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- Let me be the first to Thank you for joining us.

Welcome to the SonoSite webinar entitled Ultrasound Guided

Nerve Hydro Dissection, opening Up New Treatment Frontiers.

My name is Chris Pennell

and I'll be moderating today's webinar.

Before we begin, please be advised all attendees are muted.

You can type your questions into the q

and a box in the toolbar located at the bottom

or the side of your screen, and we'll get to those q

and a questions at the end of the presentation.

This webinar will be recorded

and archived for future reference.

You can see the URL there,

the secure sono site.com/behind the scan webinar URL there.

That's where this will be going. Up here

today with us we have Dr.

Francoise Lo. Dr.

Lo is a co-founder

and treating physician at the Bill Nellum Pain

and Research Center, the biggest comprehensive pain

clinic in Canada.

Dr. Lo is triple certified in GP anesthesia, ER medicine

and pain medicine

with multiple research interests in these fields.

He serves as a clinical associate professor at the

University of Bridge, Columbia Department of Family Practice

and is a past president of the Canadian Association

of Orthopedic Medicine

and he also serves as the chief medical Officer of Entech,

a bioscience company.

Dr. Lo is passionate about improving both physical

and mental health, exploring new paradigms

and always with the deep compassion

and making sure to put the patient at the center.

Dr. Loh, we're super excited to have you here with us,

so I'll go ahead and turn it over to you.

- Well, thank you very much Chris.

Thanks for the great introduction.

So you've got my pedigree there.

That's a nice little photo

of UBC Okanagan here in Kelowna, British Columbia.

And so yeah, we're a multidisciplinary clinic,

eight physicians.

We've got psychology, physiotherapy

and other services all under one roof.

So yes, I actually started using ultrasound more than 20

years ago and it is absolutely, I mean it's,

it's been a game changer as we know in emergency medicine,

anesthesia and of course pain medicine.

And you know, we use ultrasound guided injections for all

of our cases here in the Okanagan.

So look, let's look at the learning objectives today.

So we are gonna be discussing the, the role

of peripheral fascial nerve entrapment

in causing neuropathic pain.

We'll discuss the rationale

behind using 5% dextrose and other injects.

We're gonna look at five common nerve entrapment syndromes

that are responsive to this treatment

and I'm gonna show you some practical ultrasound guided

nerve hydro dissection interventions

that you can start doing Monday morning in the office.

So what is nerve hydro dissection?

I mean, this is a, it's a very interesting sort of

and useful technique in pain medicine

where we use high resolution ultrasound guided fluid

injection to separate nerves from their surrounding

or adjacent structures, usually fascia, which is believed

to constrict or irritate the nerve during movement or rest.

So we use various injects

corticosteroids have been used for many years.

Saline, lidocaine, platelet rich plasma as some

of you are familiar with, and 5% dextrose.

Now I've used all of these inject in the past

and there's, they all have a, a different

place in this field.

I like 5% extras.

It's very safe, it's benign, it's isotonic,

doesn't cause motor block

and there are no steroid side effects.

It also has an analgesic effect,

so a really good safe option.

So what is neurogenic inflammation?

Well, this is when these pep Pepto,

jet Pepto doic nerve fibers release pain producing

substances such as calcitonin gene-related peptides

as well as substance P.

So clinically we see patients with allodynia.

So that's pain of course due to a sort

of a non-painful stimulus

and also hyperalgesia as a result of a lowering

of the firing thresholds of peripheral nerves.

Now let's just note this is not classic

classical inflammation.

It's not like inflammatory changes surrounding sort

of gouty joint or rheumatoid arthritis.

This is more of a non-inflammatory ischemia,

reperfusion degenerative neuropathy, that's a bit

of a long word for this time of the day.

So how does most of these injected work?

Specifically de five w 5% dextrose downregulates,

the trip V one ion channel that decreases substance P

and calcitonin gene related peptides.

So you get an increased concentration

of the extracellular dextrose, which hyperpolarizes C fibers

and decreases this firing rate.

Hydro dissection also releases tract

and injured nerves from fascial constructions,

increases blood flow

and then enhance mobility of these nerves.

So don't take my word for it.

Pain receptors have been a hot topic recently.

In fact, Dr. David Julius from UCSF,

just and Dr.

Patian, they just basically shared the Nobel Prize in

medicine in 2021 for discoveries of

receptors involved in temperature and touch.

And Dr. Julius did some excellent work on

capsaicin receptors

or TR V receptors, which are really an important focus on of

these hydro dissection procedures.

So what do we use? Dosage and frequency?

I usually use between five to 20 milliliters of buffer,

5% extras with 0.1 to 0.2% lidocaine

per injection depending on the entrapment site

and severity for some hydro dissection applications, we add

a corticosteroids, which we'll get to later on.

Usually it's a fairly low dose, 10 to 20 milligrams

of triamcinolone or kog.

It's usually a great addition.

Injection interval is every one to four weeks.

So where do these nerve get constricted?

Well, they get constricted at t valet points

where these nerves pierce fascia muscles epi neurosis

where there's friction like on a bone

or a tendon where the nerve branches out,

where the nerve terminates, like in the skin

or where these nerves originate from bony canals like the

trigeminal nerve for example, in the, in the face.

So a little bit of nerve anatomy.

Again, all these nerve fibers are surrounded

by different fascial sheaths.

So the actual neurons get the fascial sheath

for the smallest subunit is the endoneurium.

And then for nerve fales,

the fascial sheath surrounding them is the perineurium.

And let's just have a look here.

And so,

and then of course there's the, the sort

of final fascial sheath around the, the whole nerve itself.

And you'll also note that there's

these vaso nerve

and n novarum, which are the nerves

and the blood vessels actually supplying this,

these nerves with blood supply.

And they can often, if you,

if you can imagine they get squished in these ent tract

sites that stops all sort of nutrient flow into these nerves

and can cause a lot of pain and dysfunction.

So the nerves that we are treating, so this is sort

of a transverse view needle coming in transversely,

and you'll see the bevel, this part of the,

the needle here sh points down towards the nerve

that ensures that the nerve does not get speared by the,

by the needle tip, it sort of slides over.

And that also when there's a jet fluid emanating from the,

from the needle, it will then be directed towards the nerve

as you'll do it above and below the, the nerve

to open up the, you know, the, the space around this nerve.

So that's the, the jet of fluid that'll then increase,

you know, flow around the nerve and, and,

and cure the entrapment.

So let's look at sort of this five high yield applications.

There are many, but I thought, you know, let's stick

to the ones you could use on Monday in the office.

So I know I'm sure lots of you like skiing

and of course here in bridge Columbia it's a, it's a,

it's a big part of what we do.

So I've got this, the nomenclature here is in, in, in green

and blue runs and,

and then black runs for the more difficult ones.

So I would say green run, some of the easiest ones would be

carpal syndrome.

As we know, the median nerve entrapment here in the carpal

tunnel is associated with more than 90%

of median nerve entrapments.

So you can see here the sort of the flexor ulu

and the inlet here between the scaphoid

and the PC form bones in the wrist

and often that can significantly entrap the,

the median nerve as it sort of courses through that area.

So here's the way to hold the probe.

So note that the patient is nice

and comfortable, the rest is slightly extend it

and then the probe has a slight cranial tilt

to better visualize the nerve

and get a nice perpendicular nerve view.

Otherwise you get, you know,

you don't get a nice perpendicular crisp view of the nerve

unless you sort of tilt it a little bit like that.

And here's a video showing the actual injection.

Now as you can see there's a little lidocaine spray there

that I use to sort of just anesthetize the skin with

and it was actually, these are quite well tolerated

with nice gentle discussion

with the patient explaining the technique

and then using a 25 gauge needle,

actually very well tolerated.

So quick little reminder of what this looks like.

That's basically the,

this hyper echoic structure here

with a hyper echoic border is the media nerve.

And this, as you can see there's sort of a, a band

of slightly more hyper coic tissue there,

it's the flexor ulu and the idea is

gonna be of course to hydro dissect the nerve away from

the flexor re tenaculum.

So up top we've got axial view, so that's a transverse view

of the media nerve

and the median nerve's usually less than 10 millimeters

squared in, in cross sectional area.

And as you can see this one is pretty large at 19.

And if you then sort of flip that probe 90 degrees

and you follow the nerve in long axis, you'll see that

there's a constriction site right here

and that's where the flexor tenaculum is.

Remember the probe is 90 degrees right now

and proximal to that constriction point

you could see there's a widening or swelling of that nerve

and that's what we usually see.

So there's sort of that attenuation or taper in the nerve

and that's a clear sign of, of entrapment

is also increased vascular f with colored doppler inside

of the nerve further sort of pointing to the fact

that there's an entra neuropathy.

So I just had this patient just sort of move the flexors the

of the, of the, of the forearm

and you'll see them sort of moving around

and the nerve is just superficial to that

or near field to that yet again there's the,

there's the flexor in inoculum.

All right, so how do we, how do dissect it?

I think it's wise to go deep to the nerve

and point that bevel up towards the nerve

and then you'll see that jet of fluid surround the nerve on

the, on the far field

or the deep part of the nerve so that if you'd start

with a deep part then you don't obscure your view more,

more near field or more closer to the, to the probe itself.

So start with that deep injection, put about 2.5,

maybe three mls in there that really sort

of releases it from the subs noal tissues and and the

and the flexor tendons deep.

And then following that you would come in here

yet again from sort of in a transverse view

and you can see that lovely little fluid inject goes in

between the flexor retina up top

and the nerve right here, just just deep to it.

Okay, supplies, as I said,

a nice little topical spray ensures patient comfort

and ensures that you get potentially a, you know,

Christmas card that year.

It's just a nice way to treat the patient

and the tray looks like this is, you know,

all your different inject that you could use

5% dextrose sodium bicarbonate and lidocaine

and needles.

I basically just use two types of needles here

for more superficial work I use 25 gauge one

and a half inch needle.

And for deeper work I would use a two inch 25 gauge

TSK stereo eject

and that's a really good needle for this work.

Alrighty, so that was a green run.

Here's this is another green run neuralgia paraesthetica,

I think we've all seen this in practice.

This is entrapment of the lateral femoral cutaneous nerve

sort of in the lateral thigh.

This nerve often gets trapped here under the inguinal

ligament over here

and then these folks present

with neuropathic pain involving the lateral thigh.

So yeah, let's look at case study.

Mr S, he's 68 years old, he's overweight but rotund

and he complains of zingers down the right lateral thigh

region and sits or dries for more than 10 minutes.

So the usual treatments well loosen those tight genes

and bells makes a difference.

Weight loss address, hyperglycemia address, hypothyroidism,

NSAIDs, analgesics, I try pregabalin and so forth.

And hey, why do we do hydro dissection for this patient?

This is how you do it.

That's is yet again a transverse view of this.

The patient's proximal thigh,

that's the anterior superior iliac spine there.

It's just slightly cordal to that

where we gonna put the probe in that sort

of transverse orientation.

And here's an injection really comfortable.

As you can see from this patient,

there's a di dead giveaway sign that his belt is too tight

and that often that's one of the presenting, that's one

of the problems here with the irritation

and chafing of that nerve.

This is from a wonderful app called the Anso anesthesia app

and I, I'm using this

with permission from them.

Look at these different muscles here.

So you start here on the, on the side.

So basically you've got your sartorious muscles here

medially and this is the tensor fascia.

Laterally is a little fat filled triangle between them

and there's a sort of fascia just above it.

The nerve lives right here in this fat filled triangle

and there's a needle path with the inject

and sort of the surrounding that nerve there.

Here's one of my videos coming in here from, this is from

lateral to medial

and as you can see I see

that knee needle is just right under the fascial alta

and around the nerve, which basically is this little hypo

hypo structure here.

Alrighty, well let's look at a blue run sort

of a little bit more, bit more difficult,

needs a little bit more training.

So don't start with this

but certainly it's a very useful technique to help patients

with various types of myofascial and neuropathic neck pain.

So the cervical plexus is a nerve plexus that basically

becomes more superficial here, just behind the stern line

and mastoid border, the posterior border and

and this includes four nerves, the less occipital nerve,

the greater auricular nerve, the transfer cervical nerve

and the supraclavicular.

So those four nerves, the wonderful thing is

it's can be they can all be accessed

through this one injection.

So let's look at another case study.

Mavis is a 69-year-old lady

and she suffer from cervical spondylosis and scleroderma

and she presents with diffuse neck

and trapezius region pain.

It's called a neuropathic nociceptive pain quality.

And yet again there's a dissection of this area

that's called the puncti nerves

or herbs point right here where all these nerves basically

become more superficial just behind the stry.

The mastoid border is right there where

that external jugular vein crosses over the posterior border

of the SCM.

I call that sort of a gold mine site

because you know everything is right there

and can be all accessed very, very nicely indeed.

So this spot is halfway between the mastoid process,

it's number three years and asteroids

and then all the way down to the clavicle.

So you basically just go use the halfway point

between these two structures.

Alright, that's your entry point for injection

yet again there's an ultrasound.

So view of this superficial plexus lives right here

that's behind the posterior border

and that's C four posterior is here on the right hand side.

So you're gonna come in from posterior,

I call this the landing strip

because there's a whole bunch of tiny nerves.

You can see these little hypo coic oval

structures here are all tiny little nerves of the

superficial plexus.

Alright, so this is just a very gentle

careful injection here of the plexus in that

with the patient's sideline from posterior

to anterior in plain.

So you're gonna be following a needle at all times

and you can see exactly where that tip of the needle goes

and it goes very superficial.

So that's the nice thing about it.

And over here I would just use basically 0.1

to 0.2% lidocaine in D five WI generally try

and stay away from corticosteroids if I can

because of all the, you know, potential side effects

yet again from that anso anesthesia app,

which I think is very useful.

They your internal jugular carotid cla mastoid

transfers process of CE five nerve root there,

your plexus there, your needle coming in

and there's your local anesthetic basically hydro dissecting

all those superficial cervical plexus nerves.

All righty. So we use this technique in the ER as well

and if you use 1% lidocaine, this is sort of the zone

of anesthesia that you get.

Of course I wouldn't use 1% lidocaine mostly for these

hydro dissections because it sort

of gives people quite a bit of anesthesia

that which could be, could sort of,

you know, make them uncomfortable.

But you could use this for clavicle fractures in the ER

and you can do it, you know, you can,

you can suture the neck with a 1% lidocaine block

or a bupivocaine local anesthetic block of this plexus.

So I've marked it out, I've tested this patient sensation

with 1%, but generally, as I said, it's not,

not a very dense anesthesia that we are looking for.

We just basically wanna hydro dissect the nerves

with something safe like mostly D five W.

And yes, injection accuracy is important in, in our field

what might, yeah, find that amusing.

So yes, let's look at a, a bit of a black run

that's a more difficult one but very useful.

We see these patients like tons

of these patients all the time.

So patients with medial scapular border pain due

to dorsal scapular nerve

and spinal accessory nerve entrapment.

So it's DSN and SAN

and these nerves, I'll, I'll get to that

where they are located.

So let's do another case study.

Alex is 49

and he complains of neuropathic quality medial scapular

border trapezius region pain.

He was backpacking there through Europe 10, 12 years ago

and, and started developing some pain here in this scapular

area and he complains of a sensation

of crawling ants and parasthesia.

So this is superimposed on deep aching,

especially when carrying or lifting objects.

Now Alex is also a rock climber

and I know there are some fine people at sauna site

that are also in interested in this field

and these people are, it's amazing what they do.

This is the, the bugaboo here in British Columbia,

famous climbing spots

and as you can see they're bedding down yet for the nights,

you know, just that's, that's a bit crazy.

I hope these people are not sleep walkers

but they truly just sort of suspend themselves your

overnights and, and then climb the next day.

And Alex has had quite a bit of shoulder pain as a result

of all of these adventures

and he is coming in for some treatments.

So if you look here in the right lower corner of the,

of the image, this is sort of your probe view

and this is what you see on your ultrasound machine.

So you'll see there's a spinal accessory nerve

and then your elevator scapula is this sort

of muscle coming in here from from more cranial

and it inserts here onto the super medial scapular border.

The OID minor muscle is more, more medial,

so medial is here on the left, lateral is here on the right

and then the serratus posterior muscle is here in the deep

to that and of course it passes underneath the,

the scapular, it doesn't insert onto the scapular

but the two nerves of interest are right there.

The spinal accessory nerve in that first layer of fascia.

And then the second nerve of interest,

the dorsal scapular nerve which runs right next to the,

to the artery is contained basically in

that second fascial plane, this fascial plane here.

So you can treat this out of plane, which I would leave

for someone who's been doing this for a few years,

but that's what I often do.

Or you can just flip your probe nine degrees

and then inject from cordal to cranial.

So that's where patients have pain

and this is sort of just a real time view.

Cordal on the right, cranial on the left

and your needle goes in plain,

you can see your needle advancing very nicely

and your spinal accessory nerve of course is that first

line there, the first fascial plane.

The second one is the dorsal scapula.

Alright, finally tarsal tunnel syndrome,

that's posterior tibial nerve entrapment

and this one is another green run

which is something you could, could do fairly easily.

Now this of course is sort of a neuropathic quality pain

just inferior to the medial malleolus, the ankle,

that's the medial ankle here.

And as we could probably remember from med school,

the mnemonic to remember those tendons and arteries

and nerves is Tom Dick

and a very nervous Harry for the different tendons

and the vein and the tibial nerve, which is right next

to this to Harry, which is the flexor lysis longest tendon,

almost like similar, it's basically similar

to the carpal tunnel where these nerves

and tendons cause through right

underneath the flexor rnac

again and they're getting trapped there.

And that's one from my video library.

As you can see this honeycomb structure there is the,

the nerve and we're coming in your in plane,

meaning you follow the needle all the way down to the nerve

and you surround that nerve with, you know,

I usually would use about five to six mls.

Some people would use more of a well-placed

generally sort of 0.1, 0.2% lidocaine in D five W.

All right, so are they really useful applications include a

bunch of, there are so many applications here,

clonal nerve entrapment greater

and less occipital nerves, sciatic nerve entrapment,

a common peroneal nerve entrapment.

And then also the branches of the trigeminal nerve in the,

in the face actually really useful for that as well

for people with atypical facial pain.

The options are legion. Yep.

So I think we all tired of this whole COVID thing

but yep, first professional footballer getting vaccine.

All right, so finally I just wanted

to put a little bonus in there for you.

There's another very useful technique which is sort

of similar to, you know,

hydro hydro dissection.

This is hydrodilatation,

so we are not dissecting nerves here.

We are basically treating the

rotator cuff interval in the shoulder as well

as the capsule in patients with frozen shoulder.

I just thought it's kind of a nice thing to to end with

because it's such a useful technique

that you could really help a lot

of patients with first shoulder.

So the rotator cuff interval of course is this anterior part

of the shoulder that's gonna be your entry there.

The rotator cuff interval is the interval

between the supraspinatus tendon

and the subscapularis tendon.

And it's basically a little space here just

between the biceps long head just

before it dips into the groove.

And there's a ligament here on top of it,

which is the caro humeral ligaments.

So you put for this I usually we use five to 10 nolls

of 1% lidocaine.

So a pretty good dose of lidocaine with 20

to 40 milligrams can log

and really does a wonderful job for patients

with decreased external rotation.

Now if patients also have significant issues with abduction

of the shoulder as a result of the frozen shoulder,

one could do this capsular dation

and for that you basically get into the glenohumeral joint

and you just dilate the capsule to create more space.

Some people use up to 40 to 50 mils of inject.

I I, I've never used more than 20 milliliters for this,

I generally just use 10,

but that could be an addition to that rotator cuff approach

for patients with frozen shoulder.

And yet again, these are just the inject

and the volumes that we sort of briefly touched upon,

but I'll leave it here for you for reference purposes.

And I evaluate these people every, you know, two weeks

to maximum of three.

But lots of times in most cases these patients get dramatic

improvement within one treatment.

Alrighty, so that's not for me.

In summary, there are multiple options in your toolbox.

Nerve heart dissection is a very useful addition.

Pain care is interdisciplinary and effective.

Interventional pain care is so rewarding

and ultrasound guided interventions are an important part

of the solution and I think if you start

doing more of this, you just really enjoy

and be humbled by, by the results

and yeah, showing compassion to our patients

and helping them out with really significant pain issues

and, and and improving that.

So I'll leave you with Hippocrates words of wisdom here.

Sometimes treat often comfort always.

If you have any questions,

my UBC email address is do low at mail ubc

ca and yes, have some fun along the way.

This is some wild chanterelle mushroom foraging here in bc.

It's just an incredible, you know, a delicacy

and fun, fun day out in the forest as well.

I've got some references. I also don't want to thank Dr.

Janice bowler here in BC for some ideas

and topics that we discussed.

And I thank you very much for your attention

and I'm open for questions.

- Alright, thank you so much Dr. Lowe.

That was an incredible amount of information.

Looks like we've got a few questions coming in.

The first one is, do you use D five W plus

and minus other meds for hydrodissection of tendons?

- Yes, that's a good question.

I have for example, for a killer's tendinopathy,

I would sort of how dissect the, the space there sort

of, you know, basically between,

between cagr fat pad and the,

and the posterior aspect of the,

actually the anterior aspect of the achilles tendon.

So I've used, yeah, 0.2% lidocaine

and D five w the nice thing is it's so benign, your risk

of tendon rupture is, is diminished.

And I think if it's a really, really sort

of inflamed tend area, I think there's some value in adding

a low dose, potentially low dose of steroid.

I, I would really stay very low for fear

of causing any tendon degeneration.

You could use like, you know, three milli, two

to three milligrams of dexamethasone

or like, you know, 10 milligrams of kenalog.

I've never seen any significant issues with that,

but i, I like to stay safe here.

So I have actually used that for, for for tendon sort

of hydro dissections as well.

Yes.

- Great. And sort of along those lines as well,

would you ever suggest 10 to 15% dextrose

as a concentration?

Is there harm or would you think it causes excessive

irritation or are there some benefits?

- Yeah, that's a good question.

I think we use, lots of us use dextrose prolotherapy

for more tendon attachment or enthesis targets

and also intraarticular applications

and it's, it's a very useful technique.

Make no mistake, it's, it's, I use it a lot.

The problem is if you use more than 10% of texts,

it becomes inflammatory, which is what you want

when you treat the enthesis.

You do want that sort of collagen healing

cascade to be triggered.

But if you use more than 10% dextrose in a,

an enclosed space, like say

for example the median nerve in the carpal tunnel,

it could certainly cause inflammatory changes.

It can also cause some issues with

potentially sort of just narrowing that space as a result of

that inflammatory cascade which might irritate the nerve.

So I usually just sort of stick

to 5% dextrose when I do hydro dissections.

I mean I have used for say, you know,

these spine accessory nerves and, and and, and

and so forth in the, in the medial scapular area,

one could sort of go for a use a slightly higher

concentration, you know,

but especially if you sort of wanna do a little bit

of trigger point injection at the same time.

But that the problem is it becomes a little bit more

inflammatory, patients might flare,

especially if they are sensitized,

if they've got peripheral sensitization.

So the nice thing about this 5% dextrose concentration is

that it's non-inflammatory

and it's, it's definitely analgesic.

So I usually stick to that.

- Excellent. The next question is,

can you review real quick the recommended volumes to inject

for each of the five sites you discussed?

- Okay, yeah, I'll, well the thing is there's

so many different depends on your source.

You know, I would say

for these smaller nerves like the media nerves,

I find excellent results just with five to six milliliters,

same with the tarsal tunnel, five to six.

When you do the, the larger nerves like

say the, the well

or the, the, the larger areas

to be covered like the lateral cutaneous femoral nerve,

you could fairly easily use, you know, 10 to 50 milliliters

when one uses the, when you sort of treat

that medial scapula border area, I've used up

to 10 milliliters per per nerve in that area,

but I would not exceed to any milliliters.

And I think some, some, some authorities might, might,

might sort of, you know, go for larger volumes

but I really don't think if you are very accurate

with your injecting, if you truly perineural

then you don't need large volumes.

It depend on your, you know, it depends on your accuracy.

So small nerves, five medium nerves like 10

and for larger nerves

or you know, big areas up to 20 milliliters.

Yeah,

- Excellent.

Next question is, do you have experiences

with things like the sulcus ra?

Hopefully I said that correctly.

- No, I, I wouldn't say that's something

that I could really sort of comment on.

It's, I'll have to go and look it up. Okay, so we, yeah,

- No worries.

And last question that I've got here

for right now is instead of the use of a steroid,

do you consider an NSAID

as an anti-inflammatory For an example,

keto ketorolac 30 to 60 milligrams?

- Yeah, no, yeah, absolutely. Good question.

Yep, I, I, I we've, we've used that in the past.

Ketorolac or Toradol it's called in North America is,

is useful as an anti-inflammatory.

We don't routinely use it in the pain practice.

I think, you know,

it's ostensibly somewhat safer than a steroid

because of course, you know, we don't want tendon rupture,

we don't want a significant atrophy and so forth

and the ketorolac would be something that would

potentially be safer in that regard.

But to be honest, I, I've had, I've used ketorolac for

in the past for trigger point injections in the ER

and it's something that's really sort of quite,

there's a really significantly inflamed tender area

but we are not using it

for nerve hydro dissections at present.

The two, the two injections we use are basically just

low-dose dexamethasone and triamcinolone.

- Excellent. It looks like we don't have any more questions

coming in so let me thank you Dr.

Lo for coming and talking with us about hydro dissection.

I think everybody can agree

that we all learned a lot here today.

You can find the other behind the scan webinars

and this one will be up shortly

as well@securesonosite.com slash behind the scan webinar.

You can see the URL down there at the bottom.

And with that, well thank you very much

and everybody have a great rest of your day.

- Thanks Chris. Thanks everybody.

Neuropathic pain can be caused by a number of factors including nerve entrapment and nerve compression from injury, bone spurs, tendinitis, and surgery. Ultrasound-guided peripheral nerve hydrodissection may be performed to alleviate pain from peripheral nerve entrapments and neuropathic pain in general. Watch Dr. Francois Louw as he reviews this safe and effective procedure and discusses various case examples.

What You'll Learn

Upon viewing this webinar, viewers will be able to provide better patient care by having a better understanding of how to:

  • Appraise the role of peripheral nerve fascial entrapment in causing neuropathic pain.
  • Discuss the rationale behind using 5% dextrose and other injectates.   
  • Highlight five common nerve entrapment syndromes that are responsive to this treatment.
  • Learn practical ultrasound guided nerve hydrodissection interventions that you can start doing Monday morning in the office!    
W Francois Louw
Presenter: W Francois Louw, MD CCFP(EM), FCFP, MBChB (Pret), DA(SA), ECFMG
Position: Adv. Dipl Pain Mgt CAPM (Interventional Pain Management)

Dr. Louw is a co-founder and treating physician at the Bill Nelems Pain and Research Centre, the biggest comprehensive pain clinic in Canada. Dr. Louw is triple certified in GP Anaesthesia, ER medicine and Pain Medicine with multiple research interests in these fields. He serves as Clinical Associate Professor, UBC Dept. of Family and is a Past President of the Canadian Association of Orthopaedic Medicine. He also serves as the Chief Medical Officer of EntheoTech, a bioscience company.

Dr. Louw is passionate about improving both physical and mental health, exploring new paradigms, always with deep compassion and putting the patient at the centre.

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This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.