Shoulder MR Arthrography: Comparative Evaluation of Three Different Contrast Injection Techniques Using an Anterior Approach

Abstract

BackgroundMR arthrography (MRA) is commonly used in the assessment of shoulder internal derangements. Correct intra‐articular contrast injection is required for this modality. Anterior injections under fluoroscopic, ultrasound‐guidance, or without image‐guidance have been described in the literature. However, no simultaneous comparison has been performed between the three techniques.PurposeTo compare the accuracy and performance of fluoroscopy (FL)‐guided, ultrasound (US)‐guided and non‐image‐guided intra‐articular contrast injection via an anterior approach for performing shoulder MRA.Study TypeProspective.SubjectsTwo‐hundred and ten patients (180 men and 30 women; mean age, 33 ± 12 years; range 20–60 years) with clinically suspected shoulder pathology.Field Strength/Sequence1.5T/fat‐suppressed T1‐weighted, T2‐weighted, and 3D‐gradient‐echo images.AssessmentPatients underwent shoulder MRA after anterior intra‐articular contrast injection under FL‐ or US‐guidance or without image‐guidance. Patients were randomized among the three techniques with each group comprising 70. The techniques were compared according to the accuracy of intra‐articular needle placement, attempts success rate, pain during and 24 hours after injection, procedure times, contrast extravasation rate, joint distension, and MRA diagnostic efficacy. Pain was assessed by the visual analog scale (VAS) pain‐score.Statistical TestsPearson's chi‐squared and Kruskal–Wallis tests.ResultsFL‐ and US‐guided injections (100% accuracy) were significantly more accurate than non‐image‐guided (85.7% accuracy) (P < 0.05). US‐guidance was the least painful, with statistical differences between image‐guided and non‐image‐guided techniques regarding the first attempt success rate (95.7% and 92.8% for FL‐ and US‐guided vs. 78.6% for blinded), VAS‐score 24 hours‐post‐procedure (1.7 ± 1.7, and 1.5 ± 1.4 vs. 2.2 ± 1.4), procedure time (11.9 ± 1.6, and 7.4 ± 1.7 vs. 4.3 ± 0.76 minutes), and contrast extravasation rate (5.7%, and 8.6% vs. 30%) (all P < 0.05). Procedure time was also significantly different between FL and US‐guidance (P < 0.05).Data ConclusionImaging‐guided injections are more accurate and tolerable than non‐image‐guided and should be considered to confirm intra‐articular needle position, hence adequate capsular distension and good diagnostic quality of shoulder MRA. US guidance is a less painful, rapid, and safe alternative to the FL approach.Evidence Level: 2Technical Efficacy Stage: 5.J. MAGN. RESON. IMAGING 2021;53:481–490.

Is the Anterior Injection Approach Without Ultrasound Guidance Superior to the Posterior Approach for Adhesive Capsulitis of the Shoulder? A Sequential, Prospective Trial

“…In this sequential, prospective trial, we presented a new anterior landmark-based approach without the use of ultrasound, and found it was more accurate than the posterior approach. Moreover, the new anterior approach is nearly as accurate as other published ultrasound-guided approaches [1, 5, 9, 11, 13]. Consequently, we recommend using the new anterior approach in practice as it will save time and the cost associated with ultrasound.…”

“…In this prospective study, we compared two landmark-based approaches: the posterior approach and a new anterior injection approach. The new anterior approach, without the use of ultrasound, is nearly as accurate as other published ultrasound-guided approaches [1, 5, 9, 11, 13]. Therefore, we recommend using the new anterior approach for intraarticular glenohumeral injections.…”

“…Injections are administered either through imagebased or landmark-based injection approaches, as well as with ultrasound guidance. Ultrasound-guided injections are widely used and accurate because ultrasound allows real-time visualization of the needle and injected contrast [1,5,9,11]. However, ultrasound-guided injections are more challenging as they require training to coordinate the transducer and needle at the same time [2], and not every clinician or general practitioner has the ability to use ultrasound in general practice or has access to a machine.…”

Ultrasound-guided interventions of the upper extremity joints

“…Direct contrast injection can be performed under fluoroscopic guidance and ultrasound guidance or by palpation. Both fluoroscopic and ultrasound guidance have high accuracy (up to 100%) and are preferred over non-image-guided injection [ 20 ]. The accuracy of fluoroscopic versus ultrasound-guided contrast injection is comparable, although ultrasound has the advantage of lack of radiation and may be better tolerated.…”

“…The accuracy of fluoroscopic versus ultrasound-guided contrast injection is comparable, although ultrasound has the advantage of lack of radiation and may be better tolerated. Two studies comparing ultrasound versus fluoroscopic-guided contrast injection showed significantly shorter procedure times and lower reported pain for ultrasound-guided procedures [ 20 , 21 ].…”