HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Figures Only Full Text (PDF) All Versions of this Article: 2213010277v1 221/3/775    most recent Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Binkert, C. A. Articles by Hodler, J. Search for Related Content PubMed PubMed Citation Articles by Binkert, C. A. Articles by Hodler, J.

Patient’s Assessment of Discomfort during MR Arthrography of the Shoulder¹

¹ From the Department of Radiology, University Hospital Balgrist, Zurich, Switzerland. Received January 11, 2001; revision requested February 27; revision received April 18; accepted May 21. Address correspondence to C.A.B., Dotter Interventional Institute, Oregon Health Sciences University, 3181 SW Sam Jackson Park Rd, Portland, OR 97201-3098 (e-mail: binkert@compuserve.com).

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
PURPOSE: To assess patient discomfort during (a) intraarticular contrast material injection (arthrography) and (b) magnetic resonance (MR) imaging in patients referred for MR arthrography of the shoulder and to compare the relative discomfort associated with each part of the examination.

MATERIALS AND METHODS: With use of a visual analogue scale (VAS) and relative ratings, 202 consecutive patients referred for MR arthrography of the shoulder rated the expected discomfort and that actually experienced during both arthrography and MR imaging. The Student t test was used for statistical analysis.

RESULTS: The average VAS score (0 = "did not feel anything," 100 = "unbearable") was 16.1 ± 16.4 (SD) for arthrography and 20.2 ± 25.0 for MR imaging. This difference was statistically significant (P = .036, paired t test). The discomfort experienced during arthrography was as expected in 90 (44.6%) patients, less than expected in 110 (54.4%), and worse than expected in two (1.0%). MR imaging–related discomfort was as expected in 114 (56.4%) patients, less than expected in 66 (32.7%), and worse in 22 (10.9%). Arthrography was rated worse than MR imaging by 53 (26.2%) patients, equal to MR imaging by 69 (34.2%), and less uncomfortable than MR imaging by 80 (39.6%).

CONCLUSION: Arthrography-related discomfort was well tolerated, often less severe than anticipated, and rated less severe than MR imaging–related discomfort.

Index terms: Magnetic resonance (MR), arthrography, 41.12149 • Shoulder, arthrography, 41.122 • Shoulder, MR, 41.12149

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Magnetic resonance (MR) arthrography of the glenohumeral joint appears to be more accurate than conventional MR imaging for assessing the rotator cuff, especially in the presence of partial tears (1,2) and tears of the glenoid labrum (3). Despite this improved diagnostic performance, many radiologists, referring physicians, and patients are concerned about the additional discomfort of contrast material injection into the glenohumeral joint. The aspects of the procedure most feared by patients are pain and "needles" (4). Nonetheless, it has been shown that patients who undergo intraarticular contrast material injection experience less discomfort than expected (4). Authors of another study (5), in which groups of patients who had undergone conventional MR imaging or plain arthrography of the shoulder were compared, found the two modalities to be equally well tolerated. To our knowledge, in no published study has the discomfort of intraarticular contrast material administration yet been compared with that of MR imaging in a group of patients undergoing both procedures. The purpose of this investigation was to assess the discomfort during arthrography and MR imaging in patients referred for MR arthrography of the shoulder and to compare the discomfort levels associated with both parts of the examination.

	MATERIALS AND METHODS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Patients
Between August 1999 and March 2000, 202 consecutive patients (71 female and 131 male patients; age range, 13–82 years; mean age, 50 years) referred for MR arthrography of the glenohumeral joint were included in the investigation.

After undergoing MR arthrography, the patients were asked to complete a written questionnaire with the assistance of a radiology technician. Patients without working knowledge of the language of the questionnaire were excluded; this was the only exclusion criterion. The patients were asked to rate arthrography-related discomfort during skin pricking, needle advancement, and intraarticular contrast material injection and after arthrography. A visual analogue scale (VAS) was used, with the left anchor (0 mm) representing "did not feel anything" and the right anchor (100 mm) representing "unbearable pain" (Fig 1). Similarly, discomfort during MR imaging was rated between "no discomfort" (0 mm) and "unbearable" (100 mm).

View larger version (15K): [in this window] [in a new window] [Download PPT slide]   Figure 1. Diagram of a VAS used in the questionnaire. Patients drew a line between the two extremes to rate their discomfort.

Eight patients received sedative drugs because of severe claustrophobia in the MR imager: Five patients received sedatives intravenously (2–5 mg midazolam [Dormicum; Roche Pharma, Reinach, Switzerland]) in the MR imager, and three received sedatives orally (0.25 mg alprazolam [Xanax; Pharmacia & Upjohn, Dübendorf, Switzerland]) before the examination.

A second questionnaire with an addressed and prepaid envelope was handed to the patient for assessment of shoulder pain at 12, 24, 48, and 72 hours after arthrography. A VAS was again used (left anchor or 0 mm: "no pain increase whatsoever in comparison to the period before arthrography"; right anchor or 100 mm: "massive pain increase, unbearable pain").

Informed consent was obtained for MR arthrography of the shoulder, which is a standard diagnostic procedure at our facility and had been previously approved by the hospital’s ethics committee and the responsible state agency. We received a waiver from our institutional review board for completion of the questionnaires.

MR Arthrography
Intraarticular contrast material was injected by one of four radiologists: two staff physicians (M.Z., J.H.), a 2nd-year fellow in musculoskeletal imaging (C.A.B.), or a 1st-year fellow. One milliliter of mepivacaine hydrochloride (Scandicain 2%; AstraZeneca, Södertälje, Sweden) was used to anesthetize the skin, the joint capsule, and the intraarticular space. With use of fluoroscopic control, a 20-gauge needle was advanced to the medial aspect of the upper third of the humeral head (Fig 2). The intraarticular position of the needle tip was confirmed with injection of 1 mL of iopamidol (Iopamiro 200; Bracco, Milan, Italy) followed by 10 mL of 2 mmol/L gadoteridol (ProHance; Bracco).

View larger version (137K): [in this window] [in a new window] [Download PPT slide]   Figure 2a. (a) Anteroposterior radiograph of the shoulder demonstrates needle position. The medial upper third of the humeral head (arrows) was used as a bone landmark. (b) Anteroposterior arthrogram obtained after the injection of iodinated contrast material helps to confirm the intraarticular needle position.

View larger version (132K): [in this window] [in a new window] [Download PPT slide]   Figure 2b. (a) Anteroposterior radiograph of the shoulder demonstrates needle position. The medial upper third of the humeral head (arrows) was used as a bone landmark. (b) Anteroposterior arthrogram obtained after the injection of iodinated contrast material helps to confirm the intraarticular needle position.

Statistical Analysis
The unpaired two-tailed Student t test was used to compare data among patients (eg, age, sex, different radiologists). Statistical significance was accepted for a P value less than .05.

	RESULTS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
All patients completed the first questionnaire immediately after undergoing MR arthrography. The mean arthrography-related discomfort (± SD) rating was 16.1 ± 16.4. The mean discomfort ratings at the different phases of arthrography were as follows: skin prick, 17.4 ± 19.6; needle advancement into glenohumeral joint, 17.6 ± 20.6; and intraarticular contrast material injection, 13.2 ± 16.9. Skin prick and needle advancement were rated significantly worse than intraarticular contrast material injection (P = .001 for both).

The VAS scores for skin prick did not differ significantly among radiologists. The VAS scores for needle advancement and intraarticular contrast material injection, however, were significantly higher for one staff radiologist than for the other and for one of the two fellows (P = .039 vs 0.038 and P = .015 vs 0.006). The mean VAS score for lying in the MR unit was 20.2 ± 25.0. The most disturbing factors during MR imaging were noise (n = 45), the feeling of confinement (n = 36), and having to keep still (n = 30). The level of discomfort was significantly higher with MR imaging than with arthrography (P = .036). There were no statistically significant differences for either arthrography- or MR imaging–related discomfort according to sex or between age groups: younger than 40 years (n = 54), aged 40–59 years (n = 88), or aged 60 years and older (n = 60).

In 90 (44.6%) of the 202 patients, the arthrography-related discomfort they experienced was as anticipated. One hundred ten (54.4%) patients considered the discomfort to be less than expected, and only two (1%) found it to be worse than expected. MR imaging–related discomfort was equivalent to that anticipated in 114 (56.4%) patients, less than expected in 66 (32.7%), and worse than expected in 22 (10.9%). When asked to directly compare arthrography and MR imaging, 53 (26.2%) patients rated arthrography worse than MR imaging, 69 (34.2%) rated the two imaging methods equal, and 80 (39.6%) rated MR imaging worse than arthrography.

One hundred sixty-five (81.7%) of the 202 patients returned the follow-up questionnaire. A comparison of patients who returned questionnaires with those who did not found no statistically significant difference in sex or in the initially reported VAS scores. Patients who returned the questionnaire were slightly older (mean age, 51 years) than those who did not (mean age, 45 years) (P = .042).

The mean postarthrographic shoulder pain was rated 15.2 ± 21.7 immediately after the examination and reached a peak 12 hours after arthrography (18.0 ± 22.7). Pain then decreased gradually toward baseline: 16.4 ± 22.4 at 24 hours, 13.6 ± 20.8 at 48 hours, and 10.1 ± 17.9 at 72 hours.

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
MR arthrography is more accurate than conventional MR imaging in the diagnosis of partial rotator cuff tears and glenoid labral lesions (1–3). MR arthrography, however, is considered by many radiologists, clinicians, and patients to render a noninvasive test invasive. MR arthrography may be criticized because it causes pain and, rarely, serious complications such as infection or adverse reactions to contrast material (6). Other criticisms relate to the limited additional information provided with the injection, more complicated scheduling, more radiologists’ time, and—increasingly important—patient discomfort. Herein, we address patients’ perceptions regarding arthrography-related discomfort in comparison with MR imaging–related problems.

For this investigation we used the VAS, which represents a validated mechanism for the quantitative assessment of subjective information. It was first popularized by Huskisson (7) in 1974. The VAS is based on a line with an anchor at each end. No other marks are placed on the line, contrary to other commonly used semiquantitative grading systems. One anchor is usually labeled "did not feel anything" or "no pain"; the other, "unbearable pain." The patient is asked to mark a point on this line that reflects the relative severity of his or her discomfort. The investigator then measures the distance in millimeters from the origin of the scale to the marked point, yielding a percentage value. The VAS score has been shown to be more sensitive than the four-category rating scale in the evaluation of acute pain perception (8).

The arthrographic technique used in this investigation was similar for all four radiologists and resembles those reported in the literature (2–4,9). Our approach differs from that of other investigators in that we use a cranial injection site, with the needle pointed to the cranial medial humeral head. In our experience, this approach helps to avoid possibly painful conflicts with downward-pointing coracoid processes and allows for reliable intraarticular injections, even for beginners. This minor technical variation is unlikely to have resulted in outcomes that are measurably different from those of other studies. The amount of injected contrast material in the current study population was similar to that used by other investigators. For study purposes, we standardized the injected volume to 12 mL (1 mL of mepivacaine hydrochloride, 1 mL of iopamidol, and 10 mL of 2 mmol/L gadoteridol). The same amount was chosen by Kopka et al (9) to evaluate different gadolinium concentrations for MR arthrography. The results of a cadaveric study (10) in which gadolinium concentrations of 2, 5, 10, 15, and 20 mL were used to evaluate optimal glenohumeral joint distention indicated that 15 mL of intraarticular fluid appears to be optimal. Together with a small amount of physiologic synovial fluid, our total volume is very close to these optimized values.

Our results indicate that the discomfort related to arthrography (mean VAS score, 16.1 ± 16.4) and MR imaging (mean VAS score, 20.2 ± 25.0) was generally well tolerated by the patients. It was unexpected that arthrography was significantly less disturbing to the patients than was MR imaging (P = .036). Apparently, the anxiety and short interval of pain experienced during the injection are easier to tolerate than is lying in the MR imager. This effect may be more pronounced for patients with position-dependent back pain, obese patients, and patients with claustrophobia, although we did not assess such aspects in our investigation.

No significant differences among the VAS scores for arthrography were found between the two fellows and one staff radiologist. The procedure as performed by one experienced staff radiologist, however, was rated significantly more painful in comparison with the other staff member and one of the fellows. Because MR imaging ratings were independent of the responsible radiologist, this result likely related to differences among physicians and not to patient selection. We speculate that the staff radiologist was under pressure to proceed quickly and spent less time explaining the procedure to the patient and waiting for the effect of local anesthetics. We did not measure this aspect, however.

Arthrography-related discomfort was overestimated before the examination by more than half (54.4%) of our patients. Only two (1%) patients experienced more pain than anticipated. Robbins et al (4) have previously observed that arthrography-related discomfort is usually well tolerated and often overestimated. Only six (6%) of their 100 patients considered arthrography to be more painful than expected (4). Our direct comparison between arthrography and MR imaging revealed that more patients (39.6%) considered MR imaging to be worse than considered arthrography to be worse (26.2%). Similar results were presented in a previously published study (5) in which patient preferences for standard arthrography versus standard MR imaging of the shoulder were assessed. There was no preference for one of the methods in their study. However, 26% of the patients rated MR imaging as unpleasant or extremely unpleasant, as compared with 7% for arthrography.

We evaluated not only pain directly related to arthrography but also postarthrographic pain. Radiologists may not be sufficiently aware that this problem exists for some of their patients. Our patients rated their pain as being at its worst 12 hours after the procedure. Pain then decreased slowly during the next 3 days. The delayed onset of pain is probably explained by the intraarticular local anesthetics that are initially present (11) and known to ameliorate pain for about 6 hours (12). Peak pain intensity after 12 hours has previously been reported for conventional arthrography (11).

The causes of arthrography-related pain are not completely understood. Synovial irritation caused by the contrast material or joint distention may be at fault. In a rabbit model, minimal inflammatory changes consisting of infiltration of leukocytes and slight synovial hyperplasia were found after arthrography. These changes were identical with saline and with different iodinated contrast material (13) and gadolinium-containing complexes (14). The investigators in those studies concluded that the trauma of needle puncture and joint distention, not the contrast material, were responsible for the synovial reaction. The inflammatory changes seemed to be reversible and transient, since they were no longer detectable after 4 days (15). Conversely, the authors of another study (16) demonstrated that pain after arthrography was markedly lower with use of a nonionic contrast material, as compared with an iodine-containing ionic contrast material. The delayed onset of pain after shoulder arthrography may be due in part to the gradual influx of fluid, which is in turn dependent on the osmolarity of the contrast material. It is important to inform the patient about the delayed onset of shoulder pain to decrease his or her anxiety after leaving the radiology department.

In conclusion, arthrography-related discomfort was well tolerated, was often overestimated before the examination, and was rated less uncomfortable than MR imaging–related discomfort.

	FOOTNOTES

 
Abbreviation: VAS = visual analogue scale

Author contributions: Guarantor of integrity of entire study, C.A.B.; study concepts, C.A.B.; study design, C.A.B., J.H.; literature research, C.A.B.; clinical studies, C.A.B., J.H., M.Z.; data acquisition and analysis/interpretation, C.A.B., M.Z., J.H.; statistical analysis, C.A.B., J.H.; manuscript preparation, C.A.B.; manuscript definition of intellectual content, C.A.B., M.Z., J.H.; manuscript editing, J.H.; manuscript revision/review, M.Z.; manuscript final version approval, J.H.

	REFERENCES

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 

1. Flannigan B, Kursunoglu-Brahme S, Snyder S, Karzel R, Del Pizzo W, Resnick D. MR arthrography of the shoulder: comparison with conventional MR imaging. AJR Am J Roentgenol 1990; 155:829-832.
2. Hodler J, Kursunoglu-Brahme S, Snyder SJ, et al. Rotator cuff disease: assessment with MR arthrography versus standard MR imaging in 36 patients with arthroscopic confirmation. Radiology 1992; 182:431-436.
3. Chandnani VP, Yeager TD, DeBerardino T, et al. Glenoid labral tears: prospective evaluation with MR imaging, MR arthrography, and CT arthrography. AJR Am J Roentgenol 1993; 161:1229-1235.
4. Robbins MI, Anzilotti KF, Jr, Katz LD, Lange RC. Patient perception of magnetic resonance arthrography. Skeletal Radiol 2000; 29:265-269.
5. Blanchard TK, Bearcroft PW, Dixon AK, et al. Magnetic resonance imaging or arthrography of the shoulder: which do patients prefer?. Br J Radiol 1997; 70:786-790.
6. Newberg AH, Munn CS, Robbins AH. Complications of arthrography. Radiology 1985; 155:605-606.
7. Huskisson EC. Measurement of pain. Lancet 1974; 2:1127-1131.
8. Breivik EK, Bjornsson GA, Skovlund E. A comparison of pain rating scales by sampling from clinical trial data. Clin J Pain 2000; 16:22-28.
9. Kopka L, Funke M, Fischer U, Keating D, Oestmann J, Grabbe E. MR arthrography of the shoulder with gadopentetate dimeglumine: influence of concentration, iodinated contrast material, and time on signal intensity. AJR Am J Roentgenol 1994; 163:621-623.
10. Recht MP, Kramer J, Petersilge CA, et al. Distribution of normal and abnormal fluid collections in the glenohumeral joint: implications for MR arthrography. J Magn Reson Imaging 1994; 4:173-177.
11. Hall FM, Rosenthal DI, Goldberg RP, Wyshak G. Morbidity from shoulder arthrography: etiology, incidence, and prevention. AJR Am J Roentgenol 1981; 136:59-62.
12. Fellahi JL, Magues JP, Marquer B, Guerot A, Mansat M, Cathala B. Analgesia with intra-articular injection of buprenorphine after surgery of the shoulder. Cah Anesthesiol 1995; 43:313-318[French].
13. Johansen JG, Berner A. Arthrography with Amipaque (metrizamide) and other contrast media: a roentgenographic and histologic evaluation in rabbits. Invest Radiol 1976; 11:534-540.
14. Hajek PC, Sartoris DJ, Gylys-Morin V, et al. The effect of intra-articular gadolinium-DTPA on synovial membrane and cartilage. Invest Radiol 1990; 25:179-183.
15. Bjork L, Erikson U, Ingelman B. A new type of contrast medium in arthrography. Am J Roentgenol Radium Ther Nucl Med 1970; 109:606-610.
16. Hall FM, Goldberg RP, Wyshak G, Kilcoyne RF. Shoulder arthrography: comparison of morbidity after use of various contrast media. Radiology 1985; 154:339-341.

This article has been cited by other articles:

				N. Saupe, M. Zanetti, C. W. A. Pfirrmann, T. Wels, C. Schwenke, and J. Hodler Pain and Other Side Effects after MR Arthrography: Prospective Evaluation in 1085 Patients Radiology, March 1, 2009; 250(3): 830 - 838. [Abstract] [Full Text] [PDF]

				T. Moser, A. Moussaoui, M. Dupuis, V. Douzal, and J.-C. Dosch Anterior Approach for Knee Arthrography: Tolerance Evaluation and Comparison of Two Routes Radiology, December 1, 2007; 246(1): 193 - 197. [Abstract] [Full Text] [PDF]

				H. Depelteau, N. J. Bureau, E. Cardinal, B. Aubin, and P. Brassard Arthrography of the Shoulder: A Simple Fluoroscopically Guided Approach for Targeting the Rotator Cuff Interval Am. J. Roentgenol., February 1, 2004; 182(2): 329 - 332. [Abstract] [Full Text] [PDF]

This Article Abstract Figures Only Full Text (PDF) All Versions of this Article: 2213010277v1 221/3/775    most recent Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Binkert, C. A. Articles by Hodler, J. Search for Related Content PubMed PubMed Citation Articles by Binkert, C. A. Articles by Hodler, J.