Keywords:
Musculoskeletal joint, Extremities, Musculoskeletal system, Fluoroscopy, Percutaneous, Comparative studies, Equipment, Efficacy studies, Toxicity, Drugs / Reactions, Outcomes
Authors:
M. R. F. Jaring1, L. Duerden1, S. E. Davies1, G. CHATZAKIS2, S. James2, F. Jewell2, C. Pawley2; 1Bristol/UK, 2Gloucester/UK
DOI:
10.26044/ecr2019/C-1769
Aims and objectives
Post-arthrography pain is a well documented side effect of the intraarticular injection of contrast media,
generally prior to computed tomography (CT) or,
Magnetic resonance imaging (MRI).
Studies have shown this pain is both predictable and significant,
leading to the recommendation patients should be made aware of post-procedure discomfort during the consent process [1].
The process of arthrography will generally involve the fluoroscopically (or more rarely ultrasound) guided insertion of a needle into a joint.
If required position can be confirmed with iodinated contrast and following this the joint is distended using a dilute mixture of gadolinium.
The aim,
by distending the joint,
is to highlight the capsule and internal structure of the joint.
One of its most common uses is in assessment of the glenoid labrum ( Fig. 1 demonstrates the benefits of intraarticular contrast).
In order to alleviate post-procedure pain,
the use of intraarticular anaesthesia has become commonplace,
however previous studies have provided a mixed picture regarding the benefits.
A study found the use of an intraarticular anaesthetic,
in particular the longer acting bupivacaine,
was associated with a significant decrease in both early and delayed pain [2].
Subsequent research in 2012 found similar benefit to pain,
but also found intraarticular contrast reduced motion artefact in subsequent MRI [3].
However a further study of 120 patients found no reduction in pain using intraarticular anaesthetic [4].
Early justification for avoiding intraarticular anaesthesia was based on potential cost savings as well as the reduced risk of periprocedural adverse drug reactions.
Although both are important factors,
many continued to add anaesthetic to their arthrogram solutions in the hope of alleviating pain.
However more recent research has added another potential drawback: chondrotoxicity.
Intraarticular anaesthetics have been found to be chondrotoxic in vitro,
particularly when used in high concentrations or when the cartilage itself is damaged.
Exposure time is also important,
and a particular factor to bear in mind given the duration anaesthetic may remain in a joint [5].
A review concluded that given the current evidence base,
routine injection of intraarticular anaesthesia should be avoided,
instead recommending careful patient selection when required [6].
The authors objective is to compare whether the addition of intraarticular levobupivacaine during arthrography has a significant effect on post arthrography pain,
and discuss if any benefit achieved outweighs perceived risk.