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Greetings, Master class and practical class members, and all members. Welcome to our practical pain management with Dr. Lee, focusing today on calcific tendinosis of the rotator cuff. This discussion marks the first in our series, covering everything from the barbotage procedure to its rationale, prognosis, and the condition's natural progression.
I will discuss the technical aspect of the rotator calcification. I will discuss other subjects in the next series. Let's dive in.
Overview of the calcific tendinosis
Calcific tendinosis, often called calcifying tendinitis, is characterized by the deposition of carbonate apatite crystals. Though detectable on radiographs in up to 20% of asymptomatic adults, it becomes a concern when these deposits trigger acute or chronic pain. Ultrasound, more sensitive than radiography, detects even smaller calcific particles, revealing a prevalence of as high as 29% in patients with shoulder pain. The supraspinatus tendon is particularly interesting, especially its critical zone about 1 cm proximal to its insertion.
The rationale for early intervention
While conservative physical and pharmacological treatments are effective in most cases, growing extensive calcifications pose a risk of rupture-inducing chemical inflammation and tendon tear.
The encapsulated calcium cavities are likely to remain asymptomatic unless they rupture. Larger calcium deposits, especially those exceeding 1 cm in diameter, are more likely to be symptomatic and have an unfavorable prognosis. Spontaneous rupture of the calcium vesicle release of calcium induces inflammation and pain and causes delamination tears. It is the first cause of pain and the major cause of acute severe pain. The second cause of pain is the delamination tear, the leading cause of chronic pain.
The spontaneous rupture of calcium always leads to delaminated rotator cuff tears. The larger, the worse. Delamination tears cause relapsing prolonged pain and long-term poor prognosis, emphasizing the need for early calcium decompression.
Minimally invasive treatments, such as barbotage and fenestration, are at the forefront of management to prevent a worse calcification cascade.
Some calcification remains silent because of hard calcification. But the hard calcification can even cause pain if it is large enough to have mechanical properties influencing overall tendon function.
The difference in the mechanical properties of hard calcium deposits and neighboring healthy tendon fibers leads to shear stress, contributing to delamination and degeneration. Neighboring chronic degenerative tendon changes might result in the development of delamination, which manifests as pain from inflamed nociceptors and step into the worse calcification cascade. I do not primarily apply Platelet-rich plasma treatment in the calcific tendinosis, but situations need Platelet-rich plasma treatment in this case.
The single-needle barbotage procedure
Now, to the heart of today's discussion: the barbotage procedure.
The barbotage technique is a minimally invasive, ultrasound-guided procedure that involves the fragmentation and aspiration of calcific deposits, providing relief to the patient.
Preparation:
Needles and syringes:
26 gauge 1.5-inch for local anesthetic.
18 gauge 1.5-inch for barbotage.
24 gauge 3.5-inch as a stylet.
several 5 mL Luer lock syringes.
Drugs:
3~4 mL 1% lidocaine for irrigation in each syringe.
A mixture of 3 mL lidocaine and 1 mL dexamethasone post-procedure
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26 авг 2024
