Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)—part VII, nerves of the lower limb

Abstract

Objectives To perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton’s neuroma) and provide clinical indications. Methods We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around peripheral nerves in the lower limb (excluding Morton’s neuroma) to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper. Results Nine statements on image-guided interventional procedures for peripheral nerves of the lower limb have been drafted. All of them received strong consensus. Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. Conclusion Despite the promising results reported by published papers on image-guided interventional procedures for peripheral nerves of the lower limb, there is still a lack of evidence on the efficacy of most procedures. Key Points • Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. • US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. • US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. The volume of local anesthetic affects the size of the blocked sensory area.

Ultrasound-guided musculoskeletal interventional procedures around the hip: a practical guide

“…Conservative treatment is recommended, reducing nerve compression with stretching exercises and massage. When these approaches are unsuccessful, ultrasound-guided perineural injection of the sciatic nerve with LA and corticosteroids can be used as a safe and effective procedure with good symptom relief, even though it is not clear if the addition of steroids to LA may improve the therapeutic efficacy of this intervention ( 13 , 26 ) . Alternatively, small cases series have highlighted the potential value of ultrasound-guided injection of botulinum toxin A in the piriformis muscle for treating this compression neuropathy, probably due to atrophy and fatty infiltration of the muscle ( 13 , 27 ) .…”

“…steroid, local anesthetic (LA), hyaluronic acid (HA), platelet-rich-plasma (PRP)), ultrasound ensures safety in reaching the target with no radiation exposure. Furthermore, as recently highlighted by the latest evidence-based consensus recommendations by the European Society of Musculoskeletal Radiology (ESSR), ultrasound guidance allows for improving accuracy and effectiveness of most musculoskeletal interventional procedures in the upper and lower limbs (7)(8)(9)(10)(11)(12)(13) .…”

Interventional Imaging Techniques as Alternative to Surgery of the Foot and Ankle

“…A recent consensus of experts from the European Society of Musculoskeletal Radiology recommended sonographic guidance to improve the efficacy of certain interventions. 3 Fluoroscopy has long been used for image-guided injection or aspiration of the joint spaces. It is popular with many operators, although it exposes the patient to ionizing radiation and usually a contrast injection.…”

Median and ulnar nerve fascicle imaging using MR microscopy and high‐resolution ultrasound

“…However, high‐resolution ultrasound (HRUS) probes offer excellent spatial resolution, even superior to conventional MRI 1,17 . In addition, US offers the advantage of dynamic examinations and application in a variety of interventional procedures 1,18–20 . The knowledge on sonographic nerve structure could also aid in understanding of issues in the peripheral nerve elastography interpretation 21 .…”

“…1,17 In addition, US offers the advantage of dynamic examinations and application in a variety of interventional procedures. 1,[18][19][20] The knowledge on sonographic nerve structure could also aid in understanding of issues in the peripheral nerve elastography interpretation. 21 It is necessary to conduct studies to standardize reference values for evaluation of peripheral nervous system.…”