Raj N. Sureja, MD
In the world of Orthopaedics and Interventional Pain Management, we physicians treat patients who have musculoskeletal pain from a variety of injuries, conditions, diseases and often, simple aging.
However, when a patient comes to see me for a consultation for their pain, I don’t get to shrug my shoulders and throw up my hands and say “Yes, you have pain, but I don’t know why!” My job, and the job of my orthopaedic colleagues, is to keep digging until we can make an accurate diagnosis. While I have many diagnostic tools up my sleeve, such as x-ray, sometimes I need a bit more information. In this article, I will explain what an arthrogram is, why it is used and what the patient can expect when having one.
Breaking down the word Arthrogram in medical terms, arthro = joint + gram = picture or record = a picture of the joint. This diagnostic test uses a contrast agent and both C-Arm Fluoroscopy (a type of x-ray) and MRI to deliver these images to the Radiologist and the ordering physician. I come from a special place of understanding about arthrogram testing, because I perform the contrast injection of the patient under fluoroscopy, before the patient is sent to the MR scanner. Not all Ortho or IPM physicians do these injections, and only two do at OSC.
Because we have MRI technology now and the test is known for being uncomfortable, the number of arthrograms performed runs only about 3-5% of our annual patient total of diagnostic testing. We typically only order them when we just can’t pinpoint a diagnosis with MRI alone, but we need to do so for specific diagnoses we suspect will take surgery to correct. Using a dye, injected directly into the joint, the internal structures of the joint are illuminated – they glow white with the injected contrast agent during MR scanning. This is usually all it takes for the Radiologist to provide a definitive diagnosis and for the treating physician/surgeon to formulate the best treatment plan for the patient.
The most important precaution that I must take with patients when an Arthrogram is ordered is to question them about any potential allergy to the contrast agent, to iodine, shellfish, medications, latex or tape or of any allergic incidents in the past. I, or another physician, must be in proximity to the patient after the injection of the contrast agent in case of an allergic or anaphylactic reaction. I will want to know if they have any implanted devices in their body that could move or get hot in the MR scanner, due to the large magnet in the device. I will want to know if they may be pregnant, what medications, vitamins and supplements they take. The patient should wear loose, comfortable clothing with no metal and no jewelry.
During an arthrogram appointment, the patient will start upstairs in our Pain Management Department where they will receive the injection of contrast agent in their affected joint. The patient will be taken into one of our sterile procedure rooms, be made comfortable in a gown or shorts to expose the affected joint, the joint area will be cleansed and sterilely draped. I will then have x-rays taken of the joint. I will then inject a numbing medication into the joint area to be injected. I may then aspirate synovial fluid from the joint, if necessary. At that point, the contrast dye will be injected into the joint. It typically burns and the joint may feel sore and full, causing some discomfort. The patient may be asked to move their joint so that the contrast agent can move throughout the joint. More pictures may be taken of the joint under fluoroscopy before the is patient taken to the MR scanner downstairs. This portion of the test typically takes around 20-30 minutes.
The patient will be taken to the MR scanner downstairs and asked specific questions by the MR technician for their safety. At that time, the patient will be asked to change completely into a gown, put in ear plugs and to proceed into the scanning room. The technician will help them onto the scanning table, may put extra pieces of equipment (coils) around specific body parts to be scanned, may provide padding and weights, as well as blankets, pillows and headphones with music. The patient will be handed a call button in case they need anything and the table upon which they lie will be moved under the body of the scanner magnet. At that time, the patient may breathe normally, but should lie as still as possible during the scan. Depending on the scan, it could take anywhere from 20 minutes to an hour.
During the scan, the patient will hear all kinds of different loud, electronic-sounding noises, emanating from the MR scanner. Don’t worry, all the “Star Wars” noises mean that the machine is just doing its job.
After the MR scan is complete, the patient will be released to go home, with written instructions on aftercare. The patient can expect to be sore for a day or two in the joint that was injected. I recommend using ice, intermittently and always with a covering between the ice pack and the skin. I may give the patient permission to take an anti-inflammatory medication, such as naproxen sodium; however, if we are anticipating a result which may lead to surgery, acetaminophen will be recommended for pain instead. Avoid strenuous exercise, taking a bath, swimming, or submerging the injection site for at least 24 hours. Showers are fine.
As with any procedure, there can be risks and complications. I (or the ordering Ortho) should be contacted if any of the following occur:
- Intense, unrelenting pain in the injected joint
- Swelling, bleeding, oozing, redness (which may indicate infection)
- A fever above 101.5°
- Swelling and soreness which lasts more than 3 days
Although not common, the patient may also have a delayed, non-life-threatening allergic reaction to the contrast agent, and may experience itching, redness, blisters, hives, dizziness, sneezing, an upset stomach or nausea and vomiting. Benadryl® is usually helpful with these types of allergic symptoms; however, if they do not relent, the ordering physician should be contacted, or the patient should head to their PCP or Urgent Care for treatment.
The Radiologist will be sent all the MR images to review and interpret. The report will be sent to me and/or the ordering physician and the results will be shared with the patient. Then, the next phase in the treatment plan can be discussed and decided upon by the patient and their physician, based on the definite diagnosis the arthrogram provided.
Make an appointment with Dr. Sureja or another OSC provider by clicking the “Request Appointment” button below or by calling (757) 596-1900.