Calcific shoulder tendinitis: outcomes after percutaneous treatment with Ultrasonography-guided needle aspiration of calcific deposits and bursal injection with steroids and local anaesthetics. Award: Winner Poster No.: P-0101 Congress: ESSR 2012 Type: Authors: Keywords: DOI: Scientific Exhibit S. van Vliet - Hein 1, M. A. Solouki 2, R. Schepers - Bok 1 ; 1 Almelo/ NL, 2 Groningen/NL Calcifications / Calculi, Treatment effects, Ultrasound, Musculoskeletal soft tissue 10.1594/essr2012/P-0101 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Page 1 of 12
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Purpose Calcific tendinitis of the rotator cuff (predominantly in the supraspinatus tendon) is a common disorder and shows the highest incidence in adults aged between 30 and 50 years. Radiologically evident calcification has been described in about 7% of patients with shoulder pain, but can also be seen in asymptomatic adults. The exact mechanism for developing tendinous calcium deposits is still controversial and unclear. Calcific tendinitis is a chronic process and can be divided in four stages: pre-calcific, calcific, resorptive and postcalcific. It is a self-limiting condition in which finally (through leakage in the bursa subacromialis subdeltoidea and spontaneous resorption) the calcfications will disappear. However, untreated, this can last up to 43 months. As this condition is characterized bij movement limitations and chronic pain (that commonly increases at night) with acute pain exacerbations (especially during the resorptive stage), many patients experience conservative shoulder treatment as unacceptable. Several therapeutic approaches are described, such as application of anti-inflammatory drugs and/ or bursal steroid injection or surgical removement of the calcified deposits. Alternatively, various (minimal) invasive, non-surgical treatments for tendinitis calcarea exist. One of these is the (US)-guided needle aspiration of calcific deposits (NACD). A Canadian study (Aina et al.) has previously shown promising results in a group of 37 shoulders treated with this technique. Del Cura et al. also described encouraging results after percutaneous needle aspiration and lavage in 65 patients with acute shoulder pain due to calcific tendinitis. The purpose of our study is to evaluate the clinical response to treatment of calcific tendinitis of the rotator cuff by using the NACD-procedure in combination with bursal steroid and local anaesthetic injection in a large cohort of patients with chronic shoulder pain. Methods and Materials Patients with a proven calcification in the supraspinatus tendon, who reported shoulder pain for at least three months were included in the study. Before they underwent the Page 3 of 12
NACD-procedure they were asked to rate their shoulder pain according to the 11-point numeric rating scale (NRS). The procedures were performed by one US-musculoskeletal-experienced radiologist using a 20/21-gauge needle under standardized sterile conditions. After identification of the calcification(s) with a 12 MHz probe, cutis and subcutis were infiltrated with lidocaine and the needle was directed towards the calcification(s) in the supraspinatus tendon (figure 1). By moving the syringe-plunger gently up- and downwards, calcifications were infiltrated with lidocaine, fragmented and removed by aspiration. The lavage was continued until the aspirate was free of visible calcifications or until a maximum time of 5-7 minutes. After completing the NACD, the bursa subacromialis subdeltoidea was injected with 4 ml bupivacaine (2.5 mg/ml) and 1 ml kenacort (40 mg/ml) (figure 2). To study the short term effect, the pain intensity was assessed two weeks after the procedure by using the NRS. On a longer term, patients were instructed to contact us in case of worsening of the shoulder pain or if an alternative therapeutic approach was chosen. Besides, the patient's medical documents were checked for follow-up / alternative treatments of the shoulder. For statistical analysis the paired t-test was used. Images for this section: Page 4 of 12
Fig. 1: After identification of the calcification(s) with a 12 MHz probe the needle was directed towards the calcification(s) in the supraspinatus tendon. Fig. 2: After completing the NACD, the bursa subacromialis subdeltoidea (star) was injected with 4 ml bupivacaine (2.5 mg/ml) and 1 ml kenacort (40 mg/ml). Page 5 of 12
Results Between November 2009 and December 2011, 122 shoulders in 114 patients were treated. 5 patients were excluded because of incomplete data. The mean NRS was 7.4 before the first NACD procedure and 2.5 two weeks after the NACD procedure (p-value = 6.9 x 10-46 ). 83% had a decline of more than 3 points NRS after the first NACD procedure. 32 % underwent a second NACD (mean NRS 7.6 before and 2.9 after NACD; p-value = 5.2 x 10-16 ). 6 % (n = 7) underwent a third NACD (mean NRS 7.7 before and 1.1 after the procedure). The procedure was tolerated well by all patients. We reported no side-effects during or directly after the procedure. During a mean follow-up time of 1 year, 4.9 % developed a bursitis, 2.5% an adhesive capsulitis and 7.4% (n = 9) were treated differently (e.g. surgical removal of the calcifications). 92.6% (113 shoulders in 105 persons) were treated successfully by NACD (63.9% after one, 86.9% after 2 procedures) (figure 4). During the US-guided procedure we noticed a reduction in calcification volume and a decrease/ disappearance of the acoustic shadow, almost without exception. Figure 5 and 6 show an anteroposterior radiograph of the right shoulder of one of our patients, a 60-year-old woman who had calcific tendinitis for 18 months. Large calcifications in the rotator cuff tendons are visible before the NACD-procedure (figure 5), six months after the needling the calcifications had largely disappeared (figure 6). However, we did not perform conventional radiographs before and after the treatment on a routine base. Images for this section: Page 6 of 12
Fig. 3: Significant decline in NRS score after the first NACD-treatment. X-axis: NRS score; y-axis: number of patients. Page 7 of 12
Fig. 4: 92.6% (113 shoulders in 105 persons) were treated successfully by NACD (63.9% after one, 86.9% after 2 procedures). Page 8 of 12
Fig. 5: Anteroposterior radiograph of the right shoulder of a 60-year-old woman who had calcific tendinitis for 18 months. Large calcifications in the rotator cuff tendons are visible before the NACD-procedure. Page 9 of 12
Fig. 6: Same patient as above, six months after the NACD-procedure. The calcifications had largely disappeared. Page 10 of 12
Conclusion In this prospective study we demonstrated that the NACD-technique combined with bursal injection of steroids and local anaesthetics causes a significant pain reduction in a large population of patients with chronic calcific tendinitis. Re-needling can be done successfully if necessary. It is a well-tolerated procedure and an effective and safe way of treating patients. Compared to performing the NACD-technique under fluoroscopic guidance, US-guidance provides the advantage of excellent visualisation of the (tip of the) needle and anatomic structures as well as recognizing co-morbidities such as bursitis or rotator cuff rupture. It is still unclear why some of the patients do not benefit from one or more NACD procedures. Probably, in those patients the pain is caused predominantly by other factors, such as omarthrosis or rupture of the rotator cuff tendon(s). A different mechanism of formation of the calcifications may also explain these exceptions. We realize that our study has some methodological shortcomings: we did not link the amount and morphology of the calcifications with the NRS score. Also, we did not compare the results with a control group and longer-term follow-up is missing. Further study is needed for optimizing this treatment: long-term follow-up, comparison with treatment with NACD or bursal injection alone, comparison with shock wave treatment and non-treated patients. References References: 1. Aina R., Cardinal E., Bureau N.J., Aubin B., Brassard P.: Calcific shoulder tendinitis: treatment with modified US-guided fine-needle technique. Radiology 2001;221:455-61. 2. Rupp S., Seil R., Kohn D.: Tendinosis calcarea of the rotator cuff. Orthopade 2000;29(10):852-76. 3. Serafini G., Sconfienza L.M., Lacelli F., Silvestri E., Aliprandi A., Sardanelli F.: Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two-needle US-guided percutaneous treatment- nonrandomized controlled trial. Radiology 2009;252: 157-64. Page 11 of 12
4. Del Cura J.L., Torre I., Zabala R., Legórburu A.: Sonographically guided percutaneous needle lavage in calcific tendinitis of the shoulder: short- and long-term results. AJR 2007;189:W128-89. 5. Ebenbichler G.R., Brdogmus C.B., Resch K. L., Funovics M. A., Kainberger F., Barisani G., Aringer M. et al.: Ultrasound therapy for calcific tendinitis of the shoulder. N Engl J Med 1999;340: 1533-8. 6. Bradley M., Bhamra M.S., Robson M.J.: Ultrasound guided aspiration of symptomatic supraspinatus calcific deposits. Br J Radiol 1995;68(811):716-9. 7. Speed C.A., Hazleman B.L.: Calcific tendinitis of the shoulder. N Engl J Med 1999;340:1582-4. Personal Information S. van Vliet - Hein 1, M. A. Solouki 2, R. Schepers - Bok 1 ; 1 Ziekenhuisgroep Twente, Postbus 7600, SZ Almelo, The Netherlands. E-mail: s.hein@zgt.nl / r.schepers-bok@zgt.nl 2 Universitair Medisch Centrum Groningen, Postbus 30.001, 9700 RB Groningen, The Netherlands. E-mail: milladsolouki@yahoo.com Page 12 of 12