An assessment of the effectiveness of magnetic resonance imaging of the shoulder: literature review.

OBJECTIVE: To analyse and compare all papers published to date (August 2000) that quantify the effectiveness, defined as the impact of clinician's diagnosis or management plans, or patient outcome, of MRI of the shoulder. DESIGN: A computerised search of Index Medicus with a broad search strategy relating to shoulder MRI was performed. Manual assessment of all papers listed was undertaken with classification of each paper depending on whether it addressed questions of (1) technical performance, (2) diagnostic performance or (3) outcome. RESULTS: Four of 265 qualifying papers addressed aspects of effectiveness and these were reviewed. The impact on the clinician's diagnosis varied widely between papers: the primary diagnosis was altered in 23% to 68% of cases, and the management plans were subsequently changed in 15% to 61% of cases. Only one paper addressed the impact on patient health. CONCLUSIONS: The effectiveness of MRI of the shoulder depends on the clinical skills of the referring clinician and prevalence of disease in the study population. This will have implications when the effectiveness of an imaging technique between different institutions is compared, and this in turn will influence any comparisons of cost-effectiveness.

Magnetic resonance imaging or arthrography for shoulder problems: a randomised study.

OBJECTIVE: Diagnostic technologies are often assessed merely by their accuracy, rather than by their impact on diagnosis and patient management. To this end the authors have undertaken a study to assess the diagnostic and therapeutic impact of magnetic resonance imaging (MRI) and arthrography of the shoulder for patients referred from a rheumatology clinic. METHODS AND PATIENTS: Patients referred from a rheumatology clinic with symptoms warranting imaging of the shoulder were randomised to either MRI or arthrography. Data on the clinician's diagnostic confidence and management were recorded before and after imaging using questionnaires. Patients were followed-up at least 10 months after imaging to see how management plans evolved, and what proportion of patients required further imaging. RESULTS: Fifty three shoulders underwent imaging over a year and entered into the study; 29 randomised to MRI and 24 to arthrography. Both MRI and arthrography had a similar beneficial diagnostic impact in terms of clinical diagnoses (refuted and retained) and new diagnoses established. MRI and arthrography had a similar therapeutic impact, although MRI was associated with a significant shift towards surgical intervention. CONCLUSION: MRI and arthrography a have similar diagnostic and therapeutic impact.

Diagnostic and therapeutic impact of MRI and arthrography in the investigation of full-thickness rotator cuff tears.

Investigation of shoulder pain is important before surgical treatment. The presence or absence of a full-thickness rotator cuff tear (FTRCT) may determine the type of surgical treatment. Both MRI and conventional arthrography can be used, but little is known about their relative diagnostic and therapeutic impact. We performed a prospective trial assessing: (a) the influence of MRI and arthrography results on the clinician's diagnostic thinking (diagnostic impact); (b) the influence of the results on the clinician's therapeutic thinking (therapeutic impact); and (c) the diagnostic performance of the two techniques in patients with surgical confirmation. A total of 104 consecutive patients with shoulder problems referred to a specialist orthopaedic shoulder clinic underwent pre-operative investigation with MRI and arthrography. The surgeon's diagnosis, diagnostic confidence and planned treatment were measured before the investigation, and then again after the results of each investigation. Before the presentation of the investigation, results, the patients were randomised into two groups. In one group MRI was presented first; in the other group, arthrography. The MRI results led to fewer changes in diagnostic category (14 of 46, 30%) than arthrography (20 of 54, 37%), but the difference was not significant (P > 0.5). Magnetic resonance imaging led to slightly more changes in planned management (17 of 47, 36%) than arthrography (14 of 55, 25%), but again the difference was not statistically significant (P > 0.3). The results of the second investigation always had less diagnostic and therapeutic impact than the first. The accuracy of MRI for FTRCT in 38 patients with surgical confirmation was 79%, sensitivity 81% and specificity 78%; the accuracy of arthrography was 82%, sensitivity 50% and specificity 96%. The clinical diagnosis and management plan can be adequately defined by a single radiological investigation. Magnetic resonance imaging and arthrography had fairly similar diagnostic and therapeutic impact and comparable accuracy, although MRI was more sensitive and less specific. Magnetic resonance imaging may be the preferred investigation because of its better demonstration of soft tissue anatomy.

Imaging of the rotator cuff: an arthrographic pitfall.

We present a case where MRI and arthrography of the shoulder reports provided seemingly conflicting data. The subsequent findings at arthroscopy revealed a potential pitfall in arthrographic interpretation.

Magnetic resonance imaging or arthrography of the shoulder: which do patients prefer?

110 consecutive patients were asked about their degree of anxiety (SAI scores), pain (VAS scores) and preferences at various stages before and after imaging in order to determine whether patients with shoulder problems prefer MRI or shoulder arthrography. 88 patients underwent MRI, 42 arthrography and 19 both. Mean levels of anxiety were slightly higher for patients undergoing MRI than those having arthrography, but this difference was not statistically significant. There was a statistically significant (p < 0.03) reduction in anxiety after arthrography, but not following MRI. Pain scores fell for both patient groups while at rest during the imaging procedure compared with their pre-imaging baseline measurement. This was statistically significant (p < 0.03) for MRI, but not for arthrography. A significantly higher proportion (p < 0.001) of patients found MRI unpleasant or extremely unpleasant (20/77) compared with arthrography (3/41). Of the 25 patients who expressed a preference on the basis of past or current experience, 11 preferred MRI and 14 arthrography (NS). There was no significant difference in the proportion of patients who would not allow the test to be repeated (29/73 for MRI, 15/39 for arthrography): Although there were minor differences in both the anxiety and pain experienced by patients undergoing MRI and arthrography, this study did not reveal any firm preference for either investigation.

Magnetic resonance imaging of the shoulder: assessment of effectiveness.

OBJECTIVES: To quantify how magnetic resonance imaging (MRI) influences clinicians' diagnosis, diagnostic confidence and management plans in patients with shoulder problems. To investigate whether such changes are associated with an improvement in health. METHODS: A prospective observational study on all patients referred to a regional centre for MRI of the shoulder over a 6-month period. Data on diagnosis, diagnostic confidence and proposed management before MRI were compared with diagnoses and actual management after MRI. In addition, short form 36 item (SF-36) health survey data were collected at referral and again 6 months later. RESULTS: In 86 of 99 MRI referrals there was sufficient clinical data for the patient to enter the study. MRI led to previously unsuspected diagnoses in 20 of 59 patients where the clinicians had provided full diagnostic information before and after the examination. When MRI confirmed the clinical diagnosis, significant improvements in clinicians' diagnostic confidence were found (P < 0.001). MRI led to a change in management (P < 0.05) in 44 (62%) of the 71 patients where full management plans were available. Health survey results were available in 62 patients; although there were some improvements in SF-36 scores, these did not reach statistical significance. CONCLUSION: Magnetic resonance imaging of the shoulder significantly influences clinicians' diagnoses and management plans. However, patients do not record a statistically significant improvement in health-related quality of life over 6 months.

Magnetic resonance imaging of the coraco-acromial ligament.

The coraco-acromial ligament is important first for the stability of the shoulder joint and second because it can impinge on the rotator cuff. In this study we demonstrate how the coraco-acromial ligament can be shown by magnetic resonance imaging (MRI) in the axial plane as well as in the more conventional coronal and sagittal planes.