Image-guided versus blind corticosteroid injections in adults with shoulder pain: A systematic review

Abstract

BackgroundCorticosteroid injections can be performed blind (landmark-guided) or with image guidance, and this may account for variable clinical outcomes. The objective of this study was to assess the effectiveness and safety of image-guided versus blind corticosteroid injections in improving pain and function among adults with shoulder pain.MethodsMEDLINE, the Cochrane Controlled Trials Register and EMBASE were searched to May 2010. Additional studies were identified by searching bibliographies of shortlisted articles. Search items included blind, landmark, anatomical, clinical exam, image-guided, ultrasound, fluoroscopy, steroid injection, frozen shoulder, random allocation, randomized controlled trial (RCT) and clinical trial.Randomized controlled studies comparing image-guided versus blind (landmark-guided) corticosteroid shoulder injections that examined pain, function and/or adverse events were included. Independent extraction was done by two authors using a form with pre-specified data fields, including risk of bias appraisal. Conflicts were resolved by discussion. The decision to pool data was based on assessment of clinical design homogeneity. When warranted, studies were pooled under a random-effects model.ResultsTwo RCTs for pain, function and adverse events (n = 101) met eligibility criteria. No serious threats to validity were found. Both trials compared ultrasound-guided versus landmark-guided injections and were judged similar in clinical design. Low to moderate heterogeneity was observed: shoulder pain I2 = 60%, function I2 = 22%. A meta-analysis demonstrated greater improvement with ultrasound-guided injections at 6 weeks after injection in both pain (mean difference = 2.23 [95% CI: 1.27, 3.18]), as assessed with a 0 to 10 visual analogue scale, and shoulder function (standardised mean difference = 1.09 [95% CI: 0.61, 1.57]) as assessed with shoulder function scores. Although more adverse events (all mild) were reported with landmark-guided injections, the difference was not statistically significant (risk ratio = 0.20 [95% CI: 0.04, 1.13]).This review was only based on two moderate-sized trials. Blinding of patients was not performed in both trials, causing some risk of bias in outcome assessment since primary endpoints were wholly or partially patient-reported.ConclusionThere is a paucity of RCTs on image-guided versus landmark-guided corticosteroid shoulder injections examining pain, function and adverse events. In this review, patients who underwent image-guided (ultrasound) injections had statistically significant greater improvement in shoulder pain and function at 6 weeks after injection. Image-guided (ultrasound) corticosteroid injections potentially offer a significantly greater clinical improvement over blind (landmark-guided) injections in adults with shoulder pain. However, this apparent benefit requires confirmation from further studies (adequately-powered and well-executed RCTs).

Should we continue to administer blind shoulder injections?

“…Furthermore, no difference was detected at first entry in fluoroscopic injection Many studies indicate that superior and earlier improvement in shoulder pain and increased range of motion in the shoulder joint are possible with US-guided injections compared to blind injections. [2,5,14] In our study, clinically improved pain was observed in all patients except one. Decrease in VAS scores continued for one month.…”

“…[1] Intra-articular injections are widely used to treat shoulder pain and can be administered blindly using anatomical or imaging guidance techniques such as ultrasound (US) or fluoroscopy (FL). [2,3] In daily practice, most of the intra-articular injections have been performed blindly for many years. However, performing the injections to the wrong place may reduce the effectiveness of treatment.…”

Musculoskeletal Ultrasound in Physical Medicine and Rehabilitation

“…The data are conflicting whether this translates into improved clinical efficacy [9,[14][15][16]. Cost-effectiveness has also become an essential part of the equation when assessing the clinical utility of procedures and tests.…”

Ultrasound-Guided Interventional Procedures for Chronic Pain Management

“…US-guided shoulder injections appear to have a higher percentage of success, more effective analgesia and better functional recovery 6 weeks after injection [54,55].…”