Analgesic Effect and Potential Cumulative Benefit from Caudal Epidural D5W in Consecutive Participants with Chronic Low-Back and Buttock/Leg Pain

The effect of perineural injection therapy on neuropathic pain: a retrospective study

Background

Among the various pain-related diseases that can be encountered at the clinic, there is a neuropathic pain that is difficult to treat. Numerous methods have been proposed to treat neuropathic pain, such as taking medication, nerve block with lidocaine, or neurolysis with alcohol or phenol. Recently, a method of perineural injection using dextrose instead of lidocaine was proposed. This study was designed to compare the effects of perineural injection therapy (PIT) with buffered 5% dextrose or 0.5% lidocaine on neuropathic pain.

Methods

The data were collected from the database of pain clinic from August 1st, 2019 to December 31st, 2022 without any personal information. The inclusion criteria were patients diagnosed with postherpetic neuralgia (PHN), trigeminal neuralgia (TN), complex regional pain syndrome (CRPS), or peripheral neuropathy (PN), and patients who had undergone PIT with buffered 5% dextrose (Dextrose group) or 0.5% lidocaine (Lidocaine group) for pain control. The data of patients, namely sex, age, and pain score (numerical rating scale, NRS) were collected before PIT. The data of NRS, side effects, and satisfaction grade (excellent, good, fair, or poor) were collected one week after each of the four PIT, and two weeks after the last PIT.

Results

Overall, 112 subjects were enrolled. The Dextrose group included 89 and Lidocaine group included 23 patients. Because the number of patients in the Lidocaine group was too small to allow statistical analysis, the trend in Lidocaine group was just observed in each disease. There were no significant side effects except for a few bruise cases on the site of injection in all groups. The NRS in most Dextrose groups except CRPS were reduced significantly; however, the Lidocaine group showed a trend of pain reduction only in PHN. The Dextrose group except CRPS showed increased satisfaction two weeks after the final PIT.

Conclusion

From the results, it is suggested that PIT with buffered 5% dextrose may have a good effect for neuropathic pain without any side effect except for patients with CRPS. This may offer a window into a new tool that practitioners can employ in their quest to help patients with neuropathic pain.

Prolotherapy at Multifidus Muscle versus Mechanical Needling and Sterile Water Injection in Lumbar Spinal Stenosis

Objective

This observational study aimed to compare ultrasound-guided (USG) prolotherapy with 5% dextrose in water (D5W) in the multifidus muscle to USG mechanical needling and sterile water injections for the treatment of lumbar spinal stenosis (LSS).

Patients and Methods

The data was extracted from the medical records of ageing patients with LSS who received USG D5W in the multifidus muscle or USG mechanical needling and sterile water injections for the treatment of LSS by the first author. Low back pain or axial pain and leg pain or radicular pain were assessed by the visual analogue scale, and gait ability with walking distance were obtained at six different time points.

Results

Among the 211 older people who were diagnosed with LSS, 104 got USG mechanical needling and sterile water injections over the course of four weeks, while the other 107 got D5W at the multifidus muscles in a single session. Chronic low back pain, radiating pain, and the ability to walk all got much better at 1 and 3 months after the intervention, compared to VAS measures taken at the start. Patients who underwent mechanical needling with injections of sterile water performed consistently and significantly better than those who received prolotherapy in the multifidus muscles on all measures at 1, 3, and 6 months.

Conclusion

After receiving USG mechanical needling and sterile water, LSS patients reported significant improvements in low back pain, radicular pain, and ability to walk for at least 6 months. Prolotherapy with D5W in the multifidus muscle has a moderate effect for only three months.

The Potential of Glucose Treatment to Reduce Reactive Oxygen Species Production and Apoptosis of Inflamed Neural Cells In Vitro

Neuroinflammation is a key feature in the pathogenesis of entrapment neuropathies. Clinical trial evidence suggests that perineural injection of glucose in water at entrapment sites has therapeutic benefits beyond a mere mechanical effect. We previously demonstrated that 12.5-25 mM glucose restored normal metabolism in human SH-SYFY neuronal cells rendered metabolically inactive from TNF-α exposure, a common initiator of neuroinflammation, and reduced secondary elevation of inflammatory cytokines. In the present study, we measured the effects of glucose treatment on cell survival, ROS activity, gene-related inflammation, and cell cycle regulation in the presence of neurogenic inflammation. We exposed SH-SY5Y cells to 10 ng/mL of TNF-α for 24 h to generate an inflammatory environment, followed by 24 h of exposure to 3.125, 6.25, 12.5, and 25 mM glucose. Glucose exposure, particularly at 12.5 mM, preserved apoptotic SH-SY5Y cell survival following a neuroinflammatory insult. ROS production was substantially reduced, suggesting a ROS scavenging effect. Glucose treatment significantly increased levels of CREB, JNK, and p70S6K (p < 0.01), pointing to antioxidative and anti-inflammatory actions through components of the MAPK family and Akt pathways but appeared underpowered (n = 6) to reach significance for NF-κB, p38, ERK1/2, Akt, and STAT5 (p < 0.05). Cell regulation analysis indicated that glucose treatment recovered/restored function in cells arrested in the S or G2/M-phases. In summary, glucose exposure in vitro restores function in apoptotic nerves after TNF-α exposure via several mechanisms, including ROS scavenging and enhancement of MAPK family and Akt pathways. These findings suggest that glucose injection about entrapped peripheral nerves may have several favorable biochemical actions that enhance neuronal cell function.

Efficacy of perineural hypertonic saline injection versus acupoints of foot in the management of diabetic neuropathy: a multicenter, double-blinded randomized controlled trial

Aim: Painful diabetic polyneuropathy is one of the most common disabling problems worldwide. We aimed to determine if a perineural injection of hypertonic saline compared with foot acupoints decreased the neuropathic pain score in patients with diabetes. Patients & methods/materials: Patients were assigned to receive either perineural or acupoints injection of hypertonic saline 5% in their feet for three weekly sessions. Douleur Neuropathique 4 (DN4) questionnaire for neuropathic pain was assessed. Results: Both groups observed a significant reduction of the DN4 score throughout 8 weeks of follow-up. Conclusion: Both perineural and acupoints hypertonic saline injections of the foot could improve neuropathic pain in patients with diabetes.

Dextrose Prolotherapy for Symptomatic Grade IV Knee Osteoarthritis: A Pilot Study of Early and Longer-Term Analgesia and Pain-Specific Cytokine Concentrations

Background: Neurocytokines may upregulate or downregulate neuropathic pain. We hypothesized that dextrose (D-glucose) injections for therapeutic purposes (dextrose prolotherapy: DPT) in painful knee osteoarthritis (KOA) would favorably affect synovial-fluid neurocytokine concentrations. Methods: Twenty participants with grade IV symptomatic KOA received synovial-fluid aspiration followed by dextrose or simulated dextrose injections, followed by the reverse after one week. All participants then received open-label dextrose injections monthly for 6 months, with serial assessments of walking pain at 20 min for 9 months, as well as synovial-neurocytokine-concentration measurements (calcitonin gene-related peptide, substance P (SP), and neuropeptide Y (NPY)) at one week and three months. Results: Clinically important analgesia was observed at 20 min and for 9 months post dextrose injection. One -week synovial-fluid SP concentration rose by 111% (p = 0.028 within groups and p = 0.07 between groups) in the dextrose-injected knees compared to synovial-fluid aspiration only. Three-month synovial-fluid NPY concentration dropped substantially (65%; p < 0.001) after open-label dextrose injection in all knees. Conclusions: Prompt and medium-term analgesia after intra-articular dextrose injection in KOA was accompanied by potentially favorable changes in synovial-fluid neurocytokines SP and NPY, respectively, although these changes were isolated. Including neurocytokines in future assessments of DPT to elucidate mechanisms of action is recommended.

The Role of Power Doppler Ultrasonography in Caudal Epidural Injection

Background and Objectives: Although the ultrasound-guided technique is used in caudal epidural injections, severe complications can happen if ultrasound cannot identify the occurrence of intravascular injection. To determine intraepidural and intravascular injection during caudal epidural injections, we used power Doppler ultrasonography (PDU) when injecting medications into the epidural space. Materials and Methods: This is a retrospective study that enrolled a total of 277 patients with refractory low back pain or degenerative disc from January 2019 to December 2019. The injectate flow of caudal epidural injections was examined with the assistance of PDU and confirmed by fluoroscopy. Four flow patterns were identified by PDU in our study: the “Earthworm sign,” the “Patch sign,” the ”Tubular sign” and the “Absent flow sign.” The accuracy of PDU in identifying intraepidural and intravascular injections was determined by fluoroscopy images recorded during each injection. Results: We evaluated 277 patients (mean age, 68.6 ± 13.2 years; 106 men). The “Patch sign” showed a sensitivity of 88.76% and a specificity of 80% in predicting epidural injection without intravascular injection. The “Earthworm sign” demonstrated a sensitivity of 70% and a specificity of 100% in detecting intravascular injection. The “Tubular sign” showed a specificity of 100% and a sensitivity of 9.4% in predicting successful epidural injection. The absence of a flow signal showed a sensitivity of 1.87% and a specificity of 90% in predicting successful epidural injection. Conclusions: Ultrasound-guided caudal epidural injection can accurately determine intraepidural and intravascular injections with the assistance of PDU and is thus a good alternative technique to fluoroscopy-guided caudal epidural injection.

A Novel Somatic Treatment for Post-traumatic Stress Disorder: A Case Report of Hydrodissection of the Cervical Plexus Using 5% Dextrose

Despite years of standard treatments, a Marine veteran and former firefighter, disabled due to severe post-traumatic stress disorder (PTSD), worsened over ten weeks while receiving usual care. Bilateral injection of 10 mL of 5% dextrose in water using a 30-gauge needle just under the sternocleidomastoid muscle was performed at weeks 10, 12, 14, 16, and 18. Clinically important improvements were observed by 18 weeks on a 0-10 anxiety rating scale (57%), the PTSD checklist for civilians (41%), EuroQol overall quality of life scale (40%), and the Hospital Anxiety and Depression Scale (28%). Improvements were stable through 22 weeks. He reported symptomatic benefit on anxiety within 20 minutes of injection, suggesting a neurogenic mechanism, potentially related to a therapeutic effect on the nearby sympathetic trunk/superior sympathetic ganglion. Advantages of this procedure over stellate ganglion blockade include its safety (no lidocaine), bilateral treatment option, simplicity, and comfort.

Ultrasound-Guided Nerve Hydrodissection With 5% Dextrose 4 Weeks After Steroid Injection in Treatment of Carpal Tunnel Syndrome: A Retrospective Study

Objective

To investigate the efficacy and safety of ultrasound-guided nerve hydrodissection (HD) with 5% dextrose (D5W) as add-on therapy after corticosteroid injection in carpal tunnel syndrome (CTS), and provide a novel strategy.

Methods

In this retrospective study, patients with CTS who received ultrasound-guided nerve HD with D5W as add-on therapy after corticosteroid injection (combination group) were enrolled. Patients who received corticosteroid injection without add-on therapy (steroid group) were recruited as the control group. Ultrasound-guided nerve HD with D5W was performed 4 weeks after corticosteroid injection. Treatment effectiveness were assessed by visual analog scale (VAS) and Boston Carpal Tunnel Syndrome Questionnaire (BCTQ). The assessment was performed at baseline and 4, 8, and 12 weeks after corticosteroid injection. In addition, adverse events were recorded in this study.

Results

A total of 49 patients and 62 wrists meeting the criteria were included, with 24 patients and 31 wrists in the steroid group and 25 patients and 31 wrists in the combination group. Compared with baseline data, both groups showed greater improvement in VAS, BCTQs (BCTQ severity), and BCTQf (BCTQ function) at 4, 8, and 12 weeks follow-up. VAS, BCTQs, and BCTQf scores at baseline and week 4 were comparable between steroid group and combination group. Compared with steroid group, combination group exhibited a significant reduction in VAS, BCTQs, and BCTQf at 8- and 12-week follow-up (P ≤ 0.01). No adverse event occurred in any group.

Conclusions

Our results showed that ultrasound-guided nerve HD with D5W as add-on therapy after corticosteroid injection was efficacious and safe in CTS, and combination therapy is more beneficial than corticosteroid monotherapy in the improvement of symptoms and function at 8- and 12-week follow-up.

Dextrose prolotherapy in knee osteoarthritis: A systematic review and meta-analysis

OBJECTIVE

To summarize the evidence for dextrose prolotherapy in knee osteoarthritis.

DATA SOURCES

The authors searched PubMed and Embase from inception to September 2020. All publications in the English language were included without demographic limits.

STUDY SELECTION

Randomized clinical trials comparing the effects of any active interventions or placebo versus dextrose prolotherapy in patients with knee osteoarthritis were included.

DATA EXTRACTION

Potential articles were screened for eligibility, and data was extracted independently. The risk of bias was assessed using the Cochrane Risk of Bias tool. Meta-analysis was performed on clinical trials with similar parameters. The Strength of Recommendation Taxonomy (SORT) was used for evaluating the strength of recommendations.

DATA SYNTHESIS

In total, eleven articles (n = 837 patients) met the search criteria and were included. The risk-of-bias analysis revealed two studies to be of low risk. The overall effectiveness was calculated using a meta-analysis method. Prolotherapy was no different from platelet-rich plasma on the pain subscale at the 6-month time point. Prolotherapy was inferior to platelet-rich plasma at 6 months (MD 0.45, 95% CI 0.06-0.85, p = 0.03) on the stiffness subscale. Prolotherapy was found to be safe with no major adverse effects.

CONCLUSION

Prolotherapy in knee osteoarthritis confers potential benefits for pain but the studies are at high risk of bias. Based on two well-designed studies, dextrose prolotherapy may be considered in knee osteoarthritis (strength of recommendation B). This treatment is safe and may be considered in patients with limited alternative options (strength of recommendation C).

Dextrose Prolotherapy to Treat Pain, Improve Activities of Daily Living, and Improve Quality of Life in an Ewing's Sarcoma Patient Following Radiation and Chemotherapy Treatment

Advances in the treatment and survival of Ewing’s sarcoma patients create a need to treat underlying symptoms that limit activities of daily living and quality of life. This case describes the treatment of pain in a 25-year-old female pediatric nurse with Ewing’s sarcoma of the pelvis that was in remission following radiation and chemotherapy. She reported medication side effects and limitations in her activities of daily living and quality of life with the chronic use of topical and oral pain medications. A dextrose prolotherapy approach was used to treat her pain, which allowed her to discontinue her pain medication regimen, resulting in an improvement in her activities of daily living and quality of life. The improvement was sustained at the three-year follow-up after the last procedure.

Subacromial corticosteroid injection versus subcutaneous 5% dextrose in patients with chronic rotator cuff tendinopathy: A short-term randomized clinical trial

Aim

The aim of this study is to compare subcutaneous 5% dextrose versus subacromial corticosteroid injection for the treatment of chronic rotator cuff tendinopathy.

Methods

We carried out a randomized clinical trial with two parallel groups at a university hospital. Overall, 57 (32 women) were included in two groups of corticosteroid (n = 29) and dextrose (n = 28). The mean pain score was 6.6 (1.0). We used a visual analog scale for pain and goniometry for the range of motion. The measurements were repeated 1 month after the interventions. For corticosteroid, a single injection of triamcinolone and 1% lidocaine, and for dextrose, a mixture of 5% dextrose and 2% lidocaine three times weekly were prescribed.

Results

Both interventions were effective in decreasing pain compared to the baseline (both p < 0.001). The difference in pain between the two groups was nearly significant 1-month post-intervention (p = 0.052). The comparison of the two groups in considerable pain reduction (≥2.8) was in favor of dextrose (p = 0.046). The differences in the range of motion were not conclusive. None of the participants reported an important adverse effect.

Conclusion

The 5% dextrose treatment is at least as effective as corticosteroid for reducing pain in patients with rotator cuff tendinopathy.

Dextrose Prolotherapy Versus Lidocaine Injection for Temporomandibular Dysfunction: A Pragmatic Randomized Controlled Trial

Objective: Several intraarticular injections, including dextrose and lidocaine, are reported to reduce pain and dysfunction in temporomandibular dysfunction (TMD) and increase maximal jaw opening; our goal was to determine whether dextrose/lidocaine outperforms sterile water/lidocaine for TMD. Design: Pragmatic randomized controlled trial. Setting: Outpatient clinic. Subjects: Chronic (≥3 months) of moderate-to-severe (≥6/10) jaw or facial pain meeting research-specific TMD criteria. Intervention: Blinded intraarticular dextrose prolotherapy (DPT) (20% dextrose/0.2% lidocaine) versus intraarticular lidocaine (0.2% lidocaine in sterile water) at 0, 1, and 2 months. Participants were then unblinded and offered DPT by request for 9 additional months. Main outcome measures: Primary: Numerical Rating Scale (0-10 points) score for facial pain and jaw dysfunction; percentage achieving ≥50% improvement in pain and dysfunction (0, 3, and 12 months). Secondary: Maximal interincisal opening (MIO; 0 and 3 months). Intention-to-treat analysis was by joint using mixed-model regression. Results: Randomization of 29 participants (25 female, 47 ± 17 years, 43 joints) produced similar groups. Three-month pain and dysfunction improvements were similar, but more DPT-treated joints improved by ≥50% in pain (17/22 vs. 6/21; p = 0.028). The MIO improved in both groups (5.6 ± 5.8 mm vs. 5.1 ± 7.0 mm; p = 0.70). From 3 to 12 months, minimal DPT was received by original DPT and lidocaine recipients, 0.5 ± 0.9 and 0.6 ± 1.5 injections, respectively, with only 2 out of 21 joints in the original lidocaine group receiving more than 1 dextrose injection after 3 months. Twelve-month analysis revealed that joints in the original DPT group improved more in jaw pain (4.8 ± 2.4 points vs. 2.6 ± 2.9 points; p = 0.026) and jaw dysfunction (5.3 ± 2.6 points vs. 2.7 ± 2.3 points; p = 0.013). More DPT than lidocaine-treated joints improved by ≥50% in both pain (19/22 vs. 5/21; p = 0.003) and dysfunction (17/22 vs. 7/21; p = 0.040). There were no adverse events; satisfaction was high. Conclusions: Intraarticular DPT resulted in clinically important and statistically significant improvement in pain and dysfunction at 12 months compared to lidocaine injection (ClinicalTrials.gov identifier NCT01617356).

Ultrasound-Guided Nerve Hydrodissection for Pain Management: Rationale, Methods, Current Literature, and Theoretical Mechanisms

Nerve hydrodissection (HD), a technique used when treating nerve entrapments, involves the injection of an anesthetic, saline, or 5% dextrose in water to separate the nerve from the surrounding tissue, fascia, or adjacent structures. Animal models suggest the potential for minimal compression to initiate and perpetuate neuropathic pain. Mechanical benefits of HD may relate to release of nervi nervorum or vasa nervorum compression. Pathologic nerves can be identified by examination or ultrasound visualization. The in-plane technique is the predominant and safest method for nerve HD. Five percent dextrose may be favored as the preferred injectate based on preliminary comparative-injectate literature, but additional research is critical. Literature-based hypotheses for a direct ameliorative effect of dextrose HD on neuropathic pain are presented.

Regenerative Medicine for Axial and Radicular Spine-Related Pain: A Narrative Review

INTRODUCTION

Regenerative injection-based therapy has established itself as a therapeutic option for the management of a variety of painful musculoskeletal conditions. The aim of this work was to review the current literature regarding regenerative injection therapy for axial/radicular spine pain.

METHODS

A comprehensive literature review was conducted on the use of regenerative medicine for axial/radicular spine pain. Eligible articles analyzed the therapeutic injection effects of platelet-rich plasma (PRP), prolotherapy, or mesenchymal signaling cells (MSCs) via intradiscal, facet joint, epidural, or sacroiliac joint delivery.

RESULTS

Regarding intradiscal PRP, there are level I/IV studies supporting its use. Regarding intradiscal prolotherapy, there are level III to IV studies supporting its use. Regarding intradiscal MSCs, there are level I/IV studies supporting its use with the exception of one level IV study that found no significant improvement at 12 months. Regarding facet joint injections with PRP, there are level I/IV studies supporting its use. Regarding facet joint injections with prolotherapy, there are level IV studies supporting its use, though the one level I study did not demonstrate any statistical significance supporting its use. Regarding epidural injections with PRP, there are level I/IV studies supporting its use. Regarding epidural injections with prolotherapy, there are level IV studies supporting its use, though the one level I study did not demonstrate statistical significance beyond 48 hours. Regarding sacroiliac joint injections with PRP, there are level I/IV studies supporting its use. Regarding sacroiliac joint injections with prolotherapy, there are level I/III studies supporting its use.

CONCLUSIONS

Currently, there are level I studies to support the use of PRP and MSC injections for discogenic pain; facet joint injections with PRP; epidural injections of autologous conditioned serum and epidural prolotherapy; and PRP and prolotherapy for sacroiliac joint pain. One level I study showed that facet joint prolotherapy has no significant benefit. Notably, no intervention has multiple published level I studies.

Treatment of Temporomandibular Dysfunction With Hypertonic Dextrose Injection (Prolotherapy): A Randomized Controlled Trial With Long-term Partial Crossover

OBJECTIVE

To assess the efficacy and longer-term effectiveness of dextrose prolotherapy injections in participants with temporomandibular dysfunction.

PATIENTS AND METHODS

A randomized controlled trial with masked allocation was conducted from January 14, 2013, through December 19, 2015. Forty-two participants (with 54 joints) meeting temporomandibular dysfunction criteria were randomized (1:1) to 3 monthly intra-articular injections (20% dextrose/0.2% lidocaine or 0.2% lidocaine) followed by as-needed dextrose/0.2% lidocaine injections through 1 year. Primary and secondary outcome measures included a 0 to 10 Numerical Rating Scale score for facial pain and jaw dysfunction; maximal interincisal opening (MIO) measured in millimeters, percentage of joints with 50% or more change (improvement) in pain and function, and satisfaction.

RESULTS

Randomization produced a control group with more female participants (P=.03), longer pain duration (P=.01), and less MIO (P=.01). Upon 3-month analysis, including pertinent covariates, dextrose group participants reported decreased jaw pain (4.3±2.9 points vs 1.8±2.7 points; P=.02), jaw dysfunction (3.5±2.8 points vs 1.0±2.1 points; P=.008), and improved MIO (1.5±4.1 mm vs -1.8±5.1 mm; P=.006). Control group participants received dextrose injections beginning at 3 months. No between-group differences were noted at 12 months; pooled data suggested that jaw pain, jaw function, and MIO improved by 5.2±2.7 points (68%), 4.1±2.8 points (64%), and 2.1±5.5 mm, respectively. Pain and dysfunction improved by at least 50% in 38 of 54 (70%) and 39 of 54 (72%) jaws, respectively.

CONCLUSION

Intra-articular dextrose injection (prolotherapy) resulted in substantial improvement in jaw pain, function, and MIO compared with masked control injection at 3 months; clinical improvements endured to 12 months. Satisfaction was high.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01706172.

Prolotherapy: Potential for the Treatment of Chronic Wounds?

Significance: Chronic skin ulcers, including venous, diabetic, and pressure ulcers, constitute a major health care burden, affecting 2-6 million people in the United States alone, with projected increases in incidence owing to the aging population and rising epidemic of diabetes. The ulcers are often accompanied by pain. Standard of care fails to heal ∼50% of diabetic foot ulcers and 25% of venous leg ulcers. Even advanced therapies do not heal >60%. Thus there is an unmet need for novel therapies that promote healing and also address the concomitant pain issue. Recent Advances: Prolotherapy involves injection of small amounts of an irritant material to the site of degenerated or painful joints, ligaments, and tendons. Multiple irritants are reported to be efficacious, but the focus here is on dextrose prolotherapy. In vitro and in vivo studies support translation to clinical use. Concentrations as low as 5% dextrose have resulted in production of growth factors that have critical roles in repair. Numerous clinical trials report pro-reparative effects of dextrose prolotherapy in joint diseases, tendon, and ligament damage, and for painful musculoskeletal issues. However, most of the studies have limitations that result in low-quality evidence. Critical Issues: The preclinical data support a role for dextrose prolotherapy in promoting tissue repair that is required for healing chronic wounds and ameliorating the associated pain. Critical issues include provision of evidence of efficacy in human chronic wounds. Another potential obstacle is limitation of reimbursement by third-party payers for a therapy with as yet limited evidence. Future Directions: Preclinical studies in models of chronic wounds would support clinical translation. As dextrose prolotherapy has some mechanistic similarities to already approved honey therapies, it may have a shortened pathway for clinical translation. The gold standard for widespread adoption would be a well-designed clinical trial.