Shoulder pain: Pain and function significantly improved with image-guided injection
Image-guided versus blind corticosteroid injections in adults with shoulder pain: a systematic reviewBMC Musculoskelet Disord. 2011 Jun 25;12:137. doi: 10.1186/1471-2474-12-137
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Findings of two randomized controlled trials were pooled in order to investigate if method of corticosteroid injection - either image-guided or anatomical landmark guided (blind) - impacted clinical outcome in patients suffering from shoulder pain. Clinical outcomes of pain and function were reported at 6 weeks, and the incidences of adverse events were recorded. Pooled effects illustrated that pain and function at 6 weeks were significantly improved with image-guided injections compared to blind injections. Incidence of adverse events was also lower in image-guided group; however, the difference did not reach statistical significance.
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Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
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Why was this study needed now?
Shoulder pain of a number of etiologies is commonly treated with injection of corticosteroid. Injections can be performed "blindly", using anatomical landmarks for guidance, or image guidance can be used for guidance, usually with ultrasound. Although studies have reported that image guidance does lead to higher injection accuracy, there are conflicting reports about whether or not higher accuracy is translated into more improved outcome compared to blind injection. Therefore, this study was designed to assess clinical outcome of patients treated with either blind or image-guided injection.
What was the principal research question?
Did image-guided injection of corticosteroid lead to improved clinical outcome, primarily pain, and function when compared to landmark-guided injection?
What were the important findings?
- Two studies were selected for inclusion, both of which reported pain, function, and adverse events experienced.
- Pain outcome (VAS 0-10) at 6 weeks was significantly improved with image-guided injection compared anatomical landmark guidance (SMD 2.23 (95%CI 1.27-3.18), p<0.00001) (I-squared = 61%).
- Functional outcome was assessed by either the Constant Score of the Shoulder Function Assessment Scale. Pooled effect resulted in significant improvement at 6 weeks with the use of image guidance compared to blind injection (SMD 1.09 (0.61-1.57), p<0.00001) (I-squared = 22%).
- Incidence of mild adverse events was lower when image-guided injection was performed (RR 0.20 (0.04-1.13)), however the difference did not reach statistical significance (p=0.07). Heterogeneity was not observed (I-squared = 0%). Time-frame of which adverse events were recorded was not reported.
What should I remember most?
Image-guidance of corticosteroid injection in shoulder pain treatment was associated with a significant improvement in pain and function at 6 weeks compared to blind injection. A lower incidence of adverse events was also associated with image-guided injection, however the difference was not statistically significant.
How will this affect the care of my patients?
The findings of this analysis suggest that improved clinical outcomes may be attained with an ultrasound- or fluoroscopy-guided injection of corticosteroid when treating shoulder pain. Since the number of studies included in this analysis was rather low (only 2), as well the noted heterogeneity in the pain outcome analysis, more trials investigating this comparison are needed to either substantiate or refute these findings, and to ultimately conclude on injection guidance efficacy.
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