Failed Shoulder injection?

[Timeoutofmind]

82yo lady. Advanced degenerative changes of GH joint on xray.

Pain on exam with any shoulder ROM tests.

Straight forward glenohumeral joint injection, pic below. 100% pain relief with the lido. Reports no sustained pain relief at f/u visit 4 weeks later...

Just curious as to your thoughts?

Is her OA just too far gone?

MRI, ortho consult, or what?

Thanks in advance.

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[oreosandsake]

Ortho most likely isn't going to touch her.

lidocaine only? or you followed up with lidocaine + ____ and wanted longer benefit?

in advanced OA, the injections do not work very long/well. MRI if you think there is another diagnosis you are missing and there is something to do about it (again, ortho prob isn't going to touch her)

some folks have had good luck with hyaluronic acid injections but it's OOP expense. suprascapular nerve innervates sensory to the AC, GH joints. it's a reasonable thing to go for. see the other threads on the topic

 

[Timeoutofmind]

Ortho most likely isn't going to touch her.

lidocaine only? or you followed up with lidocaine + ____ and wanted longer benefit?

in advanced OA, the injections do not work very long/well. MRI if you think there is another diagnosis you are missing and there is something to do about it (again, ortho prob isn't going to touch her)

some folks have had good luck with hyaluronic acid injections but it's OOP expense. suprascapular nerve innervates sensory to the AC, GH joints. it's a reasonable thing to go for. see the other threads on the topic

Yeah there was steroid in there but it seems no benefit

I agree I dont know what I am gonna do anyway if say there is a huge labral tear on MRI? I guess I can ask her if she would consider surgery

I do US guided suprascauplar nerve, but in this context seems we are talking RF? Dont see what the point of just a block here is given the severity of her clinical picture and its not like its a frozen shoulder type scenario or anything...

 

[SSdoc33]

if shes healthy, why NOT a shoulder replacement?

 

[Taus]

Ortho. Shoulder replacement unless medically can't handle it


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[bedrock]

Agree. If healthy for 82, send to Ortho for shoulder replacement. If sick 82, then do Supra scapular RFA.

 

[IN2B8R]

TSR or RF of suprascapular nerve if she's not a surgical candidate.


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[Dr. Ice]

MRI shoulder..if that much GH arthritis and considering surgery..arthrogram to detect labral pathology not necessary anyway because no surgeon will attempt to fix the labrum. MRI to assess for concomitant rotator cuff pathology and/or "cuff tear arthropathy" which may aide surgeons in determining standard total arthroplasty vs reverse total shoulder.

 

[Tapspatellas]

I concur the advanced OA just comes back quicker or doesn't get adequate analgesia with steroids.

Wouldn't do MR myself. If not a total train wreck medically I'd refer to ortho and let them decide if MR is needed. Even if borderline I'd still refer and let them make the decision. I've been surprised at times what some of the physicians I consider to be good surgeons will find a way to operate on, so I always let them make the final call.

If no-brainer too sick or absolutely doesn't want surgery, then OOP visco or SS RF, would lean more towards RF.

 

[drpainfree]

would you pulseRF SS or regular thermalRF as SS is a mixed nerve?

 

[lobelsteve]

Lots of posts on this. Burn baby burn. No functional deficits despite atrophy.

 

[DODOCSS]

non surgical and cash to burn?

If so...Nothing to lose...Stick some spun blood in the joint

 

[Timeoutofmind]

Follow up ?:

Why do you sometimes get that weird serpentine vascular looking pattern over the humeral head with intra-articular placement?...and the contrast that looks like it is sort of leaking out medially/extra-capsular under the acromion/coracoid process?

 

[IN2B8R]

I do my injections ultrasound guided....


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[IN2B8R]

Another point: most, if not all patients can handle a total shoulder replacement under regional anesthesia only (either an interscalene or supracalvicular nerve block) with a whiff of propofol, so, with very advanced OA of the shoulder, not too many patients will be deemed "non-operative" from an anesthetic point of view.... That said, there will always be those who are non-candidates from a surgical point of view (poor healers, bad bone quality, etc...)or those who simply do not want to go through it.... I see peripheral Neuromodulation as a possibility for such patients.


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[epidural man]

would you pulseRF SS or regular thermalRF as SS is a mixed nerve?

pulse first- then if results aren't adequate, burn.

No reason not to first pulse.

 

[bedrock]

pulse first- then if results aren't adequate, burn.

No reason not to first pulse.

Other than pulsed is cash pay for our pp (non-military) patients.

I agree with you clinically, but when I used to discuss the pro/cons of pulsed vs RFA including cost, many opt for thermal RFA.