Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)—part VII, nerves of the lower limb
Authors: Sconfienza Luca Maria , Adriaensen Miraude , Albano Domenico , Alcala-Galiano Andrea , Allen Georgina , Aparisi Gómez Maria Pilar , Aringhieri Giacomo , Bazzocchi Alberto , Beggs Ian , Chianca Vito , Corazza Angelo , Dalili Danoob , De Dea Miriam , del Cura Jose Luis , Di Pietto Francesco , Drakonaki Elena , Facal de Castro Fernando , Filippiadis Dimitrios , Gitto Salvatore , Grainger Andrew J. , Greenwood Simon , Gupta Harun , Ivanoski Slavcho , Khanna Monica , Klauser Andrea , Mansour Ramy , Martin Silvia , Mascarenhas Vasco , Mauri Giovanni , McCarthy Catherine , McKean David , McNally Eugene , Melaki Kalliopi , Messina Carmelo , Miron Mombiela Rebeca , Moutinho Ricardo , Olchowy Cyprian , Orlandi Davide , Prada González Raquel , Prakash Mahesh , Posadzy Magdalena , Rutkauskas Saulius , Snoj Žiga , Tagliafico Alberto Stefano , Talaska Alexander , Tomas Xavier , Vasilevska Nikodinovska Violeta , Vucetic Jelena , Wilson David , Zaottini Federico , Zappia Marcello , Isaac Amanda 
Published: September 2021

Abstract

Objectives
To perform a Delphi-based consensus on published evidence on image-guided interventional procedures for peripheral nerves of the lower limb (excluding Morton’s neuroma) and provide clinical indications.

Methods
We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around peripheral nerves in the lower limb (excluding Morton’s neuroma) to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper.

Results
Nine statements on image-guided interventional procedures for peripheral nerves of the lower limb have been drafted. All of them received strong consensus. Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications. US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role. US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia.

Conclusion
Despite the promising results reported by published papers on image-guided interventional procedures for peripheral nerves of the lower limb, there is still a lack of evidence on the efficacy of most procedures.

Key Points
• Image-guided pudendal nerve block is safe, effective, and well tolerated with few complications.
• US-guided perisciatic injection of anesthetic provides good symptom relief in patients with piriformis syndrome; however, the addition of corticosteroids to local anesthetics still has an unclear role.
• US-guided lateral femoral cutaneous nerve block can be used to provide effective post-operative regional analgesia. The volume of local anesthetic affects the size of the blocked sensory area.