<p begin="00:00:07.442" end="00:00:09.589" style="s2">- [Voiceover] A linear<br />array transducer is used</p>
<p begin="00:00:09.589" end="00:00:13.774" style="s2">to evaluate lung sliding as<br />an extension of the FAST exam.</p>
<p begin="00:00:13.774" end="00:00:16.420" style="s2">The orientation marker is<br />positioned in the direction</p>
<p begin="00:00:16.420" end="00:00:18.065" style="s2">of the patient's head.</p>
<p begin="00:00:18.065" end="00:00:21.277" style="s2">The transducer is placed in<br />a long access orientation</p>
<p begin="00:00:21.277" end="00:00:23.204" style="s2">over the anterior chest wall</p>
<p begin="00:00:23.204" end="00:00:25.921" style="s2">at the third or fourth intercostal space</p>
<p begin="00:00:25.921" end="00:00:29.921" style="s2">in the interior axillary<br />to mid-clavicular line.</p>
<p begin="00:00:34.764" end="00:00:37.763" style="s2">The ribs are identified in<br />the near field of the image</p>
<p begin="00:00:37.763" end="00:00:41.324" style="s2">as bright interface<br />with a posterior shadow.</p>
<p begin="00:00:41.324" end="00:00:42.910" style="s2">The plural line is identified</p>
<p begin="00:00:42.910" end="00:00:47.099" style="s2">as a bright hyperechoic line<br />between the rib shadows.</p>
<p begin="00:00:47.099" end="00:00:50.068" style="s2">The to and fro sliding<br />movement of the visceral plural</p>
<p begin="00:00:50.068" end="00:00:52.233" style="s2">against the parietal plural with breathing</p>
<p begin="00:00:52.233" end="00:00:54.900" style="s2">generates the lung sliding sign.</p>

<p begin="00:00:09.277" end="00:00:12.473" style="s2">- Today I will perform<br />an anatomic demonstration</p>
<p begin="00:00:12.473" end="00:00:14.176" style="s2">of the cervical spine utilizing</p>
<p begin="00:00:14.176" end="00:00:16.894" style="s2">the M-Turbo Ultrasound System,</p>
<p begin="00:00:16.894" end="00:00:20.272" style="s2">utilizing the C60 curvilinear probe.</p>
<p begin="00:00:20.272" end="00:00:22.765" style="s2">The point of this<br />exercise is to demonstrate</p>
<p begin="00:00:22.765" end="00:00:25.246" style="s2">the anatomic considerations<br />when performing</p>
<p begin="00:00:25.246" end="00:00:28.005" style="s2">cervical epidural steroid injections</p>
<p begin="00:00:28.005" end="00:00:29.905" style="s2">and cervical facet injections.</p>
<p begin="00:00:29.905" end="00:00:32.402" style="s2">Typical patients may have have<br />a variance in their anatomy</p>
<p begin="00:00:32.402" end="00:00:35.125" style="s2">and the traditional approaches utilizing</p>
<p begin="00:00:35.125" end="00:00:36.739" style="s2">loss of resistance techniques for</p>
<p begin="00:00:36.739" end="00:00:40.204" style="s2">cervical epidural steroids<br />can present come challenges.</p>
<p begin="00:00:40.204" end="00:00:43.271" style="s2">The purpose of utilizing<br />the ultrasound system</p>
<p begin="00:00:43.271" end="00:00:46.105" style="s2">for an anatomic survey<br />is that the patient,</p>
<p begin="00:00:46.105" end="00:00:49.308" style="s2">who normally has a cervical<br />epidural steroid injection</p>
<p begin="00:00:49.308" end="00:00:51.419" style="s2">performed under fluoroscopic technique</p>
<p begin="00:00:51.419" end="00:00:54.799" style="s2">may occasionally encounter<br />false losses of resistance.</p>
<p begin="00:00:54.799" end="00:00:57.909" style="s2">Utilizing this particular<br />tool as a sounding device</p>
<p begin="00:00:57.909" end="00:01:01.742" style="s2">may perhaps improve the<br />accuracy of injection.</p>
<p begin="00:01:02.726" end="00:01:06.584" style="s2">The way this is performed is<br />utilizing again the C60 probe,</p>
<p begin="00:01:06.584" end="00:01:11.234" style="s2">setting the depth to<br />approximately 9.2 centimeters,</p>
<p begin="00:01:11.234" end="00:01:14.283" style="s2">remembering that the average<br />depth to the epidural space</p>
<p begin="00:01:14.283" end="00:01:16.584" style="s2">is appx six centimeters.</p>
<p begin="00:01:16.584" end="00:01:19.283" style="s2">The nerve setting will also be used</p>
<p begin="00:01:19.283" end="00:01:22.646" style="s2">to highlight any neural structures<br />that may be of interest.</p>
<p begin="00:01:22.646" end="00:01:25.938" style="s2">On the patient, initially, I like to mark</p>
<p begin="00:01:25.938" end="00:01:29.605" style="s2">utilizing a Sharpie,<br />the C7 spinous process.</p>
<p begin="00:01:32.137" end="00:01:35.181" style="s2">This is the most easily<br />palpable spinous process,</p>
<p begin="00:01:35.181" end="00:01:37.149" style="s2">and this is facilitated with the patient</p>
<p begin="00:01:37.149" end="00:01:40.496" style="s2">in the prone position, a<br />bolster under the thorax,</p>
<p begin="00:01:40.496" end="00:01:42.913" style="s2">and the head slightly flexed.</p>
<p begin="00:01:43.954" end="00:01:45.925" style="s2">I place a copious amount of gel</p>
<p begin="00:01:45.925" end="00:01:49.821" style="s2">across the patient's C7 spinous process,</p>
<p begin="00:01:49.821" end="00:01:53.738" style="s2">and then utilizing the<br />probe in the transverse,</p>
<p begin="00:01:54.573" end="00:01:56.570" style="s2">that is the left-to-right positioning,</p>
<p begin="00:01:56.570" end="00:02:00.366" style="s2">I place contact on the<br />skin, and clearly visible</p>
<p begin="00:02:00.366" end="00:02:03.366" style="s2">is the patient's C7 spinous process.</p>
<p begin="00:02:04.461" end="00:02:07.097" style="s2">In this particular view you<br />can also see the lamina,</p>
<p begin="00:02:07.097" end="00:02:10.930" style="s2">and the transverse<br />processes of T1 just below.</p>
<p begin="00:02:12.973" end="00:02:14.856" style="s2">And in the center of the screen,</p>
<p begin="00:02:14.856" end="00:02:18.064" style="s2">under the shadow of the spinous<br />process is a white line.</p>
<p begin="00:02:18.064" end="00:02:21.897" style="s2">This white line, and I<br />will highlight it here,</p>
<p begin="00:02:24.556" end="00:02:29.129" style="s2">demonstrates the actual<br />location of the epidural space.</p>
<p begin="00:02:29.129" end="00:02:32.904" style="s2">So looking off to the right of the screen,</p>
<p begin="00:02:32.904" end="00:02:35.199" style="s2">we can see that the depth is approximately</p>
<p begin="00:02:35.199" end="00:02:38.866" style="s2">five centimeters in<br />this particular patient.</p>
<p begin="00:02:40.790" end="00:02:43.256" style="s2">Other potential views include</p>
<p begin="00:02:43.256" end="00:02:48.086" style="s2">the cranial carotid<br />orientation, or sagittal plane</p>
<p begin="00:02:48.086" end="00:02:51.910" style="s2">of the probe, and placed along the neck,</p>
<p begin="00:02:51.910" end="00:02:53.993" style="s2">and slightly off midline,</p>
<p begin="00:02:54.938" end="00:02:57.649" style="s2">again now can be seen newer structures.</p>
<p begin="00:02:57.649" end="00:03:01.164" style="s2">In this particular case<br />the facet joint line</p>
<p begin="00:03:01.164" end="00:03:05.238" style="s2">is very clearly indicated<br />at these locations.</p>
<p begin="00:03:05.238" end="00:03:08.513" style="s2">The actual location for<br />a medial branch block</p>
<p begin="00:03:08.513" end="00:03:11.513" style="s2">would be on these superior surfaces.</p>
<p begin="00:03:12.556" end="00:03:14.499" style="s2">On the lateral mass.</p>
<p begin="00:03:14.499" end="00:03:18.690" style="s2">If the probe is then rotated further out,</p>
<p begin="00:03:18.690" end="00:03:21.440" style="s2">and a more oblique view obtained,</p>
<p begin="00:03:22.365" end="00:03:25.371" style="s2">the actual foramen of the nerve roots</p>
<p begin="00:03:25.371" end="00:03:27.451" style="s2">can thus be discerned.</p>
<p begin="00:03:27.451" end="00:03:30.118" style="s2">And as we move further cephalad,</p>
<p begin="00:03:33.346" end="00:03:37.513" style="s2">it is possible to view the<br />vertebral artery pulsations.</p>
<p begin="00:03:43.765" end="00:03:44.930" style="s2">And this obviously is a structure</p>
<p begin="00:03:44.930" end="00:03:48.905" style="s2">that would want to be<br />avoided at all costs.</p>
<p begin="00:03:48.905" end="00:03:51.318" style="s2">This concludes the<br />successful anatomical survey</p>
<p begin="00:03:51.318" end="00:03:55.401" style="s2">utilizing ultrasonography<br />of the cervical spine.</p>