Magnetic resonance imaging or arthrography for shoulder problems: a randomised study

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Abstract

Objective: Diagnostic technologies are often assessed merely by their accuracy, rather than by their impact on diagnosis and patient management. To this end the authors have undertaken a study to assess the diagnostic and therapeutic impact of magnetic resonance imaging (MRI) and arthrography of the shoulder for patients referred from a rheumatology clinic. Methods and patients: Patients referred from a rheumatology clinic with symptoms warranting imaging of the shoulder were randomised to either MRI or arthrography. Data on the clinician’s diagnostic confidence and management were recorded before and after imaging using questionnaires. Patients were followed-up at least 10 months after imaging to see how management plans evolved, and what proportion of patients required further imaging. Results: Fifty three shoulders underwent imaging over a year and entered into the study; 29 randomised to MRI and 24 to arthrography. Both MRI and arthrography had a similar beneficial diagnostic impact in terms of clinical diagnoses (refuted and retained) and new diagnoses established. MRI and arthrography had a similar therapeutic impact, although MRI was associated with a significant shift towards surgical intervention. Conclusion: MRI and arthrography a have similar diagnostic and therapeutic impact.

Introduction

Magnetic resonance imaging (MRI), shoulder arthrography and ultrasound are commonly requested during the investigation of patients with shoulder problems, especially when a rotator cuff tear is a possible cause. When comparing radiological techniques, emphasis is usually placed on the relative accuracy of the technique rather than the impact on patient management or eventual patient outcome (see Fig. 1) [1].

In this study we have evaluated patients referred from a rheumatology clinic with a wide range of shoulder symptoms suggestive of rotator cuff disease in order to ascertain whether MRI or arthrography, techniques with a high diagnostic accuracy [2], [3], has the greater diagnostic and therapeutic impact. We also wanted to assess which, if any, was the best test for a particular set of shoulder problems. Patients with suspected bone or soft tissue tumour or who had undergone previous shoulder surgery were not included in the study. Ultrasound was not evaluated in this study as its accuracy is particularly operator-dependent, and although the technique is growing rapidly in availability and acceptance, it is still not offered by all radiology departments.

Section snippets

Methods and patients

Over a 12-month period, purpose-designed request forms were used to collect information on the clinicians’ diagnosis, diagnostic confidence and proposed management for all patients referred from a rheumatology clinic for imaging of the shoulder. Clinicians used their clinical history, examination and plain radiographs where available to make a preliminary diagnosis. Diagnoses (up to two) were specified in terms of the probable anatomical site of the lesion under investigation and the working

Results

Over the 12-month period, 58 patients were referred for imaging of the shoulder for pain, seven of these had to be excluded from the analysis because there was either insufficient data, patients had not attended for imaging, or the request was for disease other than rotator cuff disease. Of the 51 remaining there were 24 men aged between 33 and 85 years (median 58.5 years) and 27 women aged between 35 and 78 years (median 55 years), culminating in 53 shoulder examinations (two bilateral cases).

Discussion

MRI and arthrography have both been shown to have comparable accuracy [2], [11], [12], and patients do not seem to have any overall preference for either investigation [13]. The advantages of MRI include multiplanar imaging, comprehensive display of soft tissue anatomy and a demonstration of the causes for impingement. However, there are recognised pitfalls [14], [15], [16], [17] and the diagnosis of full thickness rotator cuff tears (RCT) still cannot be made with quite the same accuracy and

Acknowledgements

The authors wish to acknowledge the contribution from the radiographers within Addenbrooke’s Hospital. We would also like to thank Dr D.J. Lomas for the many MRI opinions, and Mr C.R. Constant for his advice in orthopaedics. IGE Medical Systems fund T.K. Blanchard’s research.

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