Ultrasound scanning can be daunting. How do I hold the probe? What setup should I choose? Why does it look dark or bright? Inevitably, these and other questions immediately pop up as soon as you face your first real ultrasound experience. Then, you face a multitude of other problems such as how to differentiate nerves from tendons, why the same structure can be white or black, what is the trick to dynamic examination.

Now that you know what you are seeing, the “snowstorm” flurry finally becomes a logical cross-sectional live anatomy picture. You are ready to do your first ultrasound-guided procedure, or are you? Apparently, hand-eye coordination is less intuitive than you might think. Everything is important: how to position your equipment, which hand should hold the transducer, where to place your needle, and much more.

So, you examine your patient, say with shoulder pain, diligently perform a physical examination and apply a battery of impingement tests, and come to the conclusion the patient may have rotator cuff syndrome with impingement. Your next step has been to send the patient to get an ultrasound exam done elsewhere.
Why not become an expert in musculoskeletal diagnostic ultrasound and use this tool as you would a stethoscope, extending your problem-solving ability?

Wizards of regional anaesthesia relied on “paraesthesia” and probably had a divine vision to find nerves. Neurosurgeons used to do what surgeons usually do: cut, explore and discover. These two methods were used at the dawn of PNS. However, thanks to the development of sonographic techniques, most of the PNS implantations are either ultrasound-guided or ultrasound-assisted.

Spine procedures have always been associated with fluoroscopy guidance. Nonetheless, ultrasonography has claimed its relevance, becoming an alternative and often the preferred method. Ultrasound offers a true axial view with control of depth not afforded by X-ray. Moreover, the entire needle path is visible and unwanted damage can be mitigated.

Blind injections are inaccurate. Even in the hands of experienced orthopaedic surgeons, the failure rate is up to 70% for shoulder injections and between 20% and 40% for hip injections. The benefits of ultrasonography have been reported in multiple clinical studies, including randomized controlled trials where ultrasound guidance (UG) was compared to the conventional palpation-guided (PG) method. The medical literature suggests that improvement after UG is greater and lasts longer than PG. The correct injection can provide valuable diagnostic information regarding the location of a pain generator. If a medicine is misplaced, it may lead to complications such as skin depigmentation, subcutaneous fat atrophy, tendon rupture, neurovascular injury, increased procedural/postprocedural pain, or seizures.

There are universal rules and methods applicable for ultrasound-guided MSK procedures. However, regenerative techniques require even more attention to detail and anatomy.

The boundaries for ultrasound imaging and guidance have constantly been evolving.

Since its inception in the 1960s, interventional pain management has been constantly evolving and bridging between different medical and surgical specialties. Novel technologies allowed faster and more efficacious pain relief in millions of patients. Some of the methods did not pass the efficacy test, some underwent multiple upgrades driven by safety and other considerations.