Ultrasound Guided Prolotherapy & PRP Injection
If we can see the needle, we are less likely to place it somewhere undesirable and very likely to place it exactly where we want it.
The use of ultrasound guidance in prolotherapy, PRP and stromal vascular fractions (MSC) injections has been experiencing increased use in the past few years as the technology has improved and become available for clinical use. When I originally trained in prolotherapy injections, palpation and anatomy knowledge were the landmarks that were used to target the injection sites. Certainly many doctors were highly skilled and excellent clinical results occurred using what are called “blind” techniques. Even when ultrasound first became available, I initially believed as many still do, that the excellent results did not require better guidance.
Since first studying ultrasound guidance methods in 2011, I have come to a different opinion. Although ultrasound guidance will make identification and injection of targeted sites more specific, the debate about its use is whether there are better outcomes with it. There is no substitute for good clinical diagnostic skills, assessment, proper treatment choices, patient selection and anatomical and pathological knowledge. Examination, palpation, anatomy, physiology and injection experience are critical factors in outcome success. Ultrasound use is not a substitute for poor clinical skills, and in fact, a good “blind” prolotherapy treatment is still better than an ultrasound guided injection without the clinical skill. However, when we combine good clinical skills with good ultrasound skills, it is my opinion that we can get a better outcome with less risk. If we can see the needle, we are less likely to place it somewhere undesirable and very likely to place it exactly where we want it.
The other advantage of using ultrasound, is the ability to identify pathology and more accurately identify the causes of pain. For example spurs, calcifications and tears cannot be palpated and visualization on ultrasound provides very specific treatment options such as injection into tears, aspiration or breakup of calcifications and tenotomy of spurs with the needle. Boney erosion sites are also identifiable. Often pain may be caused by nerve entrapments which can be identified, targeted and successfully treated with needle hydro dissection. Images of pathology can be taken and saved and compared to future images to determine progress.
Studies Comparing Ultrasound with Blind Injection
There have been many studies that have compared ultrasound guided injections to “blind” injections. It can be demonstrated that ultrasound guided injection, improves treatment outcomes. The research does indicate that there is a significantly higher rate of accuracy, which by inference would suggest better outcomes.
It is a safe, noninvasive, and low-cost alternative to other imaging modalities. Ultrasound has no radiation exposure and provides dynamic assessment of needle placement during injections. By visualizing nearby neurovascular structures, ultrasound-guided injections allow safe and precise delivery into the involved soft-tissue structure. American Academy of Orthopaedic Surgeons, January, 2015
Limited data exist comparing the clinical efficacy of ultrasound-guided to palpation-guided injections, and the majority of those studies only address the shoulder joint. However, from those studies it was found that patients who received an ultrasound-guided injection demonstrated statistically significant greater improvement in pain and shoulder function at 6 weeks compared to those who received a blind injection. American Academy of Orthopaedic Surgeons, January, 2015
Image-guided (ultrasound) corticosteroid injections potentially offer a significantly greater clinical improvement over blind injections in adults with shoulder pain. American Academy of Orthopaedic Surgeons, January, 2015
Ultrasonography is challenging the standards of rheumatological clinical practice. It is more sensitive than clinical examination in the detection of synovitis and more sensitive than conventional radiography in the detection of bone erosions. Ultrasonography-guided injections may improve therapy effectiveness if compared with the traditional blind approach. BMC Musculoskeletal Disorders: A Systemic Review: 2011, 12:137.
The location of the needle was fluoroscopically confirmed to be at the proper position in 38 (66.7%) of the 57 blind interventions. . In light of our results, we suggest that blind injection of the osteoarthritic hip joint can be inaccurate even with careful technique Current Opinion in Rheumatology: January 2007 Vol. 19, Issue 1.
US provides direct visualization of soft tissues and the outer borders of bony structures. With real-time needle guidance the success rate of intra-articular injections improves and iatrogenic damage to anatomic structures can be avoided European Journal of Radiology, October 2012, Volume 81, Issue 10, Pages 2759–2770