Background/Purpose: Sonographic needle guidance (USG) of musculoskeletal injections has improved outcomes of intraarticular (IA) injections, but is associated with increased procedural costs. This practical randomized controlled pilot study was designed to determine: 1) the overall costs and cost-effectiveness of the USG technique of IA corticosteroid injections in the shoulder, and 2) provide preliminary power data to determine whether USG IA injections were more effective than the conventional anatomic landmark palpation-guided (ALMPG) method.

Methods: 29 patients with intractable shoulder pain (glenohumeral joint (GHJ) arthritis with tenderness to deep palpation anteriorly) were randomized to injection by either conventional ALMPG (15 patients) injection USG (14 patients) injection.  A two-step technique was utilized for IA procedures using one needle and two syringes.  The USG method comprised:  1) interrogation of the shoulder to find the GHJ, 2) needle introduction into the GHJ using the anterior approach under USG, 3) 3 ml 1% lidocaine injected with US visible dilation of the IA space, 4) a syringe exchange leaving the IA needle in place, and 5)  injection of 80 mg triamcinolone acetonide (2 ml) through the IA needle.   Demographics, baseline pain, procedural pain, pain at 2 weeks, pain at 24 weeks, therapeutic duration, physician satisfaction, total cost per procedure, and yearly cost per patient were collected and analyzed.  Pain was measured with the 10 cm Visual Analogue Pain Scale (VAS). 

Results: There were no complications in either treatment group. Both groups significantly improved at 2 weeks post-injection (p<0.005), supporting that both USG and ALMPG were both effective as has been previously demonstrated.  There was no significant difference in total cost (yearly cost per patient) between US and non-US methods (p<0.23), despite increased upfront procedural costs. The USG data suggested potentially improved outcomes due to statistical trends for reduced post-procedural costs (p<0.101), reduced injection pain (p<0.113), and prolongation of time to next procedure (p<0.06).  With the current subject numbers, compared to conventional ALMPG methods, USG injection did not demonstrate statistically significant improvement in pain at 2 weeks post-injection (p<0.69), pain at 24 weeks post-injection (p<0.63), pain from baseline compared to 2 weeks post-injection (p<0.78), pain from baseline to 24 weeks post-injection (p<0.60), or duration of therapeutic effect ( p<0.39).

Conclusion: USG does not increase the overall costs of IA shoulder injections and with a trend of decreasing post-procedure costs, findings of importance for medical economics.  Further, the present study trends suggest that USG may improve overall clinical outcomes of IA shoulder injections permitting power determination for future definitive studies

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/outcomes-and-cost-effectiveness-of-shoulder-injections-with-sonographic-needle-guidance/