ULTRASOUND-GUIDED INTERVENTIONAL PROCEDURES IN THE MUSCULOSKELETAL SYSTEM

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Ultrasound is a readily available, nonionizing, lower-cost imaging modality for the investigation of musculoskeletal pathology. Ultrasound can efficiently detect, localize, and characterize most soft tissue lesions.4, 37 Ultrasound is also recognized as a useful imaging technique in interventional radiology.6, 9, 15 The real-time imaging capabilities of ultrasound are a significant advantage for interventions in the musculoskeletal system, allowing monitoring of the needle position at all times. In addition to localizing the lesion and guiding the procedure, ultrasound can be used to control the efficacy of the intervention and for follow-up imaging. Several procedures may be performed under ultrasound guidance including aspiration of cysts, fluid collections and abscesses, arthrocentesis, installation of drainage catheter, biopsy, steroid injections, treatment of calcified tendinitis, and foreign body retrieval.

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TECHNICAL CONSIDERATIONS

A thorough sonographic study of the area of interest is mandatory before beginning any procedure in order to characterize the lesion and to localize it precisely with respect to adjacent anatomic structures. Basic knowledge of the musculoskeletal anatomy is essential. Sonographic investigation of the musculoskeletal system is best performed with 5- and 7-MHz linear array transducers. A 3.5-MHz probe may be used occasionally for imaging deep structures in large patients. Higher resolution probes

ASPIRATION OF CYSTS, ABSCESSES, AND HEMATOMAS

Ultrasound is the modality of choice for imaging fluid-containing lesions of the extremities and is well suited for guiding aspiration of cysts, abscesses, and hematomas. Cystic lesions of the extremities are common clinical conditions that can be painful and disabling. They include ganglion cysts, synovial cysts, meniscal cysts, or labral cysts. These cysts may be symptomatic because of chronic inflammation; increased internal pressure; or compression of adjacent anatomic structures, such as

ARTHROCENTESIS

Joint fluid aspiration or arthrocentesis may be required in various conditions, such as infection, inflammatory and crystal arthropathies, or amyloidosis.35 Joint puncture may be performed to aspirate synovial fluid for analysis, for steroid injections, or for decompression. Although arthrocentesis could be performed by the clinician, the radiologist may be asked to perform the procedure if a first attempt is unsuccessful. Arthrocentesis can be done using fluoroscopy and arthrography but may

TENDON SHEATH AND BURSAE

Bursitis and tenosynovitis leads to accumulation of synovial fluid and distention of bursae and the synovial sheath of tendons. Inflammation may result from trauma; hemorrhage; infection; crystal-induced arthritis; or from systemic diseases, such as rheumatoid arthritis, seronegative arthropathies, gout, amyloidosis, and sarcoidosis.7, 38 This may also be accompanied by synovial tissue proliferation. Puncture may be needed for synovial fluid analysis, steroid injection, or for decompression

BIOPSY OF SOFT TISSUE MASSES

Biopsies of soft tissue masses can be performed quickly and efficiently under ultrasound guidance. These should be performed only after discussion with the orthopedic surgeon to select the site of needle puncture. Because of potential spreading of malignant cells along the needle track, the latter has to be resected along with the contaminated muscle compartment if the lesion is found to be a sarcoma. Aspiration biopsies with end-cutting 20- or 22-gauge spinal or Chiba needles is usually

TREATMENT OF CALCIFIED TENDINITIS

Calcified tendinitis of the shoulder is a common painful condition that can be treated with anti-inflammatory drugs, physiotherapy, corticosteroid injection, or iontophoresis. Patients who do not respond to conservative treatment may benefit from needle puncture of the calcium combined with local corticosteroid injection. The technique has been described using fluoroscopy, but rotator cuff calcifications may also be punctured with ultrasound.17, 18, 27 A preliminary ultrasound scanning of the

BONE LESIONS

Bone has been regarded traditionally as a barrier to imaging with ultrasound. A lytic bone lesion destroying the cortex, however, can be identified with ultrasound as interruption of the bright echogenic line of the cortex, which may be accompanied by a soft tissue mass. The defect in the cortex acts like a window through which one can insert a needle under ultrasound guidance for marrow aspiration and cytologic examination.11, 20 Good results with ultrasound-guided fine needle (20- and

FOREIGN BODY RETRIEVAL

Ultrasound is very useful in identifying and localizing radiolucent soft tissue foreign bodies.14 A foreign body appears as a hyperechoic lesion surrounded by a hypoechoic halo, thought to represent the inflammatory reaction. Sonography can be used for preoperative localization of the foreign body. Removal of the foreign body can be done more efficiently by using ultrasound intraoperatively.36, 42

In conclusion, ultrasonography is a useful technique for imaging the soft tissues of the

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    Address reprint requests to Étienne Cardinal, MD, Department of Diagnostic Radiology, Centre Hospitalier de l'Université de Montréal, Pavillon Saint-Luc, 1058 Saint-Denis Street, Montreal, Quebec, Canada, H2X 3J4, e-mail: [email protected].

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