Iagnocco, Annamaria

Naredo, E.

English

Institutional Research Information System University of Turin

EditorialUltrasound-guided corticosteroid injection inrheumatology: accuracy or efficacy?Is it the best way to deliver corticosteroid injections?This editorial refers to ‘Steroid injection for hiposteoarthritis—efficacy under ultrasound guidance’,by Mihaela C. Micu et al., doi:10.1093/rheumatology/keq030, on page 1490 and ‘Ultrasound-guided sacroi-liac joint injection in patients with established sacroi-liitis: precise IA injection verified by MRI scanningdoes not predict clinical outcome’, by WolfgangHartung et al., doi:10.1093/rheumatology/kep424, onpage 1479.Two articles by Micu et al. [1] and Hartung et al. [2] inthis issue are interesting because they describe theshort-term efficacy of corticosteroid injection performedwith ultrasound (US) guidance for hip OA and sacroiliitis,respectively. In the first study, on hip OA [1], 100% ofpatients received correct IA needle placement andshowed significant clinical improvement compared withthe controls who did not receive the steroid injection. Inthe other study on US-guided injections in sacroiliac jointsin patients with sacroiliitis [2], only 40% of the proceduresreached the synovial space when verified by MRI. Whilethis accuracy rate was lower than previously publishedstudies (which ranged from 80 [3] to 93.5% [4]), thisstudy interestingly reported no significant difference inclinical improvement whether steroid was delivered intothe SI synovial space or merely the posterior periarticulararea of the SI joint. Clearly, more studies are needed toprovide evidence about short- and long-term benefit andcost effectiveness of therapeutic US-guided injections vsblinded injections.When expert clinicians deliver IA injections, they normal-ly do not need guidance from imaging techniques to placethe needle successfully in the target area. However, somestudies report variable accuracy in placement of theneedle in palpation-guided IA injections [5, 6]. To locatethe exact needle position in ‘blind’ injections is, ofcourse, difficult in deep joints (e.g. hip, SI or glenohumeraljoints). This fact might be clinically crucial for diagnostic IAaspiration or when accurate IA medication injection is ne-cessary (e.g. radioisotopes and viscosupplementation). Inaddition, in conventional ‘blind’ routes, the risk of inciden-tal damage to the adjacent non-target structures by theneedle or injected drug, or from both, cannot be avoidedcompletely. These structures include, depending on theinjected region, blood vessels, peripheral nerves, muscles,ligaments, intratendinous tissue and subcutaneous fat.Ultrasound is a valuable bedside tool for guiding accur-ate and safe musculoskeletal fluid aspiration and injec-tions [7]. Moreover, it confirms the clinical diagnosis andthe indication for injection. Real-time ultrasound enablesthe rheumatologist to correctly place the needle, accur-ately deliver medication and visualize the steroid suspen-sion during and after the procedure. Epis et al. [7] havedescribed the accuracy, safety and simplicity of US forguiding interventional procedures in the musculoskeletalsystem. US-guided injections performed by clinicians areas feasible as blind procedures in clinical practice.However, there is a learning time for the correct use ofUS-guided injections and the success of the technique isoperator dependent [3, 4, 8]. In particular, US-guidedinjections of deep anatomical targets require more experi-ence than superficial injections. The oblique direction ofthe needle to the ultrasound beam in deep injectionsdecreases its visibility during these procedures. Afterappropriate training, however, US guidance is suitablefor deep joints such as the hip and SI joints, and issuccessful and effective [3, 9].The effect of accurate needle placement in a therapeut-ic response to local corticosteroid injection reported in theliterature needs further elucidation [2, 10]. Various argu-ments can explain this controversy. The mechanism oflocal steroid action is not well understood. Both a system-ic effect and a local action by diffusion of the steroid sus-pension either into blood vessels or the surroundinganatomic structures could explain their therapeuticeffect, even when they do not reach the target tissue.Nevertheless, a recent randomized controlled study bySibbitt et al. [10] on 148 painful joints clearly showedthat US guidance significantly improved the performanceand short-term outcome of IA steroid injections comparedwith conventional palpation guidance. In conclusion,we believe that US guidance can maximize injectionaccuracy in the intended target area and minimizeadverse effects.Disclosure statement: The authors have declared noconflicts of interest.! The Author 2010. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.orgRHEUMATOLOGYRheumatology 2010;49:1427–1428doi:10.1093/rheumatology/keq081Advance Access publication 31 March 2010EDITORIAL by guest on October 29, 2016http://rheumatology.oxfordjournals.org/Downloaded from Annamaria Iagnocco1 and Esperanza Naredo21Rheumatology Department, Sapienza Universita` di Roma,Rome, Italy and 2Rheumatology Department, HospitalUniversitario Severo Ochoa. Madrid, SpainAccepted 18 February 2010Correspondence to: Esperanza Naredo, RheumatologyDepartment, Hospital Universitario Severo Ochoa, Dr AlvarezSierra 4, 4oA, 28033 Madrid, Spain.E-mail: enaredo@ser.esReferences1 Micu MC, Bogdan G, Fodor D. Steroid injection for hiposteoarthritis—efficacy under ultrasound guidance.Rheumatology 2010;49:1409–4.2 Hartung W, Ross CJ, Straub R et al. Ultrasound-guidedsacroiliac joint injection in patients with establishedsacroiliitis: precise IA injection verified by MRI scanningdoes not predict clinical outcome. Rheumatology 2010;49:1479–82.3 Klauser A, De Zordo T, Feuchtner G et al. Feasibility ofultrasound-guided sacroiliac joint injection consideringsonoanatomic landmarks at two different levels incadavers and patients. Arthritis Rheum 2008;59:1618–24.4 Pekkafal{ MZ, K{ralp MZ, Basekim CC¸ et al. Sacroiliacjoint injections performed with sonographic guidance.J Ultrasound Med 2003;22:553–9.5 Balint PV, Kane D, Hunter J, McInnes IB, Field M,Sturrock RD. Ultrasound guided versus conventionaljoint and soft tissue fluid aspiration in rheumatologypractice: a pilot study. J Rheumatol 2002;29:2209–13.6 Rosenberg JM, Quint TJ, de Rosayro AM. Computerizedtomographic localization of clinically-guided sacroiliacjoint injections. Clin J Pain 2000;16:18–21.7 Epis O, Iagnocco A, Meenagh G et al. Ultrasoundimaging for the rheumatologist XVI. Ultrasound-guidedprocederes. Clin Exp Rheumatol 2008;26:515–8.8 Atchia I, Birrell F, Kane D. A modular, flexible trainingstrategy to achieve competence in diagnostic and inter-ventional musculoskeletal ultrasound in patients with hiposteoarthritis. Rheumatology 2007;46:1583–6.9 Qvistgaard E, Christensen R, Torp-Pedersen S, Bliddal H.Intra-articular treatment of hip osteoarthritis: a randomizedtrial of hyaluronic acid, corticosteroid, and isotonic saline.Osteoarthr Cartil 2006;14:163–70.10 Sibbitt WL, Peisajovich A, Michael AA et al. Does sono-graphic needle guidance affect the clinical outcomeof intraarticular injections? J Rheumatol 2009;36:1892–902.1428 www.rheumatology.oxfordjournals.orgEditorial by guest on October 29, 2016http://rheumatology.oxfordjournals.org/Downloaded from 

Ultrasound-guided corticosteroid injection in rheumatology: accuracy or efficacy?

IAGNOCCO, Annamaria

E. Naredo

Archivio della ricerca- Università di Roma La Sapienza

https://iris.unito.it/bitstream/2318/1613128/1/120.pdf

Ultrasound-guided corticosteroid injection in rheumatology: accuracy or efficacy?

Abstract

Similar works

Full text

Available Versions

Institutional Research Information System University of Turin

Archivio della ricerca- Università di Roma La Sapienza