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Vascular and Interventional Radiology |
1 From the Department of Radiology, CHUM-Hôpital Saint-Luc, 1058 Saint-Denis, Montreal, Quebec, Canada H2X 3J4 (R.A., E.C., N.J.B., B.A.); and Division of Clinical Epidemiology, MUHC-Royal Victoria Hospital, Montreal, Quebec, Canada (P.B.). Received April 18, 2000; revision requested June 9; revision received March 21, 2001; accepted April 18. Address correspondence to E.C. (e-mail: etienne.cardinal@videotron.ca).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSION REFERENCES |
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MATERIALS AND METHODS: Thirty shoulders of 30 consecutive patients (23 women, seven men; mean age, 47.4 years) with chronic shoulder pain (average duration, 43.1 months) refractory to medical treatment were treated percutaneously by using a fine needle and US guidance. Patients were prospectively evaluated by using a shoulder pain and disability index consisting of 13 items and divided into two subcategories: pain and disability. The patient completed the questionnaire before the procedure and during the follow-up visit approximately 1 month later. A diagnostic US examination was also performed at that time.
RESULTS: There was a statistically significant improvement in the shoulder pain and disability index total score (27.0%) and the pain (30.5%) and disability (23.9%) scores. According to the index, these results indicate a significant clinical response.
CONCLUSION: This modified US-guided fine-needle technique for calcified tendinitis of the shoulder appears to be an effective therapy and was less aggressive than previously described percutaneous techniques.
Index terms: Shoulder, injuries, 414.253 • Shoulder, US, 414.12986 • Tendinitis, 414.253
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSION REFERENCES |
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In 1978, Comfort and Arafiles (7) introduced a percutaneous treatment for calcific tendinitis of the shoulder, which was used at several centers on a routine basis. This technique consisted of percutaneous needle aspiration of calcium deposits with fluoroscopic guidance. In 1995, a study performed by Farin and Jaroma (8) demonstrated the high sensitivity of ultrasonography (US) to accurately depict and localize rotator cuff calcifications without radiation exposure from fluoroscopy. They also demonstrated the feasibility of percutaneous treatment of calcific tendinitis by using US guidance (2). The method described in the literature (7–9) consists of puncturing the calcium in the rotator cuff up to 10–15 times to fragment and aspirate the calcification during a single procedure. Two needles (18–19 gauge) were used simultaneously; saline solution was injected for lavage through one needle and reaspirated through the other needle (2,10). The lavage was continued until the aspirate was free of calcified particles. After this procedure, water-soluble cortisone was injected with US-guidance into the subacromial-subdeltoid bursa.
Although this technique provides prompt and substantial pain relief in about two-thirds of the cases, with clinical success rates varying from 60% to 74% (2,9,11), there is the concern for potential injury to the tendon caused by multiple punctures of the intratendinous calcification with large-bore needles. To our knowledge, there is no study published in the literature describing a less aggressive percutaneous technique. Therefore, the purpose of our study was to evaluate the clinical response to the treatment of calcific tendinitis of the shoulder with a modified percutaneous US-guided fine-needle technique.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSION REFERENCES |
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A prospective evaluation of shoulder impairment was performed by using the Shoulder Pain and Disability Index (SPADI) questionnaire. The SPADI questionnaire is a self-administered index designed to measure the effect of the pathologic condition of the shoulder on functional status (12,13). It is also used to measure the response to treatment in time. It consists of 13 items divided into two subcategories reflecting the disability (eight items) and pain (five items) associated with the clinical syndrome of painful shoulder (Table 1). All items were rated by using a visual analog scale from "no pain" or "no difficulty" to "worst pain imaginable" or "so difficult it required help." A numeric value was obtained by dividing the scale into 11 segments from 0 to 10 for each item. The questionnaire required 5–10 minutes to complete. The SPADI questionnaire was filled out by the patient before the procedure and at the time (mean, 53 days; range, 24–129 days) of a follow-up visit.
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Before the intervention, a diagnostic US examination of both shoulders of each patient was performed with a 7.0-MHz (Acuson, Mountain View, Calif) or 9.0-MHz (Siemens Medical Systems, Issaquah, Wash) linear transducer, with the patient in a sitting position. The shoulder was examined first in a neutral position and then with the arm extended according to a standard protocol (14). All US examinations and US-guided procedures were performed by one of three radiologists (E.C., N.J.B., B.A.) experienced in musculoskeletal US. All shoulders were assessed for calcification size, location, and number; the presence of local tendon swelling, rotator cuff tears, cortical irregularities of the greater tuberosity; and the presence of fluid in the subacromio-subdeltoid bursa. Calcification of the rotator cuff was depicted as a hyperechoic focus with or without acoustic shadowing, or occasionally, with only a faint shadow (8) (Fig 1).
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The procedure was performed by using sterile technique and surgical gloves. A pencil mark was placed on the skin for localization of the calcified deposit. Then the skin was cleaned and antiseptically draped. The transducer head was also cleaned with povidone-iodine (Professional Disposables, Mississauga, Ontario, Canada) (15). Local anesthesia (1% lidocaine hydrochloride; Abbott Laboratories, Saint-Laurent, Quebec, Canada) was administered. After identifying and localizing the calcified deposit at US, the calcification was punctured, with constant US monitoring, by using a 1.5-inch (3.81 cm) 22-gauge needle (a 25-gauge needle was used in two cases due to small calcification size of < 5 mm). A horizontal course and an anteroposterior axis of the needle were favored because of easier US localization of the needle and calcification. When multiple calcifications were identified in the rotator cuff (eight shoulders), the calcification to be punctured was selected based on one of the following three findings: largest size, association with focal tendon swelling, or calcification which appeared to correlate best with the site of shoulder pain by using pressure from the US probe. Once positioned in the center of a calcification, the tip of the needle was gently rotated followed by an attempt to aspirate the fragmented calcified material by using a 5–10-mL syringe filled with lidocaine 1% (Fig 2). Occasionally, fragmentation of the calcified deposit was performed better by initially injecting lidocaine into the calcification followed by aspiration. The success of aspiration varied depending on the calcification consistency at the time of the procedure. When the calcification was very hard and no material could be extracted, grinding of the calcified deposit was performed by using gentle rotation of the needle tip, with the possibility of accelerating the process of spontaneous resorption (7,9). When the calcification had a paste-like consistency, a lavage maneuver was possible by using the syringe containing lidocaine, without any attached tubing necessary. Successive propulsion and aspiration with the syringe plunger was performed to retrieve the calcified material, with constant US monitoring of the needle position. Extracted calcium was readily identified in the syringe as a white cloud-like substance mixing with the lidocaine that would then deposit in the dependent portion of the syringe. For that reason, an attempt was made to have the syringe and needle parallel to the floor during the lavage procedure to prevent, as much as possible, the calcium from reentering the needle and the rotator cuff. The procedure was stopped after 5–10 minutes or when no further amount of calcified material could be extracted.
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Patients were reevaluated at a follow-up visit (mean, 53 days) when they again completed the SPADI questionnaire. A standard US examination of the shoulder was also performed, which recorded the same sonographic parameters mentioned previously and depicted changes in echogenicity of calcification if present.
Statistical analysis was performed by using the two-tailed paired t test, which compared SPADI scores before and after the procedures and SPADI scores according to calcification echogenicity change. The nonparametric Mann-Whitney test (two tailed) was used to compare calcification size in symptomatic and asymptomatic shoulders before the procedure.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSION REFERENCES |
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Clinical Response
At the follow-up visit (mean, 53 days), there was a statistically significant improvement in the SPADI total score (27.0%) and in the pain (30.5%) and disability (23.9%) scores (Table 5). Also, the mean area of calcified deposits is significantly smaller after the aspiration procedure, with P values of less than .001 and equal to .02 for the right and left sides, respectively (Table 6). However, the overall response of the total patient group was mostly due to the excellent response from the subgroup of patients in whom calcium deposits in the rotator cuff were successfully aspirated. According to the SPADI score, an improvement by 10 points indicates a substantial clinical improvement, which correlates with improved shoulder function and less pain (13). Patients in whom calcium deposits in the rotator cuff were successfully aspirated had a clinically significant improvement in the pain score (mean, 13.2 points) and disability score (mean, 22 points). The subgroup of patients in whom no calcium was aspirated from the rotator cuff did not have clinically significant improvement in pain score (mean, 5.9 points) or disability score (mean, 4.3 points).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSION REFERENCES |
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Needle aspiration of calcified deposits remains a minimally invasive technique providing clinical success rates varying from 60% to 74% of patients (7,9,11,16). As for arthroscopic treatment of calcified tendinitis (7), our findings suggest that it is not essential to completely remove the calcified deposit to obtain substantial clinical improvement. Theoretically, partial calcification removal would decompress the calcium-containing cavity and promote spontaneous resorption of the remaining calcification as described (1,4,7,10). Although only partially aspirated with a small needle, adequate symptomatic relief was obtained in our study as documented by the improved SPADI score. In our study, the subgroup of patients in which calcium was successfully aspirated from the rotator cuff responded better than the subgroup in which no calcium was aspirated. Even though such subjective complaints are difficult to quantify, pain and disability may be the most valid outcome measures in the treatment of shoulder problems. The SPADI has demonstrated good internal consistency, test and retest reliability, and criterion and construct validity in the literature (12,13). The SPADI has also proved able to demonstrate change in patient status with time. A SPADI score decline of greater than 10 points is highly specific for improved shoulder function (13). Likewise, a greater than 10-point increase SPADI score is highly specific for worse shoulder function (13). Our study thus indicates a statistically significant clinical response as demonstrated by improved shoulder function and less pain with the total SPADI score decrease by more than 10 points (Table 5).
The mean area of calcified deposits is also significantly smaller after the aspiration procedure (Table 6). Since asymptomatic calcifications were significantly smaller in size than the symptomatic ones, this demonstrates that the calcification size has a relationship with the presence of symptoms; smaller calcifications are less painful and disabling. This was already demonstrated as early as 1941 by Bosworth (17). According to his observations, symptoms usually arise when calcification size exceeds 1.5 cm in diameter. Therefore, our study indicates that smaller 22-gauge needles are adequate for performing calcification fragmentation, aspiration, and reduction in the mean area, without the need of larger and more traumatic needle sizes.
Calcification Echogenicity
Concerning changes in calcification echogenicity, results show that all patients, regardless of echogenic change, demonstrated adequate symptomatic relief as reflected by the improved SPADI scores (above 10 points) described in the literature (13). There is a difference between the two groups, with a more important clinical improvement among patients where the echogenicity of calcifications decreased. This is particularly noticeable for the disability subcategory (a clinical improvement of 15.5% for patients without and 30.3% for patients with calcification echogenicity change). However, according to our statistical analysis, this is not a significant finding, which could be due to the small sample size in both groups. This possible association has already been suggested by Farin et al in 1996 (16). These results would support the hypothesis that needle puncturing opens the calcium-containing cavity and provides a decrease in its pressure (10). This in turn would allow sufficient disruption and localized bleeding, which facilitates absorption of the remainder of the material or its dispersion into the subacromial space. The reflection of this phenomenon would be correlated at US either by a size reduction of the calcification or by a change in its echogenicity, both associated independently with adequate symptomatic relief. This could also explain why some tendon calcifications did have a decrease in echogenicity at the follow-up visit despite the fact that no substantial calcified material was extracted during the procedure.
US Guidance Clinical Success
As demonstrated in our study, the results of US-guided percutaneous treatment of calcified tendinitis compare favorably with those of calcium lavage with fluoroscopic monitoring (7,9,11, 16). US also has the advantage of being nonionizing and allows direct real-time three-dimensional imaging of the needle tip around the calcification during the procedure. The preliminary evaluation of the shoulder rotator cuff at US also permits identification of a tear, bursitis, or other associated conditions before performing the procedure. The superficial localization of the calcification is well suited for US guidance of the needle with a free-hand technique.
Modified Approach
There might be a concern about the residual status of the tendon fibers after being repeatedly punctured (up to 15 times) with larger 18 or 19 gauge needles as proposed by previous investigators (2,16) for the US-guided treatment of calcific tendinitis of the shoulder. Farin et al (16) described the simultaneous placement of two needles in the tendon for calcification lavage. Repetitive needle puncturing of the tendon to extract the calcium may potentially damage the tendon fibers and increase the risk of a rotator cuff tear. However, the risk in using large needles is not well defined, as data about the long-term status of the tendon are lacking in the literature; only short-term follow-up studies following percutaneous treatment of rotator cuff calcifications are available. Unfortunately, this short-term assessment is also a limitation in our study, as well as small sample size and lack of comparison with other methods. Although the use of a single smaller needle minimizes tendon injury during treatment, the benefits remain hypothetical, since it has not been documented that multiple needle puncturing of the rotator cuff with larger needles is deleterious to the tendon integrity. In addition, our findings indicate better results in patients in whom calcium was successfully aspirated from the rotator cuff compared with patients in whom no calcium was aspirated. The use of a larger needle in this latter group of patients may have improved the yield of calcified material aspirated, but this was not the aim of our study and was not assessed. However, since comparable and significant clinical improvement was obtained in our study without encountering any substantial problems, the use of a single, small, 22-gauge needle for treatment of rotator cuff calcification seems to be an effective therapy, while being less traumatic than previously described techniques. In addition, use of only a single needle to perform the procedure without attached tubing is certainly a less cumbersome technique for the operator handling the transducer in one hand and the needle in the other at the same time.
In conclusion, our findings indicate that the use of a small, single, 22-gauge needle for the treatment of calcific tendinitis of the shoulder seems to be an effective therapy, while being less traumatic than previously described percutaneous techniques. The SPADI is a useful tool to monitor the effectiveness of interventional procedures of the shoulder, as it reflects the changes in patient clinical status with time. However, larger studies and long-term assessment are needed to further document clinical improvement and associated sonographic features.
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FOOTNOTES |
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Author contributions: Guarantor of integrity of entire study, E.C.; study concepts and design, all authors; literature research, R.A.; clinical studies, E.C., N.J.B., B.A.; data acquisition, R.A.; data analysis/interpretation, R.A., N.J.B., E.C., P.B.; statistical analysis, P.B.; manuscript preparation and definition of intellectual content, E.C., N.J.B., R.A.; manuscript editing, P.B., E.C., N.J.B., R.A.; manuscript revision/review and final version approval, all authors.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTS DISCUSSION REFERENCES |
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