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We read with interest the paper by Hall and Buchbinder,1 which discussed the importance of accurate needle placement guided by imaging techniques in the therapeutic response to local corticosteroid injection (LCI) for musculoskeletal (MSK) conditions.
Certainly, as the authors state,1 more studies providing evidence of short and long term benefit and cost effectiveness of imaging guided LCI versus blinded injection are needed. However, we would like to make some comments on a number of important points.
Firstly, Hall and Buchbinder1 include in radiological guidance different imaging techniques such as radiography, computed tomography (CT), magnetic resonance imaging, and ultrasonography (US). We would like to point out that MSK US has considerable advantages over other imaging modalities as it has no secondary effects, is quick to perform, is low cost, can be repeated, and is well accepted by patients. In addition, MSK US is routinely used by an increasing number of rheumatologists from many European countries. The accuracy, safety, and simplicity of US for guiding interventional procedures in the MSK system have been widely described.2–9
Secondly, the authors mentioned the contradictory results of two papers comparing imaging guided versus blinded LCI in the shoulder.8,10 We found a better clinical response to US guided than to blinded LCI,8 whereas Shanahan et al reported a similar response to CT guided and blinded suprascapular nerve block.10 Both studies were randomised, assessor blinded, and short term. Nevertheless, both interventional procedures are essentially different. In suprascapular nerve block the aim is to place the needle next to the suprascapular nerve at the suprascapular notch so that the steroid diffuses into the nerve. The use of anatomical landmarks by an experienced operator probably is enough to achieve successful placement of the LCI. On the contrary, rotator cuff, biceps tendon, and subacromial-subdeltoid bursa are located close together. Therefore accurately siting the needle in the target as well as avoiding damaging intra-tendon injection are difficult using external landmarks. In addition, CT is radioactive, expensive, and requires a radiologist, whereas US is non-invasive, available, cheap, and can be performed by a rheumatologist at the patient’s bedside while accurately diagnosing shoulder lesions.
In conclusion, we would like to emphasise that US has become a powerful extension of MSK evaluation performed by many rheumatologists for improving diagnosis and interventional procedures.
We thank Dr Naredo and colleagues for their interest and observations.
Musculoskeletal ultrasound remains a safe, non-invasive, and (relatively) inexpensive form of imaging. It has been taken up widely by clinicians, particularly in Europe, though there has been less enthusiasm elsewhere.
However, there remains a hypothesis in need of more formal testing implicit in this communication. Naredo et al propose that some targets such as the suprascapular nerve can be identified by anatomical landmarks, whereas others require precise localisation through imaging to ensure therapeutic impact. Our editorial proposes that this assumption needs to be tested. Is it really mandatory to inject precisely into the subacromial-subdeltoid bursa as opposed to the rotator cuff or the biceps tendon in a patient with shoulder pain to guarantee a reduction in pain and improvement in function over the longer term?
Until there is sufficient evidence from both participant and outcome assessor blinded randomised trials documenting a real difference between image guided needle placement and the anatomical landmark approach over the longer term (sufficient to justify the extra cost), the requirement for precise localisation remains speculative. We welcome the results of such trials to see whether or not “the Emperor has no clothes”, the fairy tale equivalent of a null hypothesis.