Watch an Advanced Image-Guided Injection of the Shoulder: Step into Our Procedure Suite with Dr. Schultz

POSTED ON 10/9/2016 IN Shoulder BY Christopher Centeno

This weekend we had an Interventional Orthopedics Foundation  (IOF) course at our Colorado headquarters. What I kept hearing from the physicians attending the course was how much more in depth this course was than any other course they had ever taken. Today I'd like to invite you to join Dr. Schultz as he performs an advanced image-guided injection into the shoulder. You can read what I write on this blog about these procedures all day long or hear how our IOF courses are different, but there's nothing like seeing it in action to help you understand what we do and why Regenexx is very different. As you watch the short video above, you'll stand alongside Dr. Shultz as he performs advanced image-guided injections into the shoulder of a 60-year-old patient who injured himself while kayaking. Let's take a look at what interventional orthopedics looks like in a shoulder injection of our super concentrated version of platelet rich plasma (PRP).

Terminology Used in the Video

There are some medical terms used in the video that will be helpful for you to understand if you don't already know them. I have highlighted these below: Subscapularis—The subscapularis is a large butterfly-wing-shaped muscle that lives in front of and supports the shoulder joint. It is the biggest of the four muscles that make up the rotator cuff. The subscapularis tendon connects the subscapularis muscle into the head of the humerus (the upper-arm bone), which is the ball of the ball-and-socket shoulder joint. The patient's MRI showed some inflammation of his subscapularis. Supraspinatus—The supraspinatus is a smaller, but more talked about shoulder supporting muscle that lives on top of the shoulder. It is one of the four muscles that make up the rotator cuff and attaches via the supraspinatus tendon to the head of the humerus. During the procedure, using X-ray–guidance, Dr. Schultz observed a partial tear of this patient's supraspinatus tendon, something the MRI didn't show. While a tendon should be firm when he injects into it—with fibers like a “tight piano string” Dr. Schultz explains—the fibers here opened up and flew apart when he injected into them, indicating a hidden tear. It's important to note that the only way to get to this specific defect in this specific area so it can be treated with stem cells or, in this case, platelets is under precise guidance. This is why blind stem cell or platelet injections (meaning performed without imaging guidance) or those cells injected IV, whether being used to treat the shoulder, knee, hip, or so on, are never a good idea. Platelet Rich Plasma (PRP) —Dr. Schultz is using a very specialized concentration of platelets that you can notice by its color—it's amber in color as opposed to red, which means it has very few red and white blood cells. Many PRP solutions that are made by some non-Regenexx provider clinics have these high concentrations of red and white blood cells, and these can be extremely inflammatory. The Regenexx difference is eliminating these specific cells by utilizing of a state-of-the-art lab that has this capability. Also, we use super concentrated platelets, rather than the lower concentrations used by other clinics. Biceps—Everyone probably knows what the biceps muscle is. When we flex our upper arm, the bump that pops up is the biceps muscle. Body builders love to sculpt and define this muscle and show it off a bit. The biceps lives alongside the upper end of the humerus, rests in a groove at the humerus head, and connects the muscle to the shoulder joint. In the video, you will watch the X-ray monitor along with Dr. Schultz as he injects the biceps tendon. He is switching to use fluoroscopy because the area where the biceps comes from can't be seen well using ultrasound. You will also see another reason why ultraprecise guidance is so important as Dr. Schultz carefully maneuvers his needle so he doesn't injure a pumping blood vessel directly underneath the needle. Labrum—The labrum is cartilage that cushions the ball-and-socket shoulder joint and keeps it stable. The MRI showed a tear in the superior-anterior portion of the labrum. In the video, Dr. Schultz uses contrast and switches back and forth between X-ray and ultrasound to confirm accurate placement of his needle into the labrum.

Equipment Used in the Video

You will see Dr. Schultz using a equipment we frequently use in our clinics. The machine providing the advanced x-ray guidance in real time, allowing Dr. Schultz to precisely place his needle is our fluoroscopy equipment. He also uses an ultrasound during the injection of the labrum. Additionally, to monitor our patients' vital signs during their procedure, we use a full surgical monitor. And in the rare case of an emergency, we always have emergency equipment on hand as well, including oxygen, a crash cart, and an automated defibrillator. Our standard clinic setup is detailed further in my “cell therapy deception” post.

Compare and Contrast

Most providers offering stem cell or platelet injections in the shoulder do so blindly, meaning they have no idea where the cells are going, whether or not their needle is in the right location, or whether or not they are close to sensitive structures that could be injured during the procedure (e.g., a pumping blood vessel). If Dr. Shultz had not had ultrasound guidance providing him with real-time precise imaging during the procedure, he could have easily punctured the blood vessel directly under his needle as he was accessing the patient's biceps tendon. In addition, the advanced real-time imaging Dr. Schultz used during the procedure revealed something the MRI performed before the procedure did not: the partial tear in the supraspinatus tendon. So Dr. Schultz was able to go ahead and address this issue as well during the procedure. A blind injection would have left this area untreated since the MRI, not showing the tear, would have been the provider's blueprint. As good as an MRI is, it is a still-shot image, and, therefore, things can be missed when relying on an MRI alone. The upshot? Regenexx is very different from what most of the other guys are doing out there, and I hope this visit to our surgical suite to watch this advanced image-guided injection of the shoulder helped you to see why.

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  3. shoulder
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