Pubic Symphysis Injection



Pubic Symphysis Injection


Donald V. La Barge, III, MD










Anteroposterior radiograph shows subchondral cysts and sclerotic changes image of the pubic symphysis without bone destruction or other findings of infection in this patient with osteitis pubis.






Anteroposterior radiograph in a different patient shows traumatic osteitis pubis, also known as “sports hernia.” Note tremendous resorption image of the pubic symphysis and rami with joint space widening.


TERMINOLOGY


Definitions



  • Image-guided aspiration or injection of pubic symphysis to evaluate possible infection or to alleviate pain


PRE-PROCEDURE


Indications



  • Osteoarthritis


  • Osteitis pubis



    • More prevalent in athletes


  • Painful instability


  • Diagnostic: Infection


Contraindications



  • Coagulopathy


  • Local or systemic infection


  • Severe allergy to components of injectate


  • Relative



    • Pregnancy: Teratogenic effects of radiation


    • Radiographic contrast allergy


Getting Started



  • Things to check



    • Pre-procedure imaging



      • Assess for signs of infection


      • Look for other causes of pain


    • Laboratory data



      • Coagulopathy or signs of infection


    • Informed consent


  • Medications



    • Short-acting (local) anesthetic, 5 mL



      • Sodium bicarbonate to buffer anesthetic (ratio 1:9)


    • Long-acting anesthetic (e.g., 0.5% bupivacaine), 1 mL


    • Nonionic contrast, 200 strength


    • Corticosteroid


  • Equipment list



    • Sterile prep and drape materials


    • Radiopaque marker


    • 5 mL syringe and 25-gauge needle for local anesthetic


    • 5 mL syringe and extension tubing for radiographic contrast


    • 3 mL syringe for injectate/aspiration



      • Usual injection volume is ˜ 2 mL


    • 22-gauge or 25-gauge needle for injection/aspiration


    • Hydrogen peroxide



      • Skin cleanser after procedure


    • Bandage


PROCEDURE


Patient Position/Location



  • Patient supine



    • Pillow under knees to flex knees slightly increases comfort


    • Do not aim for midline



      • May end up in fibrocartilage disc


    • Aim slightly to side of midline



      • Center of joint from top to bottom


Equipment Preparation



  • Procedure “time out”



    • Correct patient, site, procedure, necessary equipment available


  • Fluoroscopy tube centered at pubic symphysis


  • Draw 5 mL of local anesthetic, and attach 1.5 inch 25-gauge needle


  • Draw 5 mL radiographic contrast, and attach and preload extension tubing


  • Draw injectate



    • Leave small amount of room in syringe for mixing immediately prior to injecting


Procedure Steps



  • Mark skin slightly to side of midline


  • Apply local anesthetic to create skin wheal



    • Anesthetize subcutaneous tissue to level of joint


  • Anchor injection/aspiration needle in subcutaneous tissue



    • Use 25- (thin patient) or 22-g (larger patient) needle


  • Assess needle trajectory with fluoroscopy


Sep 22, 2016 | Posted by in EMERGENCY RADIOLOGY | Comments Off on Pubic Symphysis Injection
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