How to Wash the Pain Away

Ultrasound-Guided Lavage for the Treatment of Calcific Tendinitis of the Shoulder

Jason I. Blaichman MD, Scott E. Sheehan MD, John J. Wilson MD, Kenneth S. Lee MD

• Calcific tendinitis of the shoulder is a common cause of self-limited, but often debilitating shoulder pain with classic imaging findings.

• When conservative management fails, ultrasound (US)-guided lavage is a safe, effective, and relatively simple procedure utilizing readily available equipment that can provide significant symptomatic improvement.

• Familiarity with US-guided lavage for calcific tendinitis of the shoulder allows radiologists to offer a valuable service to referring clinicians and their patients.

• While this procedure is currently commonly performed in Europe, it remains relatively underutilized in North America, creating opportunity for its easy adoption into many more radiology practices.

INTRODUCTION PREAMBLE

1. To review the clinical presentation, natural history and diagnostic imaging features of calcific tendinitis of the shoulder.

2. To discuss the indications, contraindications, interventional methods , potential complications and expected outcomes of US-guided lavage for the treatment of calcific tendinitis of the shoulder.

3. To highlight the single versus double-needle US-guide lavage technique.

LEARNING OBJECTIVES PREAMBLE

• Clinical Presentation and Natural History – Shoulder pain and disability with activity or rest – Chronic disease with acute exacerbations and periods of remission – Usually self-limited after a period of worsening and intense pain – Some experience cyclic, progressive course

• Demographics

– 70% of cases are in women – 4th-5th decades most common

• Why should we care?

– Can be highly incapacitating – Reduced ADLs, missed work economic impact

CLINICAL FINDINGS CALCIFIC TENDINITIS

• The culprit – Calcium hydroxyapatite crystal deposition in otherwise healthy

tendon – Distinguish from calcific enthesopathy secondary to tendon

degeneration

• Etiology and pathogenesis – Incompletely understood – Favored theory:

• Local in oxygen tension fibrocartilagenous metaplasia – Tenocyte chondrocyte intracellular calcification rupture of calcium into

extracellular space phagocytosis tendon remodeling

PATHOPHYSIOLOGY CALCIFIC TENDINITIS

NATURAL HISTORY OF CALCIFIC TENDINITIS CALCIFIC TENDINITIS

Stage Precalcific Calcific/Formative Resorptive Postcalcific

Cellular process

Local decrease in oxygen tension in an otherwise normal tendon

Fibrocartilagenous metaplasia results in calcium formation

Vascular invasion and migration of phagocytic cells with resultant resorption and edema

The deposit has been completely removed with relatively normal remodeled tendon taking its place

Calcification None Chalk-like consistency Toothpaste consistency None/minimal residual

Symptoms None low-grade shoulder pain that commonly increases at night

Spontaneous, sharp, severe pain

Usually none, occasional residual stiffness

• The differential for shoulder pain is broad and includes – Calcific tendinitis – Rotator cuff tear or tendinopathy – Adhesive capsulitis – Glenohumeral joint osteoarthritis – Subacromial-subdeltoid bursitis

• Imaging is key as clinical findings are often nonspecific

– No distinguishing specific symptoms for calcific tendinitis – Location of pain varies with position of calcification

• Supraspinatus involvement exacerbation with abduction • Subscapularis involvement mimics biceps tendon pathology

UTILITY OF IMAGING CALCIFIC TENDINITIS IMAGING

INCIDENCE AND LOCATION OF CALCIFICATIONS IMAGING

• Where do we see them? – Supraspinatus – 80%

• “Critical zone” 1.5-2 cm from insertion

– Infraspinatus – 15% • Lower third of the tendon

– Subscapularis – 5% • Preinsertional fibers

• How often do we see rotator cuff calcifications? – In 7.5-20% of asymptomatic

individuals – In 7% of symptomatic individuals – 50% of individuals with

calcifications will develop shoulder pain

Most common sites of calcific tendinitis in the shoulder. Coronal oblique PD (a), sagittal oblique T1 (b) and axial PD (c) MR images of a normal right shoulder are provided. a. The white arrow denotes the “critical zone” of the supraspinatus tendon 1.5-2 cm from its insertion on the greater humeral tuberosity. b. The black arrow denotes the lower third of the infraspinatus tendon. c. The white arrowhead denotes the preinsertional fibers of the subscapularis tendon. c.

b. a.

Large deposit of “quiescent” calcific tendinitis. Large cluster of calcifications (white arrows) in the supraspinatus tendon on (a) radiograph, (b) double oblique sagittal T2 fat sat MRI image and (c) transverse sonographic image. The greater tuberosity (white asterisks) serves as a landmark. Note the lack of surrounding edema and overlying bursitis. Large deposits can result in mild chronic pain and may cause limitations in motion due to the mechanical obstruction.

ROLE OF DIFFERENT IMAGING MODALITIES IMAGING

* a.

*

b.

* * * c.

ROLE OF DIFFERENT IMAGING MODALITIES IMAGING

• Radiographs – First line imaging – Helpful to confirm

presence of clinically important amounts of calcification

• MRI – Helpful to assess

integrity of the rotator cuff

– Can help confirm location of the calcifications

– Calcifications can be missed if radiographs are not available for correlation

• Ultrasound – Can identify and localize

calcifications – Can assess integrity of

the rotator cuff and assess the subacromial bursa

VARIABLE APPEARANCES OF CALCIFIC TENDINITIS IMAGING

Severe acute pain can develop in calcific tendinitis during the resorptive phase. 63-year-old woman presenting with sudden onset of severe shoulder pain without history of trauma. (a) AP radiograph demonstrates calcific deposits (white arrowheads) in the rotator cuff consistent with calcific tendinitis. Note the indistinct, fluffy borders of the calcifications compared to the better defined margins of the quiescent calcifications on the previous slide. (b) A Coronal T1 fat sat post-Gadolinium image from the subsequent MRI again demonstrates calcific tendinitis of the rotator cuff (white arrowhead) with associated marked enhancement of the overlying subdeltoid bursa (black arrows) consistent with bursitis.

a. b.

VARIABLE APPEARANCES OF CALCIFIC TENDINITIS IMAGING

• Imaging appearances vary based on the stage of calcific tendinitis

* *

c. d.

Calcific bursitis. 55-year-old woman with shoulder pain. (c) AP radiograph of the right shoulder demonstrates a large calcific deposit overlying the humeral head (black asterisks). (d) an oblique coronal T2 fat sat MR image confirms the location of the calcification to be within the subacromial/subdeltoid bursa (white asterisks). Calcific tendinitis can occasionally spontaneously rupture out of the tendon into the bursa, where it may continue to grow.

• Since calcific tendinitis is usually self-limited, any ideal treatment must be effective, safe and minimally invasive

Treatment Algorithm

• Short course of oral NSAIDs • Physiotherapy • Subacromial steroid injection

TREATMENT ALGORITHM MANAGEMENT

Calcific tendinitis of the shoulder

Asymptomatic No treatment required

Symptomatic Conservative therapy

Symptoms improve

Symptoms persist

Acetic acid iontophoresis

Ultrasound therapy

Shockwave lithotripsy

Surgery/arthroscopy

TREATMENT ALGORITHM MANAGEMENT

Ultrasound-guided lavage

• Failure of conservative management is not infrequent – 27% per Ogon et al, 2009

• Second line treatments all have drawbacks Treatment Pros Cons

Acetic acid iontophoresis Safe No more effective than physiotherapy or placebo

Ultrasound therapy Safe No more effective than physiotherapy or placebo

Shockwave lithotripsy Effective both short and long term with significant clinical improvement in 66-91%

• Frequently very painful • Requires special equipment

Arthroscopy or Surgery Very effective (substantial improvement in 79-100%)

• Rehabilitation is always required • Surgical complications • Considered last resort

WHEN SYMPTOMS PERSIST DESPITE CONSERVATIVE MANAGEMENT MANAGEMENT WHEN SYMPTOMS PERSIST DESPITE CONSERVATIVE MANAGEMENT MANAGEMENT

• Aka barbotage – Involves repeated injection and aspiration of small volumes of fluid

to break down and wash away calcifications – Always followed by subacromial bursa steroid injection (SBI) to

minimize bursitis

• A brief history – First described in 1978 by Comfort and Arafiles using fluoroscopic-

guidance and 2-needle technique – Farin, Jaroma et al showed feasibility of ultrasound-guided

technique in 1995 – Aina et al first described a modified single-needle technique in

2001

…AND THEN THERE IS CALCIFIC TENDINITIS LAVAGE MANAGEMENT …AND THEN THERE IS CALCIFIC TENDINITIS LAVAGE MANAGEMENT

• Some highlights from many clinical trials:

• De Witte et al, 2013: Lavage + SBI vs SBI alone – Significantly better clinical and radiographic results at 1 year with lavage +

subacromial bursa injection versus isolated subacromial bursa injection • Del Cura et al, 2007: Efficacy of single-needle lavage

– Led to significant improvement in shoulder motion, pain and disability, and radiographic findings both in short term and at 1 year

• Sarafini el al, 2009: Long-term follow-up of two-needle lavage

– Led to significantly better shoulder function and pain relief versus no treatment at 1 month, 3 months and 1 year, and similar outcomes at 5 and 10 years

– Only mild vagal-type reactions in 5% and no major complications.

CALCIFIC TENDINITIS LAVAGE IS SAFE AND EFFECTIVE BARBOTAGE CALCIFIC TENDINITIS LAVAGE IS SAFE AND EFFECTIVE BARBOTAGE

• Average procedure duration: about 10 minutes

• Serafini et al, 2009: – Cost for lavage: $120 – Cost for cycle of lithotripsy: $4,500 – Cost for arthroscopic debridement: $34,000

…AND IS ALSO RELATIVELY QUCIK AND COST-EFFECTIVE BARBOTAGE …AND IS ALSO RELATIVELY QUICK AND COST-EFFECTIVE BARBOTAGE

• Indications – Failed conservative

management – Calcific deposit

measuring at least 5 mm – Appropriate for acute

severe pain or chronic discomfort

• Contraindications – Active infection – Blood thinners

• Should be stopped – Contraindication to

corticosteroids – Allergy to anesthetics or

corticosteroids

PATIENT SELECTION BARBOTAGE PATIENT SELECTION BARBOTAGE

• Share many similarities

• No study has confirmed one to be superior to the other – Some research (Ferrero et al, 2014) suggests no significant

difference in clinical outcomes between the two techniques

• Ultimately comes down to user preference

• We use the one-needle technique at our institution and so will focus on this in this presentation with a quick review of the two-needle technique at the end

ONE VERSUS TWO NEEDLE TECHNIQUE BARBOTAGE ONE-NEEDLE VERSUS TWO-NEEDLE TECHNIQUE BARBOTAGE

• We will walk through a real case step by step

• Pre-procedure workup, correct equipment and proper patient positioning all help make calcific tendinitis lavage easier for the patient to tolerate and more straightforward for the practitioner to perform

WALKTHROUGH OF ONE-NEEDLE CALCIFIC TENDINITIS LAVAGE BARBOTAGE WALKTHROUGH OF ONE-NEEDLE CALCIFIC TENDINITIS LAVAGE BARBOTAGE

• Review prior imaging – Radiographs are essential

• Examine patient sonographically – Confirm presence and location of

calcification – Exclude a tendon tear or other

pathology • Obtain informed consent

PRE-PROCEDURE CHECKLIST SINGLE-NEEDLE LAVAGE PRE-PROCEDURE CHECKLIST SINGLE-NEEDLE LAVAGE

• Sterile cleaning and drape kit • Sterile gloves • For local anesthetic:

– 1x 10 mL syringe with 10 mL buffered 1% lidocaine

– 1 x 25 G 1.5 inch needle – (Optional: 1 x 30 G 0.5 inch

needle for initial skin anesthetic)

• For lavage: – 4 x 10 mL syringe with 50:50

mixture of 1% lidocaine and bacteriostatic sterile saline

– 1 x 18 G 1.5 inch needle • For subacromial bursa

injection: – 1 x 5 mL syringe with 1 mL

Triamcinolone 40 mg/mL, 1 mL preservative-free 1% lidocaine and 1 mL 0.5% ropivacaine

EQUIPMENT SINGLE-NEEDLE LAVAGE EQUIPMENT SINGLE-NEEDLE LAVAGE

Needle size • Authors disagree on

ideal needle size • Ranges from 16 G to

22 G • Compromise

between risk of tendon injury vs improved calcium retrieval and less risk of obstruction

• We use 18 G

Temperature and solution composition

• Some authors use saline • Some authors (Sconfienza et al,

2012) promote warmed solutions • We feel a 50:50 mix with

lidocaine decreases discomfort • We use a room-temperature

mixture for convenience

Ultrasound machine with linear probe (we prefer 12-5 MHz linear array probe) and sterile probe cover

Lee KS, Rosas HG. AJR AM J Roentgenol 2010

Lee KS, Rosas HG. AJR AM J Roentgenol 2010

Patient positioning for lavage. (a) The patient is semi-reclined in a supine position with the arm placed behind her back. This results in anterior rotation of the greater tuberosity of the humeral head along with the distal supraspinatus tendon, uncovering it from the overlying acromion. (b) Sonographic image demonstrating a large calcific deposit (white arrows) in the distal supraspinatus tendon. The greater tuberosity of the humeral head (white asterisk) serves as a useful landmark. Due to appropriate patient positioning, the calcific deposit is easily accessible by needle.

* *

PATIENT POSITIONING SINGLE-NEEDLE LAVAGE

a.

b.

PATIENT POSITIONING SINGLE-NEEDLE LAVAGE

Lee KS, Rosas HG. AJR AM J Roentgenol 2010

APPROPRIATE PROBE POSITION AND NEEDLE APPROACH SINGLE-NEEDLE LAVAGE APPROPRIATE PROBE POSITION AND NEEDLE APPROACH SINGLE-NEEDLE LAVAGE

*

Lee KS, Rosas HG. AJR AM J Roentgenol 2010

Appropriate probe positioning and needle approach. To minimize potential injury to the supraspinatus tendon, the needle should approach the calcific deposit along the long axis of the rotator cuff. The needle should be directed cranially to allow gravity to assist with aspiration of the calcific debris. (a) The yellow line indicates the orientation of the ultrasound probe to allow visualization of the supraspinatus in long axis. The red dot indicates the skin entry site of the needle. (b) Sonographic image demonstrates an 18-gauge 1.5 inch needle (white arrowheads) traversing the soft tissues and contacting the calcific deposit (white asterisk) in the supraspinatus tendon.

b. a.

Washing away the pain. Calcific tendinitis lavage works by repeated injection and aspiration of small volumes of fluid into the calcification to break it up from the inside. Once the needle tip is positioned within the calcific deposit, continuous small pumps (a) of the syringe plumber are applied, causing breakdown of the calcification due to dissolution and pressure waves from the injected fluid (b). Between each pump, the build up of backpressure pushes fluid and calcific debris back into the syringe without the operator needing to actively aspirate (c and d). It is important to avoid fenestrating the calcific deposit, as doing so might allow the injected fluid to decompress through the resultant holes and prevent backpressure from building up.

a. b.

c. d.

HOW DOES IT WORK? SINGLE-NEEDLE LAVAGE

CALCIFIC TENDINITIS BEFORE AND AFTER LAVAGE SINGLE-NEEDLE LAVAGE CALCIFIC TENDINITIS BEFORE AND AFTER LAVAGE SINGLE-NEEDLE LAVAGE

a.

*

b.

Calcific tendinitis before and after lavage. Rather than attempt to fenestrate the calcification, the needle tip is buried in the center of the calcific deposit with a single pass, which allows for greater build up of internal pressure from the pulsatile injection of a 50:50 solution of sterile saline and 1% lidocaine, resulting in improved probability of disrupting the calcific deposit. (a) Demonstrates the needle tip (black arrowhead) buried in the echogenic calcific deposit (white arrows) prior to lavage. (b) Demonstrates the calcific deposit after lavage. The deposit has been disrupted from the inside with an “exploded” appearance and hypoechoic fluid (white asterisk) now in its center. It is not necessary to aspirate all the calcium, as disrupting the deposit will incite an inflammatory reaction that usually results in resorption of most remaining calcium. Following the lavage we always inject a mixture of steroids and local anesthetic into the subacromial bursa to decrease symptoms from bursitis incited by the procedure.

CALCIFIC TENDINITIS BEFORE AND AFTER LAVAGE SINGLE-NEEDLE LAVAGE QUICK VIDEO RUN-THROUGH OF THE MAIN PROCEDURE SINGLE-NEEDLE LAVAGE

We will breakdown the procedure step by step on the following slides

Video rendered in Maya by S. Sheehan

STEP-BY-STEP (AFTER SKIN CLEANING AND STERILE DRAPING) SINGLE-NEEDLE LAVAGE

• The needle is directed cranially to allow gravity to assist with aspiration of the calcific debris.

• The needle tip is advanced into the calcification, preferably in one pass.

• Repeatedly pump and release the plunger to break up the calcification.

STEP-BY-STEP (AFTER SKIN CLEANING AND STERILE DRAPING) SINGLE-NEEDLE LAVAGE

STEP-BY-STEP SINGLE-NEEDLE LAVAGE

• Periodically check the syringe for calcific debris and switch syringes if there is build up.

• Continue until you are satisfied with the amount of calcium removed. If there are multiple deposits, reposition the needle tip into each one and repeat.

• Finally reposition the needle tip in the subacromial bursa with your 18 gauge needle, switch to the syringe containing your steroid mixture, and inject into the bursa.

STEP-BY-STEP PART 2 SINGLE-NEEDLE LAVAGE

The calcific debris tends to layer in the syringe (yellow arrows) and resembles the “snow” seen in a snow globe Lee KS, Rosas HG. AJR AM J Roentgenol 2010

Lee KS, Rosas HG. AJR AM J Roentgenol 2010

No residual calcification is seen Black arrowheads outline the distending bursa

Continuous small pulsations are produced with a 20 mL syringe

The injected fluid breaks down the calcifications and carries the debris into the other needle tip. Note that both needle bevels face each other to enable this.

The injected solution and calcific debris drains from the hub of the needle

• Usually requires two 16 G needles • Two needles allow continuous

inflow and outflow of solution to remove calcium

A QUICK SUMMARY TWO-NEEDLE LAVAGE A QUICK SUMMARY TWO-NEEDLE LAVAGE

Pre- and post-barbotage imaging. Radiographs of the left shoulder in a patient with calcific tendinitis (a) before and (b) four week following lavage. There has been complete radiographic resolution of the calcific deposit (black arrow) seen prior to the procedure with no residual rotator cuff calcifications identified (white arrow).

FOLLOW UP BARBOTAGE

a. b.

FOLLOW UP BARBOTAGE

Lee KS, Rosas HG. AJR AM J Roentgenol 2010 Lee KS, Rosas HG. AJR AM J Roentgenol 2010

i.e. what to tell the patient to expect • Rest for 48 hours • NSAIDs for pain relief after procedure • Avoid heavy lifting for 2 weeks • Resume physiotherapy after 1 week • Pain may get worse for the first few days until

the steroid injection takes affect

FOLLOW UP CARE SINGLE-NEEDLE LAVAGE FOLLOW UP CARE BARBOTAGE

• Infection is main concern, but extremely rare if proper sterile technique is used

• Subacromial bursitis is commonly induced by the procedure – This is why a subacromial bursa steroid injection should

always be performed after lavage

• Serafini et al, 2009: – Mild vagal reactions in 12 (5.1%) of 235 procedures – No other immediate complications documented

COMPLICATIONS BARBOTAGE COMPLICATIONS BARBOTAGE

• Is it necessary to try and remove all of the calcifications? – No: lavage incites a reaction by the body that usually leads to removal of most if not all of the

residual calcifications • Is it a bad sign if I don’t see any calcium debris in my syringe?

– No: for the reason listed above, aspiration of calcium is not absolutely necessary for the procedure to be clinically successful

• What if the needle becomes blocked? – Try switching the syringe first. If necessary, you may need to switch to a new needle, but this is

uncommon. • What if I can’t do ANYTHING to the calcification with lavage?

– Fenestration can be used as a last ditch effort. While this will not allow aspiration of debris, the mechanical disruption of the calcific deposit will usually elicit a reaction from the body that will result in resorption of most of the calcium

• Will I tear the tendon with lavage? – It is a theoretical risk, but very uncommon when proper technique is used, including ensuring a

needle approach along the long axis of the tendon • Do I always need to do a subacromial bursa injection at the end?

– Yes: the procedure itself will likely irritate the bursa, and patients may experience a significant flare up of shoulder pain if a steroid injection is not performed

FREQUENT QUESTIONS AND TROUBLESHOOTING BARBOTAGE FREQUENT QUESTIONS AND TROUBLESHOOTING BARBOTAGE

• Calcific tendinitis is a common cause of shoulder pain for which radiographs should always be obtained.

• Ultrasound-guided lavage is a quick, safe and effective procedure to manage symptomatic calcific tendinitis recalcitrant to conservative management.

• There is no significant different in clinical outcomes between the one- and two-needle techniques.

• This procedure should be offered in every ultrasound practice!

TAKE HOME POINTS CONCLUSION TAKE HOME POINTS CONCLUSION

1. Aina R, Cardinal E, Bureau NJ, Aubin B, Brassard P. Calcific Shoulder Tendinitis: Treatment with Modified US-guided Fine-Needle Technique. Radiology 2001;221:455-61.

2. AIUM Practice Parameter for the Performance of Selected Ultrasound-Guided Procedures (2014). 3. De Witte PB, van Adrichem RA, Selten JW, Nagels J, Reijnierse M, Nelissen RGHH. Radiological and clinical predictors of long-term outcome in rotator cuff

calcific tendinitis. Eur Radiol 2006;26:3401-11. 4. Del Cura JL, Torre I, Zabala R, Legorburu A. Sonographically Guided Percutaneous Needle Lavage in Calcific Tendinitis of the Shoulder: Short- and Long-

Term Results. AJR Am J Roentgenol 2007;189:W128-34. 5. Diehl P, Gerdesmeyer L, Gollwitzer H, Sauer W, Tischer T. Calcific tendinitis of the shoulder. Orthopade 2011;40:733-46. 6. Farin PU, Jaroma H, Soimakallio S. Rotator Cuff Calcifications: Treatment with US-guided Technique. Radiology 1995;195:841-3. 7. Ferrero G, Fabbro E, Orlandi D, Sconfienza LM, Lacelli F, Serafini G, Silvestri E. Ultrasound-guided percutaneous treatment of rotator cuff calcific

tendinitis: randomized comparison between one- and two-needle procedure. Presented at: European Congress of Radiology, Vienna, 2014. 8. Lee KS, Rosas HG. Musculoskeletal ultrasound: how to treat calcific tendinitis of the rotator cuff by ultrasound-guided single-needle lavage technique. AJR

AM J Roentgenol 2010;195:638. 9. Lin JT, Adler RS, Bracilovic A, Cooper G, Sofka C, Lutz GE. Clinical Outcomes of Ultrasound-guided Aspiration and Lavage in Calcific Tendinosis of the

Shoulder. HSSJ 2007;3:99-105. 10. Ogon P, Suedkamp NP, Jager M, Izadpanah K, Koestler W, Maier D. Prognostic Factors in Nonoperative Therapy for Chronic Symptomatic Calcific

Tendinitis of the Shoulder. Arthritis Rheum 2009;60:2978-84. 11. Saboeiro GR. Sonography in the Treatment of Calcific Tendinitis of the Rotator Cuff. J Ultrasound Med 2012;31:1513-8. 12. Sconfienza LM, Bandirali M, Serafini G, et al. Rotator Cuff Calcific Tendinitis: Does Warm Saline Solution Improve the Short-term Outcome of Double-

Needle US-guided Treatment? Radiology. 2012;262:560–6. 13. Sconfienza LM, Vigano S, Martini C, Aliprandi A, Randelli P, Serafini G, Sardanelli F. Double-needle ultrasound guided percutaneous treatment of rotator

cuff calcific tendinitis: tips & tricks. Skeetal Radiol 2013;42:19-24. 14. Farin PU, Rasanen H, Jaroma H, Harju A. Rotator cuff calcifications: treatment with ultrasound-guided percutaneous needle aspiration and lavage.

Skeletal Radiol 1996;25:551-4. 15. Serafini G, Sconfienza LM, Lacelli F, Silvestri E, Aliprandi A, Sardanelli F. Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two-

needle us-guidedpercutaneous treatment--nonrandomized controlled trial. Radiology 2009;252:157-64.

REFERENCES CONCLUSION REFERENCES CONCLUSION

THANK YOU!

How to Wash the Pain Away��Ultrasound-Guided Lavage for the Treatment of Calcific Tendinitis of the Shoulder Slide Number 2Slide Number 3Slide Number 4Slide Number 5Slide Number 6Slide Number 7Slide Number 8Slide Number 9Slide Number 10Slide Number 11Slide Number 12Slide Number 13Slide Number 14Slide Number 15Slide Number 16Slide Number 17Slide Number 18Slide Number 19Slide Number 20Slide Number 21Slide Number 22Slide Number 23Slide Number 24Slide Number 25Slide Number 26Slide Number 27Slide Number 28Slide Number 29i.e. what to tell the patient to expectSlide Number 31Slide Number 32Slide Number 33Slide Number 34Slide Number 35