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If you thought ultrasound was just for OB-GYN or abdominal specialists, you'll be surprised by the technology's increasing role in health care. Some orthopedic surgeons have used ultrasound for more than 30 years, but over the past decade — thanks to improved image quality — this imaging technique has begun to rival magnetic resonance imaging for visualizing tendons, ligaments, nerves, arteries, veins and other soft tissues. It's also ideal for guiding platelet-rich plasma injections and regional blocks.
Real time without radiation
Ultrasound now has clear advantages in many clinical situations over computed tomography and magnetic resonance imaging, neither of which provide ultrasound's dynamic imaging capabilities. CT scanning exposes patients to radiation and is not ideal for soft-tissue imaging. An MRI is costly, requires patients to remain still for long periods of time and is often contraindicated in patients with implants.
When I first saw how an orthopedist could use ultrasound — during a trip to Britain several years ago — I was excited about the possibilities, especially for use on the shoulder, the joint most often imaged by ultrasound. One of the benefits of ultrasound, compared to other imaging techniques, is that the orthopedic surgeon can evaluate a patient's soft tissues and joints in real time without radiation. Because the image is in real time, the surgeon can see the joint as the patient moves. The technology improves efficiencies, too. A 13-point shoulder examination takes about 5 minutes to complete.
Ultrasound is a good option for diagnosing rotator cuff and biceps tendon tears, bursitis and calcium deposits. It's also ideal for evaluating joints that have undergone previous surgeries, as the image is not distorted by artifacts caused by implants.
Many musculoskeletal clinicians use ultrasound instead of fluoroscopy to guide injections because there is no exposure to radiation and ultrasound creates better images of soft tissues below the injection site. Ultrasound is well suited for guiding intra-articular injections or aspirations in the shoulder, elbow, wrist, hip, knee and ankle.
Compact designs
Over the past few years, portable ultrasonic systems about the size of laptops have hit the market, making it easier for surgery centers, physician offices and emergency departments to add the imaging technology. The machines don't take up valuable space and can be carried from room to room or from office to surgery center. Portable ultrasound machines cost between $24,000 and $50,000 and have many of the same useful features found on larger consoles.
Reimbursement for diagnostic ultrasound and ultrasound guidance for injections is the same for portable ultrasound devices and console models, but navigating the billing landscape can be tricky. The CPT code for diagnostic ultrasound is 76880; the code for ultrasound-guided needle placement is 76942. In both cases, reimbursement usually requires medical necessity based on the payor's standard, recorded images saved as part of the patient's record (DICOM or JPEG images captured during an ultrasonic exam can be exported directly to a facility's EMR system or printed and added to a paper file) and a reading documenting the exam's results. Reimbursement varies by insurance carrier and by region. It averages $120 for a diagnostic exam and $185 for an ultrasound-guided needle placement for injection or aspiration.
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Ultrasound Key to Regional Success |
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More and more anesthesia providers are using ultrasound to locate peripheral nerves when placing suprascapular or femoral nerve blocks. Anesthesiologist Gregg Melton, MD, the medical director of the Slocum Center for Orthopedics & Sports Medicine in Eugene, Ore., is a relatively new convert to the ultrasound movement. He swears by the improvements the technology has brought to his practice. About 2 years ago, his junior partners told him the technology was the wave of the future. Once the younger docs taught him how to place blocks under ultrasound guidance, Dr Melton was sold. Turns out the timing was perfect. He was about to open an orthopedic clinic, where he wanted to do "a lot of blocks," so buying an ultrasound system made sense. Recently, Dr. Melton and those convincing partners placed their 3,300th block, having performed all but 2 with ultrasound guidance, which Dr. Melton is quick to credit for their near 99% success rate. In fact, he values the technology so much he just purchased a second unit. Dr. Melton says ultrasound lets providers see blood vessels, the exact location of target nerves, needle advancement and block placement as the local anesthetic spreads. That real-time visualization is a marked improvement over conventional nerve stimulation techniques. "It lets you confirm the variation in patients' anatomies," he explains. "Nerves are rarely where textbooks say they should be, so finding them with a nerve stimulator can be like shooting quail in a skillet." The latest ultrasound designs are compact, portable and easy to set up and use, says Dr. Melton. He hears academic types say they don't use ultrasound to place blocks and fail to grasp the technology's clinical necessity. He understands their viewpoints, but respectfully disagrees. To him, the practical usefulness of ultrasound makes it a must-have in block rooms. "The technology is so revolutionary, it should be a standard of care," he says. "What we can see and do with it is unbelievable." — Daniel Cook |
A hospital or surgery center that bills for the technical component of a procedure can pay for a portable ultrasound system in 6 months or less, depending on use. A clinician in practice who has an office-based portable ultrasound machine can bill for the professional and technical components. In an office setting, the machine could pay for itself in 3 months or less.
Ahead of the curve
One of the challenges of adding ultrasound to your imaging capabilities is the time required to master using the machine and to interpret the images it produces. For clinicians familiar with the anatomy they're viewing, the learning curve is typically between 100 and 300 exams. Attending training courses in musculoskeletal ultrasound can shorten that learning curve. Local and national training courses are available, and several portable ultrasound machine vendors sponsor informative training courses.
Once the technique is mastered, ultrasound is a quick, cost-effective way to create diagnostic images of soft tissues and images to guide needles for injection and aspiration without radiation. Ultrasound may have taken a long time to gain acceptance, but it's definitely here to stay.
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Ultrasound 101 |
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Besides better image quality, today's systems have 3-D and sometimes 4-D capability. Like a 3-D CT or MRI image, a 3-D ultrasound image is a collection of slices captured from different angles and assembled by the system's computer processor into a 3-D image. A 3-D image creates a topographical view of organs, lesions or regions of the body. A 4-D image includes the dimension of motion, which is created by continuously capturing 3-D images. Here's a quick look at how ultrasound's images are created.
Typically, the higher the frequency of the phased array transducer, the higher the resolution of the image. However, higher frequency transducers also have less depth penetration, so users must determine the frequency and depth settings needed to get images that are best suited for their clinical needs. For example, I use a variable frequency transducer that ranges from 5MHz to 13MHz for musculoskeletal applications. With this setup, I can create images of tissue and structures 2cm to 10cm below the skin. — Don Buford Jr., MD |
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