EULAR: Imaging favored over palpation for guiding procedures at joints, nerves
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Imaging should be the preferred choice over palpation in guiding targeted procedures and injections at peripheral and sacroiliac joints, and at structures encompassing peripheral nerves, according to new EULAR “points to consider.”
“Real-time visualization of the needle or instruments by ultrasound (US), CT, MRI or fluoroscopy has the potential to ensure reliable placement of the needle tip/instrument in the respective anatomical area and to monitor the success of various interventions such as synovial fluid aspiration, drug injection and/or tissue biopsy,” Christian Dejaco, MD, PhD, MBA, of the Medical University of Graz, in Austria, and colleagues wrote in the Annals of the Rheumatic Diseases.
“Imaging-guided procedures, however, are also more resource-consuming than conventional palpation-guided interventions, require additional preparation and training, and there are some studies suggesting that the outcomes of palpation and imaging guided interventions are not meaningfully different,” they added. “Clinicians are therefore still uncertain in which clinical situation, for which intervention, and in which anatomical area imaging should be used to guide interventional procedures.”
To develop points to consider for EULAR regarding the use of imaging to guide interventional procedures in patients with rheumatic and musculoskeletal diseases, Dejaco and colleagues formed a 25-member task force, including physicians, health care professionals and patients from 11 countries. Members of the task force performed a systematic literature review on the role of imaging — including ultrasound, fluoroscopy, MRI, CT and fusion imaging — in guiding procedures.
The task force discussed the resulting data from the literature review in three meetings — one conducted face-to-face prior to the COVID-19 pandemic, and two virtually. Members anonymously voted on the final points to consider during the third meeting.
The task force approved three overarching principles and six points to consider. The overarching principles are:
- Imaging techniques should be “optimized” based on the procedure and location on the body, and factor in potential side effects, radiation exposure, availability, expertise and cost;
- Procedures guided by imaging should be conducted under “adequate aseptic conditions” and
- Complex procedures guided by imaging should be conducted with adequate assistance from technical personnel.
According to the points to consider, imaging is preferred over palpation in guiding procedures at peripheral joints and periarticular structures. This includes targeted injections at structures around peripheral nerves and in the sacroiliac joints. Additionally, imaging should be used to guide targeted injections at the spine.
Among imaging modalities, ultrasound should be the first choice for procedures at peripheral joints, although fluoroscopy may be used as an alternative. Lastly, the task force stated that health care professional performing these procedures “must have adequate skills” in the imaging technique and the interventional procedure being used.
“These are the first EULAR [points to consider (PtC)] providing up-to-date guidance for the role of imaging to guide interventional procedures in patients with [rheumatic and musculoskeletal diseases (RMDs)],” Dejaco and colleagues wrote. “These PtC are supported by evidence along with expert consensus. Unresolved issues and areas of further study have been depicted in the research agenda. We expect that much progress continues taking place in the area of imaging in RMDs, and we will carefully follow developments in the field, assuming that an amendment of these PtC may be needed within a few years.”
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