CT-Guided Percutaneous Steroid Injection for Management of Inflammatory Arthropathy of the Temporomandibular Joint in Children
Abstract
OBJECTIVE. The purposes of this study were to retrospectively review an injection technique, to develop a grading system for evaluation of imaging findings, and to report preliminary outcome related to percutaneous CT-guided steroid injection into the temporomandibular joints of children with inflammatory arthropathy.
CONCLUSION. CT-guided steroid injection into the temporomandibular joint of children with inflammatory arthropathy results in clinical and imaging improvement in a substantial proportion of children treated.
Introduction
Juvenile idiopathic arthritis is a chronic disease of children characterized by inflammatory synovitis. Juvenile idiopathic arthritis encompasses both juvenile rheumatoid arthritis and the HLA-B27-associated spondyloarthropathy. The condition is defined by arthritis that persists for a minimum of 6 consecutive weeks, involves one or more joints, and begins before the age of 16 years [1]. Juvenile idiopathic arthritis occurs in approximately one in 1,000 North Americans and may lead to significant morbidity and deformity. Clinically, the knee, ankle, and finger joints are commonly involved [2].
Corticosteroid joint injection has been popularized as prompt and lasting therapy for juvenile idiopathic arthritis [3, 4]. Although radiologic evidence of temporomandibular joint (TMJ) involvement has been reported in as many as 63% of persons with juvenile idiopathic arthritis [5, 6], little attention has been paid to corticosteroid injection for inflammatory TMJ arthritis.
Normal TMJ anatomy is described in Figure 1. Evidence of inflammatory arthropathy on imaging of the TMJ includes acute changes such as joint effusion, inflamed synovium, and marrow edema; subacute changes including juxtaarticular erosion; and chronic changes such as beaking, flattening or loss of the mandibular condyle, bone sclerosis, and meniscal (disk) thinning and displacement. Most children with juvenile idiopathic arthritis also have clinical signs and symptoms of TMJ involvement and associated craniofacial growth alterations that result in malocclusion, facial asymmetry, restricted opening of the mouth (tooth-to-tooth gap), and facial pain [7]. Radiologic guidance has been shown to be useful for accurate injection of corticosteroids in deep and in small joints [8]. Injection into the TMJ can be worrisome because of the proximity of facial nervous and vascular structures. In addition, injection into the TMJ space is complicated by the disturbance of the normal TMJ anatomy caused by inflammatory joint destruction. We chose CT guidance as an approach to ensure proper needle placement in the involved TMJ.
The purposes of this study were to describe our injection technique, to develop a grading system for the description of imaging findings for use in future prospective treatment trials, to analyze imaging effects, and to report preliminary clinical outcome of intraarticular steroid injection into the TMJ of children with chronic arthropathy.
Materials and Methods
Patients
From October 2002 to February 2004, 27 CT-guided intraarticular TMJ steroid injections were performed in 14 girls and one boy with juvenile idiopathic arthritis (nine cases of arthritis were of the oligoarticular type; four, polyarticular type; one case, systemic; and one case, psoriatic arthropathy). Informed consent from the parent or legal guardian was obtained for all procedures. Institutional review board approval was obtained for this study.
At admission to the study, all patients were considered to have advanced involvement of the TMJ with facial asymmetry, limited mobility, or pain. A history of pain at the TMJ (measured at palpation, chewing, speaking, and rest) was elicited from eight of 15 patients before their first treatment session. These parameters are reported for patients with both preprocedure and postprocedure results (Table 1). Preprocedure MRI showed signs of inflammatory arthropathy in all 27 joints considered for treatment, including joint changes in 24 (89%) of 27 joints and bone changes in 27 of 27 joints (Table 2). Injections were administered to 27 joints during 17 sessions, 10 for bilateral injections and seven for unilateral injections, including repeated injections in two patients. The mean age of the study group was 8.3 years (range, 4.5-16 years). The mean weight was 29 kg (range, 18-50 kg).
| Patient No. | Pain | Clinical Change | ||
|---|---|---|---|---|
| Before Procedure | After Procedure | Pain | Tooth-to-Tooth Gap | |
| 1 | + | – | ↓ | ++++ |
| 3 | + | – | ↓ | + |
| 4 | + | – | ↓ | + |
| 10 | NA | NA | NA | + |
| 11 | NA | NA | NA | +++ |
| 13 | + | + | ↔ | + |
| 2 | NA | NA | NA | + |
| 6 | + | – | ↓ | ++ |
| 7 | + | – | ↓ | ++ |
| 9 | + | – | ↓ | NA |
| 8a | NA | NA | NA | – |
| 14 | + | – | ↓ | +++ |
Note—Assessment of temporomandibular joint pain and mobility (measured as tooth-to-tooth gap, that is, the space between the upper and lower incisors during maximal opening of mouth) before and 3–4 months after steroid injection for 12 of 17 treatment sessions. Pain diminished or resolved (↓) after seven (88%) of eight treatment sessions and persisted (↔) after one session. Patients experienced slight to substantial improvement in temporomandibular joint mobility after five (45%) of 11 treatment sessions and a decrease (–) after one session. This patient (no. 8) received a second treatment. NA = data not available, ++++ = 31–40% (substantial) improvement, +++ = 21–30% (moderate) improvement, ++ = 11–20% (slight) improvement, + = 0–10% (negligible) improvement
a
First injection for this patient
| Joint Changes | Bone Changes | Joint Changes | Bone Changes | ||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Patient No. | Effusion | Disk/Space | Erosion | Condylar Structure | Gradea Before | Effusion | Disk/Space | Erosion | Condylar Structure | Gradea After | Change | Follow-Up (wk) | |||||||||||
| R | L | R | L | R | L | R | L | R | L | R | L | R | L | R | L | R | L | R | L | R | L | ||
| 5 | + | + | nl | nl | + | + | + | + | 4a | 4a | ⇓ | ⇓ | nl | nl | ⇔ | ⇔ | ⇔ | ⇔ | 4 | 4 | ⇓ | ⇓ | 24.8 |
| 8b | + | + | nl | + | + | + | + | + | 4a | 4a | ⇓ | ⇓ | nl | ⇔ | ⇓ | ⇓ | ⇓ | ⇔ | 4 | 4a | ⇓ | ⇓ | 22.4 |
| 11 | + | + | nl | nl | + | + | + | + | 4a | 4a | ⇓ | ⇔ | nl | nl | ⇑ | ⇑ | ⇔ | ⇔ | 4a | 4a | ⇔ | ⇔ | 26.4 |
| 12c | + | + | nl | nl | + | + | nl | nl | 3a | 3a | ⇑ | ⇑ | ⇑ | ⇑ | ⇑ | ⇔ | nl | nl | 3a | 3a | ⇑ | ⇑ | 23.4 |
| 13 | + | + | nl | nl | + | + | nl | nl | 3a | 3a | ⇓ | ⇓ | nl | nl | ⇔ | ⇔ | nl | nl | 3 | 3 | ⇓ | ⇓ | 29.1 |
| 6 | NA | nl | NA | + | NA | nl | NA | + | NA | 4 | NA | nl | NA | ⇔ | NA | nl | NA | ⇔ | NA | 4 | NA | ⇔ | 54.6 |
| 7 | NA | + | NA | nl | NA | + | NA | nl | NA | 4a | NA | ⇓ | NA | nl | NA | ⇓ | NA | nl | NA | 4 | NA | ⇓ | 46.4 |
| 9 | NA | + | NA | nl | NA | + | NA | + | NA | 4a | NA | ⇓ | NA | nl | NA | ⇓ | NA | ⇓ | NA | 4 | NA | ⇓ | 59.8 |
| 14 | + | NA | nl | NA | + | NA | + | NA | 4a | NA | ⇓ | NA | nl | NA | ⇔ | NA | ⇓ | NA | 4 | NA | ⇓ | NA | 29.1 |
| 15 | + | NA | nl | NA | + | NA | + | NA | 4a | NA | ⇓ | NA | nl | NA | ⇔ | NA | ⇓ | NA | 4 | NA | ⇓ | NA | 32.2 |
Note—MRI through the temporomandibular joint was performed 22–60 weeks (average, 36 weeks; SD, 14 weeks) after injection in 10 treatment sessions representing 15 joint injections. Joint changes (i.e., effusion, meniscal [disk] abnormalities, loss of normal joint space) and bone changes (i.e., erosions or abnormalities of the mandibular condyle) were present (+) in all 10 patients before injection. Follow-up imaging showed improvement in 67% of the treated joints. One patient (no. 6) had persistence of or increase in several imaging parameters, including effusion, and received a second treatment. R = right, L = left, nl = normal, ⇓ = improvement, ⇔ = unchanged or equivocal finding, ⇑ = disease progression, NA = data not available
a
Grade reported as follows: 3 = subacute juxtaarticular erosions; 3a = acute on subacute finding; 4 = chronic morphologic change or sclerosis of condyle, abnormal deviation of the meniscus, or loss of articular cartilage; 4a = acute on chronic finding
b
Second injection for this patient
c
First injection for this patient
Procedure
All children underwent MRI before the procedure because MRI has been shown to be the most sensitive radiographic technique for detection of TMJ arthritis [9]. For both preprocedure and postprocedure MRI, 2- to 3-mm-thick axial T1-weighted localizer images were obtained through the TMJ to determine the position and orientation of the mandibular condyles. T1-weighted (TR/TE, 600/14), proton density-weighted (3,500/15), and fat-saturated conventional T2-weighted (3,500/105) images 2- to 3-mm thick were obtained parallel to the long axis of the condyle (sagittal). Additional T1- and T2-weighted images were obtained perpendicular to the condyle (coronal) through the region of the TMJ. All images were obtained using a head coil with the patient's mouth closed.
Preprocedure clinical assessment was performed before sedation or general anesthesia. Routine laboratory testing was not required. Most patients had undergone recent complete blood cell counts and basic metabolic panel screens for routine analysis of the toxicity of antiinflammatory therapy. All but one of the 17 treatments sessions were performed with deep IV sedation. This sedation consisted of IV fentanyl citrate (Sublimaze, Janssen) 1-3 μg/kg, pentobarbital sodium (Nembutal, Abbott) 2-5 mg/kg, and midazolam hydrochloride (Versed, Hoffman-LaRoche) 0.1-0.3 mg/kg in combination. One treatment was performed with general anesthesia because injections were administered to other joints the same day. Continuous cardiorespiratory monitoring was performed during all treatments.
The procedures were performed by experienced pediatric interventional radiologists. The child was placed supine on the CT table, and the child's head was rotated 45° away from the joint to be injected. Axial CT was performed through the area of interest as a continuous acquisition with 1-mm collimation. A suitable access site was localized just anterior to the tragus, a radiopaque marker was placed, and an appropriate entry site was confirmed. The site was prepared with povidone-iodine and alcohol and draped in standard surgical manner. The access site was locally anesthetized with 1% lidocaine buffered with sodium bicarbonate (8:2 mixture) through a 30-gauge needle.
Needle access (Fig. 2) for injection of the joint was obtained either with a tandem needle technique with a 30-gauge needle as the guide or with a single 18- or 21-gauge needle. Satisfactory needle position within the mandibular fossa was confirmed with CT in all cases. Through the access needle, a volume of 1 mL (40 mg) of triamcinolone acetonide (Kenalog-40, Bristol-Myers Squibb), a long-acting steroid, was injected into the joint with a 1-mL syringe, and the needle was withdrawn. The child was discharged from the postsedation recovery area when discharge criteria were met.
Data Collection
Clinical parameters were evaluated by pediatric rheumatologists. Change in TMJ mobility was measured as percentage change in the patient's ability to open the gap between the upper and lower incisors. Postprocedure change in tooth-to-tooth gap was available for 11 of 15 patients. Pain at the TMJ was measured at palpation, chewing, speaking, and rest and was reported as present or absent at initial examination and better, worse, or absent at follow-up examination. These data were available for eight of 15 patients.
Preprocedure and postprocedure MR images were evaluated by a pediatric neuroradiologist for joint changes (effusion, abnormality of the meniscus, synovial thickening, and loss of normal joint space) or bone changes (erosion, abnormal signal in the marrow, and flattening or irregularity of the structure of the mandibular condyle) characteristic of inflammatory arthropathy [7, 10, 11]. Imaging findings were reported for each injected joint as normal or present on preprocedure imaging and normal, unchanged, interval improvement, or interval disease progression at follow-up examination. Each injected joint was assigned a grade based on a consensus of four radiologists as follows: grade 1 (normal), no finding characteristic of TMJ arthrop-athy; grade 2 (acute), joint effusion, synovial thickening, or marrow edema; grade 3 (subacute), jux-taarticular erosions; grade 3a, acute on subacute findings; grade 4 (chronic), morphologic change or sclerosis of the condyle, abnormal deviation of the meniscus, or loss of articular cartilage; grade 4a, acute on chronic findings; grade 5 (end stage), ankylosis of the TMJ.
Results
The 27 joint injections were performed with a 22-gauge angiocatheter (n = 13), an 18-gauge hypodermic needle (n = 8), a 21-gauge hypodermic needle (n = 2), or a 30-gauge hypodermic needle (n = 4). One procedure-related minor complication, injection of 1 mL of absolute alcohol into the joint space, was recognized immediately. The alcohol was aspirated and the joint space flushed with sterile saline solution followed by corticosteroid. There were no sequelae. Otherwise, all TMJ injections were technically successful, even in children who had marked anatomic disturbance due to the disease.
Clinical follow-up examinations were performed 3-4 months after injection. Preprocedure and postprocedure clinical data were available for 12 of 15 patients. These data included tooth-to-tooth gap measurements for 11 and pain assessment for eight children. No patient had a significant change in facial asymmetry during the follow-up period. Tooth-to-tooth gap (Table 1) showed moderate to substantial improvement in three of 11 patients and slight improvement in two of 11 patients (mean increase, 12.2%). For seven (88%) of eight children, pain was qualitatively decreased or absent after treatment (Table 1). Two patients had no perceptible change in mobility or discomfort. One patient (patient 5) had decreased mobility and was referred for repeated injection.
Follow-up MRI was performed after 10 of 17 treatment sessions (Table 2), on average 9 months after injection (range, 5-15 months). Compared with preprocedure imaging, improvement in acute signs (Figs. 3A and 3B) was seen as substantial reduction or resolution of effusion in 11 (73%) of 15 treated joints. Equivocal findings were seen in three (20%) of 15 treated joints with a decrease in effusions but an increase in erosions in one case (patient 11) and no appreciable change in the one patient (patient 6) who did not have preprocedure imaging evidence of acute disease. Patient 8 had a substantial increase in effusions, erosions, and bilateral flattening of the condyles. This patient was referred for repeated injections.
No patient was found to have an increase in grading scale score after injection. In general, absence of acute findings on MRI (“a” in the MRI grading scale nomenclature) correlated with improvements in clinical findings (Tables 1 and 2). Therefore this grading scheme may be a useful tool for prospective treatment trials.
Discussion
Triamcinolone acetonide, the long-acting corticosteroid used in our study population, is a well-established steroid for intraarticular injection. This drug appears to be effective in reducing synovitis and structural articular changes commonly associated with inflammatory arthropathy such as juvenile idiopathic arthritis. The peak effect occurs after approximately 6 weeks of treatment, and the expected duration is 6-17 months [12, 13]. Known potential immediate reactions to intraarticular steroid injection, such as pain and headache, or delayed side effects, such as joint infection and loss of subcutaneous fat [14, 15], were not found in our study. Our results support the hypothesis that intraarticular TMJ injection of a long-acting steroid in children is a safe procedure even in patients with joint space deformities.
All procedures were performed on an outpatient basis, and the children were discharged home the same day. This system simplifies the procedure for families to obtain repeated joint injections as required. The two children with clinical or radiographic deterioration after the first treatment received a second injection approximately 6 months after the first.
Many of our patients had substantial relief of clinical symptoms associated with TMJ arthropathy and resolution of related imaging abnormalities measured as reduction in acute and subacute inflammatory changes on MRI. This finding is consistent with successful management of the acute component of juvenile idiopathic arthritis. Because our cohort had severe disease involvement by the time of entry into the study, we did not study whether intervention earlier in the course of disease prevents disease progression.
We hypothesize that chronic structural changes in the TMJ may not be amenable to treatment with intraarticular steroids. However, evaluation of chronic features of juvenile idiopathic arthritis, such as bone changes and craniofacial asymmetry, is expected to require longer-term follow-up than the time frame of this pilot study.
A small sample size, lack of an appropriate control group, incomplete preprocedure and postprocedure imaging, use of a head coil rather than a surface coil during MR image acquisition, inconsistent measurement and recording of related clinical parameters, and a relatively short follow-up period limited this retrospective study. Consequently, objective evidence of lasting improvements in TMJ structure and function, amelioration of pain, and modification of progression of craniofacial deformities has not yet been assessed in this patient population.
Lack of a screening program makes it difficult to identify patients who may benefit from this therapy early in the clinical course, once effusions are detected in the TMJ but before the disease has advanced to bone changes, facial asymmetry, and limited mobility [11]. It may be possible through earlier intervention to preserve normal structure and function in these children until they achieve disease remission [16]. We are currently enrolling juvenile idiopathic arthritis patients in a prospective assessment of TMJ arthritis with MRI and sonography at the time of diagnosis. Use of the grading system proposed in this study may assist in standardization of results reporting and be a consistent basis for comparison with other measures of clinical and pathophysiologic changes related to juvenile chronic arthropathy.
Acknowledgments
We thank David D. Sherry for critical review of the manuscript.
Footnotes
R. Q. Cron was funded in part by the Nickolett Family Awards Program for JRA Research and the Ethel Brown Foerderer Fund for Excellence.
Address correspondence to K. M. Baskin.
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History
Submitted: July 13, 2004
Accepted: July 22, 2005
First published: November 23, 2012
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