TREATMENTS PROVIDED
treatments to provide our patients with relief, allowing them to live improved lives.
We provide a variety of therapies to aid in the management of pain based on your needs, including Interventional Pain Medicine, which involves special procedures to treat and manage pain. Interventional Pain Medicine refers to a group of minimally invasive surgical procedures typically done as an outpatient to alleviate acute, chronic, or cancer-related pain conditions. Common pain procedures include, but are not limited to: epidural steroids (interlaminar, nerve root, and caudal injections), facet injections, peripheral nerve blocks, joint injections, sympathetic blocks (stellate, lumbar sympathetic, celiac plexus, hypogastric plexus, and ganglion impar blocks), neurolytic procedures (radiofrequency lesioning and chemical neurolysis). Dr Binegar also does more ADVANCED procedures such as Regenerative Medicine(Stem Cells and PRP), SCS(Spinal Cord Stimulation), PNS(Peripheral Nerve Stimulation), US guided CTR(Carpal Tunnel Release), MILD(Minimally Invasive Lumbar Decompression for Spinal Stenosis), VA(Vertebral Augmentation, kyphoplasty/vertebroplasty for compression fractures). Dr. Binegar has the specific training and expertise that is required to perform each of these types of procedures, as well as the management of potential complications. Dr. Binegar will use fluoroscopy (X-Ray) or US ( Ultrasound) imaging to ensure proper placement of your therapeutic medication.
MEDICINE
REGENERATIVE MEDICINE
To enhance the body's own repair mechanisms is the ideal sought-after approach in all of medicine, as human physiology and function will always be better and more complete than any pharmacological or surgical fix. Regenerative medicine covers a broad range of therapies from organ transplants to wound healing to many pain therapies. The regenerative medicine techniques utilized at PCB include Stem Cells, Platelet-Rich Plasma (PRP) therapy and Prolotherapy. Athletes and even the elderly are now able to take advantage of this technology. These regenerative medicine techniques help repair or strengthen musculoskeletal problems such as osteoarthritis, tendon defects, meniscus tears, degenerative disc disease, and cartilage defects. To learn more, check out the following pages on Stem Cell Treatments, PRP and Prolotherapy.
INJECTIONS
STEM CELL INJECTIONS
What QUESTIONS to ask when considering a Regenerative Medicine Clinic?
- Do I want to use my own stem cells (versus another person’s)?
- Do I want to use stem cells from their natural environment (versus those that have been processed, frozen and thawed)?
- Do I want the provider to be an M.D. or D.O. (versus a nurse practitioner or physician assistant)?
- Is the provider certified in Pain Medicine?
- Is the Pain Medicine certification recognized by the ABMS(American Board of Medical Specialties)?
- Are the injections done with ultrasound(US) guidance?
- Is the provider certified in US?
- Has the provider done thousands of US procedures?
- Has the provider done hundreds of regenerative procedures?
- Does your provider understand the current research?
- Can your provider discuss the technical terms such as autogenic, allogenic, homologous, minimally manipulated…?
- Has your provider read the November, 2017 FDA guidelines regarding what is legal/appropriate in the USA?
The answer to all of the above is YES, when you decide to have your procedures done at Pain Care Boise with William G Binegar, MD. To better understand STEM CELLS, see below:
There are 3 Classifications of STEM CELLS:
- 1. Human Embryo—Highly controversial due to ethical issues and availability. Not used.
- 2. Induced Stem Cells—A process that can convert almost any cell into a stem cell by gene manipulation. This could lead to cancer. Also not used.
- 3. Adult Stem Cells. There are 3 types:
- a. Adipose or Fat-- Starts with the highest number of stem cells. Unfortunately, the processing of fat to get the stem cells can be difficult. The FDA has outlawed using enzymes. Mechanical separation may be considered, but is very time consuming(3-4 hours). The final product does NOT have many platelets and/or growth factors. Therefore, an extra step such as adding PRP from your blood is required. Also fat stem cells in several studies revealed they do not convert to cartilage as easily as bone marrow stem cells. The FDA also requires that any harvested tissue perform a similar function in the eventual recipient(termed homologous). That is why fat stem cells may be considered for aesthetics (such as when used as a filler for wrinkles), but scrutinized when used for musculoskeletal problems.
- b. Bone Marrow—Using this tissue has many advantages. As mentioned above they more easily convert to cartilage than fat stem cells. Because bone marrow does not require processing, they remain in their natural environment. This allows them to be able to continue to communicate with surrounding cells, making them more functional. When collecting bone marrow, we also collect the platelets that live with them. Platelets(see PRP section) release growth factors helping things to grow. This process from collecting the bone marrow to injecting in your joint, typically takes less than 30 minutes. Pain Care Boise recommends using Bone Marrow for your STEM CELL treatments.
- c. Umbilical Cord/Blood-- Although confusing, this is an adult stem cell from the delivering mother. There are many CAUTIONS against the use of this product as listed below:
- i. This product may have some living cells. However, they are NOT “good functioning” cells. And many of the cells are “damaged” by the freeze/thaw process, which could lead to “problems” in the recipient.
- ii. The companies have not received Section 351 status, which means they have NOT proven efficacy.
- iii. Most companies have received Section 361 status, which means they have been tested for communicable diseases. Unfortunately, there have been reported diseases such as hepatitis with Section 361 products.[Why take the chance with someone else’s cells, when you can use your own?
- iv. Given all of the above the FDA has NOT approved this product.
- v. So why is the product used in some clinics? There is the sales pitch of using “younger cells”. Remember many of the cells are damaged and/or not functioning well. Another reason you’ll see this offered is simplicity for the provider. The provider simply draws the product from of a vile and injects (oftentimes without ultrasound or x-ray guidance). You’ll often see the product used clinics with an NP/PA or a doctor not well trained or educated in regenerative medicine.
The STEM CELL treatment offered at Pain Care Boise is simple, safe and effective! Our provider is experienced and keeps up-to-date with the cutting edge of stem cell technology and research. Obtaining your own readily available stem cells is easily done in a timely manner with image guidance.
Disorders commonly treated by STEM CELL injections:
- Osteoarthritic joints
- Cartilage defects
- Meniscus tears
- Tendon tears complete
- Degenerative Discs Spine
- Rotator cuff tears complete
- Anterior cruciate ligament tears
- Achilles tendon tears
- Hamstring tendon tears
- Many other tendon or ligament injuries
PLASMA (PRP)
PLATELET RICH PLASMA (PRP)
Athletes commonly have injuries to tendons (tendinosis, tendonitis, partial or complete tears) and ligaments (sprains, strains, or tears). Tendons and ligaments do not have as good of a blood supply as other soft tissues in the body, and thus heal very slowly or sometimes the healing process will even stall due to scar tissue or pain causing immobility. PRP utilizes your body’s own blood platelets to release an abundance of growth factors to help speed up the healing of strains or tears of tendons, ligaments, or cartilage in or around the joints. Platelets also release chemotactic factors, which attract stem cells to the site of injury. Stem cells will then transform into the cell type needed to repair the damaged tissue. As examples, stem cells may become tenocytes to lay down new tendon or become chondrocytes to lay down new cartilage. With PRP therapy, we inject your own concentrated platelets and healing factors directly into the site of injury to stimulate a quicker recovery. At Pain Care Boise, we are highly skilled at the use of ultrasound imaging. This allows us to diagnose the exact injury site. Also with ultrasound, we are able to precisely place the PRP at the correct injury site. Typically, 2-4 injections are done 4-6 weeks apart. World class athletes from professional sports, the Olympics, and the local weekend warriors are now taking advantage of this low-risk procedure with high healing capacity to get them competing again. Now even the elderly are finding benefits with PRP for osteoarthritis, allowing them to be more active and avoiding or delaying total joint surgery.Common indications for PRP:
- Tennis elbow (lateral epicondylitis)
- Golfer’s elbow (medial epicondylitis)
- Degenerative Discs of Spine
- Rotator cuff partial tears
- Jumper’s knee (patellar tendinosis)
- Achilles tendinosis and tears
- Plantar fasciitis
- Hip or gluteal tendons of the greater trochanter
- Groin or adductor tendons
- Hamstrings tendons of the ischial tuberosity
- Knee meniscal tears (if peripheral)
- Osteoarthritis – any joint
- Many other tendon or ligament injuries
RELEASE W US
CARPAL TUNNEL RELEASE W US
Carpal tunnel syndrome (CTS) affects nearly 12 million Americans. CTS occurs when the median nerve is compressed as it goes through the carpal tunnel in your wrist, being trapped under the transverse carpal ligament (TCL). CTS is typically caused by repetitive hand and finger motion. Common examples are typing, mousing, gaming on computers, playing an instrument, manual labor that especially requires a significant amount of gripping and other similar activities. CTS symptoms include numbness, tingling and burning in the thumb and fingers and often wakes you up at night. You may feel weakness of the hand or difficulty with coordination. Sometimes shock-like sensations in the wrist or fingers. Historically the diagnosis is made with EMG/NCV. This procedure can be painful as it involves shocking the nerves or muscles. We can now make the CTS diagnosis with Ultrasound (US), a painless procedure.
The goal of surgical intervention is to cut the transverse carpal ligament (TCL) to reduce compression of the median nerve, which significantly decreases the pain, numbness and tingling as well as improving your function. Traditional open CTR surgeries are relatively safe and effective, but may lead to painful scars and your return to normal activities and work may be prolonged up to 2-6 weeks or months. (Endoscopic CTR may help, but is more expensive and potential greater risk of postoperative nerve symptoms.)
Pain Care Boise is now offering new technology to cut the TCL with US guidance. No IV or anesthesia is needed. Only numbing with a local anesthetic. A very small incision (less than 5 mm) is made. Through this small incision is placed a patent pending device. The Sonex Health SX–One MicroKnife is a surgical tool with inflatable balloons along both sides of a retractable retrograde cutting knife. Deploying the balloons help expend the safety zone to protect against cutting any unwanted neurovascular structures. Utilizing direct US visualization the cutting knife is then activated to transect the ligament.
The instrument is removed. The completeness of the ligament cut can then safely be evaluated with US to ensure a complete release. (Rarely a second pass is needed.) The very small incision is closed with Steri-Strips (and rarely needs 1 or 2 sutures). Mild tenderness last for 1-2 days, but only requires Tylenol or ibuprofen-no opioids needed.
There have been no neurovascular complications with US guided CTR. There have been over 1600 procedures with the SX-One Microknife. Clinical results have been excellent showing a quicker improvement at 1-2 weeks and the same or better results at 6 months when compared to mini-open, endoscopic or other ultrasound guided techniques.
Are you suffering with the pain and numbness of moderate to severe CTS? Have you been trying to avoid diagnosis with the painful EMG/nerve conduction test? Have you been put off by the pain and recovery time of traditional surgery? You can now get a painless diagnosis with US. The above microinvasive technique is quickly done also with US guidance. Recovery is quicker allowing you to get back to the activities you want to do. To learn more go to www.sonexhealth.com
(SCS)
SPINAL CORD STIMULATION (SCS)
SCS uses a similar technology to a pacemaker with the end result being an electrode placed in the epidural space, which is connected to a generator placed under your skin (typically upper buttocks/hip/back). This technology is usually reserved for patients with refractory neuropathic extremity pain not responsive to other conservative treatments. There have been recent ADVANCES in technology utilizing higher frequencies and doing “burst” stimulation. With the older/classic/tonic waveforms people would feel a “tingling” sensation in the area of their pain. For failed back surgery patients with LOW BACK & LEG PAIN, they would often get benefit of the LEG PAIN, but sometimes not their BACK PAIN. Also people would get tired of the “tingling” and/or they would need to turn it off at night, waking up in pain. Also you would need to turn it off when driving. With the newer high frequency/burst technology there is no tingling sensation, just decreased pain–––including decreased BACK PAIN. There is no need to turn it off at night or when driving.
A nice aspect of SCS is you can first do a TRIAL to test the effectiveness. The trial lead is placed first and connected to a generator outside of your body. You go home for about a week doing your normal activities with the trial lead in to determine if this technology alleviates your pain. The trial lead is then pulled. If the trial is successful, the total system is then implanted two to four weeks later. Adjustments may be made with an external computer if required.
SCS is most commonly done for low back and leg pain, but also for CRPS/RSD(Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy), PHANTOM PAIN and sometimes other neuropathic pain problems.
STIMULATION (PNS)
PERIPHERAL NERVE STIMULATION (PNS)
PNS is exciting new technology being similar to SCS (Spinal Cord Stimulation). Instead of the electrodes being placed in the spine, the electrode is placed next to a peripheral nerve. Prior to the trial and the implant we’ll first do a DIAGNOSTIC NERVE block with numbing medicine only. If this takes away your pain the day of the injection, then we go on to the next step. The next step is similar to again SCS where we do a trial. Again this is what people really like about PNS (& SCS) is you can first do this trial prior to the implant. With a trial we place the electrode next to the peripheral nerve with image guidance (typically Ultrasound-sometimes with x-ray). The end of the lead is not tunneled under the skin during the trial. You go home for 4-7 days doing your normal activities to see if this helps your pain. If indeed you have benefit, then you are scheduled for the implant. With the implant the lead is tunneled along with the generator that is built into the lead. One of the drawbacks with PNS, is you are required to wear a garment that contains the external transmitter over the lead. Typically, you only need to wear the garment for 2-4 hours at a time once or twice a day.
PNS has opened the door to treat some historically difficult pain problems. Unfortunately, sometimes after surgery, people will continue to struggle with chronic POSTOPERATIVE pain. Examples of this are:
- GROIN PAIN after HERNIA REPAIR or other lower abdominal surgeries
- THORACIC PAIN after THORACOTOMY or after SHINGLES
- ANKLE & FOOT PAIN after ORTHOPEDIC surgeries or TARSAL TUNNEL (or Sural Nerve)
- FOREARM/WRIST PAIN after CARPAL TUNNEL RELEASE or Ulnar nerve surgeries or Arthritis
- KNEE PAIN after TOTAL KNEE, other knee surgeries or for Arthritis
- SHOULDER PAIN after TOTAL SHOULDER, other shoulder surgeries or for Arthritis
PNS is also done for:
- LOW BACK PAIN, SACROILIAC PAIN and PELVIC PAIN, postsurgical or not.
There are many other conditions to be considered. Remember PNS is typically done when one has failed other conservative treatments with medications, PT, steroid injections or other treatments. Oftentimes surgery is no longer an option and/or the patient cannot have surgery due to health reasons or does not want further surgery. If you have a good response with a peripheral nerve block, then we will proceed with the trial and hopefully the implant.
LUMBAR DECOMPRESSION
FOR SPINAL STENOSIS
MILD= Minimally Invasive Lumbar Decompression
MILD is a procedure done for people with LSS( Lumbar Spinal Stenosis) due to LFH(Ligamentum Flavum Hypertrophy) who have NC(Neurogenic Claudication). WOW---that’s a lot of big words and acronyms!!!! Let’s break it down.
LSS is a narrowing of the spinal canal in the lumbar (lower back- not mid back or neck) region. The narrowing/stenosis is caused by a number of degenerative changes that occur as we age such as degenerative/bulging discs, excess bone formation, and thickening/hypertrophy of a ligament that runs on the inside of your spinal canal(called the Ligamentum Flavum).
LFH is thus simply the enlargement of this ligament contributing to the LSS. With the canal being too narrow we can have compression and irritation of the nerve roots leading to your symptoms.
NC is the medical term for your symptoms of PAIN, NUMBNESS, or TINGLING sensations in your low back, buttocks, and legs. Oftentimes it may simply be your back or legs just feel TIRED or WEAK when you are standing or walking. These symptoms are typically relieved with sitting or bending forward such as leaning against a grocery cart.
Read MoreKYPHOPLASTY
VERTEBROPLASTY / KYPHOPLASTY
Kyphoplasty and/or Vertebroplasty are new procedures sometimes done for patients with lower thoracic and lumbar vertebral compression fractures. However, typically vertebral compression fractures do heal over time and can be treated with pain medications, bracing, and/or facet/epidural steroid injections. If these more conservative measures fail, then one can consider doing a kyphoplasty or vertebroplasty. This requires careful placement of one to two needles into the vertebral body. With a kyphoplasty a cavity is first created within the vertebral body. Slow injection of a special cement glue containing dye is done while looking at an x-ray machine. If any of the dye goes into a blood vessel or near the epidural space, the procedure may have to be stopped before completed. The procedure does have the extra increased risks of paraplegia, pulmonary embolus and possible death. However, it often helps decrease the significant pain and decrease the amount of pain medications required.INJECTIONS /
INTERLAMINAR TECHNIQUE
EPIDURAL STEROID INJECTIONS / INTERLAMINAR TECHNIQUE
Epidural injections are typically done for people with radicular pain (i.e., neck/arm pain, or low back/leg pain). The epidural space is within the spinal canal and extends from the base of the skull to the sacrum. All the nerve roots course through the epidural space. Irritation of the nerve roots can be caused by degenerative disc disease, herniated or bulging disc, spinal stenosis, bone spurs, arthritis, or scar tissue from prior surgeries. After appropriate anesthetic (usually only subcutaneous local anesthetic), a needle is placed into the epidural space at the level of the problem between two vertebrae (interlaminar). Injection of 4-10 cc of a mixture of local anesthetic/steroid is then placed in the epidural space to bathe the nerve roots at not just one level but several levels. The local anesthetic quiets the nerves down while the steroid is to decrease the inflammation of the nerve roots. If an initial injection is helpful, typically a series of two to three injections is done.TRANSFORAMINAL EPIDURAL
NERVE ROOT INJECTION TRANSFORAMINAL EPIDURAL
Nerve root injections are a special type of epidural injection referred to as transforaminal epidural steroid. Instead of bathing several nerve roots as with an epidural injection, only one nerve root is injected but with a higher dose of steroid. Often this is done with a far lateral herniated disc and/or foraminal stenosis. It may be helpful for surgeons for diagnosis of the correct level. Nerve root injections do require use of x-ray.INJECTIONS
CAUDAL STEROID INJECTIONS
Caudal injections are another special type of epidural injection. A caudal approach requires placing the needle through an opening, the sacral hiatus, near the tailbone to reach the lower nerve roots of the spine. This approach is most commonly done for people with prior back surgeries and especially if prior fusion, yet have persistent low back pain and buttocks pain.INJECTION
FACET JOINT INJECTION
There are two facet joints (one on each side) between every vertebra. Each vertebra is like a tripod with the front of the vertebra resting on the disc and the back part of the vertebra resting on the two facets. The facet joints can develop arthritis like any other joint in the body. Arthritis can occur from trauma, such as with a whiplash injury causing cervical facet arthritis. However, most often facet arthritis is seen in the lower lumbar segments, which bears most of the weight. Injection of the facet requires use of x-ray. The injectate is again a local anesthetic/steroid combination. As with most steroid injections, if the initial injection is helpful, a series of two to three injections may be done.BLOCK
STELLATE GANGLION BLOCK
A stellate ganglion block is done most often for people with RSD (Reflex Sympathetic Dystrophy), also called CRPS (Complex Regional Pain Syndrome) of the arms. RSD may result from an impaired sympathetic nervous system (the fight or flight part of our nervous system). Typically RSD occurs after an injury, fracture, or surgery to the arm resulting in a very sensitive upper extremity with vascular changes such as edema and/or color changes and often decreased range of motion. The stellate ganglia lives in front of the lower cervical spine on each side of your voice box. Blocking the ganglia interrupts the sympathetic nervous system in an attempt to "reset" the sympathetic nervous system. With a sympathetic block, you should not experience numbness or weakness, however, you should feel a warmth in your extremity. A sympathetic block allows less pain and better movement of the extremity.BLOCK
LUMBAR SYMPATHETIC BLOCK
Lumbar sympathetic blocks are done for people with RSD (Reflex Sympathetic Dystrophy), also called CRPS (Complex Regional Pain Syndrome) of the legs. RSD may result from an impaired sympathetic nervous system (the fight or flight part of our nervous system). Typically RSD occurs after an injury, fracture, or surgery to the leg resulting in a very sensitive lower extremity with vascular changes such as edema and/or color changes and often decreased range of motion. The lumbar sympathetic ganglia live in front of the L2, L3, and L4 vertebrae. Blocking the ganglia interrupts the sympathetic nervous system in an attempt to "reset" the sympathetic nervous system. With a sympathetic block, you should not experience numbness or weakness, however, you should feel a warmth in your extremity. A sympathetic block allows less pain and better movement of the extremity.BLOCK
CELIAC PLEXUS BLOCK
The celiac plexus innervates the lower esophagus, stomach, small intestines, most of the large intestines, liver, pancreas, spleen, adrenal glands, and kidneys. Therefore, by blocking the celiac plexus, you can interrupt the pain fibers from these abdominal organs. The celiac plexus is actually a series of ganglia just in front of the aorta and the first and second lumbar vertebrae. A diagnostic block is done first with local anesthetic only. If the patient has a good response, we then consider proceeding with a neurolytic block (usually alcohol). This is most commonly done for patients with pancreatic cancer with upper abdominal pain, but may also be tried for cancer of the other above listed organs.PLEXUS BLOCK
SUPERIOR HYPOGASTRIC PLEXUS BLOCK
The superior hypogastric plexus innervates the lower sigmoid colon, bladder, ureters, testes, and ovaries. Therefore, by blocking the superior hypogastric plexus, you can interrupt the pain fibers from these pelvic organs. The superior hypogastric plexus is actually a series of ganglia just in front of the fifth lumbar and first sacral vertebra. A diagnostic block is done first with local anesthetic only. If the patient has a good response, we then consider proceeding with a neurolytic block. This is most commonly done for patients with pelvic cancer with lower abdominal/pelvic pain who are already incontinent, as one of the significant side effects or complications with this procedure can be bladder incontinence.ABLATION
RADIOFREQUENCY ABLATION
Radiofrequency (RF) techniques require a special machine allowing interruption of the nerve conduction on a semi-permanent basis. With the "classic" RF technology, RF waves pass down a needle causing an increased temperature and partial destruction of the nerve it is near. This is most commonly done for people with neck or back pain due to facet arthritis, who have had a very good response (but unfortunately only for a short period of time) with a steroid injection of their facet joint. Newer technology allows us to do a "pulsed" RF, or intermittent bursts of RF, creating an electromagnetic field (EMF) about the nerve to interrupt the nerve conduction. Pulsed RF is most commonly done with peripheral neuralgias on nerves that have only a sensory component (i.e., only on nerves that do not also innervate or control our muscles). Prior to either RF technique, diagnostic blocks with local anesthetic only are required. RF often provides permanent benefit, but does sometimes require a repeat RF in the future.INJECTIONS
ULTRASOUND-GUIDED INJECTIONS
Recent advances in high-resolution Ultrasound (US) imaging present new opportunities in improving the care of patients with pain due to musculoskeletal and nerve injuries. US uses sound waves to provide real-time, high resolution images of tendons, ligaments, muscles, and nerves throughout the body. US allows us to deliver treatments precisely and safely to the effected tissue. During ultrasound-guided injections, Dr Binegar and his trained staff can directly visualize the needle passing to the targeted tissue. Direct visualization ensures accurate placement of the medication and offers a greater margin of safety. Smaller needles can be used, improving patient comfort and potentially reducing risk to the patient. Applications for ultra-sound-guided injections include:- Needle placement into joints for injection
- Injection into tendon sheaths and bursa
- Aspiration and injection of ganglion cysts
- Diagnostic or therapeutic nerve blocks, including carpal tunnel syndrome
INJECTIONS
JOINT INJECTIONS
Orthovisc or Synvisc may be used to treat knee osteoarthritis to prevent or delay needing a total knee replacement surgery. When the synovial fluid becomes thinner and loses its elasticity and viscosity (ability to lubricate), the osteoarthritic, synovial fluid cannot provide "cushioning" in your knee joint. A lubricant such as Orthovisc is injected into the joint cavity to replace the lost synovial joint fluid. Corticosteroid injections are used to treat conditions such as bursitis, tendonitis, and arthritis. Intra-Articular or JOINT Steroid Injections Provide prompt and effective reduction in local inflammation. Steroid injections are often given into the joint cavity. Common examples are the shoulder, hip, knee, AC (acromial-clavicular), and SI (sacroiliac) joints. Injections into BURSA Used to reduce pain and inflammation of the bursa (which is a closed fluid-filled sac that functions to provide a gliding surface to reduce friction between tissues of the body). This injection does not go into the joint cavity itself. Common examples are the subacromial bursa (shoulder), trochanteric bursa (hip), ischial tuberosity bursa (buttocks), and the pes anserine bursa (knee). TENDON Injections are commonly done for tendonitis or tendinopathy problems to decrease the pain and inflammation. Common examples are tennis elbow and golfer's elbow (epicondylitis), rotator cuff( shoulder), runner's knee ( iliotibial tract), jumper's knee (patellar tendon) and others. All of the above injections are done with US (Ultrasound) guidance, allowing us to see the intended structure.INJECTIONS
