Alternative and effective treatment of shoulder ganglion cyst: ultrasonographically guided aspiration

Musculoskeletal ultrasound: a technical and historical perspective

During the past four decades, musculoskeletal ultrasound has become popular as an imaging modality due to its low cost, accessibility, and lack of ionizing radiation. The development of ultrasound technology was possible in large part due to concomitant advances in both solid-state electronics and signal processing. The invention of the transistor and digital computer in the late 1940s was integral in its development. Moore's prediction that the number of microprocessors on a chip would grow exponentially, resulting in progressive miniaturization in chip design and therefore increased computational power, added to these capabilities. The development of musculoskeletal ultrasound has paralleled technical advances in diagnostic ultrasound. The appearance of a large variety of transducer capabilities and rapid image processing along with the ability to assess vascularity and tissue properties has expanded and continues to expand the role of musculoskeletal ultrasound. It should also be noted that these developments have in large part been due to a number of individuals who had the insight to see the potential applications of this developing technology to a host of relevant clinical musculoskeletal problems. Exquisite high-resolution images of both deep and small superficial musculoskeletal anatomy, assessment of vascularity on a capillary level and tissue mechanical properties can be obtained. Ultrasound has also been recognized as the method of choice to perform a large variety of interventional procedures. A brief review of these technical developments, the timeline over which these improvements occurred, and the impact on musculoskeletal ultrasound is presented below.

Diagnostic and therapeutic value of ultrasonography in the detection of paralabral ganglion cysts with a curved array transducer: A case report

BACKGROUND

Paralabral cysts are a rare cause of shoulder pain. Linear ultrasound transducers are often used for musculoskeletal evaluation and intervention. However, the use of linear transducer is limited when the target structure is located deep and blocked by bony barriers, as is the case of paralabral ganglion cysts.

OBJECTIVE

This case report aims to describe a beneficial role of using a convex transducer on the evaluation and ultrasonography-guided intervention of paralabral cysts below the acromion.

CASE DESCRIPTION

Two patients visiting the outpatient clinic of Physical Medicine and Rehabilitation complained of severe pain during shoulder movement. Ultrasound scans with linear transducer detected rotator cuff lesions. Shoulder magnetic resonance imaging was done because of the persistent pain despite therapeutic interventions for the rotator cuff lesion, and confirmed paralabral cysts. Although a linear array transducer could not visualize the cystic lesion but could only perform suprascapular nerve block and intra-articular injection, the use of a convex array transducer improved the visualization of the cystic lesion which we treated using ultrasound-guided aspiration and intra-cystic injection. Visual analog scale and Shoulder Pain and Disability Index were checked to assess the treatment effect of each intervention. The intra-cystic injection with aspiration and intra-articular injection showed minimal to moderate improvement of pain score.

CONCLUSION

In pain related to shoulder movement, especially pain that continues despite appropriate treatment for rotator cuff lesions, ultrasound diagnosis of paralabral ganglion cysts using convex transducers will improve the diagnostic value and accuracy of intervention.

Intramuscular Ganglion Cyst of the Flexor Hallucis Brevis Secondary to Muscle Tear: A Case Report

In the current study, we present a case of an intramuscular ganglion cyst in the flexor hallucis brevis muscle (FHB) that arose secondary to a muscle tear. Through this study, we propose a possible aetiology for the development of intramuscular ganglionic cysts. A 50-year-old woman presented with acute pain and swelling over the right mid-plantar area after prolonged kneeling for scrubbing floors. Ultrasonography examination performed at 5 days after the onset of symptoms revealed a partial tear of the right FHB. Follow-up evaluations were conducted, with magnetic resonance imaging and ultrasonography, at 24 and 54 days after symptom onset. MRI revealed a ganglion cyst in the mid-portion of the FHB without connection to the adjacent joint capsule or tendon sheath. On the ultrasonography examination at 45 days after onset, at the same location where a tear was seen on the initial examination, an anechoic defect in the mid-portion of the FHB was observed, compatible with a ganglion cyst. Given the favourable natural evolution, no aspiration or surgery were performed. The patient was discharged with minimal symptoms. The results suggest that the intramuscular ganglion cyst can develop following a muscle tear.

A Clinical Vignette of Insidious Shoulder Pain and Weakness

We present a case of a 53-yr-old woman presenting with insidious shoulder pain and weakness. This case will go through the physical examination of the shoulder, a broad differential diagnosis, and analysis of appropriate imaging and tests to culminate in determining the final diagnosis. The objective of this clinical vignette was to highlight the importance of obtaining an extensive differential for shoulder pain and give readers a chance to critically analyze the case findings through electromyography interpretation, evaluating neurological signs and identifying key points in history taking. In addition, readers will also learn the evidence behind the available treatment options.

ACR Appropriateness Criteria® Shoulder Pain-Atraumatic

Shoulder pain is one of the most common reasons for musculoskeletal-related physician visits. Imaging plays an important role in identifying the specific cause of atraumatic shoulder pain. This review is divided into two parts. The first part provides a general discussion of various imaging modalities (radiographs, arthrography, nuclear medicine, ultrasound, CT, and MRI) and their usefulness in evaluating atraumatic shoulder pain. The second part focuses on the most appropriate imaging algorithms for specific shoulder conditions including: rotator cuff disorders, labral tear/instability, bursitis, adhesive capsulitis, biceps tendon abnormalities, postoperative rotator cuff tears, and neurogenic pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Use of a Total Shoulder Arthroplasty in a Patient with Minimally Painful Severe Glenohumeral Arthritis and a Progressive Plexopathy: A Case Report

CASE

A 70-year-old woman presented with severe but minimally painful right glenohumeral osteoarthritis (OA), with progressive weakness and numbness radiating to the right hand. Imaging revealed a large fluid collection extending from the joint to the subcoracoid space, with a mass effect on the brachial plexus. A total shoulder arthroplasty (TSA) and decompression of a ganglion cyst were performed. Follow-up with serial electromyography demonstrated resolution of the brachial plexopathy and restoration of function.

CONCLUSION

Ganglion cysts may arise secondary to severe glenohumeral OA and may compress the surrounding structures, producing a progressive plexopathy. Treatment of the underlying pathology with a TSA may be effective.

Comprehensive Shoulder US Examination: A Standardized Approach with Multimodality Correlation for Common Shoulder Disease

Shoulder pain is one of the most common musculoskeletal conditions encountered in primary care and specialty orthopedic clinic settings. Although magnetic resonance (MR) imaging is typically the modality of choice for evaluating the soft-tissue structures of the shoulder, ultrasonography (US) is becoming an important complementary imaging tool in the evaluation of superficial soft-tissue structures such as the rotator cuff, subacromial-subdeltoid bursa, and biceps tendon. The advantages of US driving its recent increased use include low cost, accessibility, and capability for real-time high-resolution imaging that enables dynamic assessment and needle guidance. As more radiologists are considering incorporating shoulder US into their practices, the development of a standardized approach to performing shoulder US should be a priority to facilitate the delivery of high-quality patient care. Familiarity with and comfort in performing a standardized shoulder US examination, as well as knowledge of the types of anomalies that can be evaluated well with US, will enhance the expertise of those working in musculoskeletal radiology practices and add value in the form of increased patient and health care provider satisfaction. This review describes the utility and benefits of shoulder US as a tool that complements MR imaging in the assessment of shoulder pain. A standardized approach to the shoulder US examination is also described, with a review of the basic technique of this examination, normal anatomy of the shoulder, common indications for shoulder US, and characteristic US findings of common shoulder diseases-with select MR imaging and arthroscopic correlation. Online supplemental material is available for this article. ^©RSNA, 2016.

Arthroscopic decompression with indigo carmine for treating paralabral cysts in the shoulder

Paralabral cysts in the shoulder are a relatively rare pathology. It is sometimes difficult to detect the location of a paralabral cyst in the shoulder using arthroscopy, and it can be difficult to confirm sufficient decompression by arthroscopy. We describe the case of a 64-year-old woman who underwent arthroscopic decompression for a paralabral cyst in the shoulder. Indigo carmine was injected into the cyst under ultrasonography guidance just before the operation. The leakage point of indigo carmine was detected using arthroscopy. Arthroscopic decompression was performed until the indigo carmine was completely discharged. Her shoulder pain, limited range of motion, and muscle weakness during abduction and external rotation improved postoperatively. Magnetic resonance imaging confirmed the disappearance of the cyst. Arthroscopic decompression using an ultrasonography-guided injection of indigo carmine is a useful treatment for a paralabral cyst in the shoulder.

Outcome After Arthroscopic Decompression of Inferior Labral Cysts Combined With Labral Repair

PURPOSE

To analyze the clinical and radiologic outcomes of arthroscopic cyst decompression and labral repair in patients with inferior paralabral cysts with chronic shoulder pain.

METHODS

Between March 2006 and September 2012, 16 patients who were identified as having inferior paralabral cysts presented with chronic shoulder pain. All patients underwent a thorough physical examination and preoperative magnetic resonance arthrographic evaluation. The mean age was 30 years (range, 17 to 50 years). The mean follow-up period was 38 months (range, 16 to 60 months). Clinical outcome scores (American Shoulder and Elbow Surgeons; University of California, Los Angeles; and Simple Shoulder Test) and passive shoulder range of motion were evaluated at last follow-up. Follow-up magnetic resonance imaging was performed at a mean of 8 months to determine the labral healing status and assess for cyst recurrence.

RESULTS

The incidence of isolated inferior paralabral cysts was 0.6% (16 of 2,656 cases). Of the patients, 8 had multiple cysts and 8 had a single cyst. The mean length and width of the cysts were 1.0 cm and 0.4 cm, respectively. Eight cases had a history of trauma, and 13 patients were involved in sports activities. Seventy-five percent of cases showed a positive relocation test. The mean American Shoulder and Elbow Surgeons; University of California, Los Angeles; and Simple Shoulder Test scores improved from 64, 22, and 8.7, respectively, preoperatively to 83, 31, and 10, respectively (P < .001), at final follow-up. Shoulder range of motion did not show any significant improvement. The location of the labral tear was as follows: anteroinferior tear in 5 cases, posteroinferior tear in 8 cases, and combined anteroinferior and posteroinferior tear in 3 cases. All cysts were found to be in association with a labral tear. A mean of 2.7 anchors were used for inferior labral repair. These cysts were found only in male patients. None of the patients showed any evidence of cyst recurrence on follow-up magnetic resonance imaging.

CONCLUSIONS

Inferior labral tears treated with cyst decompression and labral repair showed satisfactory clinical results without any recurrence. Inferior paralabral cysts should be considered in the differential diagnosis in patients presenting with chronic shoulder pain, particularly active male patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Acromio-clavicular joint cyst associated with a complete rotator cuff tear - a case report

This case report describes a patient with an acromio-clavicular joint (ACJ) cyst, associated with a complete tear of the supraspinatus tendon, and the related arthropathy. Ultrasound was a suitable imaging modality to make the diagnosis, and rule out other pathologies. Full assessment of the rotator cuff must be carried out in the presence of ACJ cysts due to their common co-existence with large cuff tears. Cyst aspiration is not a suitable treatment, due to the high likelihood of recurrence. Optimal treatment requires management of the underlying rotator cuff tear.

Premature cystic lesions in shoulders of elite junior javelin and volleyball athletes: a comparative evaluation using 3.0 Tesla MRI

BACKGROUND

The purpose of this study was to evaluate clinical and magnetic resonance imaging (MRI) findings in the shoulders of high performance competitive junior javelin athletes and volleyball players. The hypothesis was that structural lesions already exist in young and asymptomatic overhead athletes.

METHODS

Thirty-one healthy high performance junior elite athletes were included. Group 1 consisted of 15 male javelin throwers (mean age, 17.7 ± 0.8 years) and group 2 of 16 male volleyball players (16.9 ± 1.0 years). Questionnaire-based interviews, comprehensive clinical examination, and shoulder scoring systems (visual analog scale [VAS] and Constant-Murley Score) were completed. Bilateral shoulder imaging was performed using a 3.0 Tesla MRI.

RESULTS

The Constant-Murley Score of group 1 was 95.5 ± 3.6 and 94.7 ± 4.6 points for group 2. Group 1 demonstrated a mean VAS of 0.9 ± 1.6 and group 2 a mean of 0.6 ± 0.8 points. Postero-superior intraosseous cysts of the humeral head were detected in 73.3% of all javelin throwers in the dominant shoulder, but only in 13.3% in the nondominant shoulder (P = .008). In the volleyball group, such cyst formation was rarely seen in 12.5% in the dominant versus 6.3% in the nondominant shoulder (P = .66).

CONCLUSION

A high percentage of junior elite athletes already demonstrate osseus signs of overloading especially in the group of javelin athletes, although none had a history of prior shoulder pathology. Therefore, junior overhead athletes might be at risk for the early development of structural lesions at the insertion of the posterior rotator cuff similar to lesions already known for adult athletes, even though they do not present clinical signs of overuse at that age.

Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature

Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.

Suprascapular neuropathy: what does the literature show?

Suprascapular neuropathy remains a rare, albeit increasingly recognized, diagnosis. Despite its relatively low prevalence, it must be kept in the shoulder surgeon's mind as a potential cause of shoulder pain, particularly in patients where the history, physical examination, and imaging studies do not adequately explain a patient's symptoms or disability. Although challenging to identify, suprascapular neuropathy can be successfully treated. The current literature shows that the location and mechanism of nerve injury are the most important factors guiding management. Different treatment strategies are required, depending on the specific location and type of nerve injury. Controversy regarding if and when to perform an isolated suprascapular nerve release continues. Furthermore, no recommendations regarding suprascapular nerve release in conjunction with rotator cuff repair can be made at this time, and further research is necessary to better delineate the indications in the future.

Suprascapular neuropathy: diagnosis and management

Although historically considered a diagnosis of exclusion, suprascapular neuropathy may be more common than once believed, as more recent reports are describing the condition as a cause of substantial pain and weakness in patients with and without concomitant shoulder pathology. The etiology is traction or compression of the suprascapular nerve. This can result from a space-occupying lesion, such as a ganglion cyst, or a traction injury as a result of repetitive overhead activities. More recent studies have cited cases of traction injuries occurring with retraction of a large rotator cuff tear. Atrophy of the infraspinatus and/or supraspinatus rotator cuff muscles with resultant weakness in forward flexion and/or external rotation of the shoulder on physical examination may be demonstrated. Magnetic resonance imaging (MRI) is the preferred modality to assess atrophy of the rotator cuff muscles as well as assess potential causes of suprascapular nerve compression. Electromyography and nerve conduction velocity studies remain the gold standard for confirmation of the diagnosis of suprascapular neuropathy; however, nerve pain may occur even in the setting of a negative electromyography. Initial management is usually nonoperative, consisting of activity modification, physical therapy, and nonsteroidal anti-inflammatory drugs. Surgical intervention is considered for patients with nerve compression by an external source or for symptoms refractory to conservative measures. Decompression of the suprascapular nerve may be accomplished through an open approach, although arthroscopic surgical approaches have become more common in the past several years.

Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature

Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.

Ultrasonography of the shoulder

The shoulder is the most common region to be evaluated with musculoskeletal ultrasound. The shoulder's complex anatomy enables an exceptional range of mobility at the expense of static stability. Consequently, the shoulder is susceptible to a multitude of traumatic and atraumatic injuries. This article presents an overview of shoulder anatomy, recommends a standardized approach to the sonographic shoulder evaluation, and discusses common sonographically apparent pathology of the shoulder.

Suprascapular neuropathy

Suprascapular neuropathy has often been overlooked as a source of shoulder pain. The condition may be more common than once thought as it is being diagnosed more frequently. Etiologies for suprascapular neuropathy may include repetitive overhead activities, traction from a rotator cuff tear, and compression from a space-occupying lesion at the suprascapular or spinoglenoid notch. Magnetic resonance imaging is useful for visualizing space-occupying lesions, other pathological entities of the shoulder, and fatty infiltration of the rotator cuff. Electromyography and nerve conduction velocity studies remain the standard for diagnosis of suprascapular neuropathy; however, data on interobserver reliability are limited. Initial treatment of isolated suprascapular neuropathy is typically nonoperative, consisting of physical therapy, nonsteroidal anti-inflammatory drugs, and activity modification; however, open or arthroscopic operative intervention is warranted when there is extrinsic nerve compression or progressive pain and/or weakness. More clinical data are needed to determine if treatment of the primary offending etiology in cases of traction from a rotator cuff tear or compression from a cyst secondary to a labral tear is sufficient or whether concomitant decompression of the nerve is warranted for management of the neuropathy.

Ultrasound-guided therapeutic procedures in the musculoskeletal system

Ultrasound allows the exploration of most of the musculoskeletal system, including lytic bone lesions. Its flexibility, availability, and low cost make it the best tool to guide interventional therapeutic procedures in any musculoskeletal system lesion visible on ultrasound. These techniques include drainages of abscesses, bursitis, hematomas or muscular strains, treatment of cystic lesions (ganglions, Baker's cysts), arthrocentesis, injection of substances in joints and soft tissues, and aspiration of calcific tendinitis. Although the puncture of joints for arthrocentesis and injection of substances are performed by clinicians using palpation, the use of ultrasound guidance improves the effectiveness of the technique especially for small or poorly accessible lesions and joints and for obese patients. Drainage can be performed using catheters or needles and can avoid a more aggressive approach most of the time. Intracavitary urokinase helps when the aim is to drain clotted hematomas or fibrinous collections. Injection of corticoids is useful in the treatment of ganglia, Baker's cysts, tendinitis, and noninfected arthritis. Calcific tendinitis of the shoulder can be effectively treated using percutaneous "lavage" with lidocaine. Calcifications usually disappear and symptoms improve in nearly 90% of the cases within a year. Most of these techniques are low cost and require only a moderate skill. Ultrasound-guided procedures are useful tools to effectively treat some diseases of the musculoskeletal system and should be routine in any imaging department.

[Ultrasound guided interventional radiology]

Ultrasound is a valuable imaging technique for musculoskeletal pathology. It is increasingly used for image-guided procedures such as aspiration of superficial or deep collections, injection of drugs, or biopsies. Ultrasound guidance is an interesting alternative to procedures performed either blindly or under fluoroscopic or CT guidance. Advantages of US-guided procedures include the absence of ionizing radiation, real-time monitoring during needle placement, decreased risk of injury to neighboring structures (namely vessels and nerves), real time confirmation of procedure success (injection, drainage, biopsy). Minor inconveniences relate to the proper conditions for performance of ultrasound. Complications are rare and can be avoided by using proper sterile technique and evaluate for potential contra-indications to the procedure. As with any other image guided procedure, informed consent is required.

Treatment option in a SLAP-related ganglion cyst resulting in suprascapular nerve entrapment

INTRODUCTION

Our report shows a rare case of suprascapular nerve palsy due to a SLAP-related ganglion cyst resulting in isolated weakness of the infraspinatus muscle.

CASE REPORT

We report on a 31-year old volleyball player with severe shoulder pain. A ganglion cyst was excised in an open procedure and was completely resolved in a postoperative magnetic resonance imaging (MRI). But the patient again had pain and disability 7 months after this procedure. A renewed MRI scan showed a cystic mass in the spinoglenoid notch. An electromyography revealed an isolated lesion of the suprascapular nerve. The patient was treated by shoulder arthroscopy with refixation of a type-II-SLAP-lesion and drainage of the cyst formation. At latest follow-up 29 months after surgery, the patient's pain and shoulder function improved with a constant score of 94 points. A MRI scan documented complete cyst resolution.

CONCLUSIONS

Treatment options for ganglion cysts at the spinoglenoid notch are various and can be handled in conservative and operative ways. We believe that the arthroscopic concept with the management of a SLAP lesion as the cause of cyst formation, and the drainage of the ganglion is an effective way with low surgical morbidity that shows good postoperative results.

[Interventional sonography]

Diagnostic and therapeutic interventional procedures are rapidly expanding and, when guided by imaging, are more efficient then when performed with a blinded technique. Compared to fluoroscopy and CT, ultrasound does not utilize ionizing radiation. It can facilitate needle placement for arthrography, tenography or bursography or it can guide a variety of procedures such as aspiration, arthrocentesis, local steroid injections and needling of tendon calcifications. Technological improvements have increased the precision of ultrasound guidance and have contributed to reduce the risk of complication. Real time scanning allows simultaneous visualization of the target and of needle progression and has diminished the rate of complications, that are infrequent if the operator uses a strict sterile technique and respects the contraindications.

Treatment of patients with spinoglenoid cysts associated with superior labral tears without cyst aspiration, debridement, or excision

PURPOSE

To describe a case series of 10 consecutive patients with spinoglenoid cysts and associated superior labral tears treated by labral repair performed by the same surgeon without formal cyst aspiration, debridement, or excision.

METHODS

Ten patients with spinoglenoid cysts and associated superior labral tears demonstrated on preoperative magnetic resonance imaging (MRI) were retrospectively reviewed. Evidence of weakness on examination was further evaluated through nerve conduction studies. All 10 patients underwent surgical repair of the labral tear performed by the same surgeon without formal cyst aspiration, debridement, or excision. Postoperatively, detailed shoulder and neurologic examinations were performed, and follow-up nerve conduction studies and MRIs were obtained.

RESULTS

Ten patients were evaluated clinically at a mean of 10.2 months after surgical repair (range, 6 to 27 months). In all, 8 males and 2 females of average age 47.7 years (range, 35 to 56 years) were studied. Preoperative examination revealed that 6 patients had external rotation weakness. Nerve conduction studies performed in these 6 patients confirmed suprascapular neuropathy in 4 of them. Labral repair without formal cyst excision resulted in successful outcomes for all 10 patients after spinoglenoid cysts associated with superior labral tears had been diagnosed. All 4 patients with suprascapular neuropathy recovered strength and demonstrated normal nerve conduction studies postoperatively. In 8 of 10 patients, MRIs performed postoperatively demonstrated complete resolution of the cyst, along with labral healing. All patients were able to return to work with no restrictions on activities, and all were satisfied with their outcomes.

CONCLUSIONS

This study demonstrated successful clinical, electromyographic, and MRI outcomes for patients with spinoglenoid cysts and superior labral tears, who were treated by labral repair without formal cyst excision. Treatment given for intra-articular disease is the key component of surgical management.

LEVEL OF EVIDENCE

Level IV, case series study.

Kystes para-glénoïdiens gléno-huméraux

Paraglenoid glenohumeral cysts can be observed in 2-4% of the general population, particularly in men during the third and fourth decade. On average, these cysts measure 10-20 mm in diameter and are located preferentially on the posterosuperior aspect of the glenoid. An articular origin (rim injury) is generally accepted. The pathogenesis is similar to that of meniscal cysts. Depending on the exact localization, there is generally little clinical expression. The most frequent complication involves compression of the suprascapular nerve leading to suffering of the supra and/or infraspinatus. Amyotrophy can occur without clinical expression. An attentive examination is necessary to identify the cyst. EMG is often falsely negative. MRI is currently gold standard diagnostic tool but will probably be improved with arthro-MRI. Ultrasonography and computed tomography can visualize with difficulty small cysts located very close to the bone. The best treatment is arthroscopy which enables complete cure (emptying the cyst and resection or suture of the rim). We present a review of the pertinent literature together with a retrospective series of six cases of paraglenoid glenohumeral ganglion cysts.

Sonography of entrapment neuropathies in the upper limb (wrist excluded)

The progressive refinement of broadband transducers with frequencies higher than 10 MHz and improved near-field resolution has enhanced the potential of sonography to evaluate a variety of nerve entrapment syndromes occurring in the upper limb, such as suprascapular neuropathy in the area of the spinoglenoid-supraspinous notch, the quadrilateral space syndrome (axillary neuropathy), radial neuropathy in the area of the spiral groove, the supinator syndrome (posterior interosseous neuropathy), the cubital tunnel syndrome (ulnar neuropathy), and the Kiloh-Nevin syndrome (anterior interosseous neuropathy). In these settings, high-resolution sonography can depict changes in the nerve's shape and echotexture and can depict many extrinsic causes of nerve entrapment.

Sonographically guided core needle biopsy of soft tissue neoplasms

PURPOSE

This study was conducted to evaluate the usefulness of sonography (US)-guided needle biopsy in the diagnosis of soft tissue masses.

PATIENTS AND METHODS

Thirty-seven patients with a mean age of 49 years were enrolled in the study. The size of the biopsy needle was selected according to the kind of tumor suspected (ie, primary or metastatic). In patients with suspected metastases, smaller biopsy needles were used; in patients with suspected primary tumors, larger needles were used so that larger specimens could be obtained. Prebiopsy color Doppler sonography (CDUS) was routinely used to guide the cutting needle to areas of the lesion showing sufficient vascularity. From 3 to 6 cores were obtained, depending on their quality. We compared the diagnoses yielded by the core biopsy and the final histopathologic analysis of the resected tumor by classifying the results as "concordant" or "discordant."

RESULTS

A total of 37 tumors were examined. Final diagnoses were 24 malignant tumors (6 metastases and 18 primary tumors) and 13 benign tumors. The lesions were diagnosed correctly as either benign or malignant in 35 of the 36 cases for which needle biopsy specimens were adequate, with only 1 misdiagnosis. The diagnoses were concordant in 33 cases (17 primary malignant tumors, 6 metastatic tumors, and 10 benign tumors) and were discordant diagnosis in the other 4 cases (1 primary malignant tumor and 3 benign tumors). No complications were attributable to the needle biopsy.

CONCLUSIONS

US-guided percutaneous core needle biopsy of soft tissue neoplasms is an easy, safe, and useful procedure. It can be considered a first-line procedure for the acquisition of tissue specimens adequate for histopathologic diagnosis.

Nerves in a pinch: imaging of nerve compression syndromes

Nerve compression is a common entity that can result in considerable disability. Early diagnosis is important to institute prompt treatment and to minimize potential injury. Although the appropriate diagnosis is often determined by clinical examination, the diagnosis may be more difficult when the presentation is atypical, or when anatomic and technical limitations intervene. In these instances, imaging can have an important role in helping to define the site and etiology of nerve compression or in establishing an alternative diagnosis. MR imaging and ultrasound provide direct visualization of the nerve and surrounding abnormalities. For both modalities, the use of high-resolution techniques is important. Bony abnormalities contributing to nerve compression are best assessed by radiographs or CT. For the radiologist, knowledge of the anatomy of the fibro-osseous tunnels, familiarity with the causes of nerve compression, and an understanding of specialized imaging techniques are important for successful diagnosis of nerve compression.

Peritendinous lesions: the role of high-resolution ultrasonography

PURPOSE

To evaluate the peritendinous lesions over the extremities by high-resolution ultrasonography (HRUS).

MATERIALS AND METHODS

The authors retrospectively collected 328 cases, focusing on peritendinous lesions in limbs. The diagnosis was made by US findings with long-term follow-up, aspiration and biopsy proved.

RESULTS

The most common disease entity in our study is ganglion (n=270), followed by Baker's cyst (n=24). Other disease entities included tenosynovitis, bursitis, gout, hematoma, amyloidosis, thrombophlebitis, and other tumor/tumor-like lesions, such as osteogenic sarcoma (OGS), schwannoma, lymphoma, myxoid lipomsarcoma, xanthoma, intramuscular cavernous hemangioma, pigmented villonodular synovitis (PVNS), giant cell tumor of the tendon sheath (GCTTS), etc.

CONCLUSION

Because of dynamic capabilities and aid of real-time sono-guided fine needle aspiration, HRUS becomes an efficient and inexpensive tool for musculoskeletal lesions, especially in the superficial parts.

Percutaneous ultrasound-guided injections in the musculoskeletal system

Ultrasound guidance is an accurate method for the delivery of therapeutic injections in the musculoskeletal system. The visualization of the needle in real time allows for reliable placement of the needle tip in the tendon sheath, bursa, or joint of interest. Both superficial and deep articulations and tendon sheaths can be targeted for diagnostic or therapeutic interventions. In addition, intratendinous calcifications, the plantar fascia, and interdigital (Morton's) neuromas can also be visualized and injected directly under real-time guidance. Performing percutaneous interventions with ultrasound ensures accurate needle tip placement and helps direct the needle away from other regional soft-tissue structures such as nearby neurovascular bundles.

US of the shoulder: non-rotator cuff disorders

The most common indication for shoulder ultrasonography (US) is the diagnosis of rotator cuff disease. However, there is a spectrum of non-rotator cuff abnormalities that are amenable to US examination, including instability of the biceps tendon, glenohumeral joint, and acromioclavicular joint; arthropathies and bursites (inflammatory diseases, degenerative and infiltrative disorders, infections); nerve entrapment syndromes; and space-occupying lesions. Many of these conditions may be overlooked clinically or can even mimic rotator cuff tears, and US can help redirect the diagnosis if a complete shoulder examination rather than a simple rotator cuff assessment is performed. In addition, US can be remarkably helpful in guiding either needle aspiration procedures or local injection therapy in patients with synovial processes. Although radiography, magnetic resonance (MR) imaging, and computed tomographic and MR arthrography are effective modalities for the evaluation of non-rotator cuff disorders, US is both less costly and less invasive and will likely be used more frequently in this setting as experience increases. Once adequate radiographs have been obtained to exclude apparent bone disorders, high-resolution US should be the first-line imaging modality in the assessment of non-rotator cuff disorders of the shoulder, assuming the study is performed with high-end equipment by an experienced examiner.

Clinical evaluation and treatment of spinoglenoid notch ganglion cysts

Spinoglenoid notch cysts were identified by magnetic resonance imaging in 73 patients. Posterosuperior labral tears were identified in 65 patients who had spinoglenoid notch cysts. Patient follow-up was available on 88% of patients at a mean of 20.5 months after treatment. There were 52 men and 11 women, with a mean age of 39 years (range, 19-76 years). All patients reported shoulder pain. Infraspinatus atrophy occurred in 25 patients, weakness with external rotation in 43, and posterior shoulder tenderness in 30. Nineteen patients underwent nonoperative management of the cyst (group I). Eleven underwent attempted needle aspiration of the cyst (group II). Six had isolated arthroscopic treatment of a labral defect with no cyst excision (group III). Twenty-seven were treated with surgical cyst excision with the cyst and superior labral tear fixed arthroscopically or with an open approach in various combinations (group IV). Of the patients, 53% were satisfied in group I, 64% in group II, 67% in group III, and 97% in group IV.

Evaluation of calcific tendonitis of the rotator cuff: role of color Doppler ultrasonography

OBJECTIVE

To use color Doppler ultrasonography to evaluate the morphology and vascularity of calcific tendonitis and to predict the formative and resorptive phases of the calcification.

METHODS

Ninety-four patients with shoulder calcification on plain radiographs were enrolled in this study. Ultrasonography of the shoulder was focused on the rotator cuff. Color Doppler ultrasonography was applied in the calcific region. Patient symptoms were graded as painless, mild, moderate, and severe. The calcific plaques were classified as arc-shaped, fragmented or punctate, nodular, and cystic types. Color Doppler ultrasonographic signals were graded 0 to 3. The formative and resorptive phases of calcification were categorized by patient symptoms; acute onset of moderate or severe pain indicated the resorptive phase.

RESULTS

The calcific plaques appeared arc shaped in 59 patients (20 painless, 19 mild, and 20 moderate), fragmented or punctate in 27 (2 painless, 3 mild, 20 moderate, and 2 severe), nodular in 6 (1 moderate and 5 severe), and cystic in 2 (severe). There was a significant difference between the morphology of the calcific plaques and clinical symptoms (P < .01). On color Doppler ultrasonography, grade 0 signals were found in 28 patients (22 painless and 6 with mild pain); grade 1 in 18 (16 mild and 2 severe); grade 2 in 41 (all moderate); and grade 3 in 7 (all severe). The correspondence between color Doppler ultrasonographic findings and clinical symptoms was excellent (P < .01).

CONCLUSIONS

High-resolution ultrasonography with color Doppler imaging could differentiate the formative and resorptive phases of the calcification and could be used as a follow-up modality in calcific tendonitis of the shoulder.

The role of high-resolution ultrasonography in management of calcific tendonitis of the rotator cuff

This article predicts the possibility of resorption of the calcific plaques in the shoulder using high-resolution ultrasonography (HRUS) and color Doppler ultrasound (CDUS), and evaluates the therapeutic effect of US-guided fine-needle multiple punctures of the calcific plaque. A total of 100 patients with calcific tendenosis were divided into 3 groups: In group 1, patients having chronic shoulder pain received conservative treatment; in group 2, patients having acute exacerbation of shoulder pain also received conservative treatment; and group 3 patients received US-guided fine-needle multiple punctures or aspiration. In CDUS, all images were classified as grade 0 (no color flow signals), grade 1 (weak spotty color flow signal), grade 2 (few rod-like color flow signals), grade 3 (many rod-like or linear color flow signals). In the follow-up study, marked improvement of patients' clinical condition with more than 50% size reduction of calcific plaque was defined as an effective treatment. There was no significant difference between group 1 and group 3 (p = 0.558) in CDUS, but there was a significant difference between group 1 and group 2 (p = 0.000), and group 2 and group 3 (p = 0.000) on the basis of classification of grade < 1 and grade > or = 1. There was also significant difference in the follow-up result of effective management between group 1 and group 3 (p = 0.000), and group 1 and group 2 (p = 0.000). In conclusion, HRUS with CDUS proved to be a good modality in evaluating the possibility of resorption of shoulder calcification and, if CDUS > or = grade 1 in calcific tendonitis, we highly recommend conservative treatment with regular follow-up. On the other hand, if CDUS < grade 1, fine-needle repeated puncture could be considered as an effective alternative treatment.

Ultrasonography of peripheral nerves

With recent improvements in ultrasound (US) imaging equipment and refinements in scanning technique, an increasing number of peripheral nerves and related pathologic conditions can be identified. US imaging can support clinical and electrophysiologic testing for detection of nerve abnormalities caused by trauma, tumors, and a variety of nonneoplastic conditions, including entrapment neuropathies. This article addresses the normal US appearance of peripheral nerves and discusses the potential role of US nerve imaging in specific clinical settings. A series of US images of diverse pathologic processes involving peripheral nerves is presented.