Common Injections for the Family Physician : General Principles

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Common Injections for the Family Physician
General Principles

• Francis G. OConnor, MD, MPH
• Department of Military and Emergency Medicine
• Medical Director, Consortium for Health and
  Military Performance
• Uniformed Services University of the Health
  Sciences

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Objectives

• Review the indications, benefits, risks, and
  contraindications of injections in Family
  Medicine.
• Describe general principles involved in
  administering injections to include consent,
  equipment, anesthesia, choice of corticosteroid
  and technique.
• Discuss basics of coding for the procedure.

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Indications

• Therapy
• remove tense effusions
• remove blood or pus
• injection of steroids or other intra-articular
  therapies
• therapeutic lavage

• Diagnosis
• synovial fluid analysis
• therapeutic trial
• imaging studies
• synovial biopsy

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Benefits - Cochrane Reviews

• Intraarticular corticosteroid for treatment of
  osteoarthritis of the knee
• The short-term benefit of IA corticosteroids in
  treatment of knee OA is well established, and few
  side effects have been reported. Longer term
  benefits have not been confirmed based on the
  RevMan analysis. The response to HA products
  appears more durable.
• Corticosteroid injections for shoulder pain
• Despite many RCTs of corticosteroid injections
  for shoulder pain, their small sample sizes,
  variable methodological quality and heterogeneity
  means that there is little overall evidence to
  guide treatment.

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Risks/Complications

• Infection one infection per 20,000 to 50,000
  injections.
• Tendon rupture
• Post-injection flare
• Atrophy/hypo-hyperpigmentation
• Cartilage degeneration
• Hyperglycemia
• Local trauma

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Contraindications

• Cellulitis or broken skin over needle entry site
• Anticoagulation or a coagulopathy
• Intra-articular fractures
• Septic effusion
• Lack of response to prior injections
• More than three prior injections in the last year
  to a weight bearing joint.
• Inaccessible joints joint prostheses.

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General Principles

• Consent
• Equipment
• Anesthesia
• Corticosteroids
• Technique
• Post-Procedure Care

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Consent

• Consent should be obtained on all diagnostic and
  therapeutic injections!
• A detailed discussion of benefits, risks and the
  expected results should be covered.
• Consent should be witnessed and documented.

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Equipment

• Controversies
• sterile prep vs. alcohol prep
• sterile gloves vs. nonsterile
• 21 to 27 gauge needles for injections 18 to 20
  gauge for aspirations
• 1 to 10cc syringes for injections 3 to 50cc for
  aspirations
• ethyl chloride, 1 and 2 lidocaine, 0.5
  bupivicaine
• sponges, Band-Aids
• access to equipment for allergy/anaphylaxis

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Anesthesia

• Aids in providing pain relief, assisting in
  diagnosis, and providing a volume for the
  steroid.
• Lidocaine 0.5 to 2 amide 1 to 2 min onset of
  action duration 1 hr.
• Bupivicaine 0.25 to 0.5 amide 30 minute onset
  of action duration 8 hr.
• Single versus multi-dose vials
• Ethyl chloride

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Anesthesia

• Anesthetics work by causing a reversible block to
  impulse conduction along nerve fibers.

Loss of Pain Sensation
Loss of All Sensation
Loss of Motor Power
As Dose of Local Anesthetic Increases
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Corticosteroids

• Mechanism of Action complex and largely
  unknown, however, they do
• Reduce cytokines and inflammatory mediators
• Decrease capillary permeability
• Decline in PMN migration.
• Treats the local inflammatory response, not the
  clinical problem.
• Maximize glucocorticoid effects minimize
  mineralocorticoid effects.
• Increased solubility shorter duration lower
  risk for post-injection steroid flare lower
  risk for local atrophy.

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Corticosteroids
Corticosteroid Relative Potency Solubility Equivalent Dose
Kenalog 5 Intermediate 40mg/ml
Depo-Medrol 5 Intermediate 40mg/ml
Celestone Soluspan 20-30 Low 6mg/ml
Decadron LA 20-30 Low 4mg/ml
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Hylauronic Acid Derivatives

• FDA classifies these agents as devices, not
  drugs.
• Indicated only for treatment of knee
  osteoaarthritis.
• Hylan G-F20 polymers
• Heavy weight preparations
• Synvisc
• Three weekly injections
• Sodium Hyaluronate
• Hyalgan
• Five weekly injections

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Hyalgan

• Synovial fluid is an ultrafiltrate of plasma
  modified by the addition of hyaluronic acid (HA),
  which is produced by the synovium.
• In osteoarthritis, the HA is decreased and
  compromised.
• Exogenous supplementation of intraarticular HA is
  thought to support changes in the character of
  synovial fluid.

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Mixing Agents

• First, draw the anesthetic into the syringe
• Second draw the corticosteroid into the syringe
• Next draw 1cc of air into the syringe to create a
  mixing bubble
• Prior to injection, mix the agents, and then
  expel the air prior to injection.

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Technique

• Patient
• Be prepared!
• Landmarks
• Aseptic vs. Sterile technique
• Local anesthesia
• Needle insertion
• Delivering the volume
• bolus vs. peppering

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Ultrasound Guidance

• Ultrasound guidance is an accurate method for the
  delivery of therapeutic injections in the
  musculoskeletal system.
• The visualization of the needle in real time
  allows for reliable placement of the needle tip
  in the tendon sheath, bursa, or joint of
  interest.
• Both superficial and deep articulations and
  tendon sheaths can be targeted for diagnostic or
  therapeutic interventions.
• In addition, intratendinous calcifications, the
  plantar fascia, and interdigital (Morton's)
  neuromas can also be visualized and injected
  directly under real-time guidance.
• Performing percutaneous interventions with
  ultrasound ensures accurate needle tip placement
  and helps direct the needle away from other
  regional soft-tissue structures such as nearby
  neurovascular bundles.

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Trigger Point Injections

• A 22-gauge, 1.5-inch needle is usually adequate
  to reach most superficial muscles.
• Using sterile technique, the needle is then
  inserted 1 to 2 cm away from the trigger point so
  that the needle may be advanced into the trigger
  point at an acute angle of 30 degrees to the
  skin.
• A small amount (0.2 mL) of anesthetic should be
  injected inside the trigger point. The needle is
  then withdrawn to the level of the subcutaneous
  tissue, then redirected superiorly, inferiorly,
  laterally and medially, repeating the needling
  and injection process in each direction until the
  local twitch response is no longer elicited or
  resisting muscle tautness is no longer perceived.

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Post-Procedure Care

• Evaluation of patient relief in the office
• Discussion of steroid effects/expectations
• Afterpain treatment
• Ice vs. short course NSAID
• Activity Recommendations
• Rest weight bearing joints for several days to a
  week.
• Follow-up visit!

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Post-Injection Flare vs. Infection

• Post-Injection Flare
• Reaction caused by development of steroid
  crystals in the synovial space may also be the
  result of chemical synovitis from methylparaben
  in multi-dose anesthetic vials.
• Occurs 6 to 24 hrs s/p injection may last 2 to 4
  days.
• Consider aspiration to r/o infection.
• Infection
• Uncommon.
• Symptoms persist over 72 hrs.
• Warmth, redness, streaking, fever.
• Confirmed by aspiration.

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Pain Relief and Injection Therapy
Corticosteroid
Anesthetic
Pain Threshold
48hrs
Time
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Injection Frequency

• No EBM guidelines.
• General Recommendations
• Limit injections to large joints to 4 times per
  year no more than 10 times overall.
• Small joints should be injected no more than
  three times per year and four times overall.
• Steroid injections should be spaced at least 4
  weeks apart hyaluronan injections 6 months apart.

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Coding

• Reimbursement requires clinicians properly
  identify two, possibly three, appropriate codes
• The Diagnosis
• International Classification of Diseases, 9th
  Revision ICD-9
• The Procedure
• Current Procedural Terminology CPT
• The Drug Utilized
• J Code
• Evaluation and Management (E/M) Codes are
  dependent upon New patient status.

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Coding CPT Codes
CPT Description RVU
20526 Inj of Carpal Tunnel 1.77
20550 Inj tendon sheath/ligament 1.57
20551 Inj tendon orgin/insertion 1.51
20552 Inj sing/mult trigger pts (1-2 muscle grps) 1.38
20553 Inj sing/mult trigger pts (gt3 muscle grps) 1.56
20600 Asp/Inj small joint (e.g.fingers) 1.38
20605 Asp/Inj intermediate joint (e.g.fingers) 1.52
20610 Asp/Inj large joint (e.g.fingers) 1.84
20612 Asp/Inj ganglion cyst 1.53
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Coding J Codes

• J Codes for Injectable Corticosteroids

J Code Material Unit
J3301 Kenalog 10mg
J1020 Depo-Medrol 20mg
J1030 Depo-Medrol 40mg
J1040 Depo-Medrol 80mg
J0704 Celestone 6mg
J1094 Decadron LA 1mg
J7320 Synvisc 16mg
J7317 Hyalgan 20mg
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Specific Injections
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Subacromial Space

• Indications
• relief of pain in subacromial impingement
  syndrome
• diagnostic to help r/o adhesive capsulitis or
  rotator cuff tear, or confirm RTC impingement

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Subacromial Space

• Clinical anatomy landmarks
• AC joint
• posterolateral recess between the humeral head
  and the acromion

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Subacromial Space

• Technique
• seated patient
• arm relaxed with other arm used for passive
  traction
• ethyl chloride or 1 lidocaine anesthesia
• inferior to posterolateral acromion
• needle bevel up oriented cephalad and directed
  toward the anterior acromion
• bolus insertion

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Subacromial Space

• Needle size and dosage
• 1 ml of corticosteroid (celestone soluspan or
  kenalog) with 50/50 mix of 6 to 9 ml of lidocaine
  and marcaine in a 10ml syringe.
• 18 gauge needles for medicine draw 22 gauge 11/2
  needle for injection

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Lateral Tennis Elbow

• Indications
• lateral tennis elbow that fails to improve with
  conservative therapy

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Lateral Tennis Elbow

• Clinical anatomy/landmarks
• radial head, appreciated by pronation/supination
• humeral lateral epicondyle
• extensor carpi radialis brevis

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Lateral Tennis Elbow

• Technique
• supine or seated
• elbow in 90 degrees of flexion and supinated
• area of maximal tenderness found usually
  1fingerbreadth distal and medial to the lateral
  epicondyle
• needle inserted into a triangular fatty recess
  near the common extensor origin

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Lateral Tennis Elbow

• Needle size and dosage
• 25 to 27 gauge 1 inch needle
• .5ml of celestone with 1ml of 1 or 2 lidocaine

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Trochanteric Bursitis

• Indications
• recalcitrant trochanteric bursitis

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Trochanteric Bursitis

• Clinical anatomy
  landmarks
• greater trochanteric
  prominence
• illiac crest
• sciatic nerve

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Trochanteric Bursitis

• Technique
• patient in the lateral decubitus position
• point of maximal tenderness identified
• needle perpendicular to the skin
• depth of insertion 1/2 to 3 inches
• gentle peppering of the bursa

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Trochanteric Bursitis

• Needle size and dosage
• 22 to 25 gauge 11/2 inch needle
• 1ml of celestone with 3 to 5ml of 1 lidocaine

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Knee Joint

• Indications
• inflammatory or degenerative arthritis
• Remove tense effusion
• diagnostic

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Knee Joint

• Clinical anatomy/landmarks
• patellar tendon
• inferior patellar pole
• medial joint line
• lateral joint line

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Knee Joint

• Technique
• seated or supine position
  with knee flexed to 90
• recess lateral and inferior to the patellar
  tendon border identified at the level of the
  joint line
• needle directed toward the center of the knee
• depth of insertion is gt1.5
• GO DEEP

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Knee Joint

• Needle size and dosage
• 22 to 25 gauge 1-1/2 inch needle
• 10-40mg triamcinolone, /- lidocaine

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Aspiration Interpretation
Classification Appearance WBCs PMNs Crystals Culture
Normal Clear to straw colored lt150 lt25 No Negative
Noninflammatory Yellow to transparent lt3000 lt30 No Negative
Inflammatory Yellow to cloudy 3000-75,000 gt50 No Negative
Infectious Yellow, purulent 50,000-200,000 gt90 No Often positive
Hemorrhagic Red-brown 50-10,000 lt50 No Negative
Crystal Cloudy, turbid 500-200,000 lt90 Yes Negative
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Myofascial Trigger Points

• Indications
• diagnosis and treatment
  of myofascial trigger points

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Myofascial Trigger Points

• Clinical anatomy
  landmarks
• dependent on location
  of trigger and tender
  points

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Myofascial Trigger Points

• Technique
• palpable as fusiform firm nodules
• nodule trapped between the fingers of the
  nondominant hand
• sterile prep
• local twitch response
• two to five sessions may be required

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Myofascial Trigger Points

• Needle size and dosage
• 25 to 27 gauge 1 inch needle
• 1 to 5ml of 1 or 2 lidocaine

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Conclusion

• Injections, when done properly and with the right
  indications, are a tremendous asset to the
  practice of the family physician.