Metabolic and endocrinal effects of epidural glucocorticoid injections

Specific back pain - effective diagnosis and treatment from the radiologist's point of view

The diagnosis and treatment of specific back pain is important in radiology. Due to the high number of patients suffering from back pain, it is important to provide excellent diagnostic and therapeutic support.Based on a recent literature search and considering the relevant guidelines as well as expert opinions, the aspects of specific back pain important for radiologists in terms of pathogenesis, diagnosis, and treatment are presented.Clinical examination in combination with the medical history provides a valid suspected diagnosis. This should subsequently be verified radiologically. MRI is the most effective cross-sectional diagnostic method for investigating specific back pain. A conventional X-ray on two planes in a standing position can be a useful addition if postural causes are suspected. If the clinical symptoms match the morphological findings, radiological treatment can be carried out for nerve root involvement as well as for inflammatory changes of the facet joints. The improvement in symptoms after radiological therapy is considered good overall; at least a short-term improvement in symptoms can generally be achieved, but no reliable data is available regarding the long-term outcome. Using preparations containing triamcinolone, low dosages should be selected in accordance with the guidelines. Embedding in a multimodal pain therapy treatment concept should be considered.Radiology provides essential diagnostic findings regarding specific back pain. Interventional pain therapy is an effective and safe method of treating proven specific back pain. · First examine clinically, then confirm the suspected diagnosis radiologically.. · MRI is usually the method of choice.. · Interventional pain therapy should show success after a maximum of 2 interventions.. · The anti-inflammatory drug dose should be kept as low as possible.. · The individual course determines the number of interventions.. · Stueckle CA, Haage P. Specific back pain - effective diagnosis and treatment from the radiologist's point of view. Fortschr Röntgenstr 2024; DOI 10.1055/a-2371-1752.

Effect of repeated transforaminal epidural low-dose dexamethasone injections on glucose profiles of diabetic and non-diabetic patients with low back pain

PURPOSE

We aimed to investigate the effect of repeated transforaminal epidural low-dose dexamethasone injections on glucose profiles and pituitary-adrenal axis functions of diabetic and non-diabetic patients with low back pain.

METHODS

A total of 28 patients (ten diabetic [DM group] and 18 non-diabetic patients [non-DM group]) with low back pain were followed-up. Transforaminal epidural low-dose dexamethasone (1.65 mg) injections were repeated every 7-14 days for 8 weeks. Fasting blood sugar (FBS), hemoglobin A1c (HbA1c), morning plasma adrenocorticotropin (ACTH), and cortisol levels were measured at baseline and during the 8-week follow-up period.

RESULTS

There were no significant changes in FBS and HbA1c levels between baseline and 8-week follow-up period in both DM and non-DM groups (difference in FBS [95% confidence Interval, CI]: - 0.6 mg/dL [- 6.4, 5.1], p = 0.83 in the non-DM group, - 0.2 mg/dL [- 26.2, 25.8], p = 0.99 in the DM group; difference in HbA1c [95% CI] - 0.02% [- 0.1, 0.1], p = 0.69 in the non-DM group, 0.04% [- 0.3, 0.4], p = 0.79 in the DM group). There were no significant longitudinal changes in ACTH and cortisol levels (ACTH, p = 0.38 [baseline vs. 8 week], p = 0.58 [non-DM vs. DM]; cortisol, p = 0.52 [baseline vs. 8 week], p = 0.90 [non-DM vs. DM]).

CONCLUSIONS

Repeated transforaminal epidural low-dose dexamethasone injections provided no significant elevations in blood glucose or suppression of the pituitary-adrenal axis for two months from the first injection in both diabetic and non-diabetic patients. Our results indicate the intermediate-term safety of repeated transforaminal epidural low-dose dexamethasone injections with regard to the effect on glucose profile and pituitary-adrenal axis functions.

Epidural Steroid Injections Acutely Suppress Bone Formation Markers in Postmenopausal Women

CONTEXT

Over 9 million epidural steroid injections (ESIs) are performed annually in the United States. Although these injections effectively treat lumbar radicular pain, they may have adverse consequences, including bone loss.

OBJECTIVE

To investigate acute changes in bone turnover following ESI. We focused on postmenopausal women, who may be at greatest risk for adverse skeletal consequences due to the combined effects of ESIs with aging and estrogen deficiency.

METHODS

Single-center prospective observational study. Postmenopausal women undergoing lumbar ESIs and controls with no steroid exposure were included. Outcomes were serum cortisol, markers of bone formation, osteocalcin, and procollagen type-1 N-terminal propeptide (P1NP), and bone resorption by C-telopeptide (CTX) measured at baseline, 1, 4, 12, 26, and 52 weeks after ESIs.

RESULTS

Among ESI-treated women, serum cortisol declined by ~50% 1 week after injection. Bone formation markers significantly decreased 1 week following ESIs: osteocalcin by 21% and P1NP by 22%. Both markers remained suppressed at 4 and 12 weeks, but returned to baseline levels by 26 weeks. There was no significant change in bone resorption measured by CTX. Among controls, there were no significant changes in cortisol or bone turnover markers.

CONCLUSION

These results provide evidence of an early and substantial reduction in bone formation markers following ESIs. This effect persisted for over 12 weeks, suggesting that ESIs may have lasting skeletal consequences. Given the large population of older adults who receive ESIs, further investigation into the long-term skeletal sequelae of these injections is warranted.

Cumulative glucocorticoid exposure in patients receiving epidural steroid injections: A single-centre retrospective evaluation on 581 procedures against existing clinical recommendations

Background

The purpose of the study was to review the cumulative corticosteroid doses received from epidural and non-epidural-based pain interventions in a cohort of patients undergoing epidural steroid injections (ESIs) with comparison to safe dosing recommendations.

Methods

Retrospective analysis was undertaken for all 349 patients who underwent a total of 581 ESIs at a single-centre, tertiary hospital in South Australia between 2017 and 2019. The primary outcome was the yearly dose analysis of cumulative steroid doses in methylprednisolone equivalents (MDPE) administered from epidural and non-epidural interventions in post-menopausal women, interpreted against maximum recommended doses.

Results

The annual limit of 200 ​mg for postmenopausal women was exceeded in 4.7% of the time (11/235) from ESIs alone, with a significant rise to 15.3% (46/300) when non-ESI injections were included in cumulative dose totals(p ​< ​0.001). Of the 173 participants of post-menopausal female age, 4.1% (7/173) received cumulative corticosteroid doses above the 3-year 400 ​mg MPDE limit from ESIs alone, with a statistically significant increase to 13.9% (24/173) when non-epidural steroid injections were again included in cumulative dose totals (p ​< ​0.001). The mean ​± ​standard deviation administered MPDE per epidural steroid injection across the whole study cohort was 72 ​± ​22 ​mg, nearly double the recommended dose of 40 ​mg.

Conclusions

Our study underpins the need for vigilance when considering steroid-based pain interventions, wherein both the individual and cumulative steroid exposure should be considered.

Dexamethasone-Loaded Injectable In-situ Thermal Crosslinking Magnetic Responsive Hydrogel for the Physiochemical Stimulation of Acupoint to Suppress Pain in Sciatica Rats

The physicochemical stimulation of acupoints is a widespread treatment strategy for different diseases, such as sciatica. Its efficacy is mainly based on the temporal and spatial modulation of the physicochemical properties of the acupoints. The existing therapies based on the stimulation of acupoints have certain disadvantages. Therefore, in this study, injectable dexamethasone (DXM)- and magnetic Fe₃O₄ nanoparticles-loaded chitosan/β-glycerophosphate (CS/GP) thermal crosslinking hydrogels were prepared, thereby improving the performance of embedding materials. The sciatica rat models were established to compare the therapeutic effects of hydrogels and catgut. The DXM or Fe₃O₄-loaded CS/GP hydrogels were compared in terms of their gelation kinetics, release kinetics, magnetic responsiveness in-vitro, and biocompatibility as well as their analgesic effects on the chronic constriction injury of the sciatic nerve (CCI) rats in-vivo. The CS/GP/Fe₃O₄/DXM hydrogel showed comparable gelation kinetics and good magnetic responsiveness in-vitro. This hydrogel could relieve sciatica by reducing the expression levels of inflammatory factors in serum, inhibiting the p38MAPK (p38, mitogen-activated protein kinase) phosphorylation, and decreasing the expression level of the P2X4 receptor (P2X4R) in the spinal dorsal horn. In conclusion, the DXM or Fe₃O₄-loaded CS/GP hydrogels can be considered as a treatment option for the physiochemical stimulation therapy of acupoints to improve sciatica.

Repeat Epidural Injections of SP-102 (Dexamethasone Sodium Phosphate Injectable Gel) in Subjects with Lumbosacral Radiculopathy

Purpose

SP-102 is a novel epidural steroid injection (ESI) formulation of 10 mg dexamethasone sodium phosphate in a viscous gel solution. Repeat dosing of ESIs is possible if required for pain relief, but with consideration of hypothalamic–pituitary–adrenal (HPA) axis suppression from prolonged systemic exposure. This phase I/II study investigated the effect of initial and repeat SP-102 injections on HPA suppression and analgesia.

Methods

Subjects with lumbosacral radiculopathy received an initial epidural SP-102 injection (T1) on day 1, followed by a repeat injection (T2) on ≥28 days later. To determine HPA suppression, area under the effect curve over 28 days and maximum change from baseline were calculated for cortisol, glucose levels, and white blood cell (WBC) count. Equivalent effect on HPA suppression of T1 relative to T2 was determined if the 90% CIs for ratios of these measures were within 80%–125%. The effect of repeat injections on leg and back pain was also assessed.

Results

Based on the responder analysis, all subjects had achieved a cortisol response by day 3 after initial injection and by day 2 after repeat injection. The repeat injection had similar effects on glucose levels and WBC count to the initial injection. Pain scores decreased after each injection and remained low for the 28-day follow-up, with some evidence of improved analgesic effect of the second dose compared with the first. There were no serious adverse events or discontinuations due to adverse events.

Conclusion

The lack of cumulative effect and rapid resolution of HPA suppression following repeated SP-102 dosing suggests that consideration of HPA pharmacodynamics is not clinically relevant when making decisions regarding repeat dosing. SP-102 ESIs provided prolonged pain relief, with preliminary evidence of greater efficacy after repeat injection. A phase III trial is ongoing.

Clinical Trial Identifier

ClinicalTrials.gov: NCT03613662.

Safety of epidural steroids: a review

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.

Clinical Challenges and Considerations in Management of Chronic Pain Patients During a COVID-19 Pandemic

Since the coronavirus disease 2019 (COVID-19) was deemed a pandemic on 11 March 2020, we have seen exponential increases in the number of cases and deaths worldwide. The rapidly evolving COVID-19 situation requires revisions to clinical practice to defer non-essential clinical services to allocate scarce medical resources to the care of the COVID-19 patient and reduce risk to healthcare workers. Chronic pain patients require long-term multidisciplinary management even during a pandemic. Fear of abandonment, anxiety and depression may increase during this period of social isolation and aggravate pain conditions.Whilst physical consults for chronic pain patients were reduced, considerations including continuity of support and analgesia, telemedicine, allied health support and prioritising necessary pain services and interventions, were also taken to ensure biopsychosocial care for them. Chronic pain patients are mostly elderly with multiple comorbidities, and are more susceptible to morbidity and mortality from COVID-19. It is imperative to review pain management practices during the COVID-19 era with respect to infection control measures, re-allocation of healthcare resources, community collaborations, and analgesic use and pain interventions. The chronic pain patient faces a potential risk of functional and emotional decline during a pandemic, increasing healthcare burden in the long term. Clinical decisions on pain management strategies should be based on balancing the risks and benefits to the individual patient. In this commentary, we aim to discuss the basis behind some of the decisions and safeguards that were made at our tertiary pain centre over the last 6 months during the COVID-19 outbreak.