Shoulder Injections

Percutaneous injections of the glenohumeral joint are commonly performed without fluoroscopic guidance by a variety of clinicians to treat shoulder pain. However, as with hip injections,

FIGURE 9 Pulmonary artery fluoroscopic image demonstrating oblique needle course required due to arcuate configuration of tarsal navicular joint.

FIGURE 10 Pulmonary artery fluoroscopic image during glenohumeral injection using anterior approach. Source: Courtesy of Guerdon Greenway M.D., Baylor University Medical Center, Dallas, Texas, U.S.A.

fluoroscopy provides the ability to definitively assess intra-articular needle position. Glenohumeral joint injections are most commonly performed from an anterior approach, utilizing 20- to 25-gauge spinal needles. A 22-gauge needle is preferred due to its relatively small diameter and maneuverability. The technical aspects are identical to those of glenohumeral arthrography and typically involve entering the joint capsule from an anterior approach at the level of the lower one-third of the glenoid (Fig. 10). Occasionally, a posterior approach will be required due to osteophytic ridging along the anterior margin of the joint. This technique involves positioning the patient in a prone-oblique position on a conventional fluoroscopic table (Fig. 11) or utilizing an oblique orientation with a C-arm device to visualize the glenohumeral joint in profile (Fig. 12). The needle can then be advanced between the humeral head and the glenoid. This technique has been recently described as the preferred method in magnetic resonance arthrography, particularly in the assessment of anterior instability of the glenohu-meral joint (11).

Anesthetic injection of the glenohumeral joint can be useful diagnostically when dilemmas exist between joint-related pain and cervical radicular symptoms. Objective assessment of the patient's response to anesthetic injection is identical to that for hip and ankle injections described previously in this chapter.

FIGURE 11 Prone-oblique positioning used during posterior approach to the glenohumeral joint. Source: Courtesy of Christine Chung M.D., VA San Diego Healthcare System and University of California San Diego with special thanks to Troy Gonzalez M.D.
FIGURE 12 Pulmonary artery fluoroscopic image depicting glenohumeral joint in profile during posterior approach injection. Source: Courtesy of Christine Chung M.D., VA San Diego Healthcare System and University of California San Diego.

The distention shoulder arthrogram involves progressive distention of the glenohumeral joint capsule with a combination of water-soluble contrast material and anesthetic agents such as bupivicaine. This procedure has been advocated in the diagnosis and treatment of glenohumeral adhesive capsulitis or "the stiff and painful shoulder" (12). It is a minimally invasive alternative to surgical capsular release. Objective assessment of response to this procedure can be performed by comparing passive and active range of motion before and after anesthetic capsular distention. Often the administered anesthetic agents combined with the capsular disten-tion will provide enough symptomatic relief to facilitate increased exercise capacity. This can ultimately end the cycle of the stiff and painful shoulder, allowing the patient to gradually increase the duration and frequency of range of motion exercises.

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