thing is really to visually align the needle with the transducer. Take a good visual alignment. And if you do that, I mean, it sounds simple. You know, that's the basics. That's how everybody's supposed to do it. But I can't tell you how many times people get excited and start scanning all over the place, looking at the screen and not really realizing where they are relative to the needle. So if you line things up appropriately visually, don't move very far from that location. You don't have to scan very far, side to side or up and down. And when you do scan from that position, move very slowly. So it's just, you know, a millimeter, two millimeters per second as you're scanning. Because if you go too fast, you're gonna miss the needle when it flashes on the screen just briefly. Or even in the processing of the image, there's a little gap sometimes. So sometimes you'll slide past the needle before that processing loop comes through and it's displayed on the monitor. So once you see a little bit of the needle, and this is all starting really superficially and shallowly. So you wanna make sure you can see the needle when it's just in the subcute fat or the very superficial muscular layer before you get to anything too dangerous or sensitive. Move really slowly. And as soon as you see the needle, freeze for just a second. So, and take that to heart because that's easier said than done also. You're scanning, scanning and like, oh, there it is. Now I wanna make it perfect, right? So instead of like seeing the needle and going right into optimization or fine tuning, as soon as you see the needle, pause just for a second. And then think about which way you were headed when you first started to see the needle, right? So, I'm talking with my hands, but I don't know if it would help to be able to see them anyway. Once the needle's in view, move so slowly that you never lose feel, you never lose track of the needle, right? So you're basically frozen on top of it and then start by making a very subtle movement, either rotation or toggling, that's wig wag or heel toe, whatever it does to optimize the image with that little technique. And then move on to the next technique, which would be if you optimized it by rotating, then start heel toeing a little bit. Just a subtle movement, a millimeter or so. And then hesitate again and think, okay, now what do I need to do? If I was rotating and that optimized it, that might mean that I'm still slightly off plane, not quite in plane, so I need to rotate a little further. And if you go past where it is, then you think, oh, okay, now I rotated a little too far, I need to come back and play in the opposite direction. From there, I usually heel toe or toggle. And then when it really looks like the needle's optimized, then you can start advancing the needle again. If it starts to go off of the field of view, so you start to lose track of it again, then you have to repeat the sequence, slide side to side or translate, they call it. And then once you see the needle again, you think, oh, I had to translate a little bit away from me to optimize the picture. That must mean the needle is trying to go away from me. So you can use some needle guidance technique that hopefully you firm up by doing fluoroscopic procedures or just think about redirecting the needle back towards you. This is assuming that the target is still in field of view also. Advance a little bit farther and then repeat the sequence again. So it was trying to go away from me. I pushed the needle back towards me. Now I toggle, heel toe, rotate a little bit, still optimized, and then advance the needle again. If I lose it a little bit more, then I think, which direction did I have to go? It was trying to go away from me before, so it's probably still trying to go away from me. So I usually slide the probe away from me and there it is again. And now I know I got to force the needle back towards me even more aggressively. So you can do that with using, bending the shaft of the needle a little bit or just coming back out and redirecting. Don't hesitate to withdraw the needle and start over again. If it feels like the needle's trying to go away from you or towards you or dive too steep, too quickly, that probably means you're going through a dense tissue plane and the bevel of the needle's pushing it one way or the other, or your original setup is just a little bit too steep or a little bit too aggressive. So when in doubt, withdraw the needle, start over and just practice. So each case is an ability to practice, practice, practice. Another technique that helps, and most patients appreciate it, is to try to numb the skin first before your injection. You can practice using smaller gauge needles, numbing the skin. It's almost like a mock-up for the procedure when you actually go for it on the deeper procedures. Once you're experienced and skilled, it's probably less painful and much more time-efficient just to go for it with a medium-sized needle. You can just inject a hip or deeper shoulder injection with a 22-gauge spinal needle. But while you're still learning or patients are particularly squeamish or nervous, just numbing it. I usually use a 27-gauge needle, but numbing it with a 27 or 25 or occasionally even a 30-gauge needle is helpful. And then you get to practice your mock-up, your setup, and realize which direction you're trying to go and which direction the needle, or just your angle, kind of optical illusion-wise, is going to push you one way or the other. There's not much substitute for practice. You can do it with turkey breasts or buy a big ham, pork shoulders with a bone in place were great. I used those in some courses before we actually studied that and showed that it was a beneficial technique. It's right up in the Blue Journal from about 2008 or something, 2009 maybe. And then do it at home. You can also use gelatin model, just double-strength gelatin, and practice as much as you can. I don't recommend practicing on your kids or spouse with needles, though. I recommend it strongly for diagnostic purposes, but you won't make friends that way if you get the needles out. So we have a few minutes left here. We'll talk a little bit about billing and coding, but I'm gonna skip through some of this just to get to a couple other common injection examples. In general, you're adding needle guidance to your billing, but as of 2015, they added bundled codes. Instead of adding the needle guidance to the injection codes, they bundled the needle guidance into the code. The result was an increase in reimbursement for the individual injection, but a decrease overall. So it's actually 65 or 70% less reimbursement than doing the old code with the ultrasound guidance. But you can still use that 76942 ultrasound guidance with the other non-joint injection codes, so it's not really bundled yet. RVU-wise, it's not great either. You lose RVUs relative to the injection guidance, but it's helpful. This is just a little aside, a little break before discussing more individual techniques. This was an actual Cleveland Clinic patient who walked in my clinic with upper thoracic pain, and this was his real tattoo. Never knew what happened to him, but usually I'm not very optimistic when I see that type of thing. But at least he was owning it. He wasn't really living it that way or complaining about things that way, but it's a start anyway. So I mentioned subacromial subductile bursa technique before, I'll go through that quickly, but I like to put the needle close to the acromion just because it's similar to what I learned with landmark guidance, but you can put the needle anywhere along the course of that bursa. One of our radiologists would do it way out here at the greater tuberosity and use a large volume and it would backfill up, it's pretty effective, less painful. Glenohumeral injection, you can do posteriorly or anterior. I'm a little biased more towards the anterior approach, but glenohumeral's first here because this is what I learned. So you can see labral tissue here off the glenoid humeral head, and the target is deep to the labrum, but try not to bump against the humeral head too aggressively. So this is optimization in the soft tissues, moving very slowly, right? You can see the needle kind of goes in and out of view a little bit just as it goes in and out of plane, and it's directed the appropriate way, but the recording wasn't long enough. So in a subsequent case, it's gonna think for me here. In a subsequent case, we captured a more appropriate placement. See if it'll play. It's like it's not gonna. We'll give it one more chance here because it's a cool one. There it is. So this is an echogenic needle in a very large patient, really steep approach, but you can see with heel toeing the transducer, really directing those images towards the shaft of the needle, you can see the needle shaft and the, let's see if I can make it play once more. You can see a gap between the echogenic portions of the needle. The tip, even this steep, the bevel sometimes is more echogenic. You can see it deep to the labrum here. It's deep to the glenoid actually, and this was a degenerative shoulder. You can imagine there's probably not much joint space here. The humerus is displaced a little bit relative to the glenoid, but the needle's deep to the glenoid posterior. So posterior approach is a little bit more painful when you get to that location, and I think it's more technically challenged. So an alternative approach is the anterior in the rotator interval next to the bicep tendon. So between the subscap and supraspinatus, and this will flow down into the glenohumeral joint. And even more effective, I don't think I kept a image of it. I've been doing lately. I can just describe it here. I've been going through the subscapularis, between the glenoid and humerus anterior. I'll have to capture a picture of that and describe it. But the same way I showed the out-of-plane biceps injection with the tissue displacing as the needle comes down, I do that against the medial side of the humerus. And that's the preferred technique for most of the shoulder surgeons who I've worked with, doing it with landmark guidance. So we use the same technique and use, add ultrasound. It's usually even more effective. Biceps longhead, I described before, injecting on the medial side of the biceps to avoid that ascending branch of the circumflex humeral. AC joint, I usually do out-of-plane. You can see it's more parallel with the sound waves, but you can do it with a walk-down technique. So this is where the needle drops in between the acromion and clavicle. Usually the clavicle's a little bit higher, but you can see the needle disappear in here. Low volume injection, usually, 1cc maximum, I usually use half a cc of Kenalog and half cc of Lidocaine. Carpal tunnel can be from the radial or lateral side. This is a flattened nerve, one of the signs of ultrasonographic signs of carpal tunnel. Also, a borderline cross-sectional area. Here, if it'll be a little bit more visible. Here, if it'll play, you can see the needle just deep to the transverse carpal ligament. Next to the nerve, you can see as the injectate's put in, it's pushing the nerve to the side. I'll often go a little bit steeper than this. As I mentioned, it can go on the radial side or the ulnar side, just avoid the artery, the respective artery. Then the flexor carpi radialis tendon's also a challenge to get around, so I somewhat prefer the ulnar approach, but honestly, you can do it either way. I mentioned quite a few hip joints, either the same slides. And I redid the slide, or I just put the same slide in for techniques for visualization. And I think I'll stop here. I have time for a couple questions, hopefully. But move slowly, start superficially. Don't go far from how you originally visually aligned the needle. Be glancing up at the monitor and back down at the field frequently. And as soon as you see the needle stop, and then rotate or toggle subtly. You optimize it, move, and then when you see it move away from you or towards you, keep in mind that's the way the injection's gonna, the needle's gonna try to go, and you have to force it back the opposite direction when in doubt, withdraw, and use practice, practice, practice, practice. I didn't mention, I did mention before the possibility of using probe covers, and sterile technique. I recommend it for everybody who's just starting new to use fully sterile technique, sterile gloves, a tray, and a probe cover. I like the probe covers that have gel or adhesive layer built in, so you don't have to have gel billowing out around the transducer. I've had two cases where the resident put the needle through the probe cover, through the non-sterile gel, and then into the patient. And that's usually not well-received. It went fine, and it's probably sterile enough, but it's better to use the adhesive probe covers. And now I would say I probably do less than a third with a fully sterile technique, but I usually use an alcohol pad right at the insertion site. After doing quite a bit of scanning, it's risky to contaminate the site. So the way around that I've used lately is I still, as soon as, right before the needle goes in the patient, I use alcohol right on that spot, even if I'm using just a sterile needle, but not fully sterile technique otherwise. So I'll stop here. Any questions? That's great. We'll try to keep this real short. We have one question that came up. I know you have to get over to help out your daughter. Any anticoagulation comments in terms of what is your cutoff? Are there certain injections that you're more concerned than others? Sure, it's controversial, but almost all the joints are safe. I tend to use ultrasound rather than fluoroscopy when the patient's on an anticoagulant. Generally, I use 3.5 INR as my cutoff for joints, but I think that's a little bit ambitious or cowboyish, for lack of a better term. A lot of people say it should be less than 2.5, but keep people on the anticoagulants. I do think, and there's not much evidence to back it up, but I do think fairly strongly that the risk of taking the patient off is greater than the risk of bleeding keeping them on. So even for hip injections, I say INR 3.5. That's been generally the consensus in most of the experts who I've discussed with, but it's relative to the patient. And if they have had previous bleeding complications, if they're on anticoagulations just as stroke prevention for AFib, it's a very minimal risk to bring them off, but I usually keep them on. Perfect, thank you so much. I think there is a little bit of data on the spine literature about that very thing. That's the elevated risk of taking them off as opposed to keeping them on. Yeah, yeah. Thank you so much. I appreciate it. I know you have places to be that are more important than here. So thank you so much for joining us. We appreciate it very much. My pleasure. Thanks for listening, everyone. Absolutely. And for everybody else that joined us today, if you missed part of this lecture or you want to go back and review it, that's the website right there. If you have further questions for him, that is his email address on the screen, or you can reach out to me or to Candice at AAP on Twitter. Those are our Twitter handles. Thank you again for joining us. We look forward to having everybody tomorrow. Stay safe.

ultrasound-guided injection

shoulder

hip

carpal tunnel

AC joint

ultrasound image optimization

in-plane approach

out-of-plane approach

needle optimization