Cortisone InjectionIt is also a common cause of Greater Testosterone sale Pain Syndrome. Trochanteric bursitis is inflammation of the bursa a small, cushioning bursitos located where tendons pass over areas of bone around the jointswhich lies over the prominent bone on the side of your hip femur. The superficial trochanteric bursa is located over the d bol price trochanter. This trochanheric the most commonly inflamed bursa. A deep trochanteric bursa lies deeper and can become inflamed in more severe cases. The trochanteric bursa may be inflamed by a group of muscles or tendons rubbing over the bursa and causing trochanteric bursitis steroid injection side effects against the thigh bone. This injury can occur traumatically from a fall or a sport-related impact contusion.
BURSA INJECTION | Centers for Pain Control
Stojanovic; Corticosteroid injections for trochanteric bursitis: A pilot study, BJA: Numerous studies have demonstrated that therapeutic injections carried out to treat a variety of different pain conditions should ideally be performed under radiological guidance because of the propensity for blinded injections to be inaccurate.
Although trochanteric bursa injections are commonly performed to treat hip pain, they have never been described using fluoroscopy. 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. Older patients were more likely to require multiple injections than younger patients. Radiological confirmation of bursal spread is necessary to ensure that the injectate reaches the area of pathology during trochanteric bursa injections. Trochanteric bursitis TB is a common cause of hip pain and leg pain.
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. 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.
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. Permission to conduct this study was granted from the Departments of Clinical Investigation at Walter Reed Army Medical Center and Massachusetts General Hospital who designated it as an exempt protocol, and all patients who gave their informed consent for the procedure.
The study patients were 40 men and women with a clinical diagnosis of TB who underwent therapeutic trochanteric bursa injections using fluoroscopic guidance. All injections were performed under sterile conditions in the lateral decubitus position with 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. 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. 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 In addition, the following procedural information was analysed: 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.
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. The 40 subjects included 12 males and 28 females, whose average age was 61 yr range 38—84, sd The mean duration of hip pain was 2.
There were 24 right-sided blocks and 16 left hip injections. Residents performed 14 injections, fellows 11 blocks, and attending physicians the remaining 15 procedures. There were no significant differences with respect to age, sex, duration of pain, side of injection, and percentage of obese patients when broken down by the training level of the injector.
The effects of sex and side of injection on accuracy were not statistically significant. There was a propensity for trochanteric bursa injections to be less accurate in elderly patients.
The mean age of patients in whom bursagrams were obtained on the first attempt was With respect to the secondary outcome measure of hitting the GT on the first needle insertion, the average age of patients in whom the GT was contacted on the first try was Accuracy of trochanteric bursa injections based on demographic and clinical data.
Number of attempts includes all needle placements. In one patient who had undergone a unilateral total hip replacement 2 yr earlier, a bursagram was not appreciated despite eight injections four each by a fellow and attending.
The maximum number of attempts required to successfully obtain a bursagram was six, four by a resident, and two by an attending.
In the nine patients in whom the GT was missed on the first attempt, the mean number of attempts required to obtain a bursagram was 3. Overall, the mean number of attempts required to obtain a bursagram was 1. Accuracy of trochanteric bursa injections based on physician's level of training.
The mean duration of pain for the study population was 2. The average duration of pain for patients in whom bursagrams were obtained on the first attempt was 2. In those patients in whom the GT was contacted on the first attempt, the mean duration of hip pain was 2. Pearson's correlation coefficient for duration of pain and accuracy was 0. The average number of attempts it took to obtain a bursagram was 2.
None of these differences were statistically significant. The direction of missed blocks was determined only for first attempts. Of the 22 misses, the breakdown was as follows: 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.
TB is a frequent cause of hip pain in middle-aged and elderly individuals. Of the three bursae usually present around the GT, two are major and one minor. 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. 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. 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. 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. 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. 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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