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de Liyis BG, Hartawan IGAGU, Widyadharma IPE, Senapathi TGA, Mahadewa TGB. Cervical-Level Regional Paraspinal Nerve Block in Cervical Spine Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2024:S1878-8750(24)01380-9. [PMID: 39127381 DOI: 10.1016/j.wneu.2024.08.021] [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: 07/16/2024] [Accepted: 08/04/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Regional paraspinal nerve block techniques have shown promise in cervical spine surgery pain relief and opioid reduction. The study aims to evaluate cervical-level regional paraspinal nerve block techniques in cervical spine surgery. METHODS Systematic randomized controlled trial (RCT) searches in ScienceDirect, PubMed, Embase, and Cochrane was conducted until March 2024. Key outcome measures included postoperative pain scores and postoperative opioid utilization. Techniques assessed were erector spinae plane block (ESPB), inter-semispinal plane block (ISPB), and superficial cervical plexus block (CPB). RESULTS The study included 6 RCTs and 648 participants. Regional paraspinal nerve block significantly reduced postoperative pain scores at 4, 6, 8, 12, and 24 hours. Postoperative opioid usage was lower in the block group (mean difference [MD]: -1.68; 95% CI: -3.14 to -0.21; P = 0.02), with fewer complications (odds ratio: 0.51; 95% CI: 0.40-0.66; P = 0.001). Patients using fentanyl as postoperative opioid had significantly lower opioid usage with the block (MD: -1.39; 95% CI: -1.76 to -1.01; P < 0.001). Dosage >10 mL correlated with decreased opioid usage (MD: -2.78; 95% CI: -5.25 to -0.31; P < 0.001). ESPB (MD: -1.37; 95% CI: -1.83 to -0.90; P < 0.001) and ISPB (MD: -3.52; 95% CI: -7.09-0.00; P = 0.05) effectively reduced opioid consumption. Posterior approach (MD: -2.78; 95% CI: -5.25 to -0.31; P < 0.001), bilateral administration (MD: -2.14; 95% CI: -4.26 to -0.03; P < 0.001), and ultrasound-guided intervention (MD: -2.68; 95% CI: -5.24 to -0.12; P < 0.001) resulted in a significant reduction of opioid usage. CONCLUSIONS Cervical-level regional paraspinal nerve block effectively reduces postoperative pain and opioid usage, particularly with a dosage exceeding 10 mL, utilizing ESPB and ISPB techniques, administered posteriorly, bilaterally, and under ultrasound guidance.
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Affiliation(s)
- Bryan Gervais de Liyis
- Faculty of Medicine, Universitas Udayana, Prof. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia.
| | - I Gusti Agung Gede Utara Hartawan
- Faculty of Medicine, Department of Anesthesiology and Intensive Care, Universitas Udayana, Prof. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | - I Putu Eka Widyadharma
- Faculty of Medicine, Department of Neurology, Universitas Udayana, Prof. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | - Tjokorda Gde Agung Senapathi
- Faculty of Medicine, Department of Anesthesiology and Intensive Care, Universitas Udayana, Prof. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia
| | - Tjokorda Gde Bagus Mahadewa
- Department of Neurosurgery, Universitas Udayana, Prof. I.G.N.G Ngoerah General Hospital, Denpasar, Bali, Indonesia
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Hooten WM, Eberhart ND, Cao F, Gerberi DJ, Moman RN, Hirani S. Preoperative Epidural Steroid Injections and Postoperative Infections After Lumbar or Cervical Spine Surgery: A Systematic Review and Meta-Analysis. Mayo Clin Proc Innov Qual Outcomes 2023; 7:349-365. [PMID: 37655233 PMCID: PMC10466430 DOI: 10.1016/j.mayocpiqo.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Abstract
Objective To determine the risk difference and 95% prediction intervals (PIs) for postoperative infections (POIs) associated with preoperative epidural steroid injections (ESIs) in adults undergoing lumbar or cervical spine surgery. Methods Comprehensive database searches were conducted from inception dates through December 2023. Inclusion criteria included all study designs involving adults receiving a preoperative ESI before lumbar or cervical decompression or fusion spine surgery. Risk of bias was assessed using a modified tool developed for uncontrolled studies. The summary estimates of risk difference and the corresponding PIs were reported. Results A total of 12 studies were included in the systematic review, of which 9 were included in the meta-analysis. Preoperative ESIs within 1 month of lumbar spine decompression or fusion surgery were associated with a 0.6% and 2.31% greater risk of a POI, respectively. In adults ≥65 years of age, ESIs within 1 or 1-3 months of lumbar spine decompression or fusion surgery were associated with a 1.3% and 0.6% greater risk of a POI, respectively. Preoperative ESIs within 3 months of cervical spine fusion were not associated with an increased risk of a POI. The bounds of all corresponding 95% PIs were nonsignificant. Conclusion The observations of this study provide summary estimates of risk difference and 95% PIs, which could be used to support shared decision-making about the use of ESIs before cervical or lumbar spine surgery.
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Affiliation(s)
- W. Michael Hooten
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Nathan D. Eberhart
- Department of Anesthesiology and Perioperative Medicine, Anesthesiology Systematic Review Group, Mayo Clinic, Rochester, MN
| | - Fei Cao
- Department of Psychiatry, Division of Pain Medicine, University of Missouri at Kansas City, Kansas City, MO
| | | | | | - Salman Hirani
- Comprehensive Pain Center, Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science Center, Portland, OR
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Shahinfar S, Maibach H. Enigma of Intramuscular Triamcinolone Acetonide (Kenalog ®) Efficacy. Clin Pharmacokinet 2023; 62:1189-1199. [PMID: 37598107 DOI: 10.1007/s40262-023-01297-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 08/21/2023]
Abstract
Triamcinolone acetonide is a glucocorticosteroid used in standard clinical practice for its anti-inflammatory properties. Although it can be given via different routes of administration, the intramuscular route is unique compared with other corticosteroids-its effects remain potent over a longer period of time. We summarize the existing literature on the pharmacokinetic and pharmacodynamic mechanisms of intramuscular triamcinolone acetonide (Kenalog®). The fascinating nature of the purported efficacy of triamcinolone acetonide may be attributed to differing binding mechanisms, low solubility in blood, a low renal clearance rate, and various metabolites and other yet defined effects on skin. The enigma of the purported efficacy of triamcinolone acetonide may lie in the fact that it has a unique nature of having a long-term effect on dermatologic disease using a seemingly low dose compared with other routes of administration and other corticosteroids. Possible reasons for this may be binding differences at the intramuscular site, low solubility due to acetonide esters, a slow rate of absorption from the injected site, and a low renal clearance rate. There is still much to be learned about its mechanism of action, which may be of clinical and therapeutic significance.
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Affiliation(s)
- Sheeva Shahinfar
- Texas A&M University School of Medicine, 8447 Riverside Pkwy, Bryan, TX, 77807, USA.
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Spinal region corticosteroid injections are not associated with increased risk for influenza. Spine J 2022; 22:1100-1105. [PMID: 35121154 DOI: 10.1016/j.spinee.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/15/2022] [Accepted: 01/24/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Spinal region corticosteroid injections (CSI) are intended to act locally to relieve radicular or axial back pain, however some systemic absorption occurs, potentially placing recipients at risk for immunosuppressive effects of corticosteroids. No previous studies examine whether patients undergoing spinal region CSI are at increased risk for viral infections, particularly influenza-a common viral illness with potentially serious consequences, especially for patients with multimorbidity. PURPOSE To examine odds of influenza in patients who received spinal region CSI compared to matched controls. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE Adults (n=9,196) who received a spinal CSI (epidural, facet, sacroiliac, paravertebral block) during influenza seasons occurring from 2000 to 2020 were 1:1 matched to controls without spinal CSI. OUTCOME MEASURES The primary outcome was odds of influenza diagnosis in spinal CSI patients compared to matched controls. Predetermined subgroup analyses examined odds of influenza diagnosis based on vaccination status and injection location. METHODS An institutional database was queried to identify patients that received spinal CSI during influenza season (September 1 to April 30) from 2000 to 2020. Patients were matched by age, sex, and influenza vaccination status to controls without spinal CSI within the specified influenza season. Influenza diagnosis was ascertained using International Classification of Disease codes and data was analyzed using multiple logistic regression adjusted for comorbidities associated with increased risk for influenza. RESULTS A total of 9,196 adults (mean age 60.8 years, 60.4% female) received a spinal CSI and were matched to a control. There were no increased odds of influenza for spinal CSI patients as compared to matched controls (OR 1.13, [95% CI, 0.86-1.48]). When subgroups were examined, there were also no increased odds of influenza for spinal CSI patients based on immunization status (unvaccinated or vaccinated) or spinal injection location (epidural or non-epidural). CONCLUSIONS Spinal region CSI was not associated with increased odds of influenza or reduced vaccine efficacy. This is reassuring given the analgesic and functional restoration benefits of these injections. Assessing risk of viral infection associated with spinal CSI is particularly relevant in the era of the COVID-19 pandemic, and further work is needed to address this issue.
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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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Gitto L, Fuller CE, Calleo VJ, Tawil M, Thach R, Revercomb C. Late-onset of ornithine transcarbamylase deficiency: A rare medical examiner case. J Forensic Sci 2021; 67:813-819. [PMID: 34726276 DOI: 10.1111/1556-4029.14934] [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: 08/27/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 11/26/2022]
Abstract
Ornithine Transcarbamylase (OTC) is an enzyme of the urea cycle, which converts ammonia into urea in the liver cells. OTC plays a crucial role in the breakdown and removal of nitrogen in the body. OTC deficiency is a rare X-linked recessive disorder that classically presents in early life with signs of hyperammonemia and progressive central nervous system involvement resulting in seizures, coma, and death. Sentinel presentation in adulthood is quite rare. A 29-year-old man developed altered mental status after receiving an epidural steroid injection 3 days earlier for back pain. He presented to the emergency department severely agitated, and his workup revealed an elevated ammonia level of 125 µmol/L. He refused admission and was discharged against medical advice. The following day, his mentation deteriorated, he developed status epilepticus, and was transported to another emergency department. He was admitted with worsening hyperammonemia (levels rising to over 700 µmol/L). His clinical condition progressive deteriorated, and he developed encephalopathy and diffuse cerebral edema. Liver function testing indicated progressive liver damage, and amino acids were detected in his blood and urine. Clinical and laboratory findings suggested undiagnosed OTC enzyme deficiency. He died 2 days after admission. An autopsy showed an 1890 g liver with diffuse yellow discoloration and softening. Histology and electron microscopy revealed findings suggestive of urea cycle disorder, such as microvesicular steatosis, apoptosis, and scattered mitosis, clusters of clear hepatocytes at the PAS stain, and mitochondria abnormalities. Genetic analysis revealed a hemizygous pathogenic variant of the OTC gene (c.622G>A). OTC deficiency should be suspected in subjects with hyperammonemic encephalopathy. If a genetic mutation is identified in the deceased, surviving family members should be screened to prevent potential life-threatening complications.
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Affiliation(s)
- Lorenzo Gitto
- Department of Pathology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Cristine E Fuller
- Department of Pathology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Vincent J Calleo
- Upstate New York Poison Center, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Michel Tawil
- Department of Pathology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Rasmey Thach
- Department of Medicine, William Beaumont Army Medical Center, Fort Bliss, Texas, USA
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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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Migliorini F, Maffulli N, Eschweiler J, Bestch M, Tingart M, Baroncini A. Ozone injection therapy for intervertebral disc herniation. Br Med Bull 2020; 136:88-106. [PMID: 33128379 DOI: 10.1093/bmb/ldaa032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 05/10/2020] [Accepted: 08/23/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Lumbar disc herniation (LDH) is a common cause of low back pain (LBP). Recently, in the setting of LBP caused by LDH, a growing interest in ozone therapies has been observed. SOURCE OF DATA Recent published literatures. AREAS OF AGREEMENT Being low back pain more common in the elderlies, exploring conservative alternatives to the surgical intervention is of especial interest. AREAS OF CONTROVERSY Efficacy and feasibility of ozone injections for LDH is debated. Several clinical studies showed controversial results, and the true benefit has not yet been clarified. GROWING POINTS Systematically summarize current evidences, analyze the quantitative available data and investigate the role of percutaneous ozone therapy for LDH. AREAS TIMELY FOR DEVELOPING RESEARCH Current evidence encourage the use of ozone therapy for LBP from LDH. These conclusions should be interpret in light of the limitations of the present study.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics, RWTH University Clinic Aachen, Aachen, Germany, Pauwelsstraβe 30, 52074 Aachen
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081 Baronissi (SA), Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England.,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London E1 4DG, England
| | - Jörg Eschweiler
- Department of Orthopaedics, RWTH University Clinic Aachen, Aachen, Germany, Pauwelsstraβe 30, 52074 Aachen
| | - Marcel Bestch
- University of Toronto Orthopaedic Sports Medicine Program (UTOSM), Women's College Hospital, 76 Grenville St, Toronto, ON, Canada
| | - Markus Tingart
- Department of Orthopaedics, RWTH University Clinic Aachen, Aachen, Germany, Pauwelsstraβe 30, 52074 Aachen
| | - Alice Baroncini
- Department of Orthopaedics, RWTH University Clinic Aachen, Aachen, Germany, Pauwelsstraβe 30, 52074 Aachen.,Department of Orthopaedics, El Hadara University Hospital Lambroso, Alexandria, Egypt
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Kalangara J, Lanier K, Beckworth WJ, Kuruvilla M. Absence of Iodinated Contrast Hypersensitivity and Characterization of Gadolinium Utilization in an Interventional Pain Population. Pain Pract 2020; 21:184-189. [DOI: 10.1111/papr.12947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/10/2020] [Accepted: 08/28/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Jerry Kalangara
- Division of Pain Medicine Emory University School of Medicine Atlanta Georgia U.S.A
- Atlanta VA Health Care System Decatur Georgia U.S.A
| | - Kasey Lanier
- Department of Pediatrics Emory University School of Medicine Atlanta Georgia U.S.A
| | - William J. Beckworth
- Department of Physical Medicine and Rehabilitation Emory University School of Medicine Atlanta Georgia U.S.A
| | - Merin Kuruvilla
- Division of Pulmonary, Allergy and Critical Care Emory University School of Medicine Atlanta Georgia U.S.A
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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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Yuen KCJ, Blevins LS, Findling JW. Important Management Considerations In Patients With Pituitary Disorders During The Time Of The Covid-19 Pandemic. Endocr Pract 2020; 26:915-922. [PMID: 33471683 PMCID: PMC7833469 DOI: 10.4158/ep-2020-0308] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/11/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE In December 2019, a novel coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused an outbreak of coronavirus disease 2019 (COVID-19) that resulted in a global pandemic with substantial morbidity and mortality. Currently, there is no specific treatment or approved vaccine against COVID-19. The underlying associated comorbidity and diminished immune function of some pituitary patients (whether caused by the disease and its sequelae or treatment with excess glucocorticoids) increases their risk of contracting and developing complications from COVID-19 infection. METHODS A review of studies in PubMed and Google Scholar published between January 2020 to the time of writing (May 1, 2020) was conducted using the search terms 'pituitary,' 'coronavirus,' 'COVID-19', '2019-nCoV', 'diabetes mellitus', 'obesity', 'adrenal,' and 'endocrine.' RESULTS Older age and pre-existing obesity, hypertension, cardiovascular disease, and diabetes mellitus increase the risk of hospitalization and death in COVID-19 patients. Men tend to be more severely affected than women; fortunately, most men, particularly of younger age, survive the infection. In addition to general comorbidities that may apply to many pituitary patients, they are also susceptible due to the following pituitary disorder-specific features: hypercortisolemia and adrenal suppression with Cushing disease, adrenal insufficiency and diabetes insipidus with hypopituitarism, and sleep-apnea syndrome and chest wall deformity with acromegaly. CONCLUSION This review aims to focus on the impact of COVID-19 in patients with pituitary disorders. As most countries are implementing mobility restrictions, we also discuss how this pandemic has affected patient attitudes and impacted our decision-making on management recommendations for these patients. ABBREVIATIONS ACE = angiotensin-converting enzyme; AI = adrenal insufficiency; ARB = angiotensin receptor blocker; ARDS = acute respiratory disease syndrome; COVID-19 = coronavirus disease 2019; CPAP = continuous positive airway pressure; DI = diabetes insipidus; DM = diabetes mellitus; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.
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Affiliation(s)
- Kevin C J Yuen
- From the Barrow Pituitary Center, Barrow Neurological Institute and St. Joseph's Hospital and Medical Center, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, Arizona.
| | - Lewis S Blevins
- Department of Neurosurgery, University of California San Francisco, California Center for Pituitary Disorders, San Francisco, California
| | - James W Findling
- Division of Endocrinology and Molecular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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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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Stout A, Friedly J, Standaert CJ. Systemic Absorption and Side Effects of Locally Injected Glucocorticoids. PM R 2019; 11:409-419. [PMID: 30925034 DOI: 10.1002/pmrj.12042] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/18/2018] [Indexed: 12/15/2022]
Abstract
Local glucocorticoid injections are often used to treat joint, soft tissue, or spinal pain, but the systemic side effects associated with these injections are poorly understood and not well recognized. There are significant known risks to systemic administration of glucocorticoids. However, there are no guidelines that address issues of systemic absorption, overall systemic risks, or other side effects of locally injected glucocorticoids. For this review, a literature search was performed, and the available evidence on systemic absorption and clinical side effects of intra-articular and epidural glucocorticoids was synthesized. The goal was to improve clinical understanding of risks associated with these injections. Existing data suggest there is significant individual variability in the amount of systemic absorption and clinical effects of locally injected glucocorticoids. However, it is clear that both intra-articular and epidural injections can have systemic effects for weeks and that complications may be associated with their use, including Cushing syndrome, loss of bone density, infection, and hyperglycemia. The concurrent use of oral steroids, the number of injections, and the type and dose of glucocorticoids used all are important considerations in estimating risks. The total dose calculation of cumulative glucocorticoid exposure should include all local injections. Caution should be exercised when local glucocorticoid injections are used in higher risk patients, such as postmenopausal women, people with diabetes, and those considering surgery in the near term. Better provider awareness of possible systemic risks should improve decision making and informed consent with patients when considering intra-articular and epidural steroid injections for painful conditions. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Alison Stout
- Evergreen Healthcare, 12039 NE 128th St Suite 500, Kirkland, WA 98034
| | - Janna Friedly
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Christopher J Standaert
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA
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Low-Concentration Oxygen/Ozone Treatment Attenuated Radiculitis and Mechanical Allodynia via PDE2A-cAMP/cGMP-NF- κB/p65 Signaling in Chronic Radiculitis Rats. Pain Res Manag 2018; 2018:5192814. [PMID: 30651902 PMCID: PMC6311849 DOI: 10.1155/2018/5192814] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 11/22/2018] [Indexed: 11/22/2022]
Abstract
Background Oxygen/ozone therapy is a minimally invasive technique for the treatment of radiculitis from lumbar disc herniation. This study aimed at investigating whether intrathecal administration of low-concentration oxygen/ozone could attenuate chronic radiculitis and mechanical allodynia after noncompressive lumbar disc herniation and at elucidating the underlying mechanisms. Methods First, we transplanted autologous nucleus pulposus into dorsal root ganglions to establish chronic radiculitis in rats. Then, filtered oxygen or oxygen/ozone (10, 20, or 30 μg/mL) was intrathecally injected on day 1 after surgery. The ipsilateral paw withdrawal thresholds (PWTs) to mechanical stimuli were tested daily with von Frey filaments. The expression of the tumor necrosis factor- (TNF-) α, interleukin- (IL-) 1β, IL-6, cyclic adenosine monophosphate (cAMP), cyclic guanosine monophosphate (cGMP), phosphodiesterase 2A (PDE2A), and nuclear factor- (NF-) κB/p65 in spinal dorsal horns was measured by enzyme-linked immunosorbent assay, polymerase chain reaction, and western blot on day 7 after surgery. Results Chronic radiculitis was established in rats. Intrathecal administration of 10 μg/mL, 20 μg/mL, or 30 μg/mL oxygen/ozone significantly attenuated the decreased mechanical PWTs, downregulated the overexpression of spinal TNF-α, IL-1β, and IL-6, and increased the expression of cGMP and cAMP in chronic radiculitis rats. In addition, the effects of treatment with 20 μg/mL oxygen/ozone were greater than the effects of the 10 μg/mL or 30 μg/mL doses. Moreover, intrathecal administration of 20 μg/mL oxygen/ozone reversed the increased levels of spinal PDE2A and NF-κB/p65 mRNA and protein expressions in rats with chronic radiculitis. Conclusion Intrathecal administration of low-concentration oxygen/ozone alleviated mechanical allodynia and attenuated radiculitis, likely by a PDE2A-cGMP/cAMP-NF-κB/p65 signaling pathway in chronic radiculitis rats.
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