Morbidity from shoulder arthrography: etiology, incidence, and prevention

A prospective study was performed to assess patient discomfort after shoulder arthrography. Three different techniques were compared using equal intraarticular volumes of: positive contrast medium alone, positive contrast medium diluted with local anesthetic, or positive contrast medium and air. Moderate or severe exacerbation of baseline shoulder discomfort, when evaluated 24-48 hr after arthrography, occurred in 74% of all patients. There was significantly less discomfort after double-contrast examinations than after other techniques, although the level of morbidity was still high. This incidence and severity of discomfort after shoulder arthrography is higher than previously reported or generally recognized. Morbidity after shoulder arthrography is probably caused by a direct irritant effect of the positive contrast medium and/or the additional influx of fluid, into an already distended joint, in response to the hyperosmolar positive contrast medium. The latter effect is consistent with the delayed onset of symptoms which usually began 4-6 hr after the procedure, peaked in intensity 12 hr later and, when severe, often lasted for several days. Smaller volumes of intraarticular contrast medium and/or the use of nonionic and polymeric contrast agents, untested in this protocol, might reduce these symptoms.