Magnetic resonance arthrography of the shoulder: A painful procedure?

Abstract

Objective:
To compare the pain expected to that effectively caused by magnetic resonance arthrography of the shoulder and, secondarily, to describe a simplified approach to the technique for articular access.

Materials and Methods:
We prospectively evaluated 40 participants who used a visual analog scale and a simplified categorical scale to indicate the level of pain expected and that experienced after the procedure, comparing the two with the Wilcoxon matched-pairs test. We also determined gender-related differences in pain conditions using the Mann-Whitney U test. In addition, we described a modified technique involving radiographic localization and the use of standard puncture needles for articular access.

Results:
Analysis of the visual analog scales showed that the pain experienced was less than had been expected, with median scores of 1.75 and 3.75, respectively (p < 0.001). The level of pain expected was higher among women than among men, with median scores of 8.0 and 3.0, respectively (p = 0.014), as was the level of pain experienced, with median scores of 3.0 and 1.5, respectively (p = 0.139). The overall categorical evaluation corroborated that difference (p = 0.03). Articular access with the modified technique was successful in all patients.

Conclusion:
Magnetic resonance arthrography of the shoulder is less painful than patients expect. In addition, digital radiographic guidance combined with the use of standard puncture needles appears to improve the efficiency of the method.

Full text

Nascimento PCX et al. / Shoulder magnetic resonance arthrography and pain
1
Radiol Bras. 2018 Ahead of Print
Original Article
Magnetic resonance arthrography of the shoulder: a painful
procedure?
Artrorressonância do ombro: procedimento doloroso?
Paulo César Xavier do Nascimento1, André Maltez Amaral2, João Ricardo Maltez de Almeida3
Nascimento PCX, Amaral AM, Almeida JRM. Magnetic resonance arthrography of the shoulder: a painful procedure? Radiol Bras. 2018.
Abstract
Resumo
0100-3984 © Colégio Brasileiro de Radiologia e Diagnóstico por Imagem http://dx.doi.org/10.1590/0100-3984.2016.0226
Objective: To compare the pain expected to that effectively caused by magnetic resonance arthrography of the shoulder and, sec-
ondarily, to describe a simplied approach to the technique for articular access.
Materials and Methods: We prospectively evaluated 40 participants who used a visual analog scale and a simplied categorical
scale to indicate the level of pain expected and that experienced after the procedure, comparing the two with the Wilcoxon matched-
pairs test. We also determined gender-related differences in pain conditions using the Mann–Whitney U test. In addition, we de-
scribed a modied technique involving radiographic localization and the use of standard puncture needles for articular access.
Results: Analysis of the visual analog scales showed that the pain experienced was less than had been expected, with median
scores of 1.75 and 3.75, respectively (p < 0.001). The level of pain expected was higher among women than among men, with
median scores of 8.0 and 3.0, respectively (p = 0.014), as was the level of pain experienced, with median scores of 3.0 and 1.5,
respectively (p = 0.139). The overall categorical evaluation corroborated that difference (p = 0.03). Articular access with the modi-
ed technique was successful in all patients.
Conclusion: Magnetic resonance arthrography of the shoulder is less painful than patients expect. In addition, digital radiographic
guidance combined with the use of standard puncture needles appears to improve the efciency of the method.
Keywords: Magnetic resonance imaging; Arthrography; Shoulder; Pain; Visual analog scale.
Objetivo: Comparar a expectativa de dor com a efetivamente produzida em procedimentos de artrorressonância do ombro e, secun-
dariamente, descrever abordagem simplicada da técnica de acesso articular.
Materiais e Métodos: Avaliamos, prospectivamente, 40 par ticipantes, que assinalaram a sua expectativa álgica e a dor pós-pro-
cedimento em escalas visual analógica e categórica simplicada, que foram comparadas por meio de teste pareado de Wilcoxon.
Também determinamos a diferença do quadro doloroso por gênero, com aplicação do teste U de Mann-Whitney. Descrevemos,
ainda, técnica de localização radiográca e emprego de agulhas simples de punção para acesso articular.
Resultados: A análise das escalas visuais analógicas demonstrou que a dor experimentada foi inferior à esperada (medianas de
1,75 e 3,75, respectivamente; p < 0,001). As mulheres tinham expectativa de dor superior aos homens (medianas de 8,0 e 3,0; p =
0,014), assim como maior dor experimentada (medianas de 3,0 e 1,5; p = 0,139), respectivamente. Avaliação categórica global cor-
roborou tal tendência (p = 0,03). O acesso articular, empregando técnica adaptada, foi obtido com sucesso em todos os pacientes.
Conclusão: A artrorressonância do ombro é menos dolorosa do que se imagina. Adicionalmente, a orientação radiográca digital
aliada ao emprego de agulhas simples de punção aumentam a eciência do método.
Unitermos: Ressonância magnética; Artrograa; Ombro; Dor; Escala visual analógica.
Study conducted at the Clínica de Assistência à Mulher – CAM, Salvador, BA,
Brazil.
1. Biomedical Professional, Graduate Student in Bioimaging at the Escola Bahiana
de Medicina e Saúde Pública, Salvador, BA, Brazil.
2. MD, Radiologist at the Clínica de Assistência à Mulher –CAM, Salvador, BA,
Brazil.
3. PhD, Radiologist at the Clínica de Assistência à Mulher –CAM, Salvador, BA,
Brazil.
Mailing address: Dr. João Ricardo Maltez de Almeida. Clínica de Assistência à
Mulher – CAM. Avenida ACM, 237, Ed. Prof. Carlos Aristides Maltez, Itaigara. Salva-
dor, BA, Brazil, 41825-000. E-mail: jrmaltez.a@gmail.com.
Received December 12, 2016. Accepted after revision Februar y 13, 2017.
structures and can lead to signicant functional disabil-
ity when not properly diagnosed(3). Therefore, it is fun-
damental that the different diagnostic modalities be indi-
cated correctly. One such modality is magnetic resonance
arthrography, better known as MR arthrography or MRA,
which plays a prominent role because of its high accuracy,
particularly in the evaluation of glenohumeral instability,
due to its superior detailing of ligamentous, cartilaginous,
and labral structures(4,5).
The MRA examination is invasive in nature, because
the joint space is accessed by guided puncture, followed
by injection of a contrast agent. Therefore, it is often char-
acterized as intensely painful, not only by uninformed pa-
tients but also by healthcare professionals who are them-
selves uneducated regarding the technique. However, as
INTRODUCTION
Shoulder pain is one of the most common complaints
related to the musculoskeletal system(1,2). Similar signs
and symptoms can be produced by injuries to various
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2Radiol Bras. 2018
Ahead of Print
to that follow-up, and three of those nine did not indicate
the level of pain on the categorical scale immediately af-
ter the examination (all participants performed the VAS
marking). Therefore, in order to compare the categorical
scales between groups of different sizes, we constructed a
normalized index—a pain index—by dividing the sum of
the categories of pain at each time point and dividing that
by the maximum possible score, which was calculated by
multiplying it by the number of participants by 5 (maxi-
mum pain category).
Examination protocol
All procedures were performed by one of two radiolo-
gists trained in the bioimaging sector (examiners 1 and
2), who used a puncture technique directed to the rotator
interval, in the vicinity of the joint cleft, by means of an
approach previously described(13–16). That technique was
adapted for the use of conventional digital radiography,
rather than uoroscopy, as a guide for determining the
puncture site. The participants were placed in the supine
position, with slight external rotation of the shoulder, and
those who reported pain in that position were allowed to re-
main in neutral rotation(15). After palpation of the tip of the
coracoid process and estimation of the location of the joint
cleft, the radiologist applied a marker (metal clip) on the
shoulder as a reference for the site and the puncture point
was marked with a pen (Figure 2A). The radiologist diluted
a gadolinium-based contrast agent—0.1 mL of meglumine
gadoterate (Dotarem; Guerbet, Paris, France)—in a mix-
ture of 10.0 mL of 1% lidocaine hydrochloride, without
a vasoconstrictor (Xylestesin, Cristália, São Paulo, Brazil),
and 10.0 mL of sterile saline solution. A slight impression
was then made in the skin, over the designated location,
by pressing with a ballpoint pen tip, with the pen retracted
(because an ink mark would be erased when the skin
was cleaned). After rigorous asepsis, local anesthesia was
achieved with an intradermal injection of approximately
3.0 mL of 1% lidocaine hydrochloride, without a vasocon-
strictor. At that time, with the needle in loco, conventional
radiography was performed to conrm the proper position-
ing. The joint was then accessed by introducing a 21 G, 0.8
× 40 mm disposable needle, through which 2.0–3.0 mL of
iodinated contrast medium containing organically bound
iodine (Henetix; Guerbet) were injected for conrmation of
in any subjective experience, there is a relevant emotional
component, which makes it extremely difcult to mea-
sure pain by quantitative methods(6–8). In addition, there
are inherent technical variations, ranging from the type
of needle used—usually the type used in lumbar punc-
ture(1,9,10)—to the dilution of the contrast agent(11) and
the approach to accessing the glenohumeral joint(9,12,13).
The main objective of this study was to compare the
expectation of pain related to shoulder MRA (level of pain
expected) with the pain actually produced by the proce-
dure (level of pain experienced), by applying, at different
time points, a visual analog scale (VAS) and a simplied
numerical categorical scale. A secondary objective was to
describe an adaptation of the technique of localization
and anterior puncture through the rotator interval(13–16),
which simplies the procedure and reduces its cost, thus
increasing its efciency.
MATERIALS AND METHODS
Between July 2015 and March 2016, patients under-
going shoulder MRA in the Bioimaging Department of the
Clínica de Assistência à Mulher – Grupo CAM, in the city
of Salvador, Brazil, were invited to participate in the study.
Patients who had previously undergone MRA of any joint
were excluded, as were those who required sedation (no
such cases being identied during the sample selection).
The nal sample comprised 40 patients, all of whom had
been referred by orthopedists or other specialists, none of
whom were afliated with the study. The study was ap-
proved by the Research Ethics Committee of the Bahiana
School of Medicine and Public Health, also in the city
of Salvador (Ruling No. 1,195,717). All participating pa-
tients gave written informed consent.
Prior to the procedure, a trained nurse informed the
participant of the basic steps to be followed, with specic
reference to ne-needle joint puncture and contrast agent
injection, as well as the subsequent examination in the
magnetic resonance imaging (MRI) scanner. The par-
ticipant then indicated the level of pain expected, on a
standardized VAS, consisting of a straight 10.0-cm line,
the leftmost point (0.0 cm) corresponding to the absence
of pain and the rightmost point (10.0 cm) corresponding
to the greatest pain ever felt (Figure 1). The participants
also employed a categorical scale to indicate the level of
pain. For simplication and reiteration of the sensorial ex-
pectation, the categorical scale comprised ve levels: 1,
no pain; 2, mild pain; 3, moderate pain; 4, severe pain;
and 5, maximum pain. After the examination, the VAS and
the categorical scale were reapplied in order to assess the
actual level of pain experienced. The participants com-
pleted both scales in a private room, with no supervision
by the clinic staff. At approximately 4 h after the end of
the examination, the participants were contacted by text
message or telephone call, in which they were asked to
classify their current level of pain from 1 to 5 according
to the categorical scale. Nine of the participants were lost
Figure 1. The VAS, arranged horizontally, the leftmost point corresponding to
the absence of pain and the rightmost point corresponding to the greatest pain
ever felt.
Absence
of pain
0 cm
Greatest pain
ever felt
10 cm
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Nascimento PCX et al. / Shoulder magnetic resonance arthrography and pain
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Radiol Bras. 2018 Ahead of Print
articular access, with a dual-lumen port (Polix; B. Braun,
Rio de Janeiro, Brazil), as depicted in Figure 2B. If the dis-
tribution of the iodinated contrast agent was as expected,
its channel was closed and, through the second channel,
10.0–13.0 mL of the gadolinium-based contrast agent
were introduced.
After the contrast agents had been injected into the
joint, the participant was placed in an MRI scanner (Signa
HDxt; General Electric, Waukesha, WI, USA). Multipla-
nar images of the shoulder were acquired in a < 40-min
protocol that included an abduction and external rotation
sequence as the nal acquisition. For all of the partici-
pants in the sample, the MRA examinations were consid-
ered to be of satisfactory quality.
Statistical analysis
We calculated a sample size of 35 participants for a
nonparametric Wilcoxon matched-pairs test, using an es-
timated effect size of 0.50, a desired power of 0.80, and
a statistical signicance of 0.05. We described the data
related to the sample composition by measures of central
tendency and variability, using parametric or nonparamet-
ric methods, according to their distribution, as determined
by the Shapiro–Wilk test. The pain scales used (the VAS
and the categorical scale) were treated in an ordinal man-
ner and were compared by the Wilcoxon matched-pairs
test. We also used the Mann–Whitney U test in order to
compare the genders in terms of pain, on the basis of the
difference between the level of pain expected and that
experienced, as well as to compare the two examiners in
terms of the results obtained.
The sample size was calculated using the G*Power
software, version 3.9.1.2 (Heinrich-Heine University, Düs-
seldorf, Germany), and the other analyses were performed
with the IBM SPSS Statistics software package, version
19.0 (IBM Corporation, Armonk, NY, USA). All tests were
two-tailed, and the level of statistical signicance adopted
was 5% (p < 0.05).
RESULTS
Of the 40 patients who participated in the study, 29
(72.5%) were male and 11 (27.5%) were female. The over-
all mean age was 30.7 years (standard deviation [SD] =
9.92 years). Among the participants, the mean weight
was 78.28 kg (SD = 13.62 kg) and the mean height was
1.73 m (SD = 0.083 m). Immediately before the MRA, 25
(62.5%) of the participants reported feeling no shoulder
pain, which was reported by the remaining 15 (37.5%).
Only 5 of the participants (12.5%) had previously under-
gone surgery on the shoulder examined.
Analysis of the VAS results showed that the partic-
ipants had an expectation of pain, with a median score
of 3.75 (interquartile range [IQR] = 4.50), considerably
higher than the median score for the pain actually expe-
rienced, which was 1.75 (IQR = 2.88). As can be seen in
Figure 3, the reported level of pain experienced was lower
than expected in 25 participants (62.5%), higher than ex-
pected in 9 (22.5%), and exactly as expected in 6 (15%).
The Wilcoxon matched-pairs test showed that the pain ex-
pected was signicantly worse than the actual pain expe-
rienced (p < 0.001). The evaluation of the scores reported
on the numerical categorized scales revealed the same
tendency (Table 1). Of the 37 participants who completed
the categorical scale immediately after the examination,
none of the participants reported severe (category 4) or
maximum (category 5) pain, and only 3 (8.1%) reported
moderate (category 3) pain, whereas 34 (91.9%) reported
no pain or mild pain (category 1 or 2). The difference be-
tween the categorical scores reported before the proce-
dure and those reported immediately after the procedure
Figure 2. Digital radiograph of the shoulder (A) showing the ideal place for joint puncture (circle), over the upper third of the humeral head, near the glenohumeral
joint. Injection of the iodinated contrast medium (B), via a dual-lumen port, conrming access to the joint.
A B
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4Radiol Bras. 2018
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was signicant (p = 0.03). Among the 31 participants con-
tacted subsequently, the level of pain reported at 4 h after
the procedure did not differ signicantly from that report-
ed immediately after the procedure (p = 0.519). However,
the graphic interpretation of the pain indices (Figure 4)
revealed a slight trend toward an increase in the level of
pain reported at 4 h after the procedure.
The level of pain expected was considerably higher
among the women than among the men, the median scores
being 8.00 (IQR = 4.00) and 3.00 (IQR = 3.25), respec-
tively (p = 0.014). Although the same trend was observed
for the level of pain effectively experienced—the median
scores for women and men being 3.00 (IQR = 6.00) and
1.50 (IQR = 2.00), respectively—the difference was not
statistically signicant (p = 0.139). The pain expected was
signicantly worse than the pain experienced, even when
the genders were evaluated separately (p = 0.003 for males
and p = 0.049 for females). The median of the simple sub-
traction between the VAS score for the pain expected and
that for the pain experienced was similar between the gen-
ders (Figure 5), with no relevant difference demonstrable
by the Mann-Whitney U test (p < 0.563). Similarly, a
comparison between the participants who reported pain
before the procedure and those who did not showed that
the difference between the two groups was not signicant
(p = 0.705).
Examiner 1 performed 16 procedures, and examiner 2
performed 24 procedures. The analysis of the VAS scores
revealed no signicant differences between the two exam-
iners, the median VAS score for the pain expected being
5.00 (IQR = 4.50) for the MRAs performed by examiner 1,
compared with 3.00 (IQR = 5.25) for those performed by
examiner 2 (p = 0.503), whereas the median VAS score for
the pain actually experienced was 1.50 (IQR = 2.75) and
Table 1—Number of participants per category of pain at different time points,
with summation of the scores and calculation of the pain index.
Categorical pain
scale score
1 (no pain)
2 (mild pain)
3 (moderate pain)
4 (severe pain)
5 (maximum pain)
Total
Pain index†, median
Prior to the
procedure
(n = 37)
Immediately after
the procedure
(n = 37)
4 h after the
procedure
(n = 31)
N
12
16
6
2
1
(%)*
(32.4)
(43.2)
(16.2)
(5.4)
(2.7)
N
16
18
3
—
—
(%)*
(43.2)
(48.6)
(8,1)
—
—
N
15
10
5
1
—
(%)*
(48.4)
(32.3)
(16.1)
(3.2)
—
75
0.41
61
0.33
54
0.35
* Due to rounding, percentages might not total 100%. † Corresponds to the
sum of the categorical pain scale scores, for a given participant, at the different
time points, divided by the maximum possible score: [sum/(n*5)].
Figure 4. Line graph showing a reduction in the pain index immediately after
the procedure, with a slight upward trend at 4 h thereafter.
0.45
0.40
0.35
0.30
Pain index
Prior to the
procedure
Immediately after
the procedure
4 h after the
procedure
Figure 3. Graphic showing the pain expected and that experienced immedi-
ately after the procedure, by participant, based on the VAS markings.
Pain expected
Pain experienced
No difference
Participants
Visual analog scale score
10
9
8
7
6
5
4
3
2
1
0
Figure 5. Box plot of the difference between the VAS scores for the pain expected
(PreP VAS scores) and for the pain experienced immediately after the exami-
nation (ImmPostP VAS scores), by gender, showing no signicant difference
between the men and women in terms of the median score.
10.0
8.0
6.0
4.0
2.0
0
–2.0
Men
Difference between the PreP and ImmPostP
VAS scores
Women
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Radiol Bras. 2018 Ahead of Print
1.75 (IQR = 2.63) for the MRAs performed by examiner
1 and examiner 2, respectively (p = 0.855). The difference
between the pain expected and that experienced, when
evaluated by examiner, was also not signicant (p = 0.729).
In all of the examinations, the application of digital
radiography, without the use of uoroscopy, together with
the use of a standard puncture needle, allowed easy ac-
cess to the joint. In our sample, the examiners made no
errors during the procedure; that is, there were no cases
in which the needle had to be repositioned or the patient
had to recalled.
DISCUSSION
Recent studies in the radiology literature have empha-
sized the role of MRI in the evaluation of the musculoskel-
etal system(17–21). In the present study, we compared the
pain expected by patients scheduled to undergo shoulder
MRA with the pain effectively experienced after the proce-
dure, applying a VAS and a categorical scale. Our results in-
dicate that the level of pain expected is considerably higher
than the pain effectively experienced. That difference was
observed in both genders, independently. In addition, we
have described an adaptation of the anterior articular ac-
cess technique through the rotator interval(13–16), using
digital radiography to locate the puncture portal, as well
as the use of a standard needle rather than spinal needles.
For examination of the shoulder, conventional MRI
has been preferred over MRA, despite the high sensitivity
and specicity of the latter(5,22). Among the reasons given
for that is the invasive nature of shoulder MRA, which dis-
courages many patients from undergoing the procedure.
Robbins et al.(23) reported that “pain” and “needles” were
among the main fears reported by patients in relation to
MRA examination of various structures. However, the au-
thors demonstrated that the pain experienced was usually
less than that expected, only 6% of the participants report-
ing pain greater than that expected, which is in keeping
with our results.
Blanchard et al.(24) compared conventional MRI of
the shoulder with conventional arthrography of the shoul-
der, in terms of the levels of anxiety and pain. They found
that the number of patients describing the experience as
“uncomfortable” or “extremely uncomfortable” was signi-
cantly higher among those undergoing MRI than among
those undergoing arthrography. However, unlike what we
observed in the present study, those authors found that
the levels of anxiety and pain were signicantly higher
among women than among men.
In a study evaluating MRA of different joints in 1085
participants, Saupe et al.(10) employed methods similar to
those used in the present study. Their results showed that
the level of pain reported immediately after the procedure
was lower than that reported prior to the procedure. How-
ever, the authors found that the pain prole was related to
the time factor, a statistically signicant worsening of pain
being observed at 4 h after the procedure, particularly after
shoulder MRA, a tendency that was also observed in the
present study, although the difference did not reach the
level of statistical signicance in our sample. That obser-
vation was attributed to the wearing off of the anesthetic
effect, and there was progressive improvement within one
week thereafter. Although those authors also found varia-
tions by age group, they did not observe relevant differ-
ences associated with the joint involved, the type of para-
magnetic contrast used, and gender. The puncture point
used in their study (superomedial portion of the humeral
head) was similar to that employed in the present study.
In 1933, Oberholzer(25) described the technique of gle-
nohumeral joint access for arthrography, which was simpli-
ed in 1975 by Schneider et al.(26), who used uoroscopy
to guide the puncture needle to the middle/lower third of
the joint. That approach transxes the anterior stabilizing
structures of the shoulder and has the potential to cause
local anatomical distortion and, in some cases, iatrogenic
lesions(10,12). Over time, new methods of joint puncture
were developed, and anterior access through the rotator
interval became widely accepted after the works of Berná-
Serna et al.(13), Dépelteau et al.(15), and Redondo et al.(16),
all of which were published between 2004 and 2008.
In Brazil, most private diagnostic imaging clinics do
not offer uoroscopy. In the present study, we have dem-
onstrated that the digital radiography approach to guiding
joint puncture is a viable and efcient option, because it
allowed easy and uneventful access in all participants. The
training of the performing physician has a direct inuence
on the success rate, just as the success of the uoroscopy-
guided version of the approach is affected by the expe-
rience of the radiologist(15,16). For example, in the study
conducted by Dépelteau et al.(15), needle repositioning was
necessary in 6 (15%) of the 40 cases in which the proce-
dure was performed by residents. In contrast, Redondo et
al.(16) reported such failures in only 2 (2.5%) of 78 cases.
Although our sample was small in size, the examiners were
successful in all of the procedures, without statistically
relevant differences between the two examiners in terms
of the level of pain reported. That could be at least par-
tially attributable to the fact that both examiners had been
trained in the same technique and instructed to follow the
protocol to the letter. We found the performance of the
digital radiography-guided method to be satisfactory.
In the present study, another variation from the typi-
cally recommended technique(9,16,23) was the use of a stan-
dard puncture needle rather than a spinal needle. That
adaptation is aimed at further improving the efciency of
the procedure, because standard needles are considerably
less costly(27). Admittedly, the cost of MRA is higher than
is that of other methods of evaluating the shoulder, re-
gardless of the setting in which they are employed(28). In
Brazil, the aggregate difculties of obtaining nancial re-
imbursement from health insurance plans for the material
used constitute a signicant obstacle, often precluding the
use of MRA in private practice.
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Our study has some limitations, primarily those in-
herent to the evaluation of an experience as subjective as
pain(29,30). However, we believe that we were able to miti-
gate those impediments, at least in part, by using two dif-
ferent scales (a VAS and a categorical scale) in parallel,
treating them conservatively by applying nonparametric
tests. In addition, the sample size calculation was per-
formed with the primary objective in mind, which reduced
the statistical power for secondary evaluations of certain
characteristics inherent to the group studied. Furthermore,
three participants did not use the categorical scale immedi-
ately after the examination and nine were lost to follow-up
(i.e., could not be contacted at 4 h after the examination),
which also reduced the statistical power. We believe that
the three participants in question simply neglected to mark
the categorical scale, because it was on the second page of
the handout. On the VAS, two of those three participants
had indicated that the level of pain after the procedure was
lower than expected, whereas one had indicated that it was
exactly as expected. To avoid any bias related to the expec-
tations of the observer, we opted not to supervise the mark-
ing of the scales. Another potential limitation is that we
did not draw comparisons among different articular access
sites or different needles, although such comparisons were
not included in the original objectives of the study.
CONCLUSION
There have been few studies, especially in Brazil,
aimed at the qualitative or semiquantitative evaluation of
the pain related to MRA procedures. Therefore, the pres-
ent study aims to ll that gap by demonstrating that shoul-
der MRA is less painful than patients typically expect. In
addition, our ndings indicate that uoroscopy can be dis-
pensed with for radiographic guidance of articular access
and that shoulder MRA can be performed with a standard
puncture needle, both of which help reduce the costs of
the examination and increase its efciency.
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