Acta Anaesthesiologica Taiwanica 52 (2014) 93e94

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Editorial View

Ultrasound-guided chronic musculoskeletal pain control

Ultrasound (US) evaluation of musculoskeletal illness has gained more popularity because of its increased portability, decreased cost, and advanced technology.1 In the past decades, the improvement of US machines in focused and real-time highresolution imaging has facilitated the diagnosis of diseases in fine soft tissues such as tendons, ligaments, and nerve structures.2 Furthermore, high-frequency diagnostic ultrasonography has the capacity to improve the accuracy of diagnosis and management provided by neuromuscular, musculoskeletal (MSK), and interventional pain specialists.3 In the early 1950s, US was used to screen musculoskeletal disorders.4 It was not until 1994 that color Doppler US for synovitis was first described.5 Common US findings for MSK injury are hypoechoic, hypervascular, calcific, and tissue-discontinuous findings.6 Ultrasound elastography, which is an emerging set of imaging modalities that are utilized to image tissue elasticity, is effective for detecting and appraising different pathologies.7 In 1993, the first clinical report of elastography of soft tissue was published.8 Its usage is expanding, with applications including lesion detection and classification, fibrosis staging, treatment monitoring, and vascular imaging.7 More advanced development of US machines could result in a greater detection of lesions. Chronic MSK pain conditions have multiple components, and physical, emotional, psychological, and social factors are often intercalated. Potential biomarkers in localized chronic myalgias are serotonin, glutamate, lactate, and pyruvate.9 Psychotherapy and biofeedback exercises can be used as nonpharmacologic therapies to manage chronic pain. Pharmacologic options are nonsteroidal anti-inflammatory drugs, weak opioids, selective tricyclic antidepressants, serotonin reuptake inhibitors, anticonvulsants, and topical medications such as lidocaine, diclofenac, and capsaicin.10 Other management approaches include surgery and drug injections (e.g., local anesthetics, corticosteroids, sclerosing agents, hyaluronic acid, autologous blood, platelet-rich plasma, ozone, normal saline,11 and dextrose prolotherapy2). Corticosteroids are the most common drugs used for interventional chronic pain control because of their anti-inflammatory property, although they elicit no direct improvement on the functional aspects of the disorder being treated and the disability it causes.12 Platelet-rich plasma became popular in treating sportsrelated injuries because it mimics the repair processes. However, Reurink et al13 recently reported no benefits of using intramuscular platelet-rich plasma injections in comparison to a placebo in patients with acute muscle injuries. Numerous injected drugs show

Conflicts of interest: Both authors certify that there is no conflict of interest.

treatment efficacy; however, more high-quality randomized controlled trials are needed to optimize and define the role of injected therapies. Ultrasound is a diagnostic choice and a therapeutic tool for guiding needle insertion and drug injection. It stands out as a good modality to assess upper limb diseases such as rotator cuff tear,1,14 calcific tendinopathy of the rotator cuff (RCCT),15,16 elbow epicondylitis,2 and de Quervain tenosynovitis.3,17 Using RCCT as an example, US-guided interventions have served as a nonoperative treatment and, at the 1-year follow up, resulted in improvements in patients who were unresponsive to conservative treatment.16 In this issue of the Journal, Chiou et al wrote a comprehensive review article on chronic MSK pain of the limbs.18 They provided concise and clear information about complex MSK illness. Through their dedicated hard-work they have produced sonographic illustrations and showed great experience in handling MSK conditions. Readers can learn how to scan using the US probe, to show anatomic structures more easily by using their numerous exquisite images. The causes of chronic MSK pain vary. Although multiple modalities exist to diagnose MSK, the treatment options could be more delicate and specific to each patient. In many ways, US is convenient and has advantages, and it promotes interventional therapies. Ultrasound-guided procedures present patients with a more valid and safer approach to chronic MSK pain management. References 1. Nazarian LN, Jacobson JA, Benson CB, Bancroft LW, Bedi A, McShane JM, et al. Imaging algorithms for evaluating suspected rotator cuff disease: Society of Radiologists in Ultrasound consensus conference statement. Radiology 2013;267: 589e95. 2. Lee KS, Rosas HG, Craig JG. Musculoskeletal ultrasound: elbow imaging and procedures. Semin Musculoskelet Radiol 2010;14:449e60. 3. Bodor M, Fullerton B. Ultrasonography of the hand, wrist, and elbow. Phys Med Rehabil Clin N Am 2010;21:509e31. 4. Dussik KT, Fritch DJ, Kyriazidou M, Sear RS. Measurements of articular tissues with ultrasound. Am J Phys Med 1958;37:160e5. 5. Newman JS, Adler RS, Bude RO, Rubin JM. Detection of soft-tissue hyperemia: value of power Doppler sonography. AJR Am J Roentgenol 1994;163: 385e9. 6. Artul S, Habib G. Ultrasound findings of the painful ankle and foot. J Clin Imaging Sci 2014;4:25. 7. Dewall RJ. Ultrasound elastography: principles, techniques, and clinical applications. Crit Rev Biomed Eng 2013;41:1e19. 8. Cespedes I, Ophir J, Ponnekanti H, Maklad N. Elastography: elasticity imaging using ultrasound with application to muscle and breast in vivo. Ultrason Imaging 1993;15:73e88. 9. Gerdle B, Ghafouri B, Ernberg M, Larsson B. Chronic musculoskeletal pain: review of mechanisms and biochemical biomarkers as assessed by the microdialysis technique. J Pain Res 2014;7:313e26. 1875-4597/Copyright © 2014, Taiwan Society of Anesthesiologists. Published by Elsevier Taiwan LLC. All rights reserved.

94 10. Uhl RL, Roberts TT, Papaliodis DN, Mulligan MT, Dubin AH. Management of chronic musculoskeletal pain. J Am Acad Orthop Surg 2014;22:101e10. 11. Robotti G, Canepa MG, Bortolotto C, Draghi F. Interventional musculoskeletal US: an update on materials and methods. J Ultrasound 2013;16:45e55. 12. Gialanella B, Prometti P. Effects of corticosteroids injection in rotator cuff tears. Pain Med 2011;12:1559e65. 13. Reurink G, Goudswaard GJ, Moen MH, Weir A, Verhaar JA, Bierma-Zeinstra SM, et al. Platelet-rich plasma injections in acute muscle injury. N Engl J Med 2014;370:2546e7. 14. Peng PW, Cheng P. Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, sonoanatomy, and procedures. Part III: shoulder. Reg Anesth Pain Med 2011;36:592e605. 15. Louwerens JK, Sierevelt IN, van Noort A, van den Bekerom MP. Evidence for minimally invasive therapies in the management of chronic calcific tendinopathy of the rotator cuff: a systematic review and meta-analysis. J Shoulder Elbow Surg 2014;23:1240e9. 16. de Witte PB, Selten JW, Navas A, Nagels J, Visser CP, Nelissen RG, et al. Calcific tendinitis of the rotator cuff: a randomized controlled trial of ultrasoundguided needling and lavage versus subacromial corticosteroids. Am J Sports Med 2013;41:1665e73. 17. de Jesus JO, Parker L, Frangos AJ, Nazarian LN. Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis. AJR Am J Roentgenol 2009;192:1701e7.

Editorial View 18. Chiou HJ, Chou YH, Wang HK, Lai YC. Chronic musculoskeletal pain: ultrasound guided pain control. Acta Anaesthesiol Taiwan 2014;52:114e33.



Chien-Chung Huang1,2,3, Chia-Shiang Lin1,2,3,4,* Department of Anesthesiology, Mackay Memorial Hospital, Taipei, Taiwan

Mackay Medicine, Nursing and Management College, Taipei, Taiwan 3


Mackay Medical College, Taipei, Taiwan

Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan *

Corresponding author. No. 92, Sec. 2, Zhongshan N. Rd., Taipei City 10449, Taiwan. E-mail address: [email protected] (C.-S. Lin). 6 June 2014

Ultrasound-guided chronic musculoskeletal pain control.

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