Technique

- Today, I'm going to demonstrate
a greater occipital nerve block
performed under ultrasound guidance.
The purpose of this block is to help diagnose
and treat headache syndromes
that may be arising from the posterior occiput.
This can occur as a result of trauma or other incident.
The inion is located,
the occipital protuberance.
The measurement is made 3 1/2 centimeters down
and 1 1/2 centimeters over.
This is the approximate location
and the tracking of the greater occipital nerve,
and the artery with it.
Utilized in this particular block will be
the M-Turbo ultrasound system,
utilizing the high frequency HFL 50 linear probe.
The patient is placed in the prone position.
A bolster is placed under the thorax.
The head is slightly flexed.
And then the hair moved out of the way.
The anatomic location to begin
is the inion, or the occipital protuberance.
Three centimeters below this, the skin is marked
and then typically 1 1/2 centimeters lateral to that
is the entry point for the blind technique.
These will serve as our landmarks to place the ultrasound.
Part of the reason to utilize ultrasound in this case,
is to avoid the accidental injection
within the greater occipital artery
as well as hematoma and other complications
that can occur from this block.
To perform the block, the following items are used:
chlorhexidine prep,
and the local anesthetic solution,
typically a buffered lidocaine for the skin,
and then below this, approximately two to three ccs
of 1% lidocaine, and .25% bupivacaine,
and potentially a small amount of steroid, if desired.
The needle size is simply a 1 1/2 inch standard needle,
27 gauge will suffice.
We will also use ultrasound gel
as well as a band-aid if necessary
for the conclusion of the procedure.
To commence, the target site is covered
with this thin layer of ultrasound gel.
And then the probe placed in the transverse application
at the mid-line.
And then the probe is gently rolled out.
In the midpoint of the screen at this point,
when turning on the Color Flow Doppler,
we will be able to identify the greater occipital artery.
So immediately medial to this,
is the location of the greater occipital
and lesser occipital nerve,
prior to their branching.
The injection would occur
above local anesthetic injected for the skin,
followed by the 1 1/2 inch needle
to contact (mumbles),
and avoid entry into the blood vessel.
The needle removed,
and then the probe placed,
the area cleansed,
and a band-aid placed over the incision.
This concludes the successful placement
of a greater occipital block under ultrasound guidance.

Brightcove ID

5508104683001

https://youtube.com/watch?v=94tmDILJVg4

How to: Piriformis Injection

Read more about How to: Piriformis Injection

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This videos discusses some of the scanning techniques involved while performing a piriformis injection.

Clinical Specialties

Media Library Type

Media Library Tag

Nerve Entrapment Neuropathy

Subtitles

- Today I'm going to demonstrate the piriformis injection.
Piriformis injection under ultrasound guidance is useful
in diagnostic maneuvers,
specifically for patients
that may have sciatic-like symptoms
as the sciatic nerve passes close to the piriformis muscle.
In piriformis syndrome
the piriformis muscle is hypertrophied
and can mimic sciatic symptoms
caused by lumbar herniated disks.
If this has been excluded,
this particular procedure can be done
under ultrasonographic guidance.
The patient is placed in the prone position
with a pillow underneath to provide bolster.
The side in question is identified and prepped
in this particular fashion.
The gluteus is exposed.
For facilitation of visualization
I utilize the Sonosite M Turbo
with the musculoskeletal setting to help enhance
the muscular fibers of the piriformis muscle,
the gluteus minimus and maximus,
and the curvilinear shape facilitates entry of the needle
into the targeted site.
To perform this particular block
the following equipment is necessary.
Chlorhexidine for sterile technique,
local anesthetic syringe containing 1% buffered lidocaine,
and then a syringe containing five cc of bupivicaine 1/2%
mixed with five cc of 1% lidocaine,
and then 40 to 80 milligrams of triamcinolone kenalog,
which is a particulate steroid.
A 3-1/2-inch 25-gauge spinal needle
will also be utilized for the procedure.
There will be sterile four by fours
necessary to clean the area at the conclusion
and a simple BAND-AID will suffice to cover the wound.
Copious amounts of gel are required
for this particular procedure.
The middle portion of the gluteus is identified
and then in a transverse or left-to-right positioning
the probe is placed in contact with the skin.
The leg in question can be mobilized
in a abduction-adduction maneuver
demonstrating motion of the piriformis muscle
as it inserts out towards the greater trochanter
and towards the ischium centrally.
Clearly in the middle of the screen
you can also identify the sciatic nerve
as it passes very close
to the fibers of the piriformis muscle.
A central point is identified,
making sure to stay away from the investing fascia
around the sciatic nerve.
The skin is marked and then 1% local anesthetic is injected
directly in short axis view
and then a 25-gauge 3-1/2-inch needle
is passed through this anesthetized track
and approximately six cc of local anesthetic
containing bupivicaine and lidocaine in a one to one mixture
with a small amount of steroid if desired can be injected.
- [Voiceover] This is a short axis view
and the curvilinear probe is applied
in the transverse orientation.
The leg is being adducted and abducted
to show the muscle moving.
The sciatic nerve is clearly visible
in the substance of the muscle.
It is the band-like hyperechoic structure.
The injectate is the hypoechoic structure
that grows within the substance of the muscle.
- The probe is withdrawn,
the area wiped with a four by four,
and then a BAND-AID placed over the wound.
This is the successful completion
of a piriformis injection under ultrasonographic guidance.

Brightcove ID

5508136045001

https://youtube.com/watch?v=ZGcNFTHlFeQ

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How to: Greater Occipital Nerve Block

How to: Greater Occipital Nerve Block

How to: Piriformis Injection

How to: Piriformis Injection

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