Ultrasound guided procedures in the musculoskeletal system: a narrative review with illustrative examples

Introduction

Ultrasound guidance is particularly useful for diagnostic and percutaneous interventional procedures across various anatomic locations of the human body. Its application in the musculoskeletal system has grown in recent years for several reasons. This is attributed to several factors: its established efficacy as a diagnostic tool for a range of musculoskeletal conditions (1,2), its cost-effectiveness and speed compared to magnetic resonance imaging (MRI) coupled with a high level of diagnostic agreement between the two techniques (especially for soft tissue pathology in the shoulder, foot, and ankle, as well as imaging of peripheral nerves, foreign bodies, or abnormalities near hardware) (3), and its broader adoption across both physician-led and non-physician specialties (4). In fact, for at least the past decade, most ultrasound-guided interventional procedures have been performed by specialists outside the field of radiology (5).

Ultrasound-guided procedures include, for instance, tumoral biopsies, diagnostic aspiration or therapeutic drainage of abscesses, hematomas, cysts, and collections, therapeutic injections of joints, nerves, and tendons, and barbotage of calcium deposits or extraction of foreign bodies. In most cases, these interventions are considered more accurate than palpation-guided interventions based solely on external anatomic landmarks. However, this superiority is not always backed by conclusive evidence (6,7).

In this article we review the established ultrasound-guided procedures in the musculoskeletal system and the most recent advances. We complemented the review findings with illustrative images based on our experience. We present this article in accordance with the Narrative Review reporting checklist (available at https://qims.amegroups.com/article/view/10.21037/qims-24-176/rc).

Methods

We performed a literature search in PubMed, Web of Science and EMBASE using MeSH and general terms related to interventional ultrasound and musculoskeletal system {e.g., (“Ultrasonography, Interventional”[Mesh]); “Musculoskeletal System”[Mesh]; “Biopsy [Mesh]”; “Drainage[Mesh]”; “Ultrasound-guided[All Fields]”}. The search was restricted to articles published in the last 10 years and written in English. Only reviews, systematic reviews, meta-analyses, and clinical trials in humans were included. General articles related to imaging techniques different from ultrasound, or spinal, thoracoabdominal and facial procedures were excluded (Table 1). After reading titles and abstracts, a total of 59 articles were selected for the review. The references of the selected studies were carefully examined to search for additional articles that could be of interest, and 61 more studies were added. Therefore, a total of 120 articles were included in the review.

The included topics are described below under specific sections related to the main procedures and musculoskeletal conditions that can be approached through interventional techniques.

Musculoskeletal biopsies

The accuracy of ultrasound-guided biopsies is higher than that of palpation-guided biopsies, with values over 90% (8,9), and a significantly lower rate of complications compared to incisional biopsy (1% vs. 4%) (10). Biopsy tract contamination is much lower in ultrasound-guided biopsies than in incisional biopsies (1% vs. 30%) (11), shortening the time needed to begin definitive treatment (12). To achieve this, the use of automatic or semiautomatic coaxial biopsy systems is advocated, with core samples obtained through only one introductory needle (Figure 1). At least four core samples are recommended for soft tissue biopsies to increase the yield of the procedure (13). Additionally, the length of the specimen significantly impacts the yield, particularly for lesions smaller than 1 cm, where it tends to decrease (14,15).

Figure 1 Tru-Cut biopsy. (A) The introductory cannula (arrows) of the Tru-Cut needle is the same length as the armed Tru-Cut. After firing, the inner needle, which has a trough at its end, protrudes beyond the introductory cannula (arrowheads). *, stylet of the introductory cannula. (B) Ultrasound imaging showing the trough (arrowhead) of the fired inner needle. The arrow indicates the introductory cannula. (C) The outer needle (arrow) of the Tru-Cut covers the trough, securing the sample. (D) The sample core biopsy is retrieved manually after exposing the trough of the needle.

Diagnostic aspiration or therapeutic drainage of abscesses or fluid collections

Aspiration or drainage of accessible collections can be facilitated by ultrasound guidance. The thickness of the needle or catheter depends on the thickness of the contents. For instance, a Baker’s cyst at the knee can typically be aspirated with a thin needle (>20 G). Morel-Lavallée lesions, post-traumatic degloving injuries caused by a shearing force, resulting in the separation of the hypodermis layer from the deeper fascia, are traditionally described at the thigh, although they may be seen at other sites, such as the knee, calf, and lumbar regions. While thin needles may suffice for draining a Morel-Lavallée lesion, the use of sclerosing agents like doxycycline, ethanol, or talc may be considered to reduce recurrence following drainage (Figure 2) (16).

Figure 2 Drainage of fluid collections. Baker’s cyst (A) and drainage from the most distal aspect (B). Morel-Lavallée on the subcutaneous tissue over the greater tuberosity of the femur (C) and drainage from the most distal aspect (D). MG, medial gastrocnemius; Tib, tibia; P, proximal; D, distal.

Larger needles (<20 G) or even a catheter may be required for hematomas. Sometimes, hematomas are coagulated, and the introduction of fibrinolytics (e.g., urokinase) for different periods may be needed to fluidify the contents, facilitating aspiration (17).

Ganglion cysts, one of the most frequent benign soft tissue masses, usually originate from joints and tendon sheaths, although they may extend intratendinously, inside or around peripheral nerves, and intraosseously. Drainage of the cyst typically requires larger needles (14–19 G) due to the gelatinous texture of the content. To mitigate the risk of recurrence, performing multiple fenestrations on different sections of the cyst wall is advisable. The viscosity of the cyst’s contents can be decreased by injecting a small quantity of anesthetic into the cyst, thereby facilitating easier drainage (Figure 3) (18). Following drainage, the instillation of a steroid-anesthetic mixture is recommended to ensure the free movement of the mixture through the walls of the ganglion cyst, preventing refilling and the restoration of its pre-fenestration shape. Should the cyst refill, additional fenestrations may be necessary (18,19).

Figure 3 Drainage of more complex collections. (A) Tenis leg with hematoma in the musculotendinous junction of the medial gastrocnemius, before (A) and during drainage (B). Ganglion cyst of the flexor tendon (*) of the finger before drainage (C) and during drainage and fenestration (D). MG, medial gastrocnemius; S, soleus muscle; M, metacarpal; P, proximal phalanx.

When an infection is suspected, one of the most common goals is to obtain a sample for microbiological analysis. This may be indicated in osteomyelitis with periosteal involvement (20), septic arthritis, or soft tissue abscess. In such cases, draining the contents and cleaning the residual cavity may require inserting a catheter for drainage until resolution. The catheter must be flushed at intervals with saline to prevent obstruction. This approach is curative in most scenarios (21). However, certain infections (e.g., tuberculosis) may involve an abscess cavity with a thickened wall that impedes the collapse of the cavity, necessitating surgical debridement as a definitive treatment (Figure 4).

Figure 4 Abscess drainage. (A) Pigtail catheter set. (B) The draining catheter in place. (C) Abscess in the subcutaneous tissue of the groin. (D) Catheter positioned within the abscess (arrows). A, femoral artery; V, femoral vein.

Therapeutics injections

Ultrasound is very useful for guiding a wide array of procedures, including both diagnostic and therapeutic injections. These injections can be precisely administered into or around tendons, within joint spaces, or into the bursae.

Bursal injections

One of the most frequently injected sites is the subdeltoid bursa to treat external impingement syndrome. It appears to be more accurate than palpation-guided injections, although evidence about clinical superiority is conflicting. While some studies find no significant difference in efficacy between the two methods (22), others suggest that ultrasound-guided injections may lead to superior improvements (23-25). Moreover, it has been observed that the use of a high volume of ultrasound-guided local anesthetic and corticosteroids results in a quicker alleviation of pain compared to a lower volume (26). A loss of resistance during the injection serves as an indicator of correct needle placement. Ultrasound guidance allows for real-time confirmation of this through the observation of bursa distension and the fluid’s dispersal from the needle tip (27) (Figure 5).

Figure 5 Bursal injections. (A) Injection in the subdeltoid bursa. (B) Peritrochanteric injection. (C) Subgluteal injection over the hamstring tendons. (D) Injection in an olecranon bursitis. Arrows indicate the needle. B, bursa; HH, humeral head; FL, fascia lata; GT, greater tuberosity; HT, hamstring tendons; IT, ischial tuberosity; O, olecranon.

Other frequently injected bursae include the trochanteric and ischial bursae, and more rarely the iliopsoas, olecranon, and scapulothoracic bursae. Ultrasound-guided injections in the peritrochanteric area to treat trochanteric pain syndromes seem to be more effective compared to palpation-guided injections (28), although some authors consider palpation-guided injections the method of choice, reserving ultrasound for obese patients or after clinical injection failure (29). Local anesthetic and steroids should be placed between the gluteus minimus/medius tendons and the fascia lata. Opening of the space under the fascia lata is indicative of appropriate placement of the injectate.

Although frequently performed because of ischiogluteal bursitis or hamstring tendinosis, there is still limited evidence about the effectiveness of injections in the ischiogluteal bursa and/or peritendinous subgluteal area. In a previous case series, 9 out of 11 patients showed good results after injections (30).

Tendinous and peritendinous injections

Many tendons are common targets for ultrasound-guided procedures. Platelet-rich plasma (PRP) injections have been effective in alleviating pain and enhancing function in patients with partial rotator cuff tears (31) (Figure 6). Similarly, dextrose prolotherapy has shown utility in improving function in chronic rotator cuff lesions (32).

Figure 6 Tendinous and peritendinous injections in the upper limb. Intratendinous injection of platelet-rich plasma in the supraspinatus tendon (A), and common extensor tendon at the elbow (B). (C) Needling of the 1st extensor compartment tendon sheath in De Quervain’s tenosynovitis. (D) Needling of the A1 pulley in trigger finger. Arrows indicate the needle. LE, lateral epicondyle; GT, greater tuberosity; SS, supraspinatus; RS, radial styloid; ET, 1st extensor compartment tendons; PP, proximal phalanx; FT, flexor tendons of the finger; MH, metacarpal head.

Ultrasound-guided injection of the long head of the biceps tendon is more accurate than palpation-guided injection (33). A recent study reported that dual injection of the long head of the biceps tendon and the subdeltoid bursa with local anesthetic and corticoids has extended duration of symptomatic relief than injection of the bursa alone (34).

At the elbow, lateral epicondylitis is the most usual place for injections, which can be peritendinous, intratendinous, or at the enthesis (tendon-bone interface) (35). In peritendinous injections, a minimum volume of 4 ml is recommended to effectively achieve hydro dissection of the tendon-fascia interface. Steroids or hyaluronic acid may be used for this purpose (36,37).

Intratendinous needling has also demonstrated high efficacy and superior results over corticosteroids in some reports (38), even with comparable therapeutic efficacy to open-release surgery (39). To avoid pain, we recommend injecting anesthetics proximal to the lateral epicondyle before performing the needling. Many products can be injected intratendinously, including local anesthetics (40), polidocanol (41), dextrose (42), or PRP (43). The latter has shown more beneficial effects in the long term than corticosteroids (43). It is recommended to use refrigerated centrifuges to maximize platelet concentration (44) and associate dry needling to promote angiogenesis. It is suggested to avoid local anesthetics at the site of PRP administration since they decrease platelet aggregation and release of growth factors and cytokines (45).

Finally, some authors have proposed scrapping or drilling the bone enthesis, mainly in chronic refractory tendinosis (46,47), although it is less frequently performed than the above-mentioned procedures (35).

At the wrist, de Quervain’s tenosynovitis is one of the most common conditions that can be treated by peritendinous injections. Longitudinal access with needling of the thickened tendon sheaths helps to alleviate symptoms, and corticosteroid injection alone has been associated with a high recurrence rate (48). In this regard, 15-day delayed 2 mL low molecular weight hyaluronic acid injection after the baseline corticosteroids injection reduced recurrence rate (49). A new technique, releasing acupotomy of the tendon sheath, is showing promising results. It is performed using an acupuncture needle with a flat-knife shaped tip (50) (Figure 6).

The same principle applies to trigger finger in the hand, carpal and cubital tunnels, and Dupuytren’s contracture. Tendon release by needling of the A1 pulley in trigger finger is superior to corticosteroid injections alone (51), with no differences between percutaneous release and open surgery (52). Needling the pulley with the lateral side of the needle bevel facilitates tearing the pulley for tendon release (53). Additionally, injecting corticosteroids into the tendon sheath combined with percutaneous needling surpasses the effectiveness of needling alone (54).

At the lower limb, the most frequently treated tendons are the patellar tendon (PT) at the knee, and the Achilles tendon at the ankle. Peritendinous corticosteroid injection for PT has been shown to be more effective than placebo (54). Most injections are performed at the proximal tendon/patellar insertion, and less frequently at the distal end/tibial insertion. To avoid the risk of skin atrophy, dilution of the corticosteroid with a mixture of local anesthetics and saline is recommended (55), especially if part of the injectate is placed at the superficial aspect of the tendon. Combination with dry needling may improve the efficiency of treatment with corticosteroids, PRP, or physical therapy (56,57). Other treatments used for patellar tendinopathy include prolotherapy, sclerosing injections with polidocanol, and hyaluronic acid, but no previous studies have compared their efficacy, and there is insufficient clinical evidence about the appropriateness of their use (58,59) (Figure 7).

Figure 7 Tendinous and peritendinous injections at the lower limb. (A) Severe tendinosis of the proximal patellar tendon with neovascularity. (B) Needling and corticoid injection deep to the tendon. Injection over the distal patellar tendon (C) and deep to the patellar tendon after needling (D). (E) Corticoids injection around the Achilles tendon. (F) Intratendinous injection of PRP. Arrows indicate the needle. P, patella; FC, femoral condyle; T, tibia; C, calcaneus; PRP, platelet-rich plasma.

For the Achilles tendon, local anesthetics and corticosteroids are injected into the superficial and deep parts of the paratenon. In partial tears, PRP can be used. However, PRP injections and dry needling have shown similar short-term results at 3–6 months (60). Prolotherapy is another technique used to treat chronic tendinosis. This technique involves intratendinous injection of glucose to treat hypoechoic areas of tendinosis, achieving a reduction of pain in treated patients by more than 70% (61). In mid portion tendonitis, high volume corticosteroids injection and PRP in combination with eccentric exercises were found more effective in reducing pain and improving function than eccentric training alone (62) (Figure 7).

Intra-articular injections

Indications for intra-articular injections primarily include inflammatory arthritis and osteoarthritis. In the upper limb, the shoulder and wrist joints are most commonly targeted, while in the lower limb, the hip, knee, and ankle/foot joints receive the majority of injections.

Ultrasound-guided shoulder girdle injections provide more accurate needle placement control within the joint compared to landmark-guided injections (63), but, they have not demonstrated superiority in pain control and function (23). In cases of adhesive capsulitis, injections offer better short-term relief (2 weeks) compared to blind injections, although clinical differences vanish in longer follow-ups (64). Hydro dilatation, which involves the introduction of a high volume of fluid, has been successfully used to treat frozen shoulder (65). This method aims to rupture the joint capsule, thereby increasing joint capacity and mobility. However, some reports suggest that using lower volumes to achieve joint capsule distension without rupture yields better results (66). In this regard, a recent work showed that hydro dilatation with 20 ml of hyaluronic acid combined with physical therapy led to superior clinical benefit compared with physical therapy alone (67) (Figure 8).

Figure 8 Intraarticular injections in the upper limb. (A) Hydro dilatation of the shoulder joint. (B) Radiocarpal injection. (C) First carpometacarpal joint injection at the thumb base. (D) Distal interphalangeal joint injection. Arrows indicate the needle. G, glenoid; IS, ischial tuberosity; HH, humeral head; R, radius; S, semilunaris; 1st M, first metacarpal; T, trapezius; DIJ, distal interphalangeal joint.

Several joints in the wrist and hand, including the radiocarpal, distal radioulnar, metacarpophalangeal, interphalangeal, scapho-trapezium-trapezoidal, and first carpometacarpal joints, can be injected. Ultrasound guidance ensures higher accuracy in needle placement for wrist and hand joint injections compared to palpation guidance (Figure 8). For inflammatory arthritis, these injections are significantly less painful than palpation-guided methods and improve cost-effectiveness (68). Ultrasound-guided wrist injections provide superior improvement compared to palpation-guided injections (69). There are reports of more sustained improvement with hyaluronic acid (70) and PRP (71) compared to corticosteroids.

Hip injections serve as diagnostic tests or symptomatic treatments for various conditions, such as hip dysplasia, osteoarthritis, and inflammatory arthritis. Ultrasound-guided hip joint injections are more accurate than palpation-guided injections (72,73) (Figure 9). A positive response to intra-articular injection may help to predict a good outcome from hip arthroscopy for femoroacetabular impingement, although there is no universal agreement (74). It may also predict pain relief after hip surgery or replacement (75). Regarding injectates, corticosteroids are superior to hyaluronic acid in the short term, but there are no long-term differences. Similarly, no significant differences have been found between hyaluronic acid and PRP (76).

Figure 9 Intraarticular injections in the lower limb. (A) Injection in the hip joint avoiding the lateral circumflex artery (arrowhead). (B) Injection of the knee joint in the suprapatellar bursa, under the QT. (C) Injection in the ankle joint. (D) Injection in the first metatarsophalangeal joint. Arrows indicate the needle. QT, quadriceps tendon; TI, tibia; TA, talus; MT, metatarsus.

Intra-articular ultrasound-guided arthrocentesis or injection in the knee joint is more accurate than the palpation-guided technique, leading to improved fluid aspiration and therapeutic benefit (77) (Figure 9). Among the multiple approaches to the knee joint, the superomedial patellar seems to be the most accurate (78). Injections of corticosteroid and local anesthetics into the knee joint alleviate pain in the short and medium term and lead to functional improvement in inflammatory arthritis. While similar results have been observed in osteoarthritis, their effectiveness is more controversial (59).

Ultrasound-guided intra-articular injections of hyaluronic acid are safe and improve pain assessments and function in knee osteoarthritis (79), showing greater efficacy than corticosteroids in the long term (6 months) (80). It is common practice to combine both corticosteroids and hyaluronic acid in the same injection to enhance efficacy.

Regenerative drug injections (e.g., PRP) have shown clinical benefits in relieving pain and improving function in patients with knee osteoarthritis, although no clinical trials have confirmed this (59).

For ankle and foot injections, the usual targets include the tibiotalar, subtalar, midfoot, and forefoot joints. Ultrasound guidance is particularly useful for guiding injections in patients with large osteophytes and extremely narrowed joints, which may complicate palpation-guided or even fluoroscopy-guided injections (81) (Figure 9). Short-term benefits of corticosteroid therapeutic injections in the ankle and foot joints exceed 80% (82). Other injectates such as PRP and prolotherapy are useful, but evidence supporting their efficacy is limited (83). In fact, a recent work did not support the use of intraarticular PRP in patients with ankle osteoarthritis (84).

Nerve injections

Ultrasound-guided nerve blocks have recently gained popularity as an ancillary technique before interventional procedures, mostly performed by anesthesiologists. However, radiologists also apply these blocks before various imaging-guided interventional procedures, such as biopsies or thermal ablation. In the lower limb, the most commonly blocked nerves are the femoral, internal saphenous, sciatic, peroneal, and posterior tibial. In the upper limb, blocks can be performed on the brachial plexus, median, radial, or ulnar nerves (85) (Figure 10).

Figure 10 Anesthetic nerve blocks. (A) Interscalene block of the brachial plexus nerve trunks (arrowheads). (B) Femoral (arrowhead) nerve block. (C) Sciatic (arrowhead) nerve block. (D) Internal saphenous (arrowhead) nerve block. Arrows indicate the needle. MS, middle scalenus; AS, anterior scalenus; S, sartorius; RF, rectus femoris; B, biceps; ST, semitendinosus; AD, adductor magnus; VM, vastus medialis.

The main therapeutic targets of ultrasound-guided perineural injections in the upper limb include the suprascapular nerve for shoulder pain and the median nerve for carpal tunnel syndrome, showing superior benefits compared to palpation-guided injections (86). For chronic wrist pain, blocking the anterior and posterior interosseous nerves at the wrist can predict outcomes for surgical intervention (87) or ablative denervation of the wrist (88) (Figure 11).

Figure 11 Perineural injections in the upper limb. (A) Posterior interosseous nerve block at the wrist beneath the ED and EPL. (B) Anterior interosseous nerve block under the PQ muscle. (C) Longitudinal injection around the median nerve (*) at the carpal tunnel. (D) Transverse access beneath the median nerve (*) at the carpal tunnel. Arrows indicate the needle. EPL, extensor pollicis longus; ED, extensor digitorum; PQ, pronator quadratus.

For carpal tunnel syndrome, ultrasound-guided injections provide more favorable results for symptom severity and functional status in the short term compared to palpation-guided injections. However, there is no evidence regarding their effectiveness in the mid and long term (89). Hydro dissection with normal saline (90) or 5% dextrose (91) has proven to be as effective as injections with low or high doses of corticosteroids. Some studies found that carpal tunnel percutaneous release combined with corticosteroids injection achieves better outcomes than corticosteroids injection alone or carpal tunnel release alone (92-94).

Some of the main therapeutic targets of ultrasound-guided perineural injections in the lower limb include treating the lateral femoral cutaneous nerve in meralgia paresthetica and the Baxter nerve at the ankle in entrapment syndromes (95) (Figure 12). Corticosteroid injections around the lateral femoral cutaneous nerve provide relief in over 75% of cases (96).

Figure 12 Perineural injections in the lower limb. (A) Injection over the lateral femoral cutaneous nerve (*). (B) Injection around the posterior tibial nerve (*). (C) Long axis view of the injection in MN. (D) Short axis view of the injection in MN. Arrows indicate the needle. MN, Morton’s neuroma; MH, metacarpal head.

For foot conditions, the posterior tibial nerve, and the plantar digital nerves are common targets in cases of tarsal tunnel syndrome, and Morton’s neuroma/bursitis (Figure 12). Ultrasound-guided injections for Morton’s neuroma showed higher success rates (69–89%) compared to injections based on anatomical landmarks (48–59%), in both short and long-term follow-ups (97,98).

Barbotage of calcific tendonitis

Hydroxyapatite deposits are most frequently treated percutaneously in the rotator cuff tendons, although they can also occur (and be treated) in the elbow and several other tendons (99). Typically, a thick needle (less than 20 G) is utilized to inject saline into non-fragmented calcifications with an intact peripheral rim. Upon relieving the pressure, the fluid refluxes into the syringe, clouded with calcium material (100). This procedure might require several syringes to completely wash out the calcification. In the resorptive phase, the calcium material may be soft enough to be better aspirated or washed through two needles communicating within the calcification (101), although some authors prefer the two needles technique for harder calcifications (102) (Figure 13). A systematic review showed that no existing evidence favours using a specific size or number of needles (103). About 90% of patients reported being symptom-free or experiencing significant improvement (104). In addition, corticosteroids injection in the bursa after barbotage improved pain in the 6 weeks following the procedure, and function in the 3 months after, but with no significant effect on calcification resorption (105). Barbotage also provides superior benefit than high-energy extracorporeal shock wave therapy in eliminating calcium deposits (106), greater reduction of pain (107), with less treatment sessions (106,107).

Figure 13 Barbotage of calcifying tendonitis. (A) Two-needle technique. (B) One-needle technique. (C) Ultrasound imaging of the needle (arrow) inside the calcification. (D) Sedimented calcium material post-barbotage.

Foreign bodies withdrawal

Percutaneous ultrasound-guided foreign body removal is a minimally invasive, economical technique with a low risk of complications compared with surgical removal. Foreign bodies include splinters of wood, glass, plastic, or metal (108). Additionally, medical implants like contraceptive implants, Implanon, or Nexplanon rods may require ultrasound-guided removal in difficult cases, using a grasping micro forceps (109) (Figure 14).

Figure 14 Foreign body removal. (A) Splinter of wood (arrow). (B) Implanon in the subcutaneous tissue (arrows). (C) Micro forceps (arrowhead) grasping the Implanon (arrows). (D) Imaging after removal.

Other indications of ultrasound-guided procedures in musculoskeletal conditions

Ultrasound offers the significant advantage of not using ionizing radiation for arthrography, unlike fluoroscopy (110). Most joints are easily accessible under ultrasound guidance, the most common being the shoulder, hip, knee, and wrist.

Radiofrequency ablation for neuropathic pain can also be performed safely under ultrasound guidance. This procedure is often applied in the upper limb, targeting the suprascapular nerve for shoulder pain (111). In the lower limb, it is used on the lateral femoral cutaneous nerve for meralgia paresthetica (112), the obturator nerve for hip pain (113), the geniculate nerves for knee pain (114), and for treating Morton’s neuroma (115). Nevertheless, its application to other nerves and pathologies is increasing. For instance, it is being increasingly used to treat muscle spasticity in both the upper and lower limbs (116) (Figure 15).

Figure 15 Radiofrequency in peripheral nerves. (A) Ablation procedure of the lateral femoral cutaneous nerve. (B) The electrode (arrow) positioned over the lateral femoral cutaneous nerve (arrowheads). (C) Ablation of the deep branch of the obturator nerve in a case of spastic paraplegia. The arrow points out the electrode. ADL, adductor longus; ADB, adductor brevis; ADM, adductor magnus.

Pain relief lasts longer with continuous RF compared to pulsed RF, although the pain response generally diminishes around 6–9 months after the procedure. In addition, Pulsed RF is considered safer for treating mixed sensory and motor peripheral nerves (117).

Discussion

The use of ultrasound-guided interventional procedures has seen significant growth over the last decade, driven by advancements in the anatomical detailing capabilities of current ultrasound equipment and the real-time visibility of needles. These improvements facilitate precise injections or aspirations, ensuring that procedures target the correct anatomical sites. Consequently, ultrasound has become an indispensable tool across various medical specialties, as evidenced by numerous studies and reports (1-7,118).

Ultrasound-guided procedures outperform the landmark or palpation-guided procedures in most scenarios (22,23,25,33,62,71,77,97,98), despite some procedures are still accurately performed without ultrasound, being less expensive (22,29,119).

This narrative review encompasses 28 clinical trials and 9 meta-analyses, thereby reinforcing the reported data. However, data synthesis presents challenges due to the diversity of procedures, needle approaches, techniques, and dosages employed. Despite these limitations, this work provides a comprehensive overview of the vast potential of interventional musculoskeletal ultrasound (77,119,120).

Future research in interventional ultrasound should prioritize the standardization of techniques, procedures, drugs, and biological products to facilitate comparability of results.

Conclusions

Advances in ultrasound-guided procedures in the musculoskeletal system have enabled radiologists and other specialists to achieve high accuracy in diagnosing and treating various musculoskeletal conditions, including tumors, inflammatory and degenerative arthritis, tendinopathies, and bursal pathologies. This review addressed consolidated techniques and recent advances in interventional musculoskeletal ultrasound.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: With the arrangement by the Guest Editors and the editorial office, this article has been reviewed by external peers.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at: https://qims.amegroups.com/article/view/10.21037/qims-24-176/rc

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-24-176/coif). The special issue “Advances in Diagnostic Musculoskeletal Imaging and Image-guided Therapy” was commissioned by the editorial office without any funding or sponsorship. F.R.S. served as the unpaid Guest Editor of the issue and serves as an unpaid editorial board member of Quantitative Imaging in Medicine and Surgery. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for the publication of this article and accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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