CT-Guided Percutaneous Steroid Injection for Management of Inflammatory Arthropathy of the Temporomandibular Joint in Children

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1 Cahill et al. Interventional Radiology Clinical Observations 182.fm 11/30/06 Anne Marie Cahill 1 Kevin M. Baskin 2 Robin D. Kaye 3 Bita Arabshahi 4 Randy Q. Cron 4 Esi M. Dewitt 4 Larissa Bilaniuk 1 Richard B. Towbin 5 Cahill AM, Baskin KM, Kaye RD, et al. Keywords: interventional radiology, musculoskeletal imaging, pediatrics, DOI: /AJR Received July 13, 2004; accepted after revision July 22, R. Q. Cron was funded in part by the Nickolett Family Awards Program for JRA Research and the Ethel Brown Foerderer Fund for Excellence. 1 Department of Radiology, University of Pennsylvania, Children's Hospital of Pennsylvania, Philadelphia, PA Present address: Department of Radiology, Children s Hospital of Pittsburgh, 3950 CHP, 200 Lothrop St., Pittsburgh, PA Address correspondence to K. M. Baskin. 3 Present address: Department of Radiology, Children s Hospital of Wisconsin, Milwaukee, WI Department of Pediatrics, Division of Radiology, Children s Hospital of Pennsylvania, Philadelphia, PA Present address: Private Practice, Philadelphia, PA AJR 2007; 188: X/07/ American Roentgen Ray Society CT-Guided Percutaneous Steroid Injection for Management of Inflammatory Arthropathy of the Temporomandibular Joint in Children OBJECTIVE. The purposes of this study were to retrospectively review an injection technique, to develop a grading system for evaluation of imaging findings, and to report preliminary outcome related to percutaneous CT-guided steroid injection into the s of children with inflammatory arthropathy. CONCLUSION. CT-guided steroid injection into the of children with inflammatory arthropathy results in clinical and imaging improvement in a substantial proportion of children treated. J uvenile idiopathic arthritis is a chronic disease of children characterized by inflammatory synovitis. Juvenile idiopathic arthritis encompasses both juvenile rheumatoid arthritis and the HLA-B27 associated spondyloarthropathy. The condition is defined by arthritis that persists for a minimum of 6 consecutive weeks, involves one or more joints, and begins before the age of 16 years [1]. Juvenile idiopathic arthritis occurs in approximately one in 1,000 North Americans and may lead to significant morbidity and deformity. Clinically, the knee, ankle, and finger joints are commonly involved [2]. Corticosteroid joint injection has been popularized as prompt and lasting therapy for juvenile idiopathic arthritis [3, 4]. Although radiologic evidence of temporomandibular joint (TMJ) involvement has been reported in as many as 63% of persons with juvenile idiopathic arthritis [5, 6], little attention has been paid to corticosteroid injection for inflammatory TMJ arthritis. Normal TMJ anatomy is described in Figure 1. Evidence of inflammatory arthropathy on imaging of the TMJ includes acute changes such as joint effusion, inflamed synovium, and marrow edema; subacute changes including juxtaarticular erosion; and chronic changes such as beaking, flattening or loss of the mandibular condyle, bone sclerosis, and meniscal (disk) thinning and displacement. Most children with juvenile idiopathic arthritis also have clinical signs and symptoms of TMJ involvement and associated craniofacial growth alterations that result in malocclusion, facial asymmetry, re- Fig. 1 Drawing shows complex articulation of mandible with temporal bone at, combining hinge, gliding, and lateral motions during mastication. Saddle-shaped, fibrous meniscus separates mandibular condyle from articular fossa and eminence of squamous temporal bone. Meniscus also separates into superior and inferior compartments (asterisks) bounded by synovial membrane. 182 AJR:188, January 2007

2 TABLE 1: Clinical Outcome Patient Pain Clinical Change No. Before Procedure After Procedure Pain Tooth-to-Tooth Gap NA NA NA + 11 NA NA NA NA NA NA NA 8 a NA NA NA Note Assessment of pain and mobility (measured as tooth-to-tooth gap, that is, the space between the upper and lower incisors during maximal opening of mouth) before and 3 4 months after steroid injection for 12 of 17 treatment sessions. Pain diminished or resolved ( ) after seven (88%) of eight treatment sessions and persisted ( ) after one session. Patients experienced slight to substantial improvement in mobility after five (45%) of 11 treatment sessions and a decrease ( ) after one session. This patient (no. 8) received a second treatment. NA = data not available, ++++ = 31 40% (substantial) improvement, +++ = 21 30% (moderate) improvement, ++ = 11 20% (slight) improvement, + = 0 10% (negligible) improvement. a First injection for this patient. stricted opening of the mouth (tooth-to-tooth gap), and facial pain [7]. Radiologic guidance has been shown to be useful for accurate injection of corticosteroids in deep and in small joints [8]. Injection into the TMJ can be worrisome because of the proximity of facial nervous and vascular structures. In addition, injection into the TMJ space is complicated by the disturbance of the normal TMJ anatomy caused by inflammatory joint destruction. We chose CT guidance as an approach to ensure proper needle placement in the involved TMJ. The purposes of this study were to describe our injection technique, to develop a grading system for the description of imaging findings for use in future prospective treatment trials, to analyze imaging effects, and to report preliminary clinical outcome of intraarticular steroid injection into the TMJ of children with chronic arthropathy. Materials and Methods Patients From October 2002 to February 2004, 27 CTguided intraarticular TMJ steroid injections were performed in 14 girls and one boy with juvenile idiopathic arthritis (nine cases of arthritis were of the oligoarticular type; four, polyarticular type; one case, systemic; and one case, psoriatic arthropathy). Informed consent from the parent or legal guardian was obtained for all procedures. Institutional review board approval was obtained for this study. At admission to the study, all patients were considered to have advanced involvement of the TMJ with facial asymmetry, limited mobility, or pain. A history of pain at the TMJ (measured at palpation, chewing, speaking, and rest) was elicited from eight of 15 patients before their first treatment session. These parameters are reported for patients with both preprocedure and postprocedure results (Table 1). Preprocedure MRI showed signs of inflammatory arthropathy in all 27 joints considered for treatment, including joint changes in 24 (89%) of 27 joints and bone changes in 27 of 27 joints (Table 2). Injections were administered to 27 joints during 17 sessions, 10 for bilateral injections and seven for unilateral injections, including repeated injections in two patients. The mean age of the study group was 8.3 years (range, years). The mean weight was 29 kg (range, kg). Procedure All children underwent MRI before the procedure because MRI has been shown to be the most sensitive radiographic technique for detection of TMJ arthritis [9]. For both preprocedure and postprocedure MRI, 2- to 3-mm-thick axial T1-weighted localizer images were obtained through the TMJ to determine the position and orientation of the mandibular condyles. T1- weighted (TR/TE, 600/14), proton density weighted (3,500/15), and fat-saturated conventional T2- weighted (3,500/105) images 2- to 3-mm thick were obtained parallel to the long axis of the condyle (sagittal). Additional T1- and T2-weighted images were ob- tained perpendicular to the condyle (coronal) through the region of the TMJ. All images were obtained using a head coil with the patient s mouth closed. Preprocedure clinical assessment was performed before sedation or general anesthesia. Routine laboratory testing was not required. Most patients had undergone recent complete blood cell counts and basic metabolic panel screens for routine analysis of the toxicity of antiinflammatory therapy. All but one of the 17 treatments sessions were performed with deep IV sedation. This sedation consisted of IV fentanyl citrate (Sublimaze, Janssen) 1 3 µg/kg, pentobarbital sodium (Nembutal, Abbott) 2 5 mg/kg, and midazolam hydrochloride (Versed, Hoffman-LaRoche) mg/kg in combination. One treatment was performed with general anesthesia because injections were administered to other joints the same day. Continuous cardiorespiratory monitoring was performed during all treatments. The procedures were performed by experienced pediatric interventional radiologists. The child was placed supine on the CT table, and the child s head was rotated 45 away from the joint to be injected. Axial CT was performed through the area of interest as a continuous acquisition with 1-mm collimation. A suitable access site was localized just anterior to the tragus, a radiopaque marker was placed, and an appropriate entry site was confirmed. The site was prepared with povidone iodine and alcohol and draped in standard surgical manner. The access site was locally anesthetized with 1% lidocaine buffered with sodium bicarbonate (8:2 mixture) through a 30-gauge needle. Needle access (Fig. 2) for injection of the joint was obtained either with a tandem needle technique with a 30-gauge needle as the guide or with a single 18- or 21-gauge needle. Satisfactory needle position within the mandibular fossa was confirmed with CT in all cases. Through the access needle, a volume of 1 ml (40 mg) of triamcinolone acetonide (Kenalog-40, Bristol-Myers Squibb), a longacting steroid, was injected into the joint with a 1- ml syringe, and the needle was withdrawn. The child was discharged from the postsedation recovery area when discharge criteria were met. Data Collection Clinical parameters were evaluated by pediatric rheumatologists. Change in TMJ mobility was measured as percentage change in the patient s ability to open the gap between the upper and lower incisors. Postprocedure change in tooth-to-tooth gap was available for 11 of 15 patients. Pain at the TMJ was measured at palpation, chewing, speaking, and rest and was reported as present or absent at initial examination and better, worse, or absent at follow-up examination. These data were available for eight of 15 patients. AJR:188, January

3 Cahill et al. 182.fm 11/30/06 TABLE 2: Imaging Outcome Joint Changes Bone Changes Joint Changes Bone Changes Follow-Up (wk) Condylar Condylar Effusion Disk/Space Erosion Structure Grade a Before Effusion Disk/Space Erosion Structure Grade a After Change R L R L R L R L R L R L R L R L R L R L R L Patient No nl nl a 4a nl nl b + + nl a 4a nl 4 4a nl nl a 4a nl nl 4a 4a c + + nl nl + + nl nl 3a 3a nl nl 3a 3a nl nl + + nl nl 3a 3a nl nl nl nl NA nl NA + NA nl NA + NA 4 NA nl NA NA nl NA NA 4 NA NA + NA nl NA + NA nl NA 4a NA NA nl NA NA nl NA 4 NA NA + NA nl NA + NA + NA 4a NA NA nl NA NA NA 4 NA NA nl NA + NA + NA 4a NA NA nl NA NA NA 4 NA NA NA nl NA + NA + NA 4a NA NA nl NA NA NA 4 NA NA 32.2 Note MRI through the was performed weeks (average, 36 weeks; SD, 14 weeks) after injection in 10 treatment sessions representing 15 joint injections. Joint changes (i.e., effusion, meniscal [disk] abnormalities, loss of normal joint space) and bone changes (i.e., erosions or abnormalities of the mandibular condyle) were present (+) in all 10 patients before injection. Follow-up imaging showed improvement in 67% of the treated joints. One patient (no. 6) had persistence of or increase in several imaging parameters, including effusion, and received a second treatment. R = right, L = left, nl = normal, = improvement, = unchanged or equivocal finding, = disease progression, NA = data not available. a Grade reported as follows: 3 = subacute juxtaarticular erosions; 3a = acute on subacute finding; 4 = chronic morphologic change or sclerosis of condyle, abnormal deviation of the meniscus, or loss of articular cartilage; 4a = acute on chronic finding. b Second injection for this patient. c First injection for this patient. Preprocedure and postprocedure MR images were evaluated by a pediatric neuroradiologist for joint changes (effusion, abnormality of the meniscus, synovial thickening, and loss of normal joint space) or bone changes (erosion, abnormal signal in the marrow, and flattening or irregularity of the structure of the mandibular condyle) characteristic of inflammatory arthropathy [7, 10, 11]. Imaging findings were reported for each injected joint as normal or present on preprocedure imaging and normal, unchanged, interval improvement, or interval disease progression at follow-up examination. Each injected joint was assigned a grade based on a consensus of four radiologists as follows: grade 1 (normal), no finding characteristic of TMJ arthropathy; grade 2 (acute), joint effusion, synovial thickening, or marrow edema; grade 3 (subacute), juxtaarticular erosions; grade 3a, acute on subacute findings; grade 4 (chronic), morphologic change or sclerosis of the condyle, abnormal deviation of the meniscus, or loss of articular cartilage; grade 4a, acute on chronic findings; grade 5 (end stage), ankylosis of the TMJ. Results The 27 joint injections were performed with a 22-gauge angiocatheter (n = 13), an 18-gauge hypodermic needle (n = 8), a 21- gauge hypodermic needle (n = 2), or a 30- gauge hypodermic needle (n = 4). One procedure-related minor complication, injection of 1 ml of absolute alcohol into the joint space, was recognized immediately. The alcohol was aspirated and the joint space flushed with sterile saline solution followed by corticosteroid. There were no sequelae. Otherwise, all TMJ injections were technically successful, even in children who had marked anatomic disturbance due to the disease. Clinical follow-up examinations were performed 3 4 months after injection. Preprocedure and postprocedure clinical data were available for 12 of 15 patients. These data included tooth-to-tooth gap measurements for 11 and pain assessment for eight children. No patient had a significant change in facial asymmetry during the follow-up period. Tooth-to-tooth gap (Table 1) showed moderate to substantial improvement in three of 11 patients and slight improvement in two of 11 patients (mean increase, 12.2%). For seven (88%) of eight children, pain was qualitatively decreased or absent after treatment (Table 1). Two patients had no perceptible change in mobility or discomfort. One patient (patient 5) had decreased mobility and was referred for repeated injection. 184 AJR:188, January 2007

4 Follow-up MRI was performed after 10 of 17 treatment sessions (Table 2), on average 9 months after injection (range, 5 15 months). Compared with preprocedure imaging, improvement in acute signs (Fig. 3) was seen as substantial reduction or resolution of effusion in 11 (73%) of 15 treated joints. Equivocal findings were seen in three (20%) of 15 treated joints with a decrease in effusions but an increase in erosions in one case (patient 11) and no appreciable change in the one patient (patient 6) who did not have preprocedure imaging evidence of acute disease. Patient 8 had a substantial increase in effusions, erosions, and bilateral flattening of the Fig. 2 8-year-old girl with juvenile idiopathic arthritis. Axial CT image through right confirms position of tip (arrow) of 21-gauge hypodermic access needle in right before injection of corticosteroid. A condyles. This patient was referred for repeated injections. No patient was found to have an increase in grading scale score after injection. In general, absence of acute findings on MRI ( a in the MRI grading scale nomenclature) correlated with improvements in clinical findings (Tables 1 and 2). Therefore this grading scheme may be a useful tool for prospective treatment trials. Discussion Triamcinolone acetonide, the long-acting corticosteroid used in our study population, is a well-established steroid for intraarticular in- Fig year-old girl (patient 4) with polyarticular juvenile idiopathic arthritis with involvement of s. A, T2 fat-saturated parasagittal MR image through right shows normal meniscus outlined by high signal intensity, representing effusion in superior and inferior compartments. B, T2 fat-saturated parasagittal MR image obtained 25 weeks after steroid injection in joint in A shows absence of high signal intensity from effusion characteristic of acute inflammation in juvenile rheumatoid arthritis. Chronic changes in mandibular condyle, such as flattening and beaking, have not resolved over relatively short period. B jection. This drug appears to be effective in reducing synovitis and structural articular changes commonly associated with inflammatory arthropathy such as juvenile idiopathic arthritis. The peak effect occurs after approximately 6 weeks of treatment, and the expected duration is 6 17 months [12, 13]. Known potential immediate reactions to intraarticular steroid injection, such as pain and headache, or delayed side effects, such as joint infection and loss of subcutaneous fat [14, 15], were not found in our study. Our results support the hypothesis that intraarticular TMJ injection of a long-acting steroid in children is a safe procedure even in patients with joint space deformities. All procedures were performed on an outpatient basis, and the children were discharged home the same day. This system simplifies the procedure for families to obtain repeated joint injections as required. The two children with clinical or radiographic deterioration after the first treatment received a second injection approximately 6 months after the first. Many of our patients had substantial relief of clinical symptoms associated with TMJ arthropathy and resolution of related imaging abnormalities measured as reduction in acute and subacute inflammatory changes on MRI. This finding is consistent with successful management of the acute component of juvenile idiopathic arthritis. Because our cohort had severe disease involvement by the time of entry into the study, we did not study whether intervention earlier in the course of disease prevents disease progression. We hypothesize that chronic structural changes in the TMJ may not be amenable to treatment with intraarticular steroids. However, evaluation of chronic features of juvenile idiopathic arthritis, such as bone changes and craniofacial asymmetry, is expected to require longer-term follow-up than the time frame of this pilot study. A small sample size, lack of an appropriate control group, incomplete preprocedure and postprocedure imaging, use of a head coil rather than a surface coil during MR image acquisition, inconsistent measurement and recording of related clinical parameters, and a relatively short follow-up period limited this retrospective study. Consequently, objective evidence of lasting improvements in TMJ structure and function, amelioration of pain, and modification of progression of craniofacial deformities has not yet been assessed in this patient population. AJR:188, January

5 Cahill et al. Lack of a screening program makes it difficult to identify patients who may benefit from this therapy early in the clinical course, once effusions are detected in the TMJ but before the disease has advanced to bone changes, facial asymmetry, and limited mobility [11]. It may be possible through earlier intervention to preserve normal structure and function in these children until they achieve disease remission [16]. We are currently enrolling juvenile idiopathic arthritis patients in a prospective assessment of TMJ arthritis with MRI and sonography at the time of diagnosis. Use of the grading system proposed in this study may assist in standardization of results reporting and be a consistent basis for comparison with other measures of clinical and pathophysiologic changes related to juvenile chronic arthropathy. Acknowledgment We thank David D. Sherry for critical review of the manuscript. References 1. Petty RE, Southwood TR, Baum J, et al. Revision of the proposed classification criteria for juvenile idiopathic arthritis: Durban, J Rheumatol 1998; 25: Sharma S, Sherry DD. Joint distribution at presentation in children with pauciarticular arthritis. J Pediatr 1999; 134: Cron RQ, Sharma S, Sherry DD. Current treatment by United States and Canadian pediatric rheumatologists. J Rheumatol 1999; 26: Sherry DD, Stein LD, Reed AM, Schanberg LE, Kredich DW. Prevention of leg length discrepancy in young children with pauciarticular juvenile rheumatoid arthritis by treatment with intraarticular steroids. Arthritis Rheum 1999; 42: Larheim TA, Hoyeraal HM, Stabrun AE, Haanaes HR. The in juvenile rheumatoid arthritis: radiographic changes related to clinical and laboratory parameters in 100 children. Scand J Rheumatol 1982; 11: Pedersen TK, Jensen JJ, Melsen B, Herlin T. Resorption of the temporomandibular condylar bone according to subtypes of juvenile chronic arthritis. J Rheumatol 2001; 28: Yulish BS, Lieberman JM, Newman AJ, Bryan PJ, Mulopulos GP, Modic MT. Juvenile rheumatoid arthritis: assessment with MRI. Radiology 1987; 165: Newman JS. Diagnostic and therapeutic injections of the foot and ankle. Semin Roentgenol 2004; 39: Kuseler A, Pedersen TK, Herlin T, Gelineck J. Contrast enhanced magnetic resonance imaging as a method to diagnose early inflammatory changes in the in children with juvenile chronic arthritis. J Rheumatol 1998; 25: Lamer S, Sebag GH. MRI and ultrasound in children with juvenile chronic arthritis. Eur J Radiol 2000; 33: Taylor DB, Babyn P, Blaser S, et al. MR evaluation of the in juvenile rheumatoid arthritis. J Comput Assist Tomogr 1993; 17: Padeh S, Passwell JH. Intraarticular corticosteroid injection in the management of children with chronic arthritis. Arthritis Rheum 1998; 41: Breit W, Frosch M, Meyer U, Heinecke A, Ganser G. A subgroup-specific evaluation of the efficacy of intraarticular triamcinolone hexacetonide in juvenile chronic arthritis. J Rheumatol 2000; 27: Neidel J. Intraarticular steroid therapy for inflammatory rheumatic diseases in children and adolescents [in German]. Orthopade 2002; 31: Di Stefano V, Nixon JE. Skin and fat atrophy complications of local steroid injection. Pa Med 1974; 77: Duffy CM, Laxer RM, Silverman ED. Drug therapy for juvenile arthritis. Compr Ther 1989; 15: AJR:188, January 2007