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Invited Commentary

Department of Radiology, University of Colorado Health Sciences Center, Denver, Colorado

Every once in awhile we read an article that is so practical that it actually alters how we practice our trade. The preceding article by Dr Jacobson and his coauthors is such an article. Shoulder arthrography is performed ever more frequently, and time constraints require that the examination be completed quickly and easily.

All radiologists are trained to perform shoulder arthrography during their residencies, and most feel most comfortable performing the examination in the manner in which they were trained, rather than trying other methods. However, I have observed that most radiologists seem to have been trained to angle the needle toward the glenohumeral joint space, with a need to see the needle actually enter that space before being satisfied that they have placed it in the proper position. Although this method works, it can easily convert what should be a 10-minute procedure to one that takes 30 minutes or more. I strongly advocate that radiologists try the method outlined by Jacobson et al. Because their method also happens to be the one that I use and teach, I would like to offer a few additional comments.

The authors state that the patient’s arm should be placed in mild external rotation to maximize success. I agree. I furthermore caution that injection in an internally rotated arm must absolutely be avoided. If the arm were in internal rotation when the needle was advanced, the needle could pass through the subdeltoid bursa before entering the glenohumeral joint space. If this were to happen, a split injection could occur, filling both the bursa and joint and simulating a rotator cuff tear.

Jacobson et al state that, with proper patient positioning and advancement of the needle, the tip may either rest just lateral to the "joint space" or be angled obliquely toward the glenoid. In the latter case, the needle may either be appropriately placed within the joint or rest on top of the labrum. The authors advocate injecting a bit of the anesthetic to test for free flow into the joint. This is a nice method. Another test that I use when the needle is obliquely placed is to rotate the arm into internal rotation (with the needle in place). This procedure is painless. If the needle is appropriately placed within the joint, the tip will remain in position during internal rotation. If the needle tip rests on top of the glenoid in an extraarticular position, it will migrate medially over the scapular neck when the arm is rotated internally.

Jacobson and colleagues state that exercise after an arthrographic injection has no "beneficial or detrimental effect." I actually tell my patients not to exercise or stretch after the injection. If the capsule is full, exercise may cause the fluid to decompress, almost always anteriorly into the subscapularis muscle. Although these events usually do not preclude accurate diagnosis, they cause messy-looking and potentially confusing images.

I agree with the proportions of gadolinium, bacteriostatic saline, and epinephrine advocated by the authors. I would suggest one refinement. Rather than mixing the iodinated contrast material into the solution, I mix all the other ingredients of the solution, eliminate all air in the syringe and tubing, and then draw back 2 mL of iodinated contrast agent into the tubing. Once the needle is in position in the glenohumeral joint, the tubing is attached and a test injection of the iodinated contrast material is made. Because only iodinated contrast agent is in the tubing, the concentration is great enough that appropriate positioning is easily confirmed, and the injection can then continue from the same tubing and syringe without the need to change equipment and potentially introduce air or dislodge the needle tip. We have found that using this single syringe and tube system is beneficial to our procedure.

Related Article

Aids to Successful Shoulder Arthrography Performed with a Fluoroscopically Guided Anterior Approach

Jon A. Jacobson, John Lin, David A. Jamadar, and Curtis W. Hayes
RadioGraphics 2003 23: 373-378. [Abstract] [Full Text] [PDF]

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