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TrailerUltrasoundguided lavage of calcific tendinitis of shoulder ruptured calcification
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Calcific tendinosis in the rotator cuff is caused by the deposition of loosely bonded carbonate apatite crystals. Most calcium deposits remain in the silent stage, but sometimes they can produce severe pain. I will prepare the local anesthetics for the calcium barbotage procedure. • The first step is to identify the symptomatic calcification through ultrasound scanning. Conservative treatment can effectively relieve pain in most of the symptomatic calcification. However, a high probability of spontaneous rupture has been reported in some patients with extensive calcifications, resulting in delaminated rotator cuff tears. It is the case of early rupture of dense calcium. It looks well encapsulated, bigger than 1cm in diameter, but I can observe neighboring delamination and some spiculation suggesting early rupture. • I would place the transducer along the long axis of the calcium cavity. Then, under the ultrasound guidance, infiltrate local anesthetics in the skin to the subdeltoid bursal space. And then wait to anesthetize the tissue. • I will irrigate the calcium with 1 % lidocaine. Some doctors prefer warm saline, but I like to use local anesthetics because it has an additive effect, such as relieving the tendon pain. I prepare and fill 3ml of lidocaine in each 5ml syringe. I will use a high concentration of dextrose with lipid steroids after the barbotage process to relieve the inflammation and pain. • I will use an 18G 1.5-inch needle for calcium barbotage. • I would advance an 18 G needle until its tip reaches the center. What is the primary strategy of this technique? It would be easy to understand assuming that calcium crystals are deposited in the vesicle encircled by a capsule. The operator continuously irrigates a fluid to mix liquid and calcium particles to be aspirated. Any unnecessary hole or crack causes leaking the pressure, which is the most common cause of technical failure. I should avoid reposition or adjust the needle after inserting the needle into the calcium cavity. Therefore, one should keep in mind that there is only one chance to insert the needle. • Usually, calcium plug obstructs the 18 G needle lumen during the initial needle insertional process. Removal of the calcium plug with a smaller bore-long needle is an essential step. I have chosen a 6 cm long 25G needle. This process removes the calcium plug obstructing the needle lumen. • The next step is continuously irrigating fluid to mix liquid and calcium particles to be aspirated. I have chosen lidocaine instead of saline because it can relieve pain during the procedure. • The initial step is critical. I should push the plunger very gently to avoid rupture of the calcium capsule. You can observe some leaking fluid in the proximal end of the calcium captivity. If I press the piston hard, it will rupture the partially torn area. The premature disruption of the calcium capsule is the most common cause of technical failure. The plunger should be pushed very slowly, progressively aiming to mix liquid for calcium particle resolution. • Now, I can observe a calcium particle in my syringe and have a high chance of success. • Look at the movement of the needle. I intend to dig the hard calcium formed inside the capsule. The swing and rotating motion of the needle allows the bevel as a shovel excavating the solid calcium. I would ground the hard calcium gently with the needle tip by these needle maneuvers. I would continue digging the calcium until the calcium wall thin enough. • If successful, calcium fragments will begin to evacuate into the syringe and appear as white particles. If these initial barbotage steps proceed well, I can actively increase the force to the plunger to evacuate more calcium vigorously. If the lavaging fluid becomes turbid, change the lidocaine-filled new syringe. • It is very tedious working. I do not aspirate the plunger by active force but passively let-go of motion. I continuously repeat this slow and low-pressure injecting process, followed by the passive release. • Finally, I would like to irrigate with an injectant mixture of a high concentration of dextrose and 1 mL of lipid steroids in the calcium cavity and the subdeltoid bursal space. The lipid steroid will mitigate the risk of tendinitis and post-procedural bursitis. I don't recommend the particulate steroid such as triamcinolone. It would harm and inhibit the natural tendon healing. • #PracticalPainManagement #spinalintervention #imageguided #learning #imagetrain #GE #Ziehm #MSK #chronicpain #case #lecture #cervical #lumbar #knee #elbow #noninvasive #painfree #ISURA #paindiploma #montpellier #madi #precise #decisionmaking #limethasone #dexamethasone #palmitate • #μ΄λ―Έμ§νΈλ μ΄λ #λ§μ±ν΅μ¦ #ν΅μ¦ #μ΄μνμμ #μ΄μν #μμ #μμ νμμ
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