1 Pain Management Centers, Departments of Anesthesiology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA and Walter Reed Army Medical Center, Washington, DC, USA. 2 Department of Physical Medicine and Rehabilitation, Walter Reed Army Medical Center, Washington, DC, USA and Department of Radiology, Loma Linda University, Loma Linda, California, USA. 3 Pain Management Center, NYU School of Medicine, New York, USA. 4 MGH Pain Center, Deparment of Anaesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
* Corresponding author. E-mail: spc5_2000{at}yahoo.com
Accepted for publication September 16, 2004.
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Abstract |
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Methods. The authors reviewed recorded data on 40 patients who underwent trochanteric bursa injections for hip pain with or without low back pain. The initial needle placement was done blindly, with all subsequent attempts done using fluoroscopic guidance. After bone contact, imaging was used to determine if the needle was positioned on the lateral edge of the greater trochanter (GT). Once this occurred, 1 ml of radiopaque contrast was injected to assess bursa spread.
Results. The GT was contacted in 78% of cases and a bursagram obtained in 45% of patients on the first needle placement. In 23% of patients a bursagram was obtained on the second attempt and in another 23% on the third attempt. Four patients (10%) required four or more needle placements before a bursagram was appreciated. Attending physicians obtained a bursagram on the first attempt 53% of the time vs 46% for fellows and 36% for residents (P=0.64). Older patients were more likely to require multiple injections than younger patients.
Conclusions. Radiological confirmation of bursal spread is necessary to ensure that the injectate reaches the area of pathology during trochanteric bursa injections.
Keywords: complications, trochanteric bursitis ; hormones, corticosteroids ; injection ; pain, hip ; radiology, fluoroscopy
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Introduction |
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Recently, fluoroscopy has been advocated for many procedures previously performed blindly including lumbar, caudal and cervical epidural steroid injections, sacroiliac joint injections, and piriformis muscle injections.1117 This is because radiological studies have repeatedly demonstrated that injections performed blindly frequently result in failure of the injectate to reach the desired area of pathology. In our experience, many patients with confirmed TB fail to obtain any relief with therapeutic injections done with LA and steroid. As these patients should all respond with at least temporary relief from the LA, one must question either the diagnosis itself or the accuracy of the injection.
Up to 21 bursae have been described in the hip region, with at least three being present around the greater trochanter (GT).2 These bursae are dispersed throughout numerous soft tissue structures, including muscles, tendons, and fibrous tissues. This and factors such as anatomical variance and referred pain may potentially contribute to inaccuracies in blindly performed trochanteric bursa injections. Despite numerous studies assessing the potential benefits of steroid injections to treat TB, to our knowledge radiological guidance has never been utilized in these injections. This study was undertaken to determine whether or not fluoroscopy is necessary when performing trochanteric bursa injections.
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Methods |
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All injections were performed under sterile conditions in the lateral decubitus position with 22-gauge spinal needles and superficial anaesthesia. The initial needle placement was done blindly based on anatomic landmarks and physical examination. If the GT was not contacted on the first attempt, fluoroscopy was utilized to redirect the needle until bone was contacted. Once this occurred, antero-posterior fluoroscopy was used to ascertain that the tip of the needle was on the lateral edge of the GT. If needle placement was still considered inaccurate, the needle was repositioned and the process repeated. When the clinician felt the needle was correctly positioned, 1.0 ml of radiopaque contrast was injected under fluoroscopy to confirm bursa spread. If bursa spread was not appreciated, the needle was repositioned and the process repeated until a clearly recognized bursagram was obtained. After radiographic confirmation of correct needle placement, a 5 ml mixture containing depomedrol 80 mg and bupivacaine 15 mg was deposited. As radiological (e.g. magnetic resonance) imaging is not routinely used to diagnose TB, the affected bursa could not definitively be identified before injection in all but one of the patients. Consequently, spread into any one of the three major bursae surrounding the GT constituted success. In all cases, the arbiter of accuracy was the attending physician.
The patient and clinical data recorded included age, sex, duration of hip pain, side of injection, and whether or not the patient was obese. The latter variable was defined as a body mass index (BMI) more than 28. In addition, the following procedural information was analysed: (i) whether or not the needle needed to be repositioned before the GT was contacted; (ii) the number of times contrast was injected (indicating the needle was on the lateral edge of the GT) before a bursagram was obtained; (iii) needle location relative to the bursa when the needle was incorrectly positioned; (iv) training level of the injector.
Accuracy was assessed by two variables. The primary outcome measure was the total number of needle placements needed before a bursagram was obtained. This figure includes needle placements not contacting bone. The secondary outcome measure was whether or not the GT was contacted on the first attempt. Both outcome measures were used to determine success rates based on the level of training and clinical variables. Among the 40 procedures were five difficult ones that required an attending to replace the trainee as the clinician completing the injection. In these cases, the total number of injections required was ascribed to the trainee. Only injections whereby >50% of the contrast was visually determined to be in a bursa were considered correct. All residents were postgraduate yr (PGY) 3 or 4 anaesthesia or physical medicine and rehabilitation residents. The fellows were all board-certified anaesthesiologists, half (two of four) of whom had been in private pain practices before embarking on fellowship training. The attending physicians included four pain-certified anesthesiologists and one pain-certified physical medicine and rehabilitation physician with a minimum of 5 yr experience at staff level. Continuous data are presented as mean (SD), and were analysed by use of analysis of variance (ANOVA) and independent-groups t-tests. Categorical data were analysed by use of 2 tests.
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Results |
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Accuracy by level of training
Attendings obtained a bursagram on the first attempt in 53% (8 of 15) of injections, compared with 46% (5 of 11) for fellows, and 36% for residents (P=0.64). Overall, the mean number of attempts required to obtain a bursagram was 1.7 (range 13, SD 0.9) for attendings and 2.5 each for fellows (range 18, SD 2.2) and residents (range 16, SD 1.7). These differences were not statistically significant (P=0.65). Attending physicians contacted the GT on the first attempt in 87% of injections vs 82% for fellows and 64% for residents. This difference was also not significant (P=0.33; see Table 2).
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Obesity
In obese patients, a bursagram was obtained on the first attempt in 38% (three of eight) of obese patients vs 47% in non-obese patients (15 of 32). The average number of attempts it took to obtain a bursagram was 2.9 in obese patients compared with 2.0 in non-obese subjects (P=0.38). With respect to the secondary outcome measure of hitting the GT on the first attempt, the percentages for obese and non-obese patients were 78 and 75%, respectively. None of these differences were statistically significant.
Location of first miss
The direction of missed blocks was determined only for first attempts. Of the 22 misses, the breakdown was as follows: four needles were placed too anteriorly, two too posteriorly, four too superiorly and two were too inferior. There were four misses each in the antero-superior and antero-inferior directions, one in the postero-inferior direction, and one miss was both superior and superficial.
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Discussion |
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Of the three bursae usually present around the GT, two are major and one minor.35 The largest bursa, the subgluteus maximus bursa, lies lateral to the GT and deep to the converging fibres of the tensor fasciae latae and the gluteus maximus muscle as they join to form the iliotibial tract.2 5 Separating it from this bony protuberance is the gluteus medius muscle. The other major bursa is the subgluteus medius bursa, which lies beneath the gluteus medius muscle, and is situated superiorly and posteriorly to the GT. The subgluteus minimus bursa lies anterior and superior to the proximal surface of the GT. Although these three bursae are constant, others can sometimes be identified.2 Inflammation or irritation of any of these bursae can lead to the symptoms of TB.2 23
The main finding in this study is that irrespective of the level of training, fluoroscopy was necessary in a majority of patients in order to ensure the spread of injectate into the targeted bursa. The inaccuracy of trochanteric bursa injections was observed across all patient and clinical variables. Not surprisingly, the GT was contacted on the first attempt in 78% of patients. While this finding may seem auspicious at first glance, the ramifications of this bode worse than if the opposite had held true. Missing bone should never result in medication being deposited outside the bursa, as it is obvious that the needle is positioned in the wrong place. The consequences of missing bone are therefore limited to increased procedure-related pain and possibly infection.
A more striking finding was that a bursagram was obtained on the first attempt in only 45% of procedures. As a bursagram was not obtained on the second attempt in any of the nine patients in whom the GT was initially missed, this meant that in 55% of cases where the attending physician was reasonably sure that they were injecting into a bursa, they was actually depositing the medication in the surrounding soft tissue. The consequences of this error are more profound than just increased pain and a nominally increased infection risk. Incorrect injections may not only result in failure to relieve pain, but can also lead to misdiagnosing a treatable condition, the prescribing of unnecessary medications, and peripheral and central sensitization.
Recent studies carried out in pain patients have demonstrated the need for fluoroscopy when performing other therapeutic injections. White and colleagues reported that when experienced physicians performed epidural steroid injections without fluoroscopic guidance, they were successful in entering the epidural space in only 30% of cases.12 In a study by Fredman and colleagues, the authors found the loss of resistance technique to be a reliable indicator of entry into the epidural space during blinded epidural steroid injections; however, the injected contrast dye reached the area of pathology in only 26% of cases.11 In a study using computerized tomography to localize anatomically guided sacroiliac joint injections, intra-articular injection was accomplished in only 22% of patients.16
There are several reasons why corticosteroid injections performed blindly may miss the targeted area of pathology in patients with TB. First, difficulty palpating landmarks, especially in obese patients, may result in the injectate being deposited into the surrounding soft tissue. In our study, only eight patients had a BMI more than 28, with five requiring more than one attempt to obtain a bursagram. The incidence of obesity in our patients is less than that seen in the general population, and reflects the fact that many of our patients were either active duty or retired military. Although there was a trend toward obese patients needing more injections to obtain correct needle placement (2.9 vs 2.0), this difference did not reach statistical significance (P=0.38).
Secondly, referred pain and secondary hyperalgesia may lead to the injection of medicine into tender areas not involved in pain generation. This might be expected in those patients who have suffered pain for long periods of time, in whom peripheral sensitization has developed. In this study, we sought to evaluate this possibility by determining the effect duration of pain had on accuracy. While there was a slight trend towards patients with shorter durations of hip pain requiring fewer injections, this difference did not approach statistical significance.
Finally, inflammation within the bursa can lead to scar tissue and adhesions that impair the spread of injectate. This is more likely to occur in patients with a history of trauma, repeated injections, chronic inflammation and previous surgery. As illustrated in one of our patients who had undergone a hip replacement, previous surgery may even obliterate bursae, making a contained injection impossible. With scar tissue and adhesions, even if the needle is correctly placed, the medication may never reach the area of pathology.
A significant flaw in this study is that all injections were performed by pain management physicians whose primary training was in either anaesthesiology or physical medicine and rehabilitation. Had primary care physicians, who generally have less experience with injections, or orthopaedic surgeons, who have a better understanding of the anatomy and spatial relations of the hip, been included in this study, the findings may have been different.
In conclusion, the results of this study provide preliminary evidence that in the absence of fluid aspiration, radiographic guidance is needed in order to ensure accuracy during trochanteric bursa injections. Our findings are consistent with those of other studies evaluating the use of fluoroscopy for diagnostic and therapeutic injections.
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Footnotes |
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References |
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