C.K. Saadeh1, L.G. Ramos 1 , J.M. Malacara 1 , A. Mitchell 2 , D. Shelton 2 , N. Christian 2 , T. Lewis 2 , M. Gaylor 1. 1Medical, Allergy ARTS, ACCR, 2Medical, Allergy ARTS, Amarillo, United States

Background: Joint and tendon sheath injection is considered an integral and critical part in rheumatology practice. The majority of these injections are performed in the office under visual inspection and palpation of the anatomical markings. However, precise localizaiton may still be a major issue, particularly in identifying a specific pathology. The use of ultrasound with color Doppler in guided injection provides a very useful tool in the specific site of pain and inflammation.
Objectives: The advantages of ultrasound guided injections has previously been reported. In this report, we attempt to compare ultrasound guided injection in patients who already has already had blinded injections in the same area of interest. Color Doppler was used to further localize the inflammation.
Methods: In a busy rheumatology practice, transition from traditional blind injection to purely ultrasound guided injection was examined. We reviewed patients with shoulder pain (1), elbow epichondylitis (1), small joint arthiritis, and hip bursitis (6). We compared these patients to results from previous blind injections and followed up in the same patients. The patient''s conditions ranged from mere local syndrome such as rotator cuff, lateral epichondylitis or carpal tunnel to more systemic involvement such as rheumatoid arthritis. A Titan ultrasound machine (sonosite) was used with 10 mHz transducer under sterile conditions and ethyl chloride spray for local anesthesia. Triamcinolone and lidocaine were the preferred injections. Color Doppler was used to identify specific areas of inflammation prior to injection.
Results: The success rate of blind injections was previously reported at42%. After reviewing the charts and interviewing the patients, more than 95% stated that their injection was more effective when done under color Doppler ultrasound guidance in terms of comfort, pain reduction, increased range of motion and prolonged period of remission (4-5 months vs 2-3 months). However, 20% of the patients experienced post injection flare for 24-48 hours compared to 10% with blind injection. These flares were transient and resolved spontaneously or with use of NSAIDs. Color Doppler ultrasonography added more precise guidance to the area of interest.
Conclusion: Ultrasound guided injection appears to be a superior and more effective method of management of pain or inflammation, or both, than blinded injections. Although this was a retrospective observation study, having the same patient as control provided objective criteria in the assessment of joint injections. The post injection flare was higher with ultrasound guided injections and this could be due to better localization of the crystalline steroid in the joint. It was transient and of no clinic consequence.
References: 1. Musculoskeletal Interventional Ultrasoundchapter 15 Pp 283-307 on Practical Musculoskeletal Ultrasound. Eugene McNally. Elsevier 2005
2. Semin Musculoskelet Radiol. 1997;1(2):311-318.
3. Interventional Musculoskeletal Ultrasound. Cardinal E, Beauregard CG, Chhem RK.
Citation: Ann Rheum Dis 2005;64(Suppl III):187

Session: Rheumatoid arthritis – Clinical aspects


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