ticular from extraarticular symptoms and to reduce pain and inflammation accompanied with arthritis. The choice of steroid and anesthetic used is largely dependent on personal experience and preference of either the radiologist or referring physician.41 At our institution, we typically use 40 mg methylpred-nisolone acetate (Depomedrol) and 7 mL 0.5% bupi-vacaine HCl. The technique used is similar to that outlined previously for diagnostic aspirations, with the exception that a 22-gauge spinal needle is used. Aspiration is performed before contrast administration to exclude overt evidence for infection and to evacuate a joint effusion. Again, a small amount (1-2 mL) of iodinated contrast is injected to verify an in-traarticular position of the needle. The steroid and anesthetic are then injected as a mixture into the joint. The patient is then assessed for evidence of symptom improvement and to report any clinical improvement to the referring physician.
Iliopsoas bursography has been successfully used to diagnose iliopsoas tendon snapping syndrome.42 The examination is considered diagnostic of iliopsoas snapping syndrome if a jerking motion of the iliopsoas tendon is observed fluoroscopically as the patient reproduces the snapping or popping sensation. In our institution, this procedure has been replaced with ultrasound. Ultrasound has proven successful in a relatively recent report of a small group of patients examined for iliopsoas snapping syndrome43 and has been useful in our clinical practice. Ultrasound has the advantages of being noninvasive, lacks ionizing radiation, and allows concomitant evaluation of the contralateral side.
The technique for iliopsoas bursography (Figure 4.6) is similar to that of a fluoroscopically guided hip injection. With the patient on the fluoroscopic table in the supine position, a skin mark is placed directly anterior to the middle of the femoral neck. Using sterile technique and 1% buffered lidocaine HCl as a local anesthetic, a 22-gauge spinal needle is advanced toward the upper portion of the femoral head. After making contact with the anterior acetabular rim, the needle is withdrawn 2 to 3 mL. Approximately 5 mL iodinated contrast is then injected and should course in a longitudinal direction and outline the iliopsoas tendon. Additionally, 5 mL 0.5% bupivicaine is administered into the bursa. The tendon is then observed under fluoroscopy as the patient reproduces the snapping sensation, typically with straightening the leg from the flexed, externally rotated, and abducted po-sition.44 The tendon should glide normally over the anterior capsule and iliopectineal eminence. A jerking movement of the tendon at the time the patient experiences symptoms is considered diagnostic of iliop-
soas tendon snapping syndrome. Video recording of this portion of the examination is preferred for documentation purposes and enables the referring physician to review the tendon motion.
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