How I Do It: Denervation of the Hip Joint Under Ultrasound and Fluoroscopy

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spk_0 How I Do It

spk_0 Deenervation of the Hip Joint under ultrasound and fluoroscopy

spk_0 by Dr. Abdulezis Almazidi, Anthony Maki, and Howard Meng

spk_0 Introduction

spk_0 There is a 7-10% prevalence of hip pain in adults 45 years or older

spk_0 with the leading cause of chronic hip pain being osteoarthritis

spk_0 Other causes of chronic hip pain include rheumatoid arthritis,

spk_0 labral tears, osteonecrosis of the femoral head,

spk_0 a vascular necrosis, post-traumatic arthritis,

spk_0 asetabular fractures, chronic infections,

spk_0 and persistent pain after total hip replacement.

spk_0 Irrespective of the pathology,

spk_0 hip pain negatively impacts mobility and overall quality of life.

spk_0 Hip arthroplasty is one of the most common and successful types

spk_0 of orthopedic surgeries.

spk_0 However, concerns regarding patient comorbidities and perioperative risk

spk_0 may deter some patients from hip replacement surgery

spk_0 or make them poor surgical candidates.

spk_0 The lifespan of the implanted hardware is also limited to between 15 and 25 years,

spk_0 which results in patients typically being deferred for hip arthroplasty

spk_0 until they are well into their 50s or 60s.

spk_0 Consequently, there is a need for safe and effective procedural intervention

spk_0 for the management of hip joint pain in these patients.

spk_0 Intervention of the hip joint capsule

spk_0 The majority of pain in the hip joint originates from the joint capsule,

spk_0 which is richly innervated by the articular nerves

spk_0 branching from multiple nerves.

spk_0 The anterior hip capsule, which is the target of discussion,

spk_0 is innervated by articular branches of the femoral,

spk_0 obterator, and accessory obterator nerves,

spk_0 which are well described by short and others.

spk_0 The posterior hip capsule is innervated by the quadratus femoris,

spk_0 superior gluteal, and perhaps the sciatic and inferior gluteal nerves.

spk_0 Previously, the femoral nerve was thought to innervate the superior lateral

spk_0 and inferior lateral aspects of the joint capsule,

spk_0 whereas the superior medial and inferior medial aspects of the joint capsule

spk_0 were innervated by the obterator nerve and the accessory obterator nerves.

spk_0 The systematic review and meta-analysis by Tomlinson and others

spk_0 offers an updated summary pictograph of the innervation discussed.

spk_0 Indications and patient selection

spk_0 Hip denervation is indicated in patients with chronic hip pain,

spk_0 pain for more than three months, who have failed to respond to conservative management

spk_0 and are not surgical candidates or do not want to pursue surgery.

spk_0 Any pathology with the potential to cause pain in the hip joint,

spk_0 which may include, but is not limited to osteoarthritis,

spk_0 rheumatoid arthritis, a vascular necrosis, persistent pain after total hip replacement,

spk_0 post-traumatic arthritis, labral tears of acetabulum and acetabular fractures

spk_0 may be an underlying cause of the chronic hip pain.

spk_0 In the author's practices, certain subgroups of patients present most commonly.

spk_0 Those who have experienced lower extremity trauma,

spk_0 that is femur fracture, acetabular fracture, those with advanced osteoarthritis,

spk_0 who are too frail or ill to undergo hip arthroplasty,

spk_0 and those who have had hip arthroplasty, but continue to have persistent pain.

spk_0 Other patient groups that frequently benefit from hip denervation

spk_0 include patients with sickle cell disease or significant steroid use

spk_0 resulting in a vascular necrosis of the hip.

spk_0 No specific exclusion criteria exist outside of the typical contraindications,

spk_0 that is, localized infection, severe coagulopathy, etc, with respect to hip denervation.

spk_0 Ultrasound guided hip denervation.

spk_0 Hip denervation was originally described as a technique under fluoroscopic guidance.

spk_0 The targets of the articular branches of the femoral nerve,

spk_0 accessory obtrater nerve and obtrater nerve, are well established on ultrasound.

spk_0 Sonographically, the reliably targeted articular branches of the femoral nerve

spk_0 traverse between the inferior and medial portion of the anterior inferior iliac spine or AIS,

spk_0 and along the iliopubic eminence, IPE,

spk_0 a suggestion for the radiofrequency or RF cannula entry point

spk_0 being 1 to 2 centimeters lateral to the femoral artery has been made in the literature.

spk_0 However, it has been the author's experience to insert the RF cannula just medial to the AIS

spk_0 and along the same angle as the bony descent from the AIS to the IPE.

spk_0 This approach allows for improved angulation to place the needle deep to the soist tendon

spk_0 without piercing the structure.

spk_0 Sequential lesion along the target zone can also be performed easily by withdrawing the RF cannula more proximally.

spk_0 The articular branches of the accessory obtrater nerve are also best targeted along the IPE

spk_0 and are typically captured via the lesioning approach described for the articular branches of the femoral nerve.

spk_0 The target for the articular branches of the obtrater nerve can be visualized along the inferior medial acetabulum or IMA.

spk_0 This view is typically first achieved through the hip intraarticular view sonographically.

spk_0 The probe is then translated inferior to visualize the inferior medial acetabulum.

spk_0 Benefits of ultrasound use in hip denervation include improved visualization of the vasculature, neural,

spk_0 and important musculoskeletal structures when traversing the needle towards the target zone,

spk_0 in targeting the IPE where the articular branch of the femoral nerve and the accessory obtrater nerve's lie,

spk_0 care should be taken to avoid RF cannula puncture of the soist tendon,

spk_0 which otherwise may result in injury of the tendon and significant post-procedure pain.

spk_0 In targeting the inferior medial acetabulum where the articular branches of the obtrater nerve lie,

spk_0 care should be taken to avoid RF cannula through the femoral artery and femoral nerve as well as adjacent vasculature,

spk_0 such as the external pudendal artery.

spk_0 Although the rates of femoral artery and nerve injuries are not well known for hip denervation,

spk_0 a sonographic approach served to reduce the risks of inadvertent injury.

spk_0 A strict sonographic only approach to hip denervation allows for a relatively low cost of imaging modality compared to fluoroscopy.

spk_0 In combination with chemical ablation using neuralitics of these target nerves,

spk_0 hip denervation can be performed to good effect with very modest equipment cost.

spk_0 Combined ultrasound and fluoroscopic hip approach, the goal of a combined ultrasound fluoroscopic approach is to improve accuracy, efficiency, and safety in performing hip denervation.

spk_0 It is the preferred method of the authors.

spk_0 The typical setup is to have the fluoroscope come across the patient and with the ultrasound machine placed along the foot of the procedure table.

spk_0 For the particular branches of the femoral nerve and accessory obtrater nerve, the RF cannula is inserted under ultrasound guidance from lateral to medial with modest cephalad to caudad angulation from the AIS to the IPE at an overall angulation corresponding to the bony descent.

spk_0 The RF cannula is placed with the tip deep to the sois tendon or medial bypassing the sois tendon with continuous ultrasound guidance.

spk_0 A larger lesion is preferred to ensure capture of the target nerves due to the variable innervation patterns of the anterior capsule.

spk_0 The author HM typically uses a bipolar approach and therefore a second RF cannula is inserted just cephalad to the first cannula along the IPE.

spk_0 The author AM uses a cooled radio frequency ablation technique.

spk_0 Once the RF cannulas have been brought into contact with IPE, fine-tuning the cannulas position under fluoroscopic guidance is performed to ensure optimal placement of RF cannulas to one another.

spk_0 For the particular branches of the obtrater nerve, author HM inserts the RF cannula sonographically from lateral to medial caudad to cephalad towards the IMA.

spk_0 The author positions the patient with slight hip external rotation and inserts the RF cannula in a more longitudinal fashion immediately through the adductor muscles to avoid the femoral and lateral circumflex femoral arteries.

spk_0 Upon contact with bone, fluoroscopy is then used to ensure optimal placement of the RF cannula.

spk_0 Depending on the angle of insertion towards the IMA, the RF cannula may contact the bone further along the pubis and will need to be optimized.

spk_0 The author uses monopolar RF with 2-3 lesions with the RF cannula in slightly different angles on the IMA to ensure a larger area of lesioning whereas the author uses cooled radio frequency ablation.

spk_0 Conclusion. Both fluoroscopic and ultrasound guided hip denervation techniques have been described.

spk_0 The author's opinions are that a combined ultrasound and fluoroscopy guided technique allows for improved accuracy, efficiency and safety in performing hip denervation.

spk_0 For further reading, there have been several articles published on the use of dual modality imaging guided techniques including caporal and others, kumar and others, and a recently published review article by Poon and others.

spk_0 Thank you for listening. If you liked this episode of Azra Pain Medicine News, please consider subscribing, sharing with a friend or leaving us a review.

spk_0 Thank you for watching.

How I Do It: Denervation of the Hip Joint Under Ultrasound and Fluoroscopy

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