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Original Report |
1 Radiology Department, Centre Hospitalier de l'Université de
Montréal, Hôpital Saint-Luc, 1058 Saint-Denis St., Montreal, QC
H2X 3J4, Canada.
2 Division of Clinical Epidemiology, McGill University Health Center, Royal
Victoria Hospital, 687 Pine Ave. W, Ross 4.29, Montreal, QC H3A 1A1,
Canada.
Received July 29, 2003;
accepted after revision September 3, 2003.
Address correspondence to N. J. Bureau
(nathalie.bureau{at}umontreal.ca).
Abstract
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CONCLUSION. Shoulder arthrography using an anterior approach through the rotator cuff interval is an effective, rapid, and easy-to-perform injection technique. In most patients, this technique can be performed using a 1.5-inch (3.8-cm), 22-gauge needle.
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The Schneider technique uses a straight anteroposterior approach to the joint. A 3.5-inch (8.9-cm), 22-gauge needle is directed vertically at the junction of the middle and lower thirds of the glenohumeral joint under fluoroscopic guidance [2]. A recent study determined that the anterior stabilizing structures of the glenohumeral joint are often traversed by the needle when this technique is used, which may cause distortion of the healthy anatomic structures [5]. In our experience training residents, we found this technique to be difficult to master for many of them.
For many years, we have been using a modified anterior approach for shoulder arthrography: through the rotator cuff interval. We have found this technique to be effective and easy to teach to residents, who tend to rapidly master it. We were able to find only one brief description of a similar technique in the literature [9]. To our knowledge, this modified approach to enter the shoulder joint has never been specifically described in the literature, and our purpose is to do so here.
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Technique
Patients were positioned supinely on a fluoroscopy table (Diagnost 96,
Philips Medical Systems, St-Laurent, QC, Canada) with the arm in external
rotation (palm of the hand up) to avoid the long head of the biceps tendon or,
if this position was too painful for the patient, in neutral rotation (palm of
the hand against the thigh). With the X-ray tube perpendicular to the table,
the skin was marked over the upper medial quadrant of the humeral head close
to the articular joint line (Fig.
1A).
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Sterile technique was used, and the skin was anesthetized with lidocaine hydrochloride 1% (Xylocaine, Abbott Laboratories, St-Laurent, QC, Canada) using a 1.5-inch (3.8-cm) or a 3.5-inch (8.9-cm), 22-gauge needle. With intermittent fluoroscopy, we then advanced the needle parallel to the X-ray beam or with a slight medial angulation until it came in contact with the humeral head (Fig. 1B). A test injection of 0.5–1.0 mL of the anesthetic, which yields low resistance, helped to ascertain the intraarticular position of the needle. Finally, injection of iohexol USP 60% (Omnipaque, Mallinckrodt, Pointe-Claire, QC, Canada) through a short extension tubing confirmed the intraarticular position of the needle (Fig. 1C).
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Data Collection
Each patient's weight and height were recorded to assess body mass index, a
measure of body fat based on height and weight that applies to both adult men
and women. According to the National Institutes of Health, the body mass index
range is less than 18.5 kg/m2, underweight; 18.5–24.9
kg/m2, normal weight; 25–29.9 kg/m2, overweight;
and greater than or equal to 30 kg/m2, obese. The position of the
patient's shoulder (external or neutral) as seen under fluoroscopy at the
beginning of the procedure, the length of the needle used, and the time of
fluoroscopy needed to complete the procedure were assessed. We also recorded
the number of attempts required to achieve the intraarticular position of the
needle. The number of extraarticular injections of contrast material that were
made determined this. Inadvertent puncture of any extraarticular structure was
recorded, specifically looking for opacification of the long head of the
biceps tendon sheath. In the fluoroscopy room, immediately after the shoulder
injection was completed, patients were asked to verbally grade their level of
pain during the procedure on a scale of 0 (no pain) to 10 (worst pain
imaginable). Immediate complications such as exacerbation of baseline shoulder
discomfort, allergic reaction, and abnormal bleeding were assessed within 20
min after completion of the glenohumeral injection.
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At the beginning of the procedure, as seen under fluoroscopy, 48 patients (74%) appeared with the arm in external rotation and 17 (26%) with the arm in neutral rotation. The glenohumeral puncture was successful on the first attempt in 43 patients (90%) with the arm positioned in external rotation and 16 patients (94%) with the arm in neutral rotation. The long head of the biceps tendon sheath was never punctured.
Residents in training obtained 40 (62%) of the glenohumeral arthrograms with a mean fluoroscopy time of 35 sec (range, 12–86 sec). The mean level of pain reported by the patients during those procedures was 3.2 on a scale of 0–10. The patients with a clinical diagnosis of adhesive capsulitis (n = 21, 53%) reported a mean level of pain (3.8/10) slightly higher than the other 19 (47%) patients (2.4/10). A 1.5-inch (3.8-cm), 22-gauge needle was used in 31 procedures (78%) to achieve intraarticular injection. In nine patients (22%), a 3.5-inch (8.9-cm), 22-gauge needle was used to reach the glenohumeral joint because of increased thickness of the soft tissues in those patients or because the needle had not been placed directly parallel to the X-ray beam, which caused needle angulation and therefore a longer path between the skin puncture site and the joint entry site. The mean weight, height, and body mass index in these nine patients were 87 kg, 166 cm, and 32 kg/m2 (obesity range according to the NIH), respectively. Intraarticular injection of contrast material was achieved successfully on the first attempt in 34 patients (85%) and on the second attempt in four patients (10%). In one patient (2.5%), three attempts, and in another patient (2.5%), four attempts, were necessary to reach the intraarticular space.
The musculoskeletal radiologists completed all the procedures with intraarticular position of the needles on the first attempt. These radiologists obtained 25 glenohumeral arthrograms (38%) with a mean fluoroscopy time of 15.7 sec (range, 4–54 sec). The mean level of pain reported by the patients during the procedures was 2.7 on a scale of 0–10. The patients with a clinical diagnosis of adhesive capsulitis (n = 11, 44%) reported a mean level of pain slightly higher (3.1/10) than that (2.4/10) of the other 14 patients (56%). A 1.5-inch (3.8-cm), 22-gauge needle was used in 24 (96%) patients, seven of whom (29%) had a body mass index of more then 30 kg/m2 (obesity range). A 3.5-inch (8.9-cm), 22 gauge needle was used in one patient (4%) whose weight, height, and body mass index were 90 kg, 165 cm, and 33 kg/m2, respectively.
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Different techniques of shoulder arthrography have been described over the years, but we believe that the one most commonly used by radiologists today remains the Schneider technique because it is the one most radiologists were trained to use. The potential for this technique to cause distortion of the inferior glenohumeral ligament and anteroinferior labrum and create confounding findings at MR arthrography has been documented [5]. Hence, other authors have recently advocated a posterior approach to shoulder arthrography [5] when anterior shoulder disease is suspected or a modified anterior approach [11] to avoid injury to the labrum and inferior glenohumeral ligament.
For many years, we have been using an anterior approach that targets the rotator cuff interval. The rotator cuff interval constitutes a triangular space on the superomedial aspect of the humeral head. It is created by the perforation of the anterosuperior part of the rotator cuff by the coracoid process [12]. This space is located between the supraspinatus and subscapularis tendons (Fig. 2) and contains the medial and lateral bundles of the coracohumeral ligament. Deeper, the rotator cuff interval contains the superior glenohumeral ligament, frequently indistinct from the glenohumeral capsule. The long head of the biceps tendon runs through the interval but can be cleared laterally with external rotation of the arm.
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Targeting the rotator cuff interval therefore spares the subscapularis muscle and tendon, inferior glenohumeral ligament, and anteroinferior labrum of the shoulder. This modified technique allows the needle to be advanced until it contacts the medial upper third of the humeral head just lateral to the joint space, thus avoiding the anterosuperior labrum. Targeting the humeral head provides a depth limit to the insertion of the needle. Needle contact with the humeral head and a positive test injection with local anesthetic almost invariably ensure intraarticular position of the needle without confirmation by contrast material injection, which is sometimes necessary in patients who are allergic to iodine. With external rotation or neutral rotation of the arm, the long head of the biceps tendon is avoided. The subcoracoid bursa, which can be penetrated when a lower site of entry such as the junction between the middle third and lower third of the glenohumeral joint space is targeted, is easily avoided when the needle is aimed at the rotator cuff interval. A pitfall of this technique that we have encountered occurs when a patient has a long coracoid process that projects over the target site. This process can be seen fluoroscopically, and the procedure can be modified slightly by inserting the needle above the coracoid process and then angling posterior to it.
In 85% of our patients, some of them obese, a 1.5-inch (3.8-cm) needle was used successfully to enter the glenohumeral joint. This short needle is easier to manipulate than a 3.5-inch (8.9-cm) needle. A shorter needle can be used when entering the shoulder joint through the rotator cuff interval because the joint is more superficial in this location as compared with more inferiorly.
In this study, although the residents worked somewhat less rapidly than the staff radiologists, they completed the procedures on the first attempt in 85% of their patients, with their patients reporting a mean pain score similar to that of the patients treated by staff radiologists.
Although we have not performed a comparative study with the Schneider technique, we taught the Schneider technique to residents for many years before changing our technique to the one presented in this article. Our experience has been that residents learn and master the technique of shoulder arthrography more easily and more rapidly when using this modified approach than when using the Schneider technique. It is also the clear impression of experienced musculoskeletal radiologists that the procedure is easier and faster to perform than the Schneider technique. This modified technique of shoulder arthrography—aiming at the rotator cuff interval—is accurate, rapid, easy to perform, and well tolerated by patients.
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