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Taninokuchi Tomassoni M, Braccischi L, Russo M, Adduci F, Calautti D, Girolami M, Vita F, Ruffilli A, Manzetti M, Ponti F, Matcuk GR, Mosconi C, Cirillo L, Miceli M, Spinnato P. Image-Guided Minimally Invasive Treatment Options for Degenerative Lumbar Spine Disease: A Practical Overview of Current Possibilities. Diagnostics (Basel) 2024; 14:1147. [PMID: 38893672 PMCID: PMC11171713 DOI: 10.3390/diagnostics14111147] [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: 04/15/2024] [Revised: 05/20/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Lumbar back pain is one of the main causes of disability around the world. Most patients will complain of back pain at least once in their lifetime. The degenerative spine is considered the main cause and is extremely common in the elderly population. Consequently, treatment-related costs are a major burden to the healthcare system in developed and undeveloped countries. After the failure of conservative treatments or to avoid daily chronic drug intake, invasive treatments should be suggested. In a world where many patients reject surgery and prefer minimally invasive procedures, interventional radiology is pivotal in pain management and could represent a bridge between medical therapy and surgical treatment. We herein report the different image-guided procedures that can be used to manage degenerative spine-related low back pain. Particularly, we will focus on indications, different techniques, and treatment outcomes reported in the literature. This literature review focuses on the different minimally invasive percutaneous treatments currently available, underlining the central role of radiologists having the capability to use high-end imaging technology for diagnosis and subsequent treatment, allowing a global approach, reducing unnecessary surgeries and prolonged pain-reliever drug intake with their consequent related complications, improving patients' quality of life, and reducing the economic burden.
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Affiliation(s)
- Makoto Taninokuchi Tomassoni
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
- Radiology Department, IRCCS Azienda Ospedaliero-Universitaria Sant’Orsola Malpighi, 40138 Bologna, Italy
| | - Lorenzo Braccischi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
- Radiology Department, IRCCS Azienda Ospedaliero-Universitaria Sant’Orsola Malpighi, 40138 Bologna, Italy
| | - Mattia Russo
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Francesco Adduci
- Neuroradiology, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
| | - Davide Calautti
- Neuroradiology, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
| | - Marco Girolami
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Fabio Vita
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Alberto Ruffilli
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Marco Manzetti
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Federico Ponti
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - George R. Matcuk
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Cristina Mosconi
- Radiology Department, IRCCS Azienda Ospedaliero-Universitaria Sant’Orsola Malpighi, 40138 Bologna, Italy
| | - Luigi Cirillo
- Neuroradiology, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40139 Bologna, Italy
| | - Marco Miceli
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
| | - Paolo Spinnato
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy
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Hashimoto K, Kaneko M, Kinoshita S, Ozawa S, Mukudai S, Sugiyama Y, Hirano S. Effects of Repeated Intracordal Glucocorticoid Injection on the Histology and Gene Expression of Rat Vocal Folds. J Voice 2023; 37:822-828. [PMID: 34284926 DOI: 10.1016/j.jvoice.2021.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/01/2021] [Accepted: 06/10/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Local injection of glucocorticoids (GCs) into the vocal folds has been used for treating the vocal fold lesions. While the positive effects on vocal fold nodules, polyps, or scarring have been clinically reported, some concern remains around the potential adverse effects such as vocal fold atrophy, and the mechanisms remain unclear. The present study examined the histology and gene expression of locally injected GC into the vocal folds in rats. METHODS Thirteen-week-old male Sprague-Dawley rats were used in the experiments. Triamcinolone acetonide (TAA) or saline were administered repeatedly to the right vocal folds at a weekly interval, and rats were euthanized one week after the last administration for histological examination. Genetic examination was assessed hyaluronic acid (HA) metabolism at 1 or 3 days after a single TAA injection by quantitative real-time polymerase chain reaction (qRT-PCR). RESULTS The group which underwent four TAA injections showed a significant decrease in HA in the lamina propria (LP), thickness of the LP and total cell numbers of the LP compared with the saline group. In contrast, there was no significant difference in the area of collagen accumulation and the thyroarytenoid muscle, although there was a tendency of atrophy of the muscle. After single injection of TAA, qRT-PCR showed a significant decrease in the expression of HA synthases, Has2 and Has3. CONCLUSIONS The current animal study first demonstrates that repeated intracordal injection of GCs may lead to atrophy of vocal folds caused by decrease of deposition of HA in the LP and decrease of gene expression of Has.
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Affiliation(s)
- Keiko Hashimoto
- Department of Otolaryngology-Head and Neck Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Mami Kaneko
- Department of Otolaryngology-Head and Neck Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Shota Kinoshita
- Department of Otolaryngology-Head and Neck Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satomi Ozawa
- Department of Otolaryngology-Head and Neck Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shigeyuki Mukudai
- Department of Otolaryngology-Head and Neck Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoichiro Sugiyama
- Department of Otolaryngology-Head and Neck Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shigeru Hirano
- Department of Otolaryngology-Head and Neck Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Vicentini JRT, Habibollahi S, Staffa SJ, Simeone FJ, Kheterpal AB, Graeber AR, Bredella MA, Chang CY. Relationship of Imaging-guided Corticosteroid Injections to COVID-19 Incidence in the Pandemic Recovery Period. Radiology 2022; 306:237-243. [PMID: 35787202 PMCID: PMC9341274 DOI: 10.1148/radiol.220271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Corticosteroids injected for the treatment of musculoskeletal pain are systemically absorbed and can affect the immune response to viral infections. Purpose To determine the incidence of symptomatic COVID-19 disease in individuals receiving image-guided corticosteroid injections for musculoskeletal pain compared with the general population during the pandemic recovery period. Materials and Methods In this prospective cohort multicenter study, adults with a history of musculoskeletal pain who underwent imaging-guided intra-articular and spine corticosteroid injections from April 2020 to February 2021 were consecutively enrolled. Participants were followed for a minimum of 28 days through their electronic medical record (EMR) or by direct phone communication to screen for COVID-19 test results or symptoms. Clinical data, including body mass index (BMI), were also obtained from the EMR. The incidence of COVID-19 in the state was obtained using the Massachusetts COVID-19 Response Reporting website. The Student t test was used for continuous variable comparisons. Univariable analyses were performed using the Fisher exact test. Results A total of 2714 corticosteroid injections were performed in 2190 adult participants (mean age, 59 years ± 15 [SD]; 1031 women). Follow-up was available for 1960 participants (89%) who received 2484 injections. Follow-up occurred a mean of 97 days ± 33 (range, 28-141 days) after the injection. Of the 1960 participants, 10 had COVID-19 within 28 days from the injection (0.5% [95% CI: 0.24, 0.94]) and 43 had COVID-19 up to 4 months after the injection (2.2% [95% CI: 1.6, 2.9]). These incidence rates were lower than that of the population of Massachusetts during the same period (519 195 of 6 892 503 [7.5%], P < .001 for both 28 days and 4 months). Participants diagnosed with COVID-19 (n = 10) within 28 days from the injection had a higher BMI than the entire cohort (n = 1960) (mean, 32 kg/m2 ± 10 vs 28 kg/m2 ± 6; P = .04). Conclusion Adults who received image-guided corticosteroid injections for pain management during the pandemic recovery period had a lower incidence of symptomatic COVID-19 compared with the general population. © RSNA, 2022 Online supplemental material is available for this article.
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Affiliation(s)
- Joao R. T. Vicentini
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
| | - Sina Habibollahi
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
| | - Steven J. Staffa
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
| | - Frank J. Simeone
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
| | - Arvin B. Kheterpal
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
| | - Adam R. Graeber
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
| | - Miriam A. Bredella
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
| | - Connie Y. Chang
- From the Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St, Yawkey 6E, Boston, MA 02114 (J.R.T.V., S.H., F.J.S., A.B.K., A.R.G., M.A.B., C.Y.C.); and Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Mass (S.J.S.)
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Whelan G, Sim J, Smith B, Moffatt M, Littlewood C. Are Corticosteroid Injections Associated With Secondary Adrenal Insufficiency in Adults With Musculoskeletal Pain? A Systematic Review and Meta-analysis of Prospective Studies. Clin Orthop Relat Res 2022; 480:1061-1074. [PMID: 35302533 PMCID: PMC9263464 DOI: 10.1097/corr.0000000000002145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/28/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Corticosteroid injection is a common treatment for individuals experiencing musculoskeletal pain, and it is part of the management of numerous orthopaedic conditions. However, there is concern about offering corticosteroid injections for musculoskeletal pain because of the possibility of secondary adrenal insufficiency. QUESTIONS/PURPOSES In this systematic review and meta-analysis of prospective studies, we asked: (1) Are corticosteroid injections associated with secondary adrenal insufficiency as measured by 7-day morning serum cortisol? (2) Does this association differ depending on whether the shot was administered in the spine or the appendicular skeleton? METHODS We searched the Allied and Complementary Medicine (AMED), Embase, EmCare, MEDLINE, CINAHL, and Web of Science from inception to January 22, 2021. We retrieved 4303 unique records, of which 17 were eventually included. Study appraisal was via the Downs and Black tool, with an average quality rating of fair. A Grading of Recommendations, Assessment, Development, and Evaluations assessment was conducted with the overall certainty of evidence being low to moderate. Reflecting heterogeneity in the study estimates, a pooled random-effects estimate of cortisol levels 7 days after corticosteroid injection was calculated. Fifteen studies or subgroups (254 participants) provided appropriate estimates for statistical pooling. A total of 106 participants received a spine injection, and 148 participants received an appendicular skeleton injection, including the glenohumeral joint, subacromial bursa, trochanteric bursa, and knee. RESULTS Seven days after corticosteroid injection, the mean morning serum cortisol was 212 nmol/L (95% confidence interval 133 to 290), suggesting that secondary adrenal insufficiency was a possible outcome. There is a difference in the secondary adrenal insufficiency risk depending on whether the injection was in the spine or the appendicular skeleton. For spinal injection, the mean cortisol was 98 nmol/L (95% CI 48 to 149), suggesting secondary adrenal insufficiency was likely. For appendicular skeleton injection the mean cortisol was 311 nmol/L (95% CI 213 to 409) suggesting hypothalamic-pituitary-adrenal axis integrity was likely. CONCLUSION Clinicians offering spinal injections should discuss the possibility of short-term secondary adrenal insufficiency with patients, and together, they can decide whether the treatment remains appropriate and whether mitigation strategies are needed. Clinicians offering appendicular skeleton injections should not limit care because of concerns about secondary adrenal insufficiency based on the best available evidence, and clinical guidelines could be reviewed accordingly. Further research is needed to understand whether age and/or sex determine risk of secondary adrenal insufficiency and what clinical impact secondary adrenal insufficiency has on patients undergoing spinal injection. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Gareth Whelan
- Musculoskeletal Department, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Julius Sim
- School of Medicine, Keele University, Keele, UK
| | - Benjamin Smith
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK; Rehabilitation & Ageing Research Group, Injury, Inflammation and Recovery Sciences, School of Medicine, University of Nottingham, UK
| | - Maria Moffatt
- Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK
| | - Chris Littlewood
- Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK
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Gao J, Xia Z, Mary HB, Joseph J, Luo JN, Joshi N. Overcoming barriers for intra-articular delivery of disease-modifying osteoarthritis drugs. Trends Pharmacol Sci 2022; 43:171-187. [PMID: 35086691 PMCID: PMC8840969 DOI: 10.1016/j.tips.2021.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/27/2021] [Accepted: 12/20/2021] [Indexed: 02/07/2023]
Abstract
Despite four decades of research in intra-articular drug delivery systems (DDS) and two decades of advances in disease-modifying osteoarthritis drugs (DMOADs), there is still no clinically available disease-modifying therapy for osteoarthritis (OA). Multiple barriers compromise intra-articular DMOAD delivery. Although multiple exciting approaches have been developed to overcome these barriers, there are still outstanding questions. We make several recommendations that can help in fully overcoming these barriers. Considering OA heterogeneity, we also propose a patient-centered, bottom-up workflow to guide preclinical development of DDS-based intra-articular DMOAD therapies. Overall, we expect this review to inspire paradigm-shifting innovations for developing next-generation DDS that can enable clinical translation of intra-articular DMOADs.
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Affiliation(s)
- Jingjing Gao
- Center for Nanomedicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA
| | - Ziting Xia
- Center for Nanomedicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Helna B Mary
- Center for Nanomedicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - John Joseph
- Center for Nanomedicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA
| | - James N Luo
- Harvard Medical School, Boston, MA 02115, USA; Department of Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Nitin Joshi
- Center for Nanomedicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA.
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Kim KH. Timing of musculoskeletal steroid injections in pain practice during Coronavirus disease 2019 (COVID-19) vaccine administration. Korean J Pain 2022; 35:1-3. [PMID: 34966006 PMCID: PMC8728550 DOI: 10.3344/kjp.2022.35.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 11/05/2022] Open
Affiliation(s)
- Kyung-Hoon Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
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Ventura R, Daley-Yates P, Mazzoni I, Collomp K, Saugy M, Buttgereit F, Rabin O, Stuart M. A novel approach to improve detection of glucocorticoid doping in sport with new guidance for physicians prescribing for athletes. Br J Sports Med 2021; 55:bjsports-2020-103512. [PMID: 33879477 DOI: 10.1136/bjsports-2020-103512] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2021] [Indexed: 01/13/2023]
Abstract
The systemic effect of glucocorticoids (GCs) following injectable routes of administration presents a potential risk to both improving performance and causing harm to health in athletes. This review evaluates the current GC antidoping regulations defined by the World Anti-Doping Agency and presents a novel approach for defining permitted and prohibited use of glucocorticoids in sport based on the pharmacological potential for performance enhancement (PE) and risk of adverse effects on health. Known performance-enhancing doses of glucocorticoids are expressed in terms of cortisol-equivalent doses and thereby the dose associated with a high potential for PE for any GC and route of administration can be derived. Consequently, revised and substance-specific laboratory reporting values are presented to better distinguish between prohibited and permitted use in sport. In addition, washout periods are presented to enable clinicians to prescribe glucocorticoids safely and to avoid the risk of athletes testing positive for a doping test.
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Affiliation(s)
- Rosa Ventura
- Catalonian Antidoping Laboratory, IMIM, Hospital del Mar Institute for Medical Research, Barcelona, Catalunya, Spain
| | - Peter Daley-Yates
- Clinical Pharmacology & Experimental Medicine, GSK, Brentford, London, UK
| | - Irene Mazzoni
- Science & Medicine Department, World Anti-Doping Agency, Montreal, Quebec, Canada
| | - Katia Collomp
- CIAMS, Université d'Orléans, Orléans, France
- Université Paris-Saclay CIAMS, Orsay, France
- Département des Analyses, AFLD, Chatenay-Malabry, France
| | - Martial Saugy
- REDs, Research and Expertise in antiDoping sciences, University of Lausanne, Lausanne, Switzerland
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin, Germany
| | - Olivier Rabin
- Science & Medicine Department, World Anti-Doping Agency, Montreal, Quebec, Canada
| | - Mark Stuart
- International Testing Agency, Lausanne, Switzerland
- Division of Medicine, Centre for Metabolism and Inflammation, University College London, London, UK
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Symptomatic COVID-19 infections in outpatient image-guided corticosteroid injection patients during the lockdown phase. Skeletal Radiol 2021; 50:1117-1123. [PMID: 33108512 PMCID: PMC7590247 DOI: 10.1007/s00256-020-03656-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/28/2020] [Accepted: 10/16/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Musculoskeletal pain is a debilitating problem treated with image-guided corticosteroid injections. During the COVID-19 pandemic, multiple societies issued caution statements because of the unknown effect of corticosteroids on the patient's immune system. The purpose is to determine if image-guided corticosteroid injections administered during the COVID-19 lockdown phase were associated with a higher infection rate compared to the general population. MATERIALS AND METHODS In a prospective study, patients undergoing image-guided corticosteroid injections for pain management during the lockdown phase between April 15 and May 22, 2020, were enrolled. One month after the injection, patients were surveyed by telephone for any COVID-19-related symptoms, and the electronic medical record (EMR) was reviewed for symptoms and test results. RESULTS Seventy-one subjects were recruited, 31 (44%) females, 40 (56%) males, ages 58 ± 17 (20-92) years. Follow-up was available in 66 (93%) of subjects, 60 (91%) by phone survey and EMR, 6 (9%) by EMR only, 45 ± 22 (19-83) days after injection. One (1/66, 1.52%; 95% CI 0.04-8.2%) 25-year-old male subject developed symptomatic infection 19 days after a tibiotalar injection. The prevalence of COVID-19 cases in the state of Massachusetts was 0.91% (62,726/6,892,503) during the study period. There was no significant difference in the rate of occurrence of new cases of COVID-19 infection between the corticosteroid injection group and the general population (p = 0.44). CONCLUSION Image-guided corticosteroid injections for pain management performed during the lockdown phase of the COVID-19 pandemic were not associated with a higher infection rate compared to the general population.
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9
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Newton AC, Jones G, Jones JWM, Norris R, Barabas AG. Intra-articular corticosteroid injections during the COVID-19 lockdown period: A service evaluation. Musculoskeletal Care 2020; 19:236-243. [PMID: 33278324 DOI: 10.1002/msc.1530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 11/22/2020] [Accepted: 11/23/2020] [Indexed: 01/24/2023]
Affiliation(s)
- Ayla C Newton
- Trauma & Orthopaedics, Peterborough City Hospital, Cambridgeshire, UK.,Trauma & Orthopaedics, Cambridge University Hospital, Cambridgeshire, UK
| | | | | | - Rory Norris
- Trauma & Orthopaedics, Hinchingbrooke Hospital, Huntingdon, Cambridgeshire, UK
| | - Anthony G Barabas
- Pla-stic Surgery, Hinchingbrooke Hospital, Huntingdon, Cambridgeshire, UK
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Guillen Astete CA, Diaz Garcia N, Laso Jimeno B, Luque Alarcon M. Safety of the administration of local corticosteroids in diabetic patients: Historical cohort study comparing the use of triamcinolone and betamethasone. REUMATOLOGIA CLINICA 2020; 16:370-371. [PMID: 30030106 DOI: 10.1016/j.reuma.2018.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 05/29/2018] [Indexed: 06/08/2023]
Affiliation(s)
| | - Noiva Diaz Garcia
- Servicio de Urgencias, Hospital Universitario Ramón y Cajal, Madrid, España
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Mathias PM, Epstein EJ. IATROGENIC CUSHING SYNDROME IN AN HIV-INFECTED PATIENT SECONDARY TO CONCOMITANT THERAPY WITH GENVOYA AND EPIDURAL TRIAMCINOLONE. AACE Clin Case Rep 2020; 6:e217-e220. [PMID: 32984524 PMCID: PMC7511109 DOI: 10.4158/accr-2020-0138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/15/2020] [Indexed: 10/29/2023] Open
Abstract
OBJECTIVE We report the first known case of Cushing syndrome and secondary adrenal insufficiency in a patient with concomitant use of epidural triamcinolone and Genvoya® (elvitegravir 150 mg/cobicistat 150 mg/emtricitabine 200 mg/tenofovir alafenamide 10 mg) for the human immunodeficiency viruses (HIV). The prompt recognition of this drug-drug interaction is critical to avoid adverse outcomes when glucocorticoids are used with anti-retroviral treatment containing cobicistat, a potent cytochrome P450 3A (CYP3A4) inhibitor. METHODS The patient was evaluated by determining morning serum cortisol concentrations, the serum cortisol response to cosyntropin, and a urine synthetic glucocorticoid panel that is capable of measuring triamcinolone. We also employed the Naranjo Nomogram for Causality as well as a Drug Interaction Probability scale to assess medication-related adverse effects. Long term outcome was assessed by measuring morning serum cortisol and adrenocorticotropic hormone levels. RESULTS A 76-year-old female with HIV on Genvoya® presented with fatigue, weight loss, and hyperglycemia. She had received multiple epidural triamcinolone injections for chronic back pain before her presentation. We hypothesized that the patient's presentation of Cushing syndrome and adrenal insufficiency was caused by the inhibition of triamcinolone metabolism by cobicistat. The patient's antiretroviral therapy was changed to a regimen without cobicistat. She was started on maintenance hydrocortisone to prevent an adrenal crisis. A repeat urine glucocorticoid panel, within 3 days of the patient's HIV regimen being changed, showed a significant decrease in triamcinolone levels. CONCLUSION It is essential to avoid drugs that include cobicistat when administering glucocorticoids that are metabolized via the CYP3A4 pathway due to the risk of developing Cushing syndrome and secondary adrenal insufficiency.
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Affiliation(s)
- Priyanka M. Mathias
- From the Division of Endocrinology and Metabolism, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Eric J. Epstein
- From the Division of Endocrinology and Metabolism, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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Cohen SP, Hooten WM, Phillips CR. Pain Management During COVID-19 and Steroids: Striking a Balance. PAIN MEDICINE 2020; 21:1731-1733. [PMID: 32556296 PMCID: PMC7337842 DOI: 10.1093/pm/pnaa175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Steven P Cohen
- Department of Anesthesiology, Neurology and Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Anesthesiology and Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - W Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Mayo School of Medicine, Rochester, Minnesota
| | - Christopher R Phillips
- Anesthesiology Service, Department of Surgery, Naval Medical Center-San Diego, San Diego, California, USA
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Florance J, Hemke R, Chang CY, Torriani M, Bredella MA. Effects of intra-articular corticosteroid injections on lumbar trabecular density. Skeletal Radiol 2020; 49:787-793. [PMID: 31834434 DOI: 10.1007/s00256-019-03362-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/27/2019] [Accepted: 12/05/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the effect of intra-articular corticosteroid injections on lumbar spine trabecular density. MATERIALS AND METHODS This retrospective study was IRB-approved and HIPAA-compliant. We identified 50 patients (26 F, 24 M, mean age 69 ± 14 years) who had undergone at least three medium or large joint corticosteroid injections using insoluble corticosteroids and a subsequent non-contrast abdominal CT within 5 years of the first injection. About 126 age- and sex-matched controls without history of prior corticosteroid use who had undergone non-contrast abdominal CT were identified. Cumulative corticosteroid dose was calculated. Density measurements (HU) of trabecular bone of L1 to L4 were performed, and measurements of L1 were compared to established normative data. Groups were compared using a two-sided paired t-test or a chi-squared test. Linear regression analysis between cumulative corticosteroid dose and trabecular density was performed. RESULTS Patients underwent a mean of 4 corticosteroid injections (range 3 to 11) with a mean cumulative corticosteroid dose of 232 ± 100 mg triamcinolone equivalent (range 120 mg to 480 mg). There was no significant difference in trabecular density of L1 to L4 between cases and controls, and there was no significant difference in trabecular density at L1 compared to normative data (p > 0.2). There was no association between cumulative intra-articular corticosteroid dose and mean lumbar trabecular density (p > 0.3). CONCLUSION Patients who underwent repetitive intra-articular insoluble corticosteroid injections showed no increased risk of bone loss compared to controls. Cumulative intra-articular corticosteroid dose was not associated with lumbar trabecular density.
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Affiliation(s)
- Jonathon Florance
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Yawkey 6E, 55 Fruit Street, Boston, MA, 02114, USA
| | - Robert Hemke
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Yawkey 6E, 55 Fruit Street, Boston, MA, 02114, USA
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Movement Sciences (AMS), Meibergdreef 9, 1105, Amsterdam, AZ, Netherlands
| | - Connie Y Chang
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Yawkey 6E, 55 Fruit Street, Boston, MA, 02114, USA
| | - Martin Torriani
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Yawkey 6E, 55 Fruit Street, Boston, MA, 02114, USA
| | - Miriam A Bredella
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Yawkey 6E, 55 Fruit Street, Boston, MA, 02114, USA.
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Sousa AM, Grigio TR, Ashmawi HA, Ribeiro Júnior U. Cancer pain treatment during the COVID-19 pandemic: institutional recommendations. Clinics (Sao Paulo) 2020; 75:e2208. [PMID: 32844957 PMCID: PMC7426599 DOI: 10.6061/clinics/2020/e2208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Angela Maria Sousa
- Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Thiago Ramos Grigio
- Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Hazem Adel Ashmawi
- Anestesiologia Experimental LIM-08, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ulysses Ribeiro Júnior
- Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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