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Cohen SP, Ross J. Lumbar transforaminal epidural steroid injections with particulate vs. nonparticulate steroid: an evidence-informed review on shifting gear to a personalized medicine paradigm. Curr Opin Anaesthesiol 2024:00001503-990000000-00205. [PMID: 39011664 DOI: 10.1097/aco.0000000000001402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
PURPOSE OF REVIEW To provide an evidence-informed review weighing the pros and cons of particulate vs. nonparticulate steroids for lumbar transforaminal epidural steroid injections (TFESI). RECENT FINDINGS The relative use of nonparticulate vs. particulate steroids for lumbar TFESI has risen recently in light of catastrophic consequences reported for the latter during cervical TFESI. Among various causes of spinal cord infarct, an exceedingly rare event in the lower lumbar spine, embolization of particulate steroid is among the least likely. Case reports have documented cases of spinal cord infarct during lower lumbar TFESI with both particulate and nonparticulate steroids, with database reviews finding no difference in complication rates. There is some evidence for superiority of particulate over nonparticulate steroids in well-designed studies, which could lead to increase steroid exposure (i.e. more injections) and treatment failure resulting in surgical and/or opioid management when nonparticulate steroids are utilized. SUMMARY Similar to a paradigm shift in medicine, a personalized approach based on a shared decision model and the consequences of treatment failure, should be utilized in deciding which steroid to utilize. Alternatives to ESI include high-volume injections with nonsteroid solutions, and the use of hypertonic saline, which possesses anti-inflammatory properties and has been shown to be superior to isotonic saline in preliminary clinical studies.
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Affiliation(s)
- Steven P Cohen
- Departments of Anesthesiology, Neurology, Physical Medicine & Rehabilitation, Psychiatry and Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jason Ross
- Departments of Anesthesiology and Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Lasry R, Gotkine M, Kruger JM. Peribulbar Corticosteroids for Ocular Myasthenia Gravis. J Neuroophthalmol 2024:00041327-990000000-00613. [PMID: 38578695 DOI: 10.1097/wno.0000000000002148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
BACKGROUND Ocular myasthenia gravis is treated predominantly by oral medications, with the potential for systemic adverse effects. Successful treatment has been achieved using peribulbar dexamethasone. We assessed the effect of peribulbar dexamethasone or triamcinolone (40-mg Triesence), a longer-acting corticosteroid, targeting the peribulbar area as opposed to directly injecting the affected extraocular muscle. This more convenient and secure approach holds the potential for straightforward integration within clinical environments. METHODS Retrospective chart review. RESULTS Five patients were identified that were treated with peribulbar corticosteroids. In 4 of the 5 cases, ophthalmoparesis was unilateral. One case had isolated ptosis, and 4 had both ptosis and ophthalmoparesis. Three of these 4 cases reported complete resolution of symptoms within weeks of a single injection. Improvement lasted between 5 to 6 months, and all patients responded to repeated injections. CONCLUSIONS Peribulbar corticosteroids can be effective in ocular myasthenia gravis. We suggest that longer-acting agents such as triamcinolone are preferable, to reduce injection frequency.
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Affiliation(s)
- Rachel Lasry
- Department of Developmental Biology and Cancer Research (RL), The Hebrew University-Hadassah Medical School, Jerusalem, Israel; and Departments of Neurology (MG) and Ophthalmology (JMK), Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Kim SJ, Park JM, Kim YW, Yoon SY, Lee SC. Comparison of Particulate Steroid Injection vs Nonparticulate Steroid Injection for Lumbar Radicular Pain: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil 2024:S0003-9993(24)00034-0. [PMID: 38242297 DOI: 10.1016/j.apmr.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/30/2023] [Accepted: 01/02/2024] [Indexed: 01/21/2024]
Abstract
OBJECTIVE The objective of this study was to identify the difference on pain intensity and disability between particulate and nonparticulate steroid injections in patients with lumbar radicular pain. Subgroup analysis by study design, type of particulate steroid, and follow-up duration were performed. DATA SOURCES We performed the literature search in the PubMed, Embase, and Cochrane Library up March, 2023. STUDY SELECTION Studies, including randomized controlled trials (RCTs) and nonrandomized studies, that compared particulate steroid injection and nonparticulate steroid injection in patients with lumbar radicular pain were independently reviewed by 2 reviewers for eligibility for inclusion. DATA EXTRACTION Outcomes of interest were pain intensity and disability. Two reviewers independently assessed the quality of included studies using the revised Cochrane Risk of Bias (RoB2.0) tool for RCTs and the Risk of Bias in Nonrandomized Studies of Interventions Tool (ROBINS-I) for nonrandomized studies. Effect sizes were estimated using mean difference (MD) and standardized mean difference (SMD). DATA SYNTHESIS A total of 10 studies were included in this meta-analysis. The results showed no significant difference in visual analog scale, disability score and the numbers of patients with 50% pain reduction between particulate and nonparticulate steroid injection groups (P>.05). Particulate steroid injections showed significant better effect in pain scale in RCTs (MD=0.62; 95% CI 0.08-1.16, P=.02). In subgroup analysis with steroid types, methylprednisolone showed better effect compared with dexamethasone, while dexamethasone showed better effect compared with betamethasone. CONCLUSIONS This meta-analysis suggested no significant differences between the particulate and nonparticulate steroid groups in pain or disability score. Therefore, considering the safety profile of nonparticulate steroids, nonparticulate steroid injection may be helpful in patients with lumbar radicular pain.
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Affiliation(s)
- Seong Jun Kim
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Mi Park
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Wook Kim
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seo Yeon Yoon
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Sang Chul Lee
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Laredo JD, Wybier M, Laemmel E, Mirshahi M. Intra-arterial injection of particulate corticosteroids: mechanism of injury. Skeletal Radiol 2023; 52:1887-1892. [PMID: 36648522 DOI: 10.1007/s00256-022-04273-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 01/18/2023]
Abstract
Mechanism of neurologic complications after epidural spinal injections (ESI) of particulate steroids at the cervical spine include intrathecal injection, epidural hematoma, direct spinal cord injury, and brain stem or cord infarction due to an arterial spasm or inadvertent intra-arterial injection of particulate steroids. At the lumbar spine, there is evidence that a spinal cord infarction secondary to an inadvertent intra-arterial injection of particulate steroids through a transforaminal approach is the leading mechanism.Variations in the arterial supply of the spinal cord help to understand how a lumbar ESI may lead to a spinal cord infarction at the thoracic level. A radiculomedullary artery arising from the lumbar or sacral spine may participate to the supply of the spinal cord. All radicular and radiculomedullary arteries penetrate the spinal canal through the intervertebral foramen. Therefore, its catheterization carries a risk of inadvertent intraarterial injection. An ex vivo animal study has shown that particulate steroids injected in the blood stream produce an immediate and unexpected change of red blood cells into spiculated cells which aggregate and cause arterioles obstruction, while no particulate steroid macroaggregates or vascular spasm were observed. Rare instances of neurologic complications also occurred after ESI performed through a posterior approach. All occurred in previously operated on patients suggesting a pathologic role for the epidural scar.
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Affiliation(s)
- Jean-Denis Laredo
- Service de Chirurgie Orthopédique Et Traumatologique, Hôpital Lariboisière. Assistance Publique des Hôpitaux de Paris, 2, Rue Ambroise Paré, 75010, Paris, France.
| | - Marc Wybier
- Centre de Radiologie Cortambert, Paris 75116, Paris, France
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Chilmi MZ, Sugianto JA, Putra ZK, Hanum PS, Ulfa M. Is particulate or non-particulate steroid the determinant of periarticular injection efficacy for controlling postoperative TKR pain? Network meta-analysis. J Orthop 2023; 43:11-16. [PMID: 37555201 PMCID: PMC10405163 DOI: 10.1016/j.jor.2023.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/16/2023] [Indexed: 08/10/2023] Open
Abstract
PURPOSE Combining steroids for a periarticular injection (PAI) regiment has resulted in better pain control for postoperative TKR pain. Despite the available evidence, the most effective type of steroid for PAI still needs to be established. Network meta-analysis is conducted to analyze whether there is any difference in the effect of particulate compared to non-particulate periarticular steroid injection on post-TKR patients for pain control based on published literature. METHOD This study is conducted following the PRISMA guideline. In general, studies assessing the efficacy of periarticular injection analgesia added with either particulate (Triamcinolone, methylprednisolone, or prednisolone) or non-particulate (dexamethasone or betamethasone) steroid compared to the same regiment were analyzed. RESULTS Ten studies were finally included from the 108 identified papers through database searching. VAS reduction on POD1 is found to be similar in particulate (0,91; CI95%: 0,45-1,37) compared to non-particulate (0,81; CI95%: 0,34-1,28) (Fig. 2). The difference becomes wider and favors non-particulate POD3. Subgroup analysis based on each steroid type was conducted. A stark difference can be observed for each pair of steroids (particulate and non-particulate), resulting in a similar cumulative effect of particulate and non-particulate steroids and inconsistent result on POD1 compared to POD3. CONCLUSION From the available evidence, we concluded that particulate or non-particulate steroid does not significantly affect post-TKR pain management. Instead, the specific type of steroid contributes more to postoperative VAS reduction. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
- Mohammad Zaim Chilmi
- Department of Orthopedic and Traumatology, Faculty of Medicine, Universitas Airlangga / Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
- Master of Hospital Administration, Postgraduate Program, Universitas Muhammadiyah Yogyakarta, Yogyakarta, Indonesia
| | - Julius Albert Sugianto
- Department of Orthopedic and Traumatology, Faculty of Medicine, Universitas Airlangga / Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Zainurrahman Kurnia Putra
- Department of Orthopedic and Traumatology, Faculty of Medicine, Universitas Airlangga / Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | | | - Maria Ulfa
- Master of Hospital Administration, Postgraduate Program, Universitas Muhammadiyah Yogyakarta, Yogyakarta, Indonesia
- School of Medicine, Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta, Yogyakarta, Indonesia
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Shermon S, Van Acker G, Suric V, Kim C, Abd-Elsayed A, Mata N. Flushing After Lumbar Epidural Steroid Injection with Dexamethasone. Curr Pain Headache Rep 2023; 27:143-148. [PMID: 37115487 DOI: 10.1007/s11916-023-01117-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE OF REVIEW Epidural steroid injections are an accepted treatment for low back pain and radicular symptoms. While epidural steroid injections are routinely performed without complications, side effects can be seen, including flushing. Flushing has been studied using various steroid preparations, including dexamethasone, but at significantly higher doses. This was a prospective cohort study that examines the rate of flushing in ESIs with a lower dose (4 mg) of dexamethasone. Subjects undergoing lumbar epidural steroid injection were asked about the presence of flushing following the procedure prior to discharge and again at 48 h after. A total of 80 participants received fluoroscopically guided interlaminar and transforaminal epidural injections. All participants received 4 mg of dexamethasone. Of the 80 subjects, 52 were female, and 28 were male. Seventy-one underwent a transforaminal epidural injection and 9 underwent an interlaminar epidural injection. Four (5%) subjects experienced flushing-1 subject experienced immediate post-procedural flushing and 3 experienced flushing within 48 h. All 4 subjects (100%) were female. All 4 subjects received transforaminal injections (100%). RECENT FINDINGS There is a gap of knowledge about the flushing after lumbar epidural steroid injection with dexamethasone. Flushing is a known and common side effect of epidural steroid injections, varying in frequency based on type of steroid as well as dose. We found 5% incidence in flushing reaction with 4 mg of dexamethasone.
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Affiliation(s)
- Suzanne Shermon
- Physical Medicine and Rehabilitation, Metrohealth/Case Western Reserve University, Cleveland, OH, USA
| | - Gustaf Van Acker
- Physical Medicine and Rehabilitation, Metrohealth/Case Western Reserve University, Cleveland, OH, USA
| | - Vladimir Suric
- Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Chong Kim
- Physical Medicine and Rehabilitation, Metrohealth/Case Western Reserve University, Cleveland, OH, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA.
| | - Nicholas Mata
- Physical Medicine and Rehabilitation, All Star Pain Management, Annapolis, MD, USA
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Interaction between Dexamethasone, Ropivacaine, and Contrast Media Used in Interventional Pain Treatment: Considerations in Safety. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121871. [PMID: 36557073 PMCID: PMC9788574 DOI: 10.3390/medicina58121871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/15/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
Background and Objectives: Although epidural steroid injections are used as an effective treatment, this technique is associated with rare but serious ischemic complications, especially when particulate steroids are used. However, recent studies have reported that even if non-particulate steroids are used, particulates are formed by the interaction with some local anesthetics (LA), causing ischemic complications. This observational study evaluated commonly used combinations of non-particulate steroids and LA with contrast media via microscopic analysis and analyzed the chemical properties of each mixture to identify the correlation of particulate formation. Materials and Methods: Commonly used clinical non-particulate and particulate steroids, contrast media, and LA agent combinations were evaluated macroscopically and microscopically. The pH values were also measured at both room temperature (26 °C) and body temperature (36 °C). Where particulates were observed, the particulate size was measured. Results: Macroscopically, the mixture of non-particulate steroid and ropivacaine had a slightly cloudy appearance at all concentrations, but there was no visible particulate. However, when observed under a microscope, the pH-dependent particulate formation was observed at all concentration combinations tested. (0.1% ropivacaine: from 19 μm to 70 μm, and 0.2% ropivacaine: from 37 μm to 108 μm at room temperature (26 °C)). When contrast media was mixed or the temperature was raised to body temperature (36 °C), the number and size of the particulates decreased or dissolved. Conclusions: The combination of ropivacaine and dexamethasone, a non-particulate steroid, mainly used in epidural injections, forms particulates. However, when mixed with contrast media, particulates are dissolved because of changes in pH and factors affecting particulate formation. In fluoroscopy-guided injections, the use of contrast media could resolve particulate formation.
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Sayed D, Grider J, Strand N, Hagedorn JM, Falowski S, Lam CM, Tieppo Francio V, Beall DP, Tomycz ND, Davanzo JR, Aiyer R, Lee DW, Kalia H, Sheen S, Malinowski MN, Verdolin M, Vodapally S, Carayannopoulos A, Jain S, Azeem N, Tolba R, Chang Chien GC, Ghosh P, Mazzola AJ, Amirdelfan K, Chakravarthy K, Petersen E, Schatman ME, Deer T. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res 2022; 15:3729-3832. [PMID: 36510616 PMCID: PMC9739111 DOI: 10.2147/jpr.s386879] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. Objective The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. Methods The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. Results After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. Conclusion The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA,Correspondence: Dawood Sayed, The University of Kansas Health System, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA, Tel +1 913-588-5521, Email
| | - Jay Grider
- University of Kentucky, Lexington, KY, USA
| | - Natalie Strand
- Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Steven Falowski
- Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Christopher M Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nestor D Tomycz
- AHN Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry, Henry Ford Health System, Detroit, MI, USA
| | - David W Lee
- Physical Medicine & Rehabilitation and Pain Medicine, Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | - Hemant Kalia
- Rochester Regional Health System, Rochester, NY, USA,Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Soun Sheen
- Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Mark N Malinowski
- Adena Spine Center, Adena Health System, Chillicothe, OH, USA,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Michael Verdolin
- Anesthesiology and Pain Medicine, Pain Consultants of San Diego, San Diego, CA, USA
| | - Shashank Vodapally
- Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA
| | - Alexios Carayannopoulos
- Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Newport Hospital, Lifespan Physician Group, Providence, RI, USA,Comprehensive Spine Center at Rhode Island Hospital, Newport Hospital, Providence, RI, USA,Neurosurgery, Brown University, Providence, RI, USA
| | - Sameer Jain
- Interventional Pain Management, Pain Treatment Centers of America, Little Rock, AR, USA
| | - Nomen Azeem
- Department of Neurology, University of South Florida, Tampa, FL, USA,Florida Spine & Pain Specialists, Riverview, FL, USA
| | - Reda Tolba
- Pain Management, Cleveland Clinic, Abu Dhabi, United Arab Emirates,Anesthesiology, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - George C Chang Chien
- Pain Management, Ventura County Medical Center, Ventura, CA, USA,Center for Regenerative Medicine, University Southern California, Los Angeles, CA, USA
| | | | | | | | - Krishnan Chakravarthy
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA,Va San Diego Healthcare, San Diego, CA, USA
| | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA,Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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Voelker A, Pirlich M, Heyde CE. Complications of injections in conservative treatment of degenerative spine disease: a prospective unicentric study. BMC Musculoskelet Disord 2022; 23:1002. [PMID: 36419001 PMCID: PMC9682701 DOI: 10.1186/s12891-022-05970-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/09/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Spinal injection has been an accepted part of conservative therapy for degenerative diseases. The drugs used can cause side effects and severe complications. The aim of this study was to determine the occurrence of general side effects (GSE) and complications when performing consecutive different types of spinal injections and to evaluate pain reduction. METHODS Prospective data evaluation of patients with degenerative spine disease at hospital admission, discharge, and six and 12 weeks after discharge. All patients received a specific injection protocol depending on their symptoms and radiological findings. The injections performed were dorsal sacroiliac joint injections, perineural injections, epidural interlaminar and epidural periradicular injections, and facet joint injections. Potential complications were categorized and recorded as GSE and complications. In addition, the Numerical Analog Scale (NAS) for pain, the Oswestry Disability Index (ODI) were evaluated. RESULTS Forty-eight patients were enrolled. There were 282 spinal injections performed. A total of 131 common treatment-related events were recorded. Depending on the type of injection, transient pain at the injection site (32.4-73.5%), radiating pain (9.4-34.7%), and nerve root irritation (2-18.4%) were the most common. One complication with postpuncture syndrome occurred with epidural-interlaminar injection. No persistent neurologic deficits occurred. The highest rate of GSE was observed with periradicular injections (relative frequency (RF) = 0.8), followed by epidural-interlaminar injections (RF = 0.65), least frequently with FJ injections (RF = 0.32). From the time of admission to discharge, NAS scores were significantly decreased and ODI score significantly improved at discharge (p < 0.001), but relapse occurred at the 12-week follow-up. CONCLUSIONS Various consecutive spinal injections for conservative treatment of degenerative spine diseases are safe and lead to a decrease in pain and improvement in quality of life. GSE are common, but not persistent. Although complications are rare, they can have serious consequences for the patient.
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Affiliation(s)
- Anna Voelker
- grid.411339.d0000 0000 8517 9062Department for Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Markus Pirlich
- grid.411339.d0000 0000 8517 9062Clinic of Otolaryngology, Head and Neck Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Christoph-Eckhard Heyde
- grid.411339.d0000 0000 8517 9062Department for Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
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Fouquet G, Abbas G, Johnson JP, Pompermayer E, Harel C, Aldous E, Puchalski S, David F. Ultrasound-guided injection technique of the equine cervical nerve roots. Front Vet Sci 2022; 9:992208. [PMID: 36387391 PMCID: PMC9644134 DOI: 10.3389/fvets.2022.992208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/10/2022] [Indexed: 11/24/2022] Open
Abstract
Radiculopathy in horses is often a diagnosis of exclusion because of the non-specific clinical signs related to neck pain and possible forelimb lameness. There are no reported treatment options in the equine veterinary literature. The purpose of the study was to describe an ultrasound-guided injection of the cervical nerve root C3 to C8, to evaluate accuracy, time and safety and to anticipate possible complications on clinical cases. Under general anesthesia and with ultrasound guidance, five horses were injected from C3 to C8 with 1.5mL mix of contrast and latex. Immediately after euthanasia, the necks were taken for CT examination and then dissection was performed 3 days later. Data regarding the accuracy of injection, the presence of injectate in the nerve root, vertebral vessel or vertebral canal were recorded from both CT and dissection. The time of injection and ability to visualize the nerve root prior to injection were also recorded. Out of 60 intended injections, 55 (CT images) and 57 (dissection) led to injectate deposited within the target zone with direct contact between contrast/latex and cervical nerve roots noted in 76.4% and 73.7%, respectively. Presence of contrast/latex injectate within nerves (≤11%), vertebral vessels (<4%) and canal (<4%) were rarely encountered. No variation on success rate or safety noted based on the site of injection. The technique described has excellent accuracy, with injectate deposition in direct contact (≈75%) or close vicinity (≈25%) of C3-C8 cervical nerve roots. Injectate diffusion is likely to further improve success rate. Rare presence of injectate within nerve/sheath, vertebral vessels/canal along with diffusion warrants caution when performing this procedure in clinical cases.
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Affiliation(s)
- Gregoire Fouquet
- Equine Veterinary Medical Center, Member of Qatar Foundation, Doha, Qatar
| | - Ghazanfar Abbas
- Equine Veterinary Medical Center, Member of Qatar Foundation, Doha, Qatar
| | - Jessica P. Johnson
- Equine Veterinary Medical Center, Member of Qatar Foundation, Doha, Qatar
| | | | - Camille Harel
- Equine Veterinary Medical Center, Member of Qatar Foundation, Doha, Qatar
| | - Eman Aldous
- Equine Veterinary Medical Center, Member of Qatar Foundation, Doha, Qatar
| | - Sarah Puchalski
- Puchalski Equine Diagnostic Imaging Inc., Petaluma, CA, United States
| | - Florent David
- Equine Veterinary Medical Center, Member of Qatar Foundation, Doha, Qatar
- *Correspondence: Florent David
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Lee GY, Lee JW, Lee E, Yeom JS, Kim KJ, Shin HI, Kang HS. Evaluation of the efficacy and safety of epidural steroid injection using a nonparticulate steroid, dexamethasone or betamethasone: a double-blind, randomized, crossover, clinical trial. Korean J Pain 2022; 35:336-344. [PMID: 35768989 PMCID: PMC9251387 DOI: 10.3344/kjp.2022.35.3.336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 11/28/2022] Open
Abstract
Background The U.S. Food and Drug Administration has prohibited epidural steroid injection (ESI) with particulate steroids. Thus, this study aimed to compare the efficacy and safety of ESI with two nonparticulate steroids, dexamethasone and betamethasone. Methods The eligible patients (n = 600) who received ESI (0 week) with dexamethasone (ESI-dexa) or betamethasone (ESI-beta) had follow-up visits at 2, 4, and 8 weeks with a phone interview at 12 weeks. The primary endpoint was the proportion of effective responders without pain or who were much improved at 2 weeks. The secondary endpoints were the proportion of crossover injections at 2 weeks; changes in the visual analog scale (VAS) and disability index scores at 2, 4, and 8 weeks; the number of additional ESIs in 12 weeks; the number of participants having spinal surgery, as well as the incidence of adverse events over the 12 weeks. Results The proportion of effective responders at 2 weeks was not different between ESI-beta (72/216, 33.3%) and ESI-dexa (63/200, 31.5%; P = 0.670). Adverse events were more common with ESI-dexa (40/200, 20.0%) than with ESI-beta (24/216, 11.1%; P = 0.012). VAS scores decreased more with ESI-beta than with ESI-dexa at 2 weeks (difference, 0.35; P = 0.023) and 4 weeks (difference, 0.42; P = 0.011). The disability score improved significantly more with ESI-beta compared with ESI-dexa at 2 weeks (difference, 3.37; P = 0.009), 4 weeks (difference, 4.01; P = 0.002), and 8 weeks (difference, 3.54; P = 0.007). Conclusions Betamethasone would be more appropriate for ESI.
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Affiliation(s)
- Guen Young Lee
- Department of Radiology, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea
| | - Joon Woo Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Eugene Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jin S Yeom
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyung-Ik Shin
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Heung Sik Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
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Hoerner E, Stundner O, Putz G, Steinfeldt T, Mathis S, Gasteiger L. Crystallization of ropivacaine and bupivacaine when mixed with different adjuvants: a semiquantitative light microscopy analysis. Reg Anesth Pain Med 2022; 47:rapm-2022-103610. [PMID: 35738668 DOI: 10.1136/rapm-2022-103610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 06/13/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Amino-amide local anesthetics precipitate when mixed with some commonly used adjuvants, carrying the risk of perineural or vascular crystal deposition. The aim of this study was to evaluate whether crystallization occurs with routinely used local anesthetic-adjuvant combinations and if a relation with the solution's pH exists. METHODS All substances used in this trial were first visually investigated undiluted under tenfold magnification. Grade of crystallization was assessed using a 6 point grading system.Ropivacaine (0.2%, 0.75% and 1%) and bupivacaine (0.25% and 0.5%) were mixed in a 1:1 solution with the following adjuvants: dexamethasone, dexmedetomidine, clonidine, fentanyl, sodium bicarbonate 8.4% and sodium chloride 0.9%. Subsequently, ropivacaine (0.2% and 0.75%) and bupivacaine (0.25% and 0.5%) were mixed with adjuvants in concentrations commonly used in clinical practice and then serially assessed at several time points up to 1 hour. pH of all substances/combinations was assessed and correlated with crystallization grade. RESULTS All pure substances-except the reference standards sterile water and triamcinolon-showed crystallization grades ranging from grade 1 to grade 4. Addition of adjuvants lead to variable, unpredictable changes in crystal depositions. Addition of sodium bicarbonate 8.4% produced heavy crystallization in all combinations. Grade of crystallization was weakly positively related to the pH of the solution in 1:1 mixtures and clinically relevant concentrations, but not in pure substances. DISCUSSION Our study showed that crystallization is present in pure local anesthetics and may be increased or decreased by admixture of adjuvants. Higher pH of mixtures was weakly associated with more crystallization. Further research is necessary to translate these findings into clinical practice.
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Affiliation(s)
- Elisabeth Hoerner
- Department of Anesthesiology and Intensive Care, Medical University of Innsbruck, Innsbruck, Austria
| | - Ottokar Stundner
- Department of Anesthesiology and Intensive Care, Medical University of Innsbruck, Innsbruck, Austria
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Guenther Putz
- Department of Anesthesiology and Intensive Care, Medical University of Innsbruck, Innsbruck, Austria
| | - Thorsten Steinfeldt
- Department of Anesthesiology, Intensive Care and Pain Medicine, BG Unfallklinik Frankfurt am Main, Frankfurt am Main, Hessen, Germany
| | - Simon Mathis
- Department of Anesthesiology and Intensive Care, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Gasteiger
- Department of Anesthesiology and Intensive Care, Medical University of Innsbruck, Innsbruck, Austria
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13
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Zaghdoudi Z, Eldabe S, Copley S, Abbes H, Temperli P, Buchser E. Cauda Equina Syndrome after Unilateral Medial Branch Block of the Lower Right Lumbar Zygapophyseal Joints. Pain Pract 2022; 22:582-585. [DOI: 10.1111/papr.13110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/21/2022] [Indexed: 11/27/2022]
Affiliation(s)
| | - Sam Eldabe
- The James Cook University Hospital Middlesbrough UK
| | - Sue Copley
- The James Cook University Hospital Middlesbrough UK
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Park CH, Lee SH. Effect of lumbar epidural steroid injection on neuropathic pain: a prospective observational study. AIMS Neurosci 2022; 9:24-30. [PMID: 35434275 PMCID: PMC8941192 DOI: 10.3934/neuroscience.2022003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/20/2021] [Accepted: 01/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background Low back pain (LBP) is caused by disc herniation, spinal stenosis, facet syndrome or etc. This LBP could be either nociceptive or neuropathic pain (NP). In addition, these neuropathic pain is a major contributor to chronic low back pain. It is already known that lumbar epidural steroid injection (ESI) is effective for low back pain, but no study has assessed both nociceptive and neuropathic pain separately. This study investigated whether neuropathic or nociceptive pain was better improved after an epidural steroid injection. Methods This was a prospective study. Patients were classified according to the pre-procedure painDETECT questionnaire (PD-Q) score. If the PD-Q score was ≤12, it was considered as nociceptive pain, and it the PD-Q was ≥19, it was considered NP. The patients were given a transforaminal (TF) or interlaminar (IL) epidural steroid injection (ESI). The PD-Q was filled out by each patient prior to the ESI (baseline), and again at 4 weeks after the ESI. Outcomes was assessed using a numerical rating scale (NRS) score, short form McGill Pain Questionnaire (MPQ), and revised Oswestry Back Disability Index (ODI) at 1 month later. Results A total of 114 patients were enrolled and of these, 54 patients with a PD-Q score of ≤12 were classified into the nociceptive pain, and 60 patients with a PD-Q score ≥19 were classified into the neuropathic pain group. At 1 month after treatment, both groups had significantly lower than improved their mean NRS score. Not withstanding these improvements and difference between NRS, the differences in MPQ and ODI after treatment between the groups (nociceptive vs. neuropathic) not significant. After the procedure (TF-ESI or IL-ESI), the patients in group 1 (PD-Q score ≤12, n = 54) had no change in their PD-Q score. Among the patients in group 2 (pre-treatment PD-Q score ≥19, n = 41), 13 patients moved to a PD-Q score <12 and 15 patients had a PD-Q score of 13–18. Conclusion For the short-term relief of neuropathic pain, ESI was effective for both nociceptive and neuropathic pain, therefore ESI could be treat the try neuropathic pain component in patients with low back pain.
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Affiliation(s)
- Chan Hong Park
- Department of Anesthesiology and Pain Medicine, Daegu Wooridul Spine Hospital of Daegu, Daegu, South Korea
- * Correspondence: ; Tel: 82532123179; Fax: 82532123049
| | - Sang Ho Lee
- Department of Neurosurgery, Chungdam Wooridul Spine Hospital, Seoul, South Korea
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15
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Park SSE, Barmettler A. Vision Loss Secondary to Facial and Periorbital Steroid Injection: A Systematic Review. Ophthalmic Plast Reconstr Surg 2021; 37:511-521. [PMID: 33481540 DOI: 10.1097/iop.0000000000001910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The risk of ophthalmic and retinal artery occlusions following facial and periorbital steroid injection has not been explored. This systematic review examines the prevalence, risk factors, and treatment outcomes of steroid-induced vision losses. METHODS A literature search in Evidence Based Medicine Reviews, MEDLINE, Embase, Pubmed, ClinicalTrials, and WHO ICTRP was performed for vision loss following facial and periorbital corticosteroid injections through July 2020. RESULTS Of 35 case reports, series, and reviews, 49 patients (56 eyes) with steroid-induced vision loss were analyzed. Injection sites predominantly involved the nose (45%) and periocular regions (10%). The most common type of steroid is triamcinolone (54%). Most cases were unilateral, except 7 cases of bilateral vision losses, 4 of which resulted from unilateral steroid injection. Symptoms were reported during or immediately after injections in 49% of cases. Most occlusions occurred in the ophthalmic (53%) or central retinal artery (33%). Vision most commonly presented as no light perception (37%), and 90% were 20/200 or worse. Final visual outcomes varied from 20/200 or worse (56%), 20/40 or better (30%), to in between (13%). CONCLUSION Most vision losses resulted from steroid injections in the nasal and periorbital area. Triamcinolone was the most common offending agent, likely due to large particle size, low solubility, and extensive particle aggregation. Dexamethasone has the opposite pharmacologic properties and has never been reported in association with vascular occlusion related vision loss. Careful steroid selection, injection techniques, and treatment strategies should be considered to prevent and treat artery occlusion.
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Affiliation(s)
| | - Anne Barmettler
- Department of Ophthalmology and Visual Sciences, Montefiore Medical Center, Bronx, NY
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Cohen SP, Greuber E, Vought K, Lissin D. Safety of Epidural Steroid Injections for Lumbosacral Radicular Pain: Unmet Medical Need. Clin J Pain 2021; 37:707-717. [PMID: 34265792 PMCID: PMC8360670 DOI: 10.1097/ajp.0000000000000963] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/27/2021] [Accepted: 06/17/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Epidural steroid injections (ESIs) are a commonly utilized treatment for lumbosacral radicular pain caused by intervertebral disc herniation or stenosis. Although effective in certain patient populations, ESIs have been associated with serious complications, including paralysis and death. In 2014, the US Food and Drug Administration (FDA) issued a safety warning on the risk of injecting corticosteroids into the epidural space. The aims of this article were to review the neurological complications associated with ESIs and to compare the formulations, safety, and effectiveness of commercially available corticosteroids given by transforaminal, interlaminar, or caudal injection. METHODS Serious adverse events associated with ESIs were identified by a search of the FDA Adverse Event Reporting System (FAERS) database. A MEDLINE search of the literature was conducted to identify clinical trials comparing the safety and effectiveness of nonparticulate and particulate corticosteroid formulations. RESULTS Neurological complications with ESIs were rare and more often associated with the use of particulate corticosteroids administered by transforaminal injection. Among the 10 comparative-effectiveness studies reviewed, 7 found nonparticulate steroids had comparable efficacy to particulate steroids, and 3 studies suggested reduced efficacy or shorter duration of effect for nonparticulate steroids. DISCUSSION The risk of complications for transforaminal ESI is greater with particulate corticosteroids. Nonparticulate corticosteroids, which are often recommended as first-line therapy, may have a short duration of effect, and many commercial formulations contain neurotoxic preservatives. The safety profile of ESIs may continue to improve with the development of safer, sterile formulations that reduce the risk of complications while maintaining efficacy.
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Affiliation(s)
- Steven P. Cohen
- Johns Hopkins School of Medicine, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Kip Vought
- Scilex Pharmaceuticals Inc., Palo Alto, CA
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17
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First case of mechanical compression by methylprednisolone crystals following transforaminal lumbar nerve root block for left sciatic pain leading to hyperesthesia and progressive weakness: A case report. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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18
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Rubenstein JA, Chang CC, Idowu OO, Winn BJ. Intravenous Catheter Employed in Peritrochlear Injection of Triamcinolone in the Treatment of Trochleitis. Ophthalmic Plast Reconstr Surg 2021; 37:280-283. [PMID: 32852370 PMCID: PMC7902732 DOI: 10.1097/iop.0000000000001826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Injection of corticosteroid into the peritrochlear region is a widely practiced and highly successful treatment option for trochleitis, conventionally using a 25- or 27-gauge needle for the steroid injection. Injection into the vascular-rich peritrochlear region poses a risk, albeit rare, of central retinal artery occlusion or orbital hemorrhage. We describe a potentially safer method of delivering triamcinolone to the peritrochlear region using a 24-gauge intravenous catheter. METHODS Interventional retrospective case series including all patients who received peritrochlear injections of triamcinolone via intravenous catheter for trochleitis by a single surgeon (BJW). Surgical technique: After a subcutaneous wheel of local anesthetic was delivered to the medial upper eyelid skin nearest to the trochlea, a 24-gauge intravenous catheter was used to penetrate the skin and orbital septum. Once past the septum, the needle was removed and the blunt catheter was advanced into the peritrochlear region. A 1-ml syringe filled with 40 mg/ml triamcinolone was attached to the catheter. After pulling back to ensure that the catheter was not intravascular, triamcinolone was delivered to the orbit. The catheter was then removed. RESULTS Ten catheter injections were performed on 3 patients over an 8-year period. There were no complications. CONCLUSION Injection of corticosteroid into the peritrochlear region using the commonly available 24-gauge intravenous catheter is an effective and theoretically safer alternative to typical injection using a 25-gauge needle for treatment of trochleitis. Use of nonparticulate steroid solutions may further decrease the risk of adverse events.
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Affiliation(s)
| | - Chih-Chiun Chang
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA
| | - Oluwatobi O. Idowu
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA
| | - Bryan J. Winn
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA
- Department of Ophthalmology, Columbia University Medical Center, New York-Presbyterian Hospital, NY
- Ophthalmology Section, Surgical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA
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19
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Lee MS, Moon HS. Safety of epidural steroids: a review. Anesth Pain Med (Seoul) 2021; 16:16-27. [PMID: 33530678 PMCID: PMC7861892 DOI: 10.17085/apm.21002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 01/18/2021] [Indexed: 01/12/2023] Open
Abstract
Spine disease is one of the most common musculoskeletal diseases, especially in an aging society. An epidural steroid injection (ESI) is a highly effective treatment that can be used to bridge the gap between physical therapy and surgery. Recently, it has been increasingly used clinically. The purpose of this article is to review the complications of corticosteroids administered epidurally. Common complications include: hypothalamic-pituitary-adrenal (HPA) axis suppression, adrenal insufficiency, iatrogenic Cushing's syndrome, hyperglycemia, osteoporosis, and immunological or infectious diseases. Other less common complications include psychiatric problems and ocular ailments. However, the incidence of complications related to epidural steroids is not high, and most of them are not serious. The use of nonparticulate steroids is recommended to minimize the complications associated with epidural steroids. The appropriate interval and dosage of ESI are disputed. We recommend that the selection of appropriate ESI protocol should be based on the suppression of HPA axis, which reflects the systemic absorption of the corticosteroid.
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Affiliation(s)
- Min Soo Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho Sik Moon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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20
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Lee J, Kim S, Park S, Kim S, Youn SJ, Jeon Y. Comparison of Whitacre needle and Chiba needle on the incidence of intravascular injection during caudal epidural injections: A single-blind, randomized clinical consort study. Medicine (Baltimore) 2020; 99:e23665. [PMID: 33371104 PMCID: PMC7748201 DOI: 10.1097/md.0000000000023665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/08/2020] [Indexed: 11/26/2022] Open
Abstract
Caudal epidural injection (CEI) is effective for lumbar spinal pain. However, accidental intravascular injection reduces therapeutic efficacy of CEI and leads to fatal complications such as hematoma, and neurologic deficit. Whitacre needle has been reported to be effective for reducing intravascular injection during transforaminal epidural injection, compared with Quincke needle. The bevel of Chiba needle is shorter than that of Quincke needle. In this study we compared Whitacre needle and Chiba needle on incidence of intravascular injection during CEI.This was a single-blind, randomized clinical consort study. After institutional Review Board approval, a total of 164 patients underwent CEI were randomly allocated to one of 2 group (Whitacre needle or Chiba needle group). Intravascular injection was assessed with real-time fluoroscopy. In addition, total procedure time was measured. Data were compared between groups, and P < .05 was consideredstatistically significant.There were no differences between groups in terms of patient demographic and clinical characteristics. There was no significant difference on incidence of intravascular injection between Whitacre and Chiba needle group (11% vs 19.5%, P = .192). However, the procedure time is significantly longer in the Whitacre than Chiba needle group (172.8 ± 53.8 sec vs 147.1 ± 61.1 sec, P = .005).Based on current study, our results indicated that Whitacre needle was not effective to decrease the incidence of intravascular injection during CEI, compared to Chiba needle.
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Affiliation(s)
- Jungwon Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Yeungnam University Medical Center
| | - Saeyoung Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University
| | - Sungsik Park
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University
| | - Sioh Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University
| | - Si-Jeong Youn
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University
| | - Younghoon Jeon
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University
- Department of Anesthesiology and Pain Medicine, School of Dentistry, Kyungpook National University, Daegu, Republic of Korea
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21
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Husseini JS, Simeone FJ, Staffa SJ, Palmer WE, Chang CY. Fluoroscopically guided lumbar spine interlaminar and transforaminal epidural injections: inadvertent intravascular injection. Acta Radiol 2020; 61:1534-1540. [PMID: 32050772 DOI: 10.1177/0284185120903450] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inadvertent intravascular injection is a rare but catastrophic complication of lumbar epidural injections. PURPOSE To determine risk factors for inadvertent intravascular injection in fluoroscopically guided lumbar spine epidural injections. MATERIAL AND METHODS A total of 212 patients who presented for lumbar interlaminar or transforaminal injection were prospectively enrolled. Patient demographics, history of surgery, injection side, site and approach, and volume of contrast injected were recorded. RESULTS There were 89 (42%) interlaminar and 123 (58%) transforaminal injections. For 36 (17%) patients, there had been surgery at the injected or adjacent lumbar level. There were 25 (12%) inadvertent intravascular injections, with an incidence of 2/93 (2%) for interlaminar and 23/119 (19%) for transforaminal injections. The patients with inadvertent intravascular injection were older (P = 0.017) and had prior surgery at or adjacent to the level of injection (P < 0.0001). Transforaminal approach had a higher intravasation rate than interlaminar injections, both when comparing the entire cohort (P = 0.0001) and only patients without prior surgery (P = 0.01). In multivariable logistic regression analysis, transforaminal injections (odds ratio [OR] 9.77, 95% confidence interval [CI] 2.14-44.6, P = 0.003) and prior surgery at or adjacent to the level of injection (OR 5.71, 95% CI 2.15-15.15, P < 0.001) were independently associated with increased risk of inadvertent intravascular injections. CONCLUSION Inadvertent intravascular injection occurred in 12% of our lumbar injection cohort and is more common with transforaminal injections, in older patients, and with prior lumbar surgery at or adjacent to the level of injection.
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Affiliation(s)
- Jad S Husseini
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Boston, MA, USA
- Harvard Medical School, Boston, MA
| | - F Joseph Simeone
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Boston, MA, USA
- Harvard Medical School, Boston, MA
| | - Steven J Staffa
- Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - William E Palmer
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Boston, MA, USA
- Harvard Medical School, Boston, MA
| | - Connie Y Chang
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Boston, MA, USA
- Harvard Medical School, Boston, MA
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Hadzimuratovic B, Mittelbach A, Bahrami A, Zwerina J, Kocijan R. Confluent abscesses in autochthonous back muscles after spinal injections : A case report and narrative review of the literature on low back pain and spinal injections. Wien Med Wochenschr 2020; 172:247-255. [PMID: 32748365 DOI: 10.1007/s10354-020-00773-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/01/2020] [Indexed: 12/13/2022]
Abstract
Injection therapy is a frequently used method for the treatment of subacute and chronic low back pain (LBP) despite scant evidence for its effectiveness. To date there are relatively few studies comparing this method with other treatments. Moreover, there are many possible side effects associated with injection therapies, some of which are potentially life threatening. We present the case of a 59-year-old woman admitted to the emergency department with confluent abscess formations of autochthonous back muscles and staphylococcal sepsis caused by injection therapy performed by a general practitioner for LBP. The findings of this case report emphasize a careful selection of patients for this type of treatment and a multidisciplinary approach to treatment of LBP.
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Affiliation(s)
- Benjamin Hadzimuratovic
- Ludwig Boltzmann Institute of Osteology, I. Medizinische Abteilung, Mein Hanusch-Krankenhaus, Heinrich Collin-Straße 30, 1140, Vienna, Austria
| | - Andreas Mittelbach
- Institut für Physikalische Medizin und Rehabilitation, Mein Hanusch-Krankenhaus, Heinrich Collin-Straße 30, 1140, Vienna, Austria
| | - Arian Bahrami
- Zentralröntgeninstitut mit Fachbereich Nuklearmedizin, I. Medizinische Abteilung, Mein Hanusch-Krankenhaus, Heinrich Collin-Straße 30, 1140, Vienna, Austria
| | - Jochen Zwerina
- Ludwig Boltzmann Institute of Osteology, I. Medizinische Abteilung, Mein Hanusch-Krankenhaus, Heinrich Collin-Straße 30, 1140, Vienna, Austria
| | - Roland Kocijan
- Ludwig Boltzmann Institute of Osteology, I. Medizinische Abteilung, Mein Hanusch-Krankenhaus, Heinrich Collin-Straße 30, 1140, Vienna, Austria.
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Duszynski B. Spine Intervention Society Position Statement on Best Practices for Epidural Steroid Injections in the Setting of a Preservative-Free Dexamethasone Shortage. PAIN MEDICINE 2020; 20:1277-1280. [PMID: 31034052 DOI: 10.1093/pm/pnz063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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24
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Ultrasound-Guided Selective Nerve Root Block versus Fluoroscopy-Guided Interlaminar Epidural Block versus Fluoroscopy-Guided Transforaminal Epidural Block for the Treatment of Radicular Pain in the Lower Cervical Spine: A Retrospective Comparative Study. Pain Res Manag 2020; 2020:9103421. [PMID: 32617125 PMCID: PMC7306851 DOI: 10.1155/2020/9103421] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/11/2020] [Accepted: 05/27/2020] [Indexed: 02/06/2023]
Abstract
Background Recently, ultrasound- (US-) guided selective nerve root block (SNRB) has been reported to have similar effects compared to fluoroscopy- (FL-) guided cervical epidural steroid injection (CESI). There is no published study comparing the therapeutic efficacy and safety of interlaminar- (IL-) CESI and transforaminal- (TF-) CESI with US-guided SNRB. Our retrospective study aimed to compare the mid-term effects and advantages of the US-guided SNRB, FL-guided IL-CESI, and TF-CESI for radicular pain in the lower cervical spine through assessment of pain relief and functional improvement. Methods Patients with radicular pain in the lower cervical spine who received guided SNRB (n = 44) or FL-guided IL (n = 41) or TF-CESI (n = 37) were included in this retrospective study. All procedures were performed using a FL or US. The complication frequencies during the procedures, adverse event, treatment effects, and functional improvement were compared at 1, 3, and 6 months after the last injection. Results Both the Neck Disability Index (NDI) and Verbal Numeric Scale (VNS) scores showed improvements at 1, 3, and 6 months after the last injection in all groups, with no significant differences between groups (P < 0.05). Furthermore, the treatment success rate at all time points was not significantly different between groups. Logistic regression analysis revealed that the injection method (US- or FL-guided), cause, sex, age, number of injections, and pain duration were not independent predictors of treatment success. Blood was aspirated before injection in 7% (n = 3), 14% (n = 6), and 0% patients in the FL-guided IL, TF, and US-guided groups, respectively. In 2 patients of FL-guided IL and 7 of FL-guided TF group, intravascular contrast spread was noted during injection. Conclusions Our results suggest that, compared with FL-guided IL and TF-CESI, US-guided SNRB has a low intravascular injection rate; it is unlikely that serious complications will occur. Also, US-guided SNRB requires a shorter administration duration while providing similar pain relief and functional improvements. Therefore, for the treatment of patients with lower cervical radicular pain, US-guided SNRB should be considered as a prior epidural steroid injection.
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Munglani R, Knaggs R, Eyre G. Particulate steroids in axial spinal blockade and the increasing role of patient consent: Les grains de sable dans l'engrenage. Br J Pain 2020; 14:141-146. [PMID: 32537153 DOI: 10.1177/2049463720921199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The complexity of modern medical practice is such that it is very unlikely that on any single issue we can give a definitive answer in any circumstance, and in our view the medical debate as to the use of particulate corticosteroid medicines in axial spinal blockade is one such argument. The medical discussion of the use of particulate corticosteroids has to be set against the uncertain risk and benefits of axial spinal procedures in which the drugs are utilised, and in which the most likely catastrophic complication may occur with their use, and then, as the law now demands, involve the patient in the relevant consenting issues.
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Affiliation(s)
| | - Roger Knaggs
- School of Pharmacy, University of Nottingham, Nottingham, UK
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26
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Gossner J. Safety of CT-guided cervical nerve root infiltrations using a dorsal approach. Neuroradiology 2020; 62:1185-1187. [PMID: 32363483 DOI: 10.1007/s00234-020-02426-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 03/31/2020] [Indexed: 11/29/2022]
Abstract
Cervical nerve root infiltrations are frequently performed in patients with radiculopathy, and computed tomography (CT) is commonly used for image guidance. With the traditional anterolateral approach, catastrophic side events due to spinal ischemia have been reported. To minimize risk, a dorsal approach has been advised, but the safety of this dorsal approach has not been studied systematically. In a 5-year period, 137 cervical nerve root infiltrations using a dorsal approach were performed on 109 patients and retrospectively reviewed. In our series, no major complications like spinal ischemia, spondylodiscitis, large hematomas with the need for surgery or severe allergic reactions occurred. In conclusion, using a dorsal approach, CT-guided cervical nerve root infiltrations with an extraforaminal needle position seem to be a safe intervention.
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Affiliation(s)
- Johannes Gossner
- Department of Diagnostic and Interventional Radiology, Evangelisches Krankenhaus Göttingen-Weende, An der Lutter 24, 37074, Göttingen, Germany.
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Donohue NK, Tarima SS, Durand MJ, Wu H. Comparing pain relief and functional improvement between methylprednisolone and dexamethasone lumbosacral transforaminal epidural steroid injections: a self-controlled study. Korean J Pain 2020; 33:192-198. [PMID: 32235020 PMCID: PMC7136301 DOI: 10.3344/kjp.2020.33.2.192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 11/25/2022] Open
Abstract
Background Previous studies have shown varying results between lumbosacral transforaminal epidural steroid injections (TFESIs) performed with particulate versus non-particulate corticosteroids. The purpose of this study was to investigate the difference in pain relief and functional improvement between particulate and non-particulate lumbosacral TFESIs in patients who had undergone both injections, sequentially. Methods This was a self-controlled, retrospective study of 20 patients who underwent both a methylprednisolone and a dexamethasone TFESI to the same vertebral level and side. Primary outcomes included pain relief according to the visual analogue scale (VAS) and functional improvement determined by a yes/no answer to questions regarding mobility and the activities of daily living. Post-injection data was recorded at 2, 3, and 6 months. Results A decrease in VAS scores of –3.4 ± 3.0 (mean ± standard deviation), –3.1 ± 3.1, and –2.8 ± 3.4 was seen for the methylprednisolone group at 2, 3, and 6 months, respectively. Similar decreases of –3.9 ± 3.5, –3.4 ± 2.8, and –2.3 ± 3.4 were seen in the dexamethasone group. There was no significant difference in pain relief at any point between the two medications. The percentage of subjects who reported improved function at 2, 3, and 6 months was 65%, 51%, and 41%, respectively, for the methylprednisolone group and 75%, 53%, and 42% for the dexamethasone group. Conclusions These findings support the use of non-particulate corticosteroids for lumbosacral TFESIs in the context of documented safety concerns with particulate corticosteroids.
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Affiliation(s)
- Nicholas K Donohue
- Department of Physical Medicine & Rehabilitation, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sergey S Tarima
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Matthew J Durand
- Department of Physical Medicine & Rehabilitation, Medical College of Wisconsin, Milwaukee, WI, USA.,Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Hong Wu
- Department of Physical Medicine & Rehabilitation, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
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Hewedy ESS, Sabaa BESI, Mohamed WS, Hegab DS. Combined intralesional triamcinolone acetonide and platelet rich plasma versus intralesional triamcinolone acetonide alone in treatment of keloids. J DERMATOL TREAT 2020; 33:150-156. [PMID: 32063079 DOI: 10.1080/09546634.2020.1730742] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background: Keloids are benign fibro-proliferative growths occurring after skin injury or spontaneously. Intralesional triamcinolone acetonide (TA) is their first-line therapy, but commonly associated with side effects or recurrence. Platelet rich plasma (PRP) is an autologous blood-derived product with promising results in improving wound healing with lower keloid occurrence.Objective: To compare the efficacy of combined intralesional TA and PRP versus TA alone in keloids treatment.Methods: Forty patients with keloids were divided randomly into two equal groups (A and B). Both groups received intralesional TA (20 mg/ml) for four sessions, 3 weeks apart. Group A patients received additional intralesional PRP 1 week after TA injections. Evaluation was done after 3 months of follow up by Vancouver scar scale (VSS) and verbal rating scale (VRS) for pain and itching.Results: Both groups showed significant improvement in all parameters of VSS and VRS in comparison with baseline. Significantly better improvement in height, pigmentation, and pliability and overall VSS was detected in patients of group A. A significantly higher incidence of post-TA atrophy and hypopigmentation was observed in group B.Conclusion: Combining intralesional PRP with TA could yield cosmetically better outcomes in keloid treatment with lower incidence of TA-induced side effects especially atrophy and hypopigmentation.
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Affiliation(s)
| | | | - Wesam Salah Mohamed
- Clinical Pathology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Doaa Salah Hegab
- Dermatology and Venereology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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29
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Lipetz J, Zelinger P, Kline M, Chahine N, Bloom O. Lumbar Radicular Pain Response to First Injection with Non-particulate Steroid. Cureus 2020; 12:e7104. [PMID: 32257652 PMCID: PMC7100620 DOI: 10.7759/cureus.7104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction Recent studies on the use of transforaminal epidural steroid injection (TFESI) to treat lumbar radicular pain have highlighted controversies pertaining to the choice of corticosteroid agent utilized in lumbosacral TFESI, in terms of both safety and efficacy. The primary objective was to characterize the radicular pain response after a first transforaminal injection with dexamethasone. The secondary objective was to document the response of those who failed to respond to a dexamethasone injection when particulate steroid was utilized for a second injection. Methods It was a retrospective study of 94 consecutive patients undergoing transforaminal injection for lumbosacral radicular pain. At two-week follow-up, patients rated their pain response on a clinically oriented five-point survey. First injection non-responders were given a second injection with particulate steroid and again completed the survey. Results Approximately one-third (N = 31/94) of patients received no meaningful relief from a single injection with dexamethasone. No patients achieved lasting and complete pain relief after a single injection. Of initial non-particulate steroid non-responders, approximately two-thirds (N = 19/28) demonstrated a notable or complete response to a second injection with particulate steroid. Conclusions We are now able to better inform patients with regard to their anticipated pain response to an initial dexamethasone injection. Only one-third of patients realized more significant and lasting relief after a single injection. Of those who did not demonstrate a more meaningful response, a second injection with particulate steroid resulted in more pronounced pain relief in two-thirds of patients.
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Affiliation(s)
- Jason Lipetz
- Physical Medicine and Rehabilitation, Hofstra-Northwell School of Medicine/ Long Island Spine Rehabilitation Medicine, Great Neck, USA
| | - Perry Zelinger
- Physical Medicine and Rehabilitation, Rusk Rehabilitation, NYU Langone Health, New York, USA
| | - Myriam Kline
- Biostatistics Unit, Feinstein Institute for Medical Research, Northwell Health, Manhasset, USA
| | | | - Ona Bloom
- Molecular Medicine, Physical Medicine and Rehabilitation, The Feinstein Institute for Medical Research/Hofstra Northwell School of Medicine, Manhasset, USA
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30
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31
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Vydra D, McCormick Z, Clements N, Nagpal A, Julia J, Cushman D. Current Trends in Steroid Dose Choice and Frequency of Administration of Epidural Steroid Injections: A Survey Study. PM R 2019; 12:49-54. [DOI: 10.1002/pmrj.12192] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 05/20/2019] [Indexed: 02/01/2023]
Affiliation(s)
- Darrell Vydra
- Department of Physical Medicine and RehabilitationUT Health San Antonio San Antonio TX
| | - Zack McCormick
- Division of Physical Medicine and RehabilitationUniversity of Utah School of Medicine Salt Lake City UT
| | - Nate Clements
- Department of Physical Medicine and RehabilitationUT Health San Antonio San Antonio TX
| | - Ameet Nagpal
- Department of AnesthesiologyUT Health San Antonio San Antonio TX
| | - Jonathan Julia
- Department of AnesthesiologyUT Health San Antonio San Antonio TX
| | - Daniel Cushman
- Division of Physical Medicine and RehabilitationUniversity of Utah School of Medicine Salt Lake City UT
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Safe Injectate Choice, Visualization, and Delivery for Lumbar Transforaminal Epidural Steroid Injections: Evolving Literature and Considerations. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00244-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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33
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Smith CC, McCormick ZL, Mattie R, MacVicar J, Duszynski B, Stojanovic MP. The Effectiveness of Lumbar Transforaminal Injection of Steroid for the Treatment of Radicular Pain: A Comprehensive Review of the Published Data. PAIN MEDICINE 2019; 21:472-487. [DOI: 10.1093/pm/pnz160] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Abstract
Objective
To determine the effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain.
Design
Comprehensive systematic review.
Outcome Measures
The primary outcome of interest was the proportion of individuals with reduction of pain by ≥50%. Additional outcomes of interest were a more-than-two-point reduction in pain score, patient satisfaction, functional improvement, decreased use of pain medication, and avoidance of spinal surgery.
Results
For patients with disc herniations, using the criterion of ≥50% reduction in pain, success rates across included studies (range) were 63% (58–68%) at one month, 74% (68–80%) at three months, 64% (59–69%) at six months, and 64% (57–71%) at one year. For patients with lumbar spinal stenosis, success rates across included studies (range) were 49% (43–55%) at one month, 48% (35–61%) at three months, 43% (33–53%) at six months, and 59% (45–73%) at one year, but there was a lack of corroboration from appropriately controlled studies.
Conclusions
There is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. There is a lack of high-quality evidence demonstrating their effectiveness for the treatment of radicular pain due to spinal stenosis, though small studies suggest a possible benefit. Lumbar transforaminal injection of nonparticulate steroids is as effective as injections with particulate steroids.
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Affiliation(s)
- Clark C Smith
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ryan Mattie
- Providence Cedars-Sinai Tarzana Hospital, Providence Specialty Medical Group, Comprehensive Spine & Interventional Pain Management, Tarzana, California
| | | | | | - Milan P Stojanovic
- Anesthesiology, Critical Care and Pain Medicine Service, VA Boston Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
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34
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Kang WY, Lee JW, Lee E, Kang Y, Ahn JM, Kang HS. Systemic effects of fluoroscopically guided epidural steroid injection with dexamethasone. Korean J Pain 2019; 32:178-186. [PMID: 31257826 PMCID: PMC6615449 DOI: 10.3344/kjp.2019.32.3.178] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 01/31/2023] Open
Abstract
Background Epidural steroid injections (ESIs) have been widely used in managing spinal pain. Dexamethasone has recently emerged as a useful drug in this setting, relative to particulate steroids, although the associated systemic effects have not been fully elucidated. This study aimed to investigate the incidences and types of systemic effects after fluoroscopically guided ESI with dexamethasone. Methods This retrospective study included 888 ESIs with dexamethasone (fluoroscopically guided at the cervical and lumbosacral levels) performed on 825 patients during January to June 2017. Data regarding systemic effects were collected via telephone interviews using a standardized questionnaire at 2 weeks after the procedure. Data on patient demographic, clinical, and procedural characteristics were collected and analyzed to identify factors that were associated with systemic effects. All statistical analyses were performed using the chi-squared test. Results Among the 825 patients, 40 patients (4.8%) experienced systemic effects during the 2-week follow-up period. The most common systemic effect was facial flushing (12 patients, 1.5%), which was followed by urticaria (7 patients, 0.8%) and insomnia (7 patients, 0.8%). A history of spine surgery was significantly associated with the occurrence of systemic effects (P = 0.036). Systemic effects were significantly more common for injections at the cervical level than at the lumbar level (P = 0.019). Conclusions Approximately 4.8% of the patients who underwent ESI with dexamethasone experienced minor and transient systemic effects. These effects were more common in patients who had undergone a previous spine surgery or received a cervical ESI.
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Affiliation(s)
- Woo Young Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Radiology, Chungbuk National University Hospital, Cheongju, Korea
| | - Joon Woo Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eugene Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yusuhn Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Joong Mo Ahn
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Heung Sik Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
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35
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Alcántara Guardado A, Cooper G, Weightman A, Spiess R, Baker ADL. Dilution and microfiltration of particulate corticosteroids for spinal epidural injections: impact on drug concentration and agglomerate formation. Anaesthesia 2019; 74:1551-1557. [PMID: 31228255 DOI: 10.1111/anae.14733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2019] [Indexed: 02/04/2023]
Abstract
Particulate corticosteroids have been described to lead to greater pain improvement compared with their non-particulate counterparts when used in epidural injections. It is hypothesised that filtering may significantly impact their concentration and long-term efficacy. We investigated if passing particulate suspensions through different commonly-used filters affects drug dosage. Two particulate corticosteroid formulations, triamcinolone acetonide and methylprednisolone acetate, were mixed at different concentrations with either bupivacaine hydrochloride or 0.9% sodium chloride. Solutions were passed through a 5-μm and a 0.2-μm filter. Mass spectroscopy results indicated a complete loss of corticosteroid from the solutions using both filters, and light microscopy imaging demonstrated agglomerate formation, suggesting that filtering interferes with drug dosage. The choice of diluents must also be considered to reduce large agglomerate formation. Clinicians should be aware of the consequences of filtering particulate suspensions and carefully consider the selection of diluent when considering treatment plans.
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Affiliation(s)
- A Alcántara Guardado
- School of Mechanical, Aerospace & Civil Engineering, University of Manchester, UK
| | - G Cooper
- School of Mechanical, Aerospace & Civil Engineering, University of Manchester, UK
| | - A Weightman
- School of Mechanical, Aerospace & Civil Engineering, University of Manchester, UK
| | - R Spiess
- Experimental Officer, Manchester Institute of Biotechnology, University of Manchester, UK
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36
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Clements N, Vydra D, Cushman DM, Nagpal A, Julia J, Zheng P, McCormick ZL. Trends in steroid agent and diluent choices for epidural steroid injections: a survey of Spine Intervention Society physicians. Reg Anesth Pain Med 2019; 44:rapm-2018-100366. [PMID: 31129616 DOI: 10.1136/rapm-2018-100366] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 04/09/2019] [Accepted: 05/08/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Epidural steroid injections (ESIs) are a frequently used treatment for refractory radicular spinal pain. ESIs, particularly transforaminal epidural steroid injections (TFESI), may provide pain relief and delay the need for surgery. Corticosteroid agent and diluent choices are known to impact the safety of ESIs. In particular, the risk of embolization with particulate corticosteroids has led to recommendations for non-particulate steroid use by the Multisociety Pain Workgroup. Additionally, there is in vitro evidence that ropivacaine can crystalize in the presence of dexamethasone, potentially creating a particulate-like injectate. Despite widespread use and known risk mitigation strategies, current practice trends related to steroid and diluent choices are unknown. OBJECTIVE Identify the use of particulate versus non-particulate corticosteroids for epidural steroid injections in the cervical and lumbar spine, as well as local anesthetics commonly used as diluents during these procedures. METHODS Cross-sectional survey study of 314 physician members of the Spine Interventional Society. RESULTS 41% and 9% of providers reported using particulate corticosteroids during lumbar TFESIs and cervical TFESI, respectively. Four per cent of providers reported the use of ropivacaine in cervical TFESIs. Forty-four per cent of respondents reported using anesthetic in cervical interlaminar ESIs. 21% of providers report using high volumes (> 4.5 mL) during cervical interlaminar ESIs. CONCLUSION Current trends, as assessed by this survey study, indicate substantial variability in steroid and diluent choice for ESIs. Patterns were identified that may impact patient safety including the continued use of particulate corticosteroids for TFESIs and the use of ropivacaine during TFESIs by a subset of respondents.
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Affiliation(s)
- Nathan Clements
- Physical Medicine and Rehabilitation, UT Health San Antonio, San Antonio, Texas, USA
| | - Darrell Vydra
- Physical Medicine and Rehabilitation, University of Texas Health Science Center at San Antonio Texas - Research Park Campus, San Antonio, Texas, USA
| | - Daniel M Cushman
- Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah, USA
| | - Ameet Nagpal
- Anesthesiology, University of Texas Health Science Center at San Antonio Texas - Research Park Campus, San Antonio, Texas, USA
| | - Jonathan Julia
- Anesthesiology, University of Texas Health Science Center at San Antonio Texas - Research Park Campus, San Antonio, Texas, USA
| | - Patricia Zheng
- Orthopaedic Surgery, University of California San Francisco Department of Otolaryngology Head and Neck Surgery, San Francisco, California, USA
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
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van Zuylen ML, ten Hoope W, Bos EME, Hermanides J, Stevens MF, Hollmann MW. Safety of epidural drugs: a narrative review. Expert Opin Drug Saf 2019; 18:591-601. [DOI: 10.1080/14740338.2019.1617271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- ML van Zuylen
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W ten Hoope
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - EME Bos
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J Hermanides
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - MF Stevens
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - MW Hollmann
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
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38
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Shin WS, Ahn DK, Kim MJ, Cho KJ, Go YR. Influence of Epidural Steroid Injection on Adrenal Function. Clin Orthop Surg 2019; 11:183-186. [PMID: 31156770 PMCID: PMC6526135 DOI: 10.4055/cios.2019.11.2.183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 01/28/2019] [Indexed: 11/06/2022] Open
Abstract
Background Spinal diseases are self-limited or non-progressive in many cases. Epidural steroid injection (ESI) is a common nonsurgical treatment option for spinal pain. Despite concerns about complications of repeated steroid injection, few studies reported on the adrenal function of spine disease patients undergoing surgery after ESI. We investigated the influence of preoperative multiple ESIs on adrenal function in spine surgery patients. Methods This was a retrospective study with prospective data collection. Those who underwent elective spinal operations and had a history of multiple ESIs from January to June 2017 were selected as a study group. Those who underwent knee arthroplasty and did not have a history of ESI and any kind of steroid injection in other areas during 6 months before surgery were selected as a control group. Demographic data were compared to assess homogeneity between groups. We assessed the preoperative serum cortisol level (SCL) to compare the basal adrenal function between groups. Also, we assessed the elevation of SCL postoperatively to evaluate the adrenal response to the surgical stress in each group. For subgroup analysis, we divided all patients into normal (7-28 µg/dL) and subnormal groups according to SCL and analyzed risk factors of adrenal suppression with multivariate logistic regression test. Results There were 53 patients in the study group and 130 in the control group. Age and sex were homogeneous between groups. There was significant intergroup difference in preoperative SCL (10.4 ± 4.8 µg/dL in the study group vs. 12.0 ± 4.2 µg/dL in the control group; p = 0.026).The postoperative day one SCL was 11.6 ± 5.0 µg/dL in the study group without significant increase from the preoperative level (p = 0.117), whereas the increase was significant in the control group with a postoperative level of 14.4 ± 4.4 µg/dL (p < 0.001). Among all patients, the SCL was subnormal in 18 patients and within the normal range in 165. Spine surgery was the independent risk factor irrespective of age and sex (odds ratio, 3.472; p = 0.015). Conclusions Our results suggest that concern should be raised about the influence of preoperative multiple ESIs on adrenal suppression in spine surgery patients.
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Affiliation(s)
- Won Shik Shin
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Dong Ki Ahn
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Myung Jin Kim
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Kyung Jun Cho
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Young Rok Go
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
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Wahezi SE, Mohamed SE, Lederman A, Beck AP. Aggregation properties of triamcinolone acetonide injection in human serum: considerations when performing epidural steroid injections. J Pain Res 2019; 12:1033-1039. [PMID: 30936741 PMCID: PMC6430988 DOI: 10.2147/jpr.s181038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Morbidity has been reported as a sequelae of crystalline steroid epidural steroid injections (ESIs), and particulate steroid size, aggregation, and embolization in brain and spinal cord may be the mechanism related to these neurologic effects. Objective The objective of the study was to examine the aggregation properties of triamcinolone acetonide in commonly used local anesthetics with and without human serum. Setting This study was conducted in an academic tertiary care center. Hypothesis Triamcinolone acetonide shows different aggregation characteristics in serum compared to a non-physiologic solution. Design Triamcinolone acetonide was mixed with lidocaine 1% (first group) and bupivacaine 0.5% (second group) in a 1:1 ratio and then mixed with either distilled water (control group) or serum ex vivo. A pathologist blinded to our hypothesis inspected all solutions under light microscopy with 100× and 400× magnifications. Total number of particulate steroid aggregates and the number of particles forming each aggregate (recorded as single,1 double,2 triple,3 quadruple,4 or large [>4} crystals) were counted. Particle size and aggregate size were measured (in μm). The ratios of quadruple to total aggregates, large to total, and quadruple with large to total aggregates were calculated. Steroid-serum solutions and steroid-sterile water were then compared. Results Triamcinolone aggregates showed an increased crystal and aggregate size when compared with other steroids. Within the triamcinolone subgroup, the mixture of lidocaine 1% and serum resulted in the largest crystal aggregates. Limitations Whole blood analysis may have provided a more physiologically accurate model but was not chosen due to poor microscopic analysis. Serum donor variability may also have affected particle characteristics. Conclusion Fewer large triamcinolone aggregates were noted in the presence of serum when compared to the non-serum control groups. However, when compared to previously studied particulate steroids, it had the largest aggregates when added to serum.
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Affiliation(s)
- Sayed E Wahezi
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA,
| | - Salah Eldin Mohamed
- Burke Rehabilitation Hospital, Albert Einstein College of Medicine, White Plains, NY, USA
| | - Andrew Lederman
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA,
| | - Amanda P Beck
- Department of Pathology, Albert Einstein College of Medicine, Bronx, NY, USA
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Musculoskeletal Corticosteroid Administration: Current Concepts. Can Assoc Radiol J 2019; 70:29-36. [DOI: 10.1016/j.carj.2018.11.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 11/12/2018] [Accepted: 11/14/2018] [Indexed: 12/11/2022] Open
Abstract
Numerous corticosteroid preparations are available, but the type and dose administered is frequently at the discretion of the clinician. This is often based on anecdotal evidence and experience rather than formal clinical guidelines. In order to better understand current practice, we anonymously surveyed 100 members of the British Society of Skeletal Radiologists. The results of the survey demonstrated the arbitrary use of all types of steroid preparation at different anatomical locations. In this article, we review the commonly used corticosteroids and propose a guideline to help practitioners decide on the type and dose of steroid depending on the treatment location.
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Segmental Spinal Myoclonus Complicating Lumbar Transforaminal Epidural Steroid Injection. Reg Anesth Pain Med 2019; 43:554-556. [PMID: 29462057 DOI: 10.1097/aap.0000000000000742] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Lumbar transforaminal epidural steroid injection is commonly used for treating lumbar radicular pain. We report a case of segmental spinal myoclonus that developed during lumbar transforaminal epidural injection with local anesthetic and steroid. CASE REPORT A 58-year-old woman with failed back surgery syndrome presented with low back and right L3 and L4 radicular pain. As she had responded well previously to diagnostic selective nerve root injection with local anesthetic at the right L3 and L4 levels, lumbar transforaminal epidural steroid injection at the same levels was scheduled. During injection of ropivacaine and triamcinolone at the right L3-4 intervertebral foramen, she complained of back pain and immediately developed involuntary contraction of her right hip. The procedure was terminated. No new neurological deficit was detected when she was examined 15 minutes after the procedure. There were no abnormalities from blood tests and magnetic resonance imaging of the lower thoracic and lumbar spine. A neurologist subsequently made the clinical diagnosis of segmental spinal myoclonus. The myoclonus improved over 1 month and eventually resolved completely. CONCLUSIONS Segmental spinal myoclonus is a rare complication after lumbar transforaminal epidural steroid and local anesthetic injection. Pain physicians should be aware of this potential complication.
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Abstract
Osteoarthritis is a common condition that affects many individuals resulting in pain, reduced mobility, and decreased function. Corticosteroids have been a mainstay of osteoarthritis treatment. Studies have shown that they provide short-term pain improvement and can be used for osteoarthritis flares. Hyaluronic acid injections have extensively been studied in knee osteoarthritis but to a lesser degree in other joints. Despite some debate between societies, a large number of recent studies have shown hyaluronic acid to be a viable treatment option showing longer-term improvement in both pain and function.
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Affiliation(s)
- Nina A Yaftali
- Primary Care Sports Medicine, Rush University Medical Center, Midwest Orthopaedics at Rush, 1611 West Harrison, 3rd Floor, Chicago, IL 60612, USA
| | - Kathleen Weber
- Department of Orthopaedics, Rush University Medical Center, Midwest Orthopaedics at Rush, 1611 West Harrison, 3rd Floor, Chicago, IL 60612, USA.
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43
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Park KD, Lee WY, Nam SH, Kim M, Park Y. Ultrasound-guided selective nerve root block versus fluoroscopy-guided interlaminar epidural block for the treatment of radicular pain in the lower cervical spine: a retrospective comparative study. J Ultrasound 2018; 22:167-177. [PMID: 30519991 DOI: 10.1007/s40477-018-0344-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 11/30/2018] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Recent studies have compared the therapeutic efficacy and safety of the procedure using ultrasound and fluoroscopy. However, there are no published studies comparing the therapeutic efficacy and safety of fluoroscopy (FL)-guided cervical interlaminar epidural steroid injection (CIESI) with that of ultrasound (US)-guided selective nerve root block (SNRB). This study aimed to compare the mid-term effects and advantages of US-guided SNRB with FL-guided CIESI for radicular pain in the lower cervical spine through assessment of pain relief and functional improvement. METHODS Patients with radicular pain in the lower cervical spine who received US-guided SNRB (n = 51) or FL-guided CIESI (n = 61) were included in this retrospective study. All procedures were performed using FL or US. The complication frequencies during the procedures, adverse events, treatment effects, and functional improvement were compared at intervals of 1, 3, and 6 months after the last injection. RESULTS Both the neck disability index and verbal numeric scale showed improvements at 1, 3, and 6 months after the last injection in both groups, with no significant differences between groups (p < 0.05). Furthermore, the treatment success rate at all time points was not significantly different between groups. Logistic regression analysis revealed that the injection method (US- or FL-guided), sex, analgesic use, pain duration, number of injections, and age were not independent predictors of treatment success. Blood was aspirated before injection in 8% (n = 5) and 0% of patients in the FL-guided and US-guided groups, respectively. In seven patients of the FL-guided group, intravascular contrast spread was noted during injection. CONCLUSIONS Our results suggest that, compared with FL-guided CIESI, US-guided SNRB requires a shorter administration duration while providing similar pain relief and functional improvements.
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Affiliation(s)
- Ki Deok Park
- Department of Rehabilitation Medicine, Gachon University, Gil Medical Center, Incheon, South Korea
| | - Woo Yong Lee
- Department of Anesthesiology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, South Korea
| | - Sang Hyun Nam
- Department of Plastic and Reconstructive Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, South Korea
| | - Myounghwan Kim
- Department of Obstetrics and Gynecology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, South Korea
| | - Yongbum Park
- Department of Physical Medicine and Rehabilitation, Sanggye Paik Hospital, Inje University College of Medicine, Sanggye 7 dong 761-7, Nowon-gu, 139-707, Seoul, South Korea.
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Chutatape A, Menon M, Fook-Chong SMC, George JM. Metabolic and endocrinal effects of epidural glucocorticoid injections. Singapore Med J 2018; 60:140-144. [PMID: 30402653 DOI: 10.11622/smedj.2018140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Epidural steroid injections are an integral part of nonsurgical management of radicular pain from lumbar spine disorders. We studied the effect of dexamethasone 8 mg epidural injections on the hypothalamic-pituitary-adrenal axis and serum glucose control of Asian patients. METHODS 18 patients were recruited: six diabetics and 12 non-diabetics. Each patient received a total of dexamethasone 8 mg mixed with a local anaesthetic solution of lignocaine or bupivacaine, delivered into the epidural space. Levels of plasma cortisol, adrenocorticotropic hormone (ACTH), serum glucose after an overnight fast and two-hour postprandial glucose, as well as weight, body mass index, blood pressure and heart rate were measured within one week prior to the procedure (baseline) and at one, seven and 21 days after the procedure. RESULTS Median fasting blood glucose levels were significantly higher on post-procedure Day 1 than at baseline. However, there was no significant change in median two-hour postprandial blood glucose from baseline levels. At seven and 21 days, there was no significant difference in fasting or two-hour postprandial glucose levels. Both ACTH and serum cortisol were significantly reduced on Day 1 compared to baseline in all patients. There was no significant difference in ACTH and serum cortisol levels from baseline at Days 7 and 21. CONCLUSION Our study shows that epidural steroid injections with dexamethasone have a real, albeit limited, side effect on glucose and cortisol homeostasis in an Asian population presenting with lower back pain or sciatica.
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Affiliation(s)
| | - Mahesh Menon
- Department of Pain Medicine and Palliative Care Services, Kokilaben Dhirubhai Ambani Hospital, Mumbai, India
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45
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Marcia S, Zini C, Hirsch JA, Chandra RV, Bellini M. Steroids Spinal Injections. Semin Intervent Radiol 2018; 35:290-298. [PMID: 30402012 DOI: 10.1055/s-0038-1673421] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Spinal pain is a common condition leading to significant disability and high cost. Spinal injections have been demonstrated to be effective short-term treatments with cost-utility superior to numerous other treatments, including surgical procedures. Appropriate patient selection-based on clinical and imaging finding-and the use of image guidance associated with technical precautions improve the safety and effectiveness of spinal injection and overall patient outcomes.
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Affiliation(s)
- Stefano Marcia
- Chief of Diagnostic and Interventional Radiology, Ospedale "Santissima Trinità", Cagliari, Italy
| | - Chiara Zini
- Department of Radiology, Ospedale "Santa Maria Annunziata", Azienda Ospedaliera Toscana Centro, Firenze, Italy
| | - Joshua A Hirsch
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Ronil V Chandra
- Diagnostic and Interventional Neuroradiology, Monash Imaging, Monash Health, Melbourne, Australia.,Chief of Stroke Imaging and Endovascular Clot Retrieval, Monash Imaging, Monash Health, Melbourne, Australia.,Neurovascular Surgery, Monash Health, Melbourne, Australia.,Chief of Neurovascular Imaging Research, Monash Health, Melbourne, Australia.,Departments of Surgery and Medicine, Monash Health, Melbourne, Australia
| | - Matteo Bellini
- Chief of Minimal Invasive Spinal Treatment Unit.,Neuroimaging and Neurointerventional Unit.,Department of Neurological and Neurosensorial Sciences.,Ospedale "Santa Maria alle Scotte", Azienda Ospedaliera Universitaria Senese, Siena, Italy
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46
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McCormick Z, Chang Chien GC, So M, Datta R, Singh JR. Three Epidural Steroid Techniques. PM R 2018; 10:1271-1278. [DOI: 10.1016/j.pmrj.2018.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 09/23/2018] [Indexed: 10/27/2022]
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Kesikburun S, Aras B, Kelle B, Yavuz F, Yaşar E, Taşkaynatan MA. The effectiveness of cervical transforaminal epidural steroid injection for the treatment of neck pain due to cervical disc herniation: long-term results. Pain Manag 2018; 8:321-326. [PMID: 30278822 DOI: 10.2217/pmt-2018-0002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To investigate the long-term effect of fluoroscopy guided cervical transforaminal epidural steroid injection on neck pain radiating to the arm due to cervical disc herniation. MATERIALS & METHODS 64 patients (26 women [40.6%], 38 men [59.4%]; mean age, 44.9 ± 12.1 years) who had received fluoroscopy guided cervical transforaminal epidural steroid injection for neck pain due to cervical disc herniation at least 1 year before were included in the study. The effectiveness of transforaminal epidural steroid injection was assessed using data obtained by medical records and a standardized telephone questionnaire. Multiple linear regression analysis was applied to evaluate the factors affecting the pain reduction after injection and the duration of treatment effect. RESULTS The mean duration of neck pain symptom was 23.3 ± 23.9 months. Most of the patients received a single injection (50 patients, 78.1%). The mean time since injection at the time of interview was 21.4 ± 9.4 months. There was a significant reduction in mean pain visual analog scale (VAS [10 cm]) score, from 8.6 ± 1.4 at baseline to 3.2 ± 2.5 at check visit two weeks after injection (p < 0.001). 52 patients (81.2%) reported pain relief of more than 50%. The mean duration of treatment effect was 13.3 ± 9.44 months. Greater pain on the VAS was found to predict strongly the higher pain reduction and longer treatment effect (p = 0.042 and 0.011, respectively). CONCLUSION The results suggested that cervical transforaminal epidural steroid injections might be an effective treatment for neck back pain radiating to the arm due to cervical disc herniation.
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Affiliation(s)
- Serdar Kesikburun
- Department of Physical Medicine & Rehabilitation, Gulhane School of Medicine, University of Health Science, Ankara 06100, Turkey
| | - Berke Aras
- Kastamonu Rehabilitation Centre, Kastamonu 37100, Turkey
| | - Bayram Kelle
- Çukurova University, Physical Therapy & Rehabilitation Department, Adana 01100, Turkey
| | - Ferdi Yavuz
- Fizyocare Physical Therapy & Rehabilitation Centre, Ankara 01110, Turkey
| | - Evren Yaşar
- Department of Physical Medicine & Rehabilitation, Gulhane School of Medicine, University of Health Science, Ankara 06100, Turkey
| | - Mehmet A Taşkaynatan
- Department of Physical Medicine & Rehabilitation, Gulhane School of Medicine, University of Health Science, Ankara 06100, Turkey
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Suleiman ZA, Kolawole IK, Ahmed BA, Babalola OM, Ibraheem GH. Transforaminal epidural steroid injections for the treatment of lumbosacral radicular pain in a Nigeria tertiary hospital: observational study. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2018. [DOI: 10.1080/22201181.2018.1489464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- ZA Suleiman
- Department of Anaesthesia, University of Ilorin, Ilorin Nigeria
| | - IK Kolawole
- Department of Anaesthesia, University of Ilorin, Ilorin Nigeria
| | - BA Ahmed
- Department of Surgery, University of Ilorin, Ilorin Nigeria
| | - OM Babalola
- Department of Surgery, University of Ilorin, Ilorin Nigeria
| | - GH Ibraheem
- Department of Surgery, University of Ilorin, Ilorin Nigeria
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49
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Van Boxem K, Rijsdijk M, Hans G, de Jong J, Kallewaard JW, Vissers K, van Kleef M, Rathmell JP, Van Zundert J. Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group. Pain Pract 2018; 19:61-92. [PMID: 29756333 PMCID: PMC7379698 DOI: 10.1111/papr.12709] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/03/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Epidural corticosteroid injections are used frequently worldwide in the treatment of radicular pain. Concerns have arisen involving rare major neurologic injuries after this treatment. Recommendations to prevent these complications have been published, but local implementation is not always feasible due to local circumstances, necessitating local recommendations based on literature review. METHODS A work group of 4 stakeholder pain societies in Belgium, The Netherlands, and Luxembourg (Benelux) has reviewed the literature involving neurological complications after epidural corticosteroid injections and possible safety measures to prevent these major neurologic injuries. RESULTS Twenty-six considerations and recommendations were selected by the work group. These involve the use of imaging, injection equipment particulate and nonparticulate corticosteroids, epidural approach, and maximal volume to be injected. CONCLUSION Raising awareness about possible neurological complications and adoption of safety measures recommended by the work group aim at reducing the risks for these devastating events.
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Affiliation(s)
- Koen Van Boxem
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
| | - Mienke Rijsdijk
- Pain Clinic, Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Guy Hans
- Multidisciplinary Pain Center, Antwerp University Hospital, Edegem, Belgium.,Laboratory for Pain Research, University of Antwerp, Wilrijk, Belgium
| | - Jasper de Jong
- Department of Pain Management, Westfriesgasthuis, Hoorn, The Netherlands
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Management, Rijnstate Ziekenhuis, Arnhem, The Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands
| | - James P Rathmell
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.,Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A
| | - Jan Van Zundert
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium.,Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands
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50
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Tammachote N, Seangleulur A, Kanitnate S. Lumbar Epidural Corticosteroid Injection Reduces Subacute Pain and Improves Knee Function in the First Six Weeks After Total Knee Arthroplasty: A Double-Blinded Randomized Trial. J Bone Joint Surg Am 2018; 100:950-957. [PMID: 29870446 DOI: 10.2106/jbjs.17.00578] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pain control immediately following total knee arthroplasty (TKA) has been a focus for orthopaedists. However, control of subacute pain, which may persist up to 3 months, is usually not optimized. The efficacy of epidural corticosteroids in reducing pain after surgery is documented, but data on their efficacy in controlling subacute pain after TKA are lacking. Our aim was to investigate the efficacy of an epidural corticosteroid in controlling pain in the first 3 months following TKA using a double-blinded randomized clinical trial. METHODS One hundred and eight patients with osteoarthritis of the knee who underwent TKA and received analgesic drugs through an epidural catheter for 48 hours were randomized to receive either 40 mg (1 mL) of triamcinolone acetonide plus 5 mL of 1% lidocaine, or 6 mL of 1% lidocaine alone before catheter removal. The outcomes of interest were pain level during motion and at rest, knee function, and range of motion, which were recorded up to 3 months after surgery. Multilevel regression models were used to estimate the differences between groups. RESULTS The corticosteroid + lidocaine group had a lower average level of pain during motion compared with the lidocaine-only group, as measured by a visual analog scale (VAS), from day 3 to 7 weeks postoperatively (p < 0.05). At 7 weeks, the mean difference was -7 points (95% confidence interval [CI], -12.8 to -1.0 points; p = 0.033). The corticosteroid + lidocaine group also had a better mean overall modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 6 weeks postoperatively (28 compared with 33 points; 95% CI, -8.6 to -0.6 points; p = 0.03). There was no difference between the groups in the level of pain at rest and knee range of motion during the 3-month period (p > 0.05). CONCLUSIONS Lumbar epidural corticosteroid injection reduced pain during motion for 7 weeks and provided better knee function at 6 weeks postoperatively compared with lidocaine alone. There was no difference detected with respect to pain at rest and knee range of motion during the 3-month follow-up. Epidural corticosteroids could improve patient satisfaction during the early weeks of recovery after TKA. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nattapol Tammachote
- Departments of Orthopedics (N.T. and S.K.) and Anesthesiology (A.S.), Thammasat University, Pathumthani, Thailand
| | - Alisa Seangleulur
- Departments of Orthopedics (N.T. and S.K.) and Anesthesiology (A.S.), Thammasat University, Pathumthani, Thailand
| | - Supakit Kanitnate
- Departments of Orthopedics (N.T. and S.K.) and Anesthesiology (A.S.), Thammasat University, Pathumthani, Thailand
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