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Technical Innovation |
1
Department of Diagnostic Radiology, Eberhard-Karls-University,
Hoppe-Seyler-Str. 3, 72076 Tübingen,
Germany.
2
Department of Rheumatology, Eberhard-Karls-University, 72076
Tübingen, Germany.
Received July 12, 1999;
accepted after revision December 8, 1999.
Address correspondence to P.L. Pereira.
Introduction
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The interventions were performed on a 0.2-T MR unit (Magnetom Open; Siemens, Erlangen, Germany) using a multipurpose coil. Patients were placed in a prone position within the MR system. Edematous changes of the sacroiliac joints were assessed, with inversion-recovery sequences (TR/TE, 4000/48; inversion time, 110; slice thickness, 6 mm) before intervention. To determine the accurate puncture site, we used a T1-weighted fast spin-echo sequence (400/15; slice thickness, 6 mm). All images were obtained in the axial plane. The puncture site was marked first with a capsule of nifedipine (Adalat 5; Bayer AG, Leverkusen, Germany) and subsequently with permanent ink. All interventions were performed with local anesthesia (Lidocaine 1%; Braun, Melsungen, Germany). For imaging-guided placement of the needle, we used a two-dimensional spoiled gradient-echo sequence (70/9; flip angle, 70°; slice thickness, 5 mm) in a paraaxial slice direction (Fig. 1A). In nonobese patients, near real-time imaging with a two-dimensional gradient-echo sequence (18/8; flip angle, 70°; slice thickness, 5 mm; measurement interval, 5.2 sec) during the insertion of the needle was available in-room on an additional shielded monitor (Fig. 1B). Correct positioning of the needle was verified with a spin-echo sequence (400/15; slice thickness, 6 mm) in an oblique plane along the needle axis (Fig. 1C). In accordance with results reported in the literature [1], we considered a penetration of at least 10 mm of the needle into the joint sufficient for an intraarticular location. Commercially available MR-compatible needles (0.9 x 100 mm Therapy needle; Somatex, Berlin, Germany) used in this procedure were visualized passively by their susceptibility artifacts.
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All patients underwent an MR examination on a 1.5-T imager (Magnetom Vision; Siemens) before the MR-guided intervention and underwent a followup examination 3 months later (time range, 72-109 days). The following MR examinations were performed with a phased array body coil with T1-weighted imaging (430/12), T2-weighted imaging (3300/17, 20), and fat-suppressed sequences (4800/22-90; inversion time, 180). Three radiologists, not aware of clinical data, reviewed all MR images to compare the extent of subchondral edema (mild = inferior to 25%, moderate = 25-50%, severe = superior to 50% of the sacroiliac joint) before intervention with that found 3 months after infiltration.
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All patients had subchondral marrow edema that resolved on follow-up MR examination minimally (n = 3), partially (n = 3), or completely (n = 3) after steroid injection. In one patient, no changes were observed at follow-up examination. Clinical response was deemed good to excellent in eight of 10 patients with a subjective improvement for a mean of 13.5 ± 5.4 months (time range, 5-19 months). Dolorimetry showed a marked decrease of pain after infiltration from 7.7 ± 0.6 to 3.1 ± 1.7 in responders. In patients who underwent bilateral infiltrations, improvement was always bilateral (n = 9). Two patients with relapse after 8 and 6 months were reinfiltrated and are troublefree to this day. Two nonresponders suffered from either reactive depression or fibromyalgia. In four patients, nonsteroidal antiinflammatory therapy could be discontinued while physiotherapy alone was maintained in three of these four patients. In three other patients, oral therapy could be reduced.
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The use of MR guidance for percutaneous procedures such as biopsies [6] or tumor ablations [7] has already been described. Frequent volumetric updates for assessing the position of the needle with fast gradient-echo sequences allow a safe percutaneous approach without the disadvantage of cumulative ionizing radiation. MR imaging additionally facilitates the procedure by generating images in any desired plane, especially images along the axis of the obliquely inserted needle, in contrast to CT with the inevitable repetition of overlapping scans for the search of the needle tip.
Before clinical application at our institution, many different sequences were performed during the procedures to determine which pulse sequences would be most useful during needle placement. With more technical expertise, fewer sequences are now used. The time required for the complete procedure was reduced to approximately 60 min for a bilateral and 40 min for a unilateral injection. We previously reported in experimental studies that the length of the needle is reproduced with an accuracy of ±2 mm caused by "blooming ball" artifacts [8]. Because a penetration of 10 mm into the joint space seems to be sufficient for an intraarticular location [1], a precision of ±2 mm in locating the needle tip can be considered sufficient. Considering the positive results achieved by other groups [1, 2, 3], we did not include a placebo-treated control group in our study. Under these circumstances, only an indirect comparison can be made. Periods of pain reduction lasted for 13.5 ± 5.4 months in our series and compared favorably with the 10 ± 5 months achieved by Bollow et al. [9] or the 9.6 ± 4.2 months reported by Maugars et al. [1] in 1992.
Concerning interventional MR, the most important finding of this study is that injections of corticosteroids into an inflamed sacroiliac joint can be successfully performed with MR imaging for guidance. Our results indicate that overall periods of pain reduction are at least equal to those achieved with CT or fluoroscopic techniques. Exposure to ionizing radiation with CT or fluoroscopic guidance is not to be underestimated. Considering that symptoms necessitating further interventions frequently recur in the course of the disease, we regarded this technique as particularly useful in young patients. Nevertheless, the time needed for placement of the needle with MR guidance, compared with the time required using fluoroscopy or CT, remains a drawback.
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