<p begin="00:00:09.683" end="00:00:12.658" style="s2">- Today I'm going to demonstrate<br />the piriformis injection.</p>
<p begin="00:00:12.658" end="00:00:15.497" style="s2">Piriformis injection under<br />ultrasound guidance is useful</p>
<p begin="00:00:15.497" end="00:00:17.249" style="s2">in diagnostic maneuvers,</p>
<p begin="00:00:17.249" end="00:00:18.672" style="s2">specifically for patients</p>
<p begin="00:00:18.672" end="00:00:20.710" style="s2">that may have sciatic-like symptoms</p>
<p begin="00:00:20.710" end="00:00:24.529" style="s2">as the sciatic nerve passes<br />close to the piriformis muscle.</p>
<p begin="00:00:24.529" end="00:00:25.709" style="s2">In piriformis syndrome</p>
<p begin="00:00:25.709" end="00:00:28.103" style="s2">the piriformis muscle is hypertrophied</p>
<p begin="00:00:28.103" end="00:00:30.632" style="s2">and can mimic sciatic symptoms</p>
<p begin="00:00:30.632" end="00:00:33.389" style="s2">caused by lumbar herniated disks.</p>
<p begin="00:00:33.389" end="00:00:34.722" style="s2">If this has been excluded,</p>
<p begin="00:00:34.722" end="00:00:36.467" style="s2">this particular procedure can be done</p>
<p begin="00:00:36.467" end="00:00:38.598" style="s2">under ultrasonographic guidance.</p>
<p begin="00:00:38.598" end="00:00:40.381" style="s2">The patient is placed<br />in the prone position</p>
<p begin="00:00:40.381" end="00:00:44.048" style="s2">with a pillow underneath<br />to provide bolster.</p>
<p begin="00:00:48.281" end="00:00:51.638" style="s2">The side in question is<br />identified and prepped</p>
<p begin="00:00:51.638" end="00:00:53.467" style="s2">in this particular fashion.</p>
<p begin="00:00:53.467" end="00:00:55.414" style="s2">The gluteus is exposed.</p>
<p begin="00:00:55.414" end="00:00:58.256" style="s2">For facilitation of visualization</p>
<p begin="00:00:58.256" end="00:01:01.351" style="s2">I utilize the Sonosite M Turbo</p>
<p begin="00:01:01.351" end="00:01:06.008" style="s2">with the musculoskeletal<br />setting to help enhance</p>
<p begin="00:01:06.008" end="00:01:09.299" style="s2">the muscular fibers of<br />the piriformis muscle,</p>
<p begin="00:01:09.299" end="00:01:11.143" style="s2">the gluteus minimus and maximus,</p>
<p begin="00:01:11.143" end="00:01:14.489" style="s2">and the curvilinear shape<br />facilitates entry of the needle</p>
<p begin="00:01:14.489" end="00:01:16.744" style="s2">into the targeted site.</p>
<p begin="00:01:16.744" end="00:01:18.415" style="s2">To perform this particular block</p>
<p begin="00:01:18.415" end="00:01:21.556" style="s2">the following equipment is necessary.</p>
<p begin="00:01:21.556" end="00:01:24.336" style="s2">Chlorhexidine for sterile technique,</p>
<p begin="00:01:24.336" end="00:01:28.503" style="s2">local anesthetic syringe<br />containing 1% buffered lidocaine,</p>
<p begin="00:01:30.111" end="00:01:34.278" style="s2">and then a syringe containing<br />five cc of bupivicaine 1/2%</p>
<p begin="00:01:35.932" end="00:01:39.878" style="s2">mixed with five cc of 1% lidocaine,</p>
<p begin="00:01:39.878" end="00:01:43.843" style="s2">and then 40 to 80 milligrams<br />of triamcinolone kenalog,</p>
<p begin="00:01:43.843" end="00:01:46.704" style="s2">which is a particulate steroid.</p>
<p begin="00:01:46.704" end="00:01:48.943" style="s2">A 3-1/2-inch 25-gauge spinal needle</p>
<p begin="00:01:48.943" end="00:01:52.173" style="s2">will also be utilized for the procedure.</p>
<p begin="00:01:52.173" end="00:01:53.482" style="s2">There will be sterile four by fours</p>
<p begin="00:01:53.482" end="00:01:56.627" style="s2">necessary to clean the<br />area at the conclusion</p>
<p begin="00:01:56.627" end="00:02:00.634" style="s2">and a simple BAND-AID will<br />suffice to cover the wound.</p>
<p begin="00:02:00.634" end="00:02:02.384" style="s2">Copious amounts of gel are required</p>
<p begin="00:02:02.384" end="00:02:05.677" style="s2">for this particular procedure.</p>
<p begin="00:02:05.677" end="00:02:08.878" style="s2">The middle portion of<br />the gluteus is identified</p>
<p begin="00:02:08.878" end="00:02:12.559" style="s2">and then in a transverse or<br />left-to-right positioning</p>
<p begin="00:02:12.559" end="00:02:16.309" style="s2">the probe is placed in<br />contact with the skin.</p>
<p begin="00:02:24.660" end="00:02:27.660" style="s2">The leg in question can be mobilized</p>
<p begin="00:02:29.333" end="00:02:32.083" style="s2">in a abduction-adduction maneuver</p>
<p begin="00:02:34.757" end="00:02:38.329" style="s2">demonstrating motion of<br />the piriformis muscle</p>
<p begin="00:02:38.329" end="00:02:40.985" style="s2">as it inserts out towards<br />the greater trochanter</p>
<p begin="00:02:40.985" end="00:02:44.042" style="s2">and towards the ischium centrally.</p>
<p begin="00:02:44.042" end="00:02:45.208" style="s2">Clearly in the middle of the screen</p>
<p begin="00:02:45.208" end="00:02:49.141" style="s2">you can also identify the sciatic nerve</p>
<p begin="00:02:49.141" end="00:02:50.858" style="s2">as it passes very close</p>
<p begin="00:02:50.858" end="00:02:54.108" style="s2">to the fibers of the piriformis muscle.</p>
<p begin="00:02:55.482" end="00:02:58.353" style="s2">A central point is identified,</p>
<p begin="00:02:58.353" end="00:03:01.180" style="s2">making sure to stay away<br />from the investing fascia</p>
<p begin="00:03:01.180" end="00:03:03.263" style="s2">around the sciatic nerve.</p>
<p begin="00:03:04.531" end="00:03:08.462" style="s2">The skin is marked and then 1%<br />local anesthetic is injected</p>
<p begin="00:03:08.462" end="00:03:10.712" style="s2">directly in short axis view</p>
<p begin="00:03:14.359" end="00:03:16.971" style="s2">and then a 25-gauge 3-1/2-inch needle</p>
<p begin="00:03:16.971" end="00:03:20.121" style="s2">is passed through this anesthetized track</p>
<p begin="00:03:20.121" end="00:03:23.460" style="s2">and approximately six<br />cc of local anesthetic</p>
<p begin="00:03:23.460" end="00:03:26.903" style="s2">containing bupivicaine and<br />lidocaine in a one to one mixture</p>
<p begin="00:03:26.903" end="00:03:31.070" style="s2">with a small amount of steroid<br />if desired can be injected.</p>
<p begin="00:03:31.926" end="00:03:33.186" style="s2">- [Voiceover] This is a short axis view</p>
<p begin="00:03:33.186" end="00:03:35.477" style="s2">and the curvilinear probe is applied</p>
<p begin="00:03:35.477" end="00:03:38.224" style="s2">in the transverse orientation.</p>
<p begin="00:03:38.224" end="00:03:40.699" style="s2">The leg is being adducted and abducted</p>
<p begin="00:03:40.699" end="00:03:42.866" style="s2">to show the muscle moving.</p>
<p begin="00:03:46.159" end="00:03:47.673" style="s2">The sciatic nerve is clearly visible</p>
<p begin="00:03:47.673" end="00:03:50.345" style="s2">in the substance of the muscle.</p>
<p begin="00:03:50.345" end="00:03:53.845" style="s2">It is the band-like hyperechoic structure.</p>
<p begin="00:03:57.117" end="00:03:59.101" style="s2">The injectate is the hypoechoic structure</p>
<p begin="00:03:59.101" end="00:04:02.934" style="s2">that grows within the<br />substance of the muscle.</p>
<p begin="00:04:22.176" end="00:04:24.259" style="s2">- The probe is withdrawn,</p>
<p begin="00:04:25.810" end="00:04:28.727" style="s2">the area wiped with a four by four,</p>
<p begin="00:04:33.066" end="00:04:36.566" style="s2">and then a BAND-AID placed over the wound.</p>
<p begin="00:04:38.385" end="00:04:40.235" style="s2">This is the successful completion</p>
<p begin="00:04:40.235" end="00:04:44.402" style="s2">of a piriformis injection under<br />ultrasonographic guidance.</p>