Value of imaging to guide interventional procedures in rheumatic and musculoskeletal diseases: a systematic literature review informing EULAR points to consider

Abstract

ObjectivesTo summarise current data on the value of imaging to guide interventional procedures in patients with rheumatic and musculoskeletal disease (RMDs) informing an European Alliance of Associations for Rheumatology taskforce.MethodsA systematic literature review was conducted to retrieve prospective and retrospective studies published in English and comparing different (imaging) techniques, different settings and procedural protocols to guide interventions in patients with RMDs. MEDLINE, EMBASE, the Cochrane Library and Epistemonikos databases were searched through October 2021. Risk of bias (RoB) was assessed using the Cochrane RoB tool for randomised trials V.2 (ROB2), the RoB tool for Non-Randomised Studies of Interventions and the appraisal tool for cross-sectional studies.ResultsSixty-six studies were included (most with moderate/high RoB); 49 were randomised controlled trials, three prospective cohort studies and 14 retrospective studies. Fifty-one studies compared either one imaging technique with another imaging technique, or with palpation-guided interventions. Ultrasound (US) was most frequently studied (49/51), followed by fluoroscopy (10/51). Higher accuracy was found for US or fluoroscopy compared with palpation-guided interventions. Studies comparing different imaging techniques (12/51) did not endorse one specific method. Different settings/equipment for imaging-guided procedures (eg, automatic vs manual syringes) were investigated in three studies, reporting heterogeneous results. Fifteen studies compared different imaging-guided procedures (eg, intra-articular vs periarticular injections).ConclusionHigher accuracy of needle positioning at joints and periarticular structures was seen in most studies when using imaging (especially US) guidance as compared with palpation-guided interventions with the limitation of heterogeneity of data and considerable RoB.

EULAR points to consider for the use of imaging to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs)

“…10 Some of them reported more adverse events in patients undergoing palpation guided injections (eg, hand weakness, finger numbness, skin discolouration or subcutaneous fat atrophy) 30 31 whereas others found no difference in terms of safety and efficacy. 10 The task force members recognised that most studies might have been underpowered to detect rare adverse events such as accidental nerve puncture or injury of the persistent median artery, particularly in patients with anatomical variants of the median nerve. Based on clinical experience, such adverse events can easily be avoided if imaging is used to guide the injections.…”

“…Details of the studies cited are summarised in the SLR accompanying these PtC. 10 B. Imaging guided interventional procedures should be conducted under adequate aseptic conditions.…”

“…Evidence from clinical studies indicate a better accuracy (including correct needle placement and superiority in tissue and fluid acquisition) and safety (less procedural and postprocedural pain and discomfort) for imaging than for palpation guided interventions whereas data regarding short-term and long-term efficacy are contrasting. 10 The most important limitation of these studies, however, is that they did not detangle easy (eg, subcapsular space of a highly swollen joint) from difficult to reach targets (eg, small ganglion compressing a peripheral nerve). Accordingly, the task force had to extrapolate the evidence to conclude that imaging should be preferred when a high level of precision is needed in order to reach a specific anatomical area.…”

“…The majority of studies at peripheral joints were available for US and fluoroscopy with comparable results concerning efficacy and accuracy. 10 While fluoroscopy is still widely used in clinical practice, 25 the task force agreed that US should be preferred over fluoroscopy if both techniques were available with similar Intra-articular injections in sacroiliitis and ACJ arthritis 8 18 19 Periarticular Superior for short-term, 19 and long-term pain 18 Shoulder joint injections in adhesive capsulitis 46 47 SASD bursa Superior for short-term, 47 and long-term pain. 46 47 Mixed results for efficacy Subscapularis muscle injection in scapular pain 48 Scapulothoracic bursa No difference in safety and efficacy Medial access for knee injections in OA 49 50 Midlateral/superolateral access No difference in safety and accuracy US in-plane injection in knee OA 51 US out-of-plane No difference in accuracy, adverse events or procedural time Bone biopsy in suspected osteomyelitis 52 Paravertebral soft tissue No difference in tissue acquisition Intra-tendon sheath injection in trigger fingers 53 54 Extra tendon sheath No difference in safety and efficacy Intra-epineurium injections in CTS 29 Extra-epineurium Superior for symptom severity and efficacy Ulnar access for injection in CTS 55 56 Midline/radial access Inferior for long-term pain reduction compared with radial access 55 Injection above the median nerve in CTS 57 Injection under the median nerve No difference in safety and efficacy ACJ, acromioclavicular joint; CTS, carpal tunnel syndrome; OA, osteoarthritis; SASD, subacromial/subdeltoid; US, ultrasound.…”

“…MRI is rarely used to guide injections at the spine and there are little data from clinical studies to support its use. 10…”