Objectives
To update the 2012 European Society of Musculoskeletal Radiology (ESSR) clinical consensus guidelines for musculoskeletal ultrasound referral in Europe.
Methods
Twenty-one musculoskeletal ...imaging experts from the ESSR participated in a consensus study based on a Delphic process. Two independent (non-voting) authors facilitated the procedure and resolved doubtful issues. Updated musculoskeletal ultrasound literature up to July 2017 was scored for shoulder, elbow, wrist/hand, hip, knee, and ankle/foot. Scoring of ultrasound elastography was included. The strength of the recommendation and level of evidence was scored by consensus greater than 67% or considered uncertain when the consensus was consensus less than 67%.
Results
A total of 123 new papers were reviewed. No evidence change was found regarding the shoulder. There were no new relevant articles for the shoulder, 10 new articles for the elbow, 28 for the hand/wrist, 3 for the hip, 7 for the knee, and 4 for the ankle/foot. Four new evidence levels of A were determined, one for the hip (gluteal tendons tears), one for the knee (meniscal cysts), one for the ankle (ankle joint instability), and one for the foot (plantar plate tear). There was no level A evidence for elastography, although for Achilles tendinopathy and lateral epicondylitis evidence level was B with grade 3 indication.
Conclusions
Four new areas of level A evidence were included in the guidelines. Elastography did not reach level A evidence. Whilst ultrasound is of increasing importance in musculoskeletal medical practice, the evidence for elastography remains moderate.
Key Points
• Evidence and expert consensus shows an increase of musculoskeletal ultrasound indications.
• Four new A evidence levels were found for the hip, knee, ankle, and foot.
• There was no level A evidence for elastography.
Background
Image-guided interventional procedures around the shoulder are commonly performed in clinical practice, although evidence regarding their effectiveness is scarce. We report the results of ...a Delphi method review of evidence on literature published on image-guided interventional procedures around the shoulder with a list of clinical indications.
Methods
Forty-five experts in image-guided musculoskeletal procedures from the ESSR participated in a consensus study using the Delphic method. Peer-reviewed papers regarding interventional procedures around the shoulder up to September 2018 were scored according to the Oxford Centre for Evidence-based Medicine levels of evidence. Statements on clinical indications were constructed. Consensus was considered as strong if more than 95% of experts agreed and as broad if more than 80% agreed.
Results
A total of 20 statements were drafted, and 5 reached the highest level of evidence. There were 10 statements about tendon procedures, 6 about intra-articular procedures, and 4 about intrabursal injections. Strong consensus was obtained in 16 of them (80%), while 4 received broad consensus (20%).
Conclusions
Literature evidence on image-guided interventional procedures around the shoulder is limited. A strong consensus has been reached for 80% of statements. The ESSR recommends further research to potentially influence treatment options, patient outcomes, and social impact.
Key Points
• Expert consensus produced a list of 20 evidence-based statements on clinical indications of image-guided interventional procedures around the shoulder.
• The highest level of evidence was reached for five statements.
• Strong consensus was obtained for 16 statements (80%), while 4 received broad consensus (20%).
Objectives
Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional ...Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region.
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 foot and ankle in order 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 that was shared with all panel members for final approval.
Results
A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement.
Conclusion
According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton’s neuroma, particularly using platelet-rich plasma and corticosteroids, respectively.
Key Points
•
The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle.
• Strong consensus was obtained for all statements.
• The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton’s neuroma and PRP for plantar fasciitis.
Background
Although image-guided interventional procedures of the elbow and wrist are routinely performed, there is poor evidence in the literature concerning such treatments. Our aim was to perform ...a Delphi-based consensus on published evidence on image-guided interventional procedures around the elbow and wrist and provide clinical indications on this topic.
Methods
A board of 45 experts in image-guided interventional musculoskeletal procedures from the European Society of Musculoskeletal Radiology were involved in this Delphi-based consensus study. All panelists reviewed and scored published papers on image-guided interventional procedures around the elbow and wrist updated to September 2018 according to the Oxford Centre for Evidence-based Medicine levels of evidence. Consensus on statements drafted by the panelists about clinical indications was considered as “strong” when more than 95% of panelists agreed and as “broad” if more than 80% agreed.
Results
Eighteen statements were drafted, 12 about tendon procedures and 6 about intra-articular procedures. Only statement #15 reached the highest level of evidence (ultrasound-guided steroid wrist injections result in greater pain reduction and greater likelihood of attaining clinically important improvement). Seventeen statements received strong consensus (94%), while one received broad consensus (6%).
Conclusions
There is still poor evidence in published papers on image-guided interventional procedures around the elbow and wrist. A strong consensus has been achieved in 17/18 (94%) statements provided by the panel on clinical indications. Large prospective randomized trials are needed to better define the role of these procedures in clinical practice.
Key Points
•
The panel provided 18 evidence-based statements on clinical indications of image-guided interventional procedures around the elbow and wrist.
•
Only statement
#
15 reached the highest level of evidence: ultrasound-guided steroid wrist injections result in greater pain reduction and greater likelihood of attaining clinically important improvement.
•
Seventeen statements received strong consensus (94%), while broad consensus was obtained by 1 statement (6%).
Chronic apical periodontitis (CAP) is one of the most common endodontic
diagnosis caused by microbial infection within the root canal system of the
affected tooth. Endodontic therapy is one of the ...possible treatment
modalities for CAP, but the prognosis depends on numerous factors. The size
of the periapical lesion is always singled out as one of the most
significant, as its increase drastically decreases the degree of success of
endodontic therapy. Certain periapex radiographic indices (PAI, CBCT-PAI,
PESS) are used to evaluate the size and characteristics of the periapical
lesion, as well as to monitor the outcome of the implemented therapy. A
30-year-old patient presented with pain caused by an acute exacerbation of
CAP on tooth 37. Radiographic analysis revealed the presence of an
extensive, diffuse radiolucency in the area of tooth 37. A complete
endodontic procedure was performed. One year after, there were clear,
radiographic signs of the reduction of the lesion. Findings of periapical
radiographic indices indicated the success of therapy as well. The aim of
this paper was to present, on one case from clinical practice, complete
endodontic therapy protocol of an extensive periapical lesion with symptoms
of exacerbation.
Introduction. Good physicochemical properties of endodontic materials are one
of the main preconditions for successful endodontic treatment. Modern
endodontic materials are expected to have good ...adhesiveness, stability and
low solubility in order to enable high-quality and permanent obturation of
the root canal. The aim of this study was to test in vitro the stability and
degree of solubility of two endodontic materials: Mineral Trioxide Aggregate
(MTA) and Gutta Flow. Materials and methods. The solubility of endodontic
materials Mineral Trioxide Aggregate - MTA (Angelus) and Gutta Flow
(Colthane) was tested by the aging method using artificial saliva according
to the prescription of Ira and Shannon. Twelve samples of single-rooted
teeth (6 MTA, 6 Gutta Flow) were used. The samples were analyzed after 7,
14, 21, 28 and 35 days. After obturation, the samples were longitudinally
cut and filled with auto-polymerizing acrylate and stored in artificial
saliva at a temperature of 37? ?} 2? C. Results. The results of the analysis
of the longitudinal sections of the roots through MTA and Gutta Flow showed
the absence of damage to both endodontic materials after 14 days of exposure
to the artificial saliva. The appearance of the first morphological damage,
as well as the weakening of the bonding with dentin wall, were observed on
the 21st day with Gutta Flow, and on the 28th day with MTA from the
beginning of the experiment. After a period of 35 days, both materials
showed increased porosity, solubility and breaking of the bond with dentin
wall of the root canal. Conclusion. Based on the obtained results, it can be
concluded that MTA showed lower solubility and better adhesiveness with
dentin wall of the tooth root canal than Gutta Flow.
Background
Image-guided interventional procedures of the nerves are commonly performed by physicians from different medical specialties, although there is a lack of clinical indications for these ...types of procedures. This Delphi-based consensus provided a list of indications on image-guided interventional procedures for nerves of the upper limb based on updated published evidence.
Methods
An expert panel of 45 members of the Ultrasound and Interventional Subcommittees of the ESSR participated in this Delphi-based consensus study. After revision of the published papers on image-guided interventional procedures for nerves of the upper limb updated to September 2018, the experts drafted a list of statements according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus on statements regarding clinical indications was considered as strong when more than 95% of experts agreed, and broad if more than 80% agreed.
Results
Ten statements were drafted on procedures for nerves of the upper limb. Only two statements reached the highest level of evidence (ultrasound guidance is a safe and effective method for brachial plexus block; ultrasound-guided non-surgical approaches are safe and effective methods to treat carpal tunnel syndrome in the short term, but there is sparse evidence on the mid- and long-term effectiveness of these interventions). Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%).
Conclusions
This Delphi-based consensus study reported poor evidence on image-guided interventional procedures for nerves of the upper limb. Sixty percent of statements on clinical indications provided by the expert board reached a strong consensus.
Key Points
• An expert panel of the ESSR provided 10 evidence-based statements on clinical indications for image-guided interventional procedures for nerves of the upper limb
• Two statements reached the highest level of evidence
• Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%)
Objectives
Image-guided musculoskeletal interventional procedures around the hip are widely used in daily clinical practice. The need for clarity concerning the actual added value of imaging guidance ...and types of medications to be offered led the Ultrasound and the Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) to promote, with the support of its Research Committee, a collaborative project to review the published literature on image-guided musculoskeletal interventional procedures in the lower limb in order to derive a list of clinical indications.
Methods
In this article, we report the results of a Delphi-based consensus of 53 experts who reviewed the published literature for evidence on image-guided interventional procedures offered in the joint and soft tissues around the hip in order of their clinical indications.
Results
Ten statements concerning image-guided treatment procedures around the hip have been collected by the panel of ESSR experts.
Conclusions
This work highlighted that there is still low evidence in the existing literature on some of these interventional procedures. Further large prospective randomized trials are essential to better confirm the benefits and objectively clarify the role of imaging to guide musculoskeletal interventional procedures around the hip.
Key Points
• Expert consensus produced a list of 10 evidence-based statements on clinical indications of image-guided interventional procedures around the hip.
• The highest level of evidence was only reached for one statement.
• Strong consensus was obtained for all statements.
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
.
Objectives
Interventional procedures around the knee are widely adopted for treating different musculoskeletal conditions. A panel of experts from the Ultrasound and Interventional Subcommittees of ...the European Society of Musculoskeletal Radiology (ESSR) reviewed the existing literature to assess the evidence on image-guided musculoskeletal interventional procedures around the knee, with the goal of highlighting some controversies associated with these procedures, specifically the role of imaging guidance, as well as the efficacy of the medications routinely injected.
Methods
We report the results of a Delphi-based consensus of 53 experts in musculoskeletal radiology, who reviewed the published literature for evidence on image-guided interventional procedures around the knee to derive a list of pertinent clinical indications.
Results
A list of 10 statements about clinical indications of image-guided procedures around the knee was created by a Delphi-based consensus. Only two of them had the highest level of evidence; all of them received 100% consensus.
Conclusions
Ultrasonography guidance is strongly recommended for intra-articular and patellar tendinopathy procedures to ensure the precision and efficacy of these treatments. Prospective randomized studies remain warranted to better understand the role of imaging guidance and assess some of the medications used for interventional procedures around the knee.
Key Points
• A list of 10 evidence-based statements on clinical indications of image-guided interventional procedures around the knee was produced by an expert panel of the ESSR.
• Strong consensus with 100% agreement was obtained for all statements.
• Two statements reached the highest level of evidence, allowing us to strongly recommend the use of ultrasonography to guide intra-articular and patellar tendon procedures to ensure higher accuracy and efficacy of these treatments.