Role of Interventional Radiology in Management of Chronic Shoulder Pain

INTRODUCTION

Type 1 diabetes (T1D) is one of the most common Shoulder pain is a frequent musculoskeletal condition in the overall population, with incidence of 6.7 –66.7 percent.¹

Chronic shoulder pain is caused by several etiologies: from rotator cuff disease to peripheral nerve entrapment.²

Advancement in ultrasound (US) technologies enables static and dynamic assessment and guiding on treatment modalities.³

Obviously, there is a greater safety range for intervention approaches under US guideline. Depending on the intended location, doctors may simply pick the needle insertion procedure and so prevent injuries to the surrounding structures. It is vital to realise that US guidance intervention should not be assumed to be an appropriate target alone; they provide full guidance on therapy beginning with clinical practice.⁴

Distinsion of the glenohumeral joint by fluid, which can decrease pain by widening the range of

motion and damage the joint capsule and can decrease the intraarticular inflammation by intraarticular steroid injection.⁵

Intraarticular distension has been demonstrated to enhance short-term pain and function, although this effect is sustained up to 3 months, and the outcome of cases with diabetes is less than that of nondiabetics.⁶ 

The most beneficial strategy is intra-articular steroid injection which leads to a quick decrease in pain and an enhancement in the mobility and capacity to do physical treatment.⁷ 

We aimed in this work to assess the interventional radiology role in management of chronic shoulder pain.

PATIENTS AND METHODS

This prospective research involved sixty cases with chronic shoulder pain and was conducted at Radio-diagnosis Department, Faculty of Medicine, Al-Azhar University during the period from 1 January 2020 to 1 January 2021.

The study was accepted by the Ethics Board of Al-Azhar University and all study individuals give an informed written consent.

Inclusion criteria:

Any patients with chronic shoulder pain, limitation / restricted of movements of the shoulder joint, patient cannot lie on the shoulder due to pain & who are showing cacific tendonitis.

Exclusion criteria:

Patients with poor general and mental condition.

Local infection.

Recurrent shoulder dislocation

Autoimmune inflammatory diseases.

Pregnancy (when using Fluoroscopy guided injection).

Patients refuse to participate

Malignancy.

Methods:

All patients subjected to the following:

Full history taking and pre-procedure diagnostic MRI examination.

Musculoskeletal assessment (visual analogue scale and range of movement) of shoulder joint before the injection, immediately after, during the first 24 h and after 2 weeks ⁽²⁾. 

Injection of the shoulder could be part of the treatment of the shoulder pain, especially if the pain is more than what patient can handle, shoulder pain will probably hinder the progress of the therapy.

The injection could be done by posterior, lateral, or anterior approaches.

Regional injection had been done guided by ultrasound, fluoroscopy &/or CT for e.g: hydrodilatation of the gleno-humeral capsule, hydro-dissection of the subacromial bursa, neurolysis of suprascapular & subaxillary nerves.

Statistical Analysis of Data:

The collected data organized, tabulated and statistically analyzed using statistical package for social sciences (SPSS) version 22 (SPSS Inc, Chicago, USA). For qualitative data, frequency and percent distributions was calculated. For quantitative data, mean, standard Error (SE), minimum and maximum was calculated. Statistical significance was defined as P value < 0.05.

The following tests were done:

Chi-square test: For categorical variables, to compare between different groups.

The one-way analysis of variance (ANOVA): is used to determine whether there are any statistically significant differences between the means of data at basal, immediately, 1^st 24 hour and 2 weeks postinjection.

RESULTS

This study included 60 patients with chronic shoulder pain, the majority were males 34 (56.7%). Their mean of age was 65.17 year.

Considering diagnosis, 25 (41.7%) patients diagnosed as frozen shoulder, 20 (33.3%) Subacromial bursitis and 15 (25%) as Bicepital tenosynovitis. Regarding Radiological interventions, patients with frozen shoulder treated by partial technique 10 (16.7%) and full technique 15 (25%), patients with Subacromial bursitis treated by Low volume injection 5 (8.3%) and high volume injection 15 (25%) while in patients with Bicepital tenosynovitis treated by Extra-articular injection 5 (8.3%) and intra-articular injection 10 (16.7%) (Table 1).

There is a significant difference between basal, immediately, 1st 24 hr and 2 weeks VAS after injection at movement, sleep and total mean score while there is no significant difference between basal, immediately, 1st 24 hr and 2 weeks VAS after injection at rest (Table 2).

Full technique has significantly higher improvement in VAS, ROM and SPADI than partial technique (p < 0.05) (Table 3).

High volume injection has significantly higher improvement in VAS, ROM and SPADI than Low volume injection (p < 0.001) (Table 4).

Intra-articular injection has significantly higher improvement in VAS, ROM and SPADI than Extra-articular injection (p < 0.001) (Table 5).

*Partial technique= hydrodilatation of the gleno-humeral capsule, hydro-dissection of the subacromial bursa.

#Full technique= hydrodilatation of the gleno-humeral capsule, hydro-dissection of the subacromial bursa and neurolysis of suprascapular & subaxillary nerves.

Table 1: Distribution of patients as regard to radiological interventions

Differences compared with basal value

Table 2: Distribution of patients as regard to basal, immediately postinjection, 1st 24 hr and 2 weeks after intervention Visual analogue score

Table 3: Comparison between partial and full technique in frozen shoulder treatment

Table 4: Comparison between Low and high volume injection in Subacromial bursitis treatment

Table 5: Comparison between Extra and intra-articular injection in Bicepital tenosynovitis treatment

                            a                                        b                                         c

d                                                   e                                       f

g                                                   h                                          i

Case 1:  female patient 70 Years presented with painful limited movements in all direction (frozen shoulder), selected MRI images (a , b and c) showing evidence  of fibrosis within rotator interval (white arrow), and thickened coraco-humeral ligament (black arrow), patient underwent fluoroscopic guided hydro dilatation of glenohumeral  joint capsule (images d , e and f), then fluoroscopic guided pulsed radiofrequency of supra scapular nerve (images g, h and i)  within  supra scapular notch (dashed white lines).

                           a                                                 b                                                  c         

Case. 2: male patient 30 year old presented with anterior and lateral  shoulder pain  MRI showed evidence of subacromial bursitis, patient underwent ultrasound guided high volume hydro dissection of  subacromial bursa.