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Reviews of Educational Material  |   June 2012
Atlas of Ultrasound-guided Procedures in Interventional Pain Management
Author Notes
  • Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Article Information
Reviews of Educational Material / Pain Medicine / Radiological and Other Imaging
Reviews of Educational Material   |   June 2012
Atlas of Ultrasound-guided Procedures in Interventional Pain Management
Anesthesiology 6 2012, Vol.116, 1402-1403. doi:10.1097/ALN.0b013e318249cf7e
Anesthesiology 6 2012, Vol.116, 1402-1403. doi:10.1097/ALN.0b013e318249cf7e
Edited by Samer N. Narouze, M.D., M.Sc., D.A.B.P.M., F.I.P.P. New York, Springer Science+Business Media LLC, 2010. Pages: 372. Price: $189.00.
Ultrasound-guided interventional pain procedures are a decidedly multidisciplinary sport; practitioners of physiatry, neurology, orthopedic surgery, and interventional radiology benefit from the application of ultrasound in diagnosis and treatment. Anesthesiologists and pain management physicians are at the forefront of those capitalizing on the safety, portability, flexibility, and low cost (relative to other imaging modalities) of the sonography machine. Dr. Samer N. Narouze's text, Atlas of Ultrasound-guided Procedures in Interventional Pain Management  , appeals to the broad range of providers who use ultrasound to guide acute and chronic pain procedures. Its greatest strengths as a textbook lie in both its practicality and its breadth. In its 30 expertly written and extensively referenced chapters, it explores the scientific basis of ultrasound use and delves into a wide variety of ultrasound-guided pain management injections, from the neuraxis to the finger. In addition, it offers an excellent study of sonoanatomy relevant to the field, with 465 figures, 350 of which are in full color. The figures comprise cadaver dissections, anatomic illustrations, photography of surface landmarks, and vivid sonoanatomic prints.
The beginning sonographer will benefit tremendously from study of part I of the text, which provides a practical introduction to ultrasound physics and scientific principles. The authors demonstrate commendable restraint in description, making the text easily accessible to the beginner but appropriately detailed for most practicing physicians. The chapters entitled Essential Knobology for Ultrasound-guided Regional Anesthesia and How to Improve Needle Visibility will prove particularly relevant to the junior sonographer, offering clear descriptions of the concepts of depth, gain, focus, and Doppler, and offering useful tips on needle selection, angle of insertion, and ergonomic considerations. The text explores hydrolocalization, contrast agents, and peripheral nerve stimulation as aids to visualization. Indeed, part I of the text is its most universally applicable section; neither wordy nor superficial in its treatment of the subject matter, it successfully introduces the science and practical application of ultrasound to a wide variety of practitioners.
Part II focuses primarily on interventions of the spine, with chapters on spine sonoanatomy, occipital nerve and cervical medial branch blocks, cervical zygapophyseal facet injections, and cervical nerve root and central neuraxial blocks. Most chapters select one or a few related blocks and subsequently explore the evidence and literature behind application of the block, traditional approaches to the block, the anatomy of the block, and the advantages and disadvantages to ultrasound application. A detailed practical guide follows in all instances; in describing the ultrasound-guided ganglion impar block, the authors instruct, “with the patient in the prone position, the sacral hiatus is palpated and a linear high-frequency transducer … is placed transversely in the midline … The transducer is then rotated 90 degrees to obtain a longitudinal view of the sacral hiatus and the coccyx … The first cleft caudal to the sacral hiatus is the SCJ [sacrococcygeal joint]… a 22–25 gauge needle is then advanced into the SCJ under real-time ultrasonography” (pp 184–5). Pitfalls and limitations are appropriately addressed, and the authors acknowledge the operator-dependent nature of these techniques. In reference to ultrasound-guided central neuraxial blocks, the authors note that the techniques are “by far the most difficult USG [ultrasound guided] interventions,” the learning of which “demands a high degree of manual dexterity, hand-eye coordination, and an ability to conceptualize 2D information into a 3D image …” (pp 175–6).
Part III explores abdominal and pelvic blocks; the chapter discussing transversus abdominis plane blocks may interest the operating room anesthesiologist, whereas the chapter on blocks for pelvic pain, which includes a discussion of piriformis syndrome and pudendal neuralgia, may be applicable to the chronic pain physician. Part IV describes peripheral nerve blocks, discussing the commonly performed brachial plexus and lower extremity blocks and their continuous blockade with catheter use. A chapter on peripheral nerve blockade in chronic pain management explores lateral femoral cutaneous, intercostal, and suprascapular nerve blocks. Part V focuses on musculoskeletal techniques, including injections of the shoulder, elbow, wrist, and hip joints.
Part VI, the final portion of the text, is entitled Advanced and New Applications of Ultrasound in Pain Management. Paying homage to the promise of ultrasound's exciting future, it explores the potential for its use in peripheral neuromodulation and neurolysis. Possible uses described include percutaneous electrode implantation for commonly blocked peripheral nerves, groin neurostimulation for postherniorrhaphy pain, and occipital neurostimulation for intractable headache. There is currently a notable lack of evidence for the use of ultrasound in these techniques.
The interdisciplinary nature of the book reflects our ever-changing scope of practice as anesthesiologists. Its contributors not only are from anesthesiology departments but also neurosurgery, physical medicine and rehabilitation, sports medicine, and radiology departments. Most practitioners will likely perform a limited number of described techniques; the physician who inserts continuous nerve catheters, for example, may not perform elbow steroid injections for chronic pain. Nevertheless, the text is a useful addition to the library of any physician who uses, or aims to use, ultrasound to perform pain-management related procedures. Admirably, the text acknowledges the real limitations of sonography, including limited resolution and artifacts, and it effectively compares ultrasound use with current imaging modalities for each technique. It urges physicians who use these techniques to seek formal mentorship so ultrasound enhances safety and so the recipients of these approaches are helped—and are not harmed—by the ever-expanding application of this technology. Both patients and providers would benefit from a more rigorous examination of the education and training required to demonstrate competency in these techniques. To that end, a useful addition to the text would be an interactive media component to facilitate learning the complex multidimensional anatomy at hand. Inclusion of such would only enhance the ‘atlas’ designation of the text.