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Benzon HT, Elmofty D, Shankar H, Rana M, Chadwick AL, Shah S, Souza D, Nagpal AS, Abdi S, Rafla C, Abd-Elsayed A, Doshi TL, Eckmann MS, Hoang TD, Hunt C, Pino CA, Rivera J, Schneider BJ, Stout A, Stengel A, Mina M, FitzGerald JD, Hirsch JA, Wasan AD, Manchikanti L, Provenzano DA, Narouze S, Cohen SP, Maus TP, Nelson AM, Shanthanna H. Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections - guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, the International Pain and Spine Intervention Society, and the North American Spine Society. Reg Anesth Pain Med 2024:rapm-2024-105593. [PMID: 39019502 DOI: 10.1136/rapm-2024-105593] [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: 04/23/2024] [Accepted: 06/14/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND There is potential for adverse events from corticosteroid injections, including increase in blood glucose, decrease in bone mineral density and suppression of the hypothalamic-pituitary axis. Published studies note that doses lower than those commonly injected provide similar benefit. METHODS Development of the practice guideline was approved by the Board of Directors of American Society of Regional Anesthesia and Pain Medicine with several other societies agreeing to participate. The scope of guidelines was agreed on to include safety of the injection technique (landmark-guided, ultrasound or radiology-aided injections); effect of the addition of the corticosteroid on the efficacy of the injectate (local anesthetic or saline); and adverse events related to the injection. Based on preliminary discussions, it was decided to structure the topics into three separate guidelines as follows: (1) sympathetic, peripheral nerve blocks and trigger point injections; (2) joints; and (3) neuraxial, facet, sacroiliac joints and related topics (vaccine and anticoagulants). Experts were assigned topics to perform a comprehensive review of the literature and to draft statements and recommendations, which were refined and voted for consensus (≥75% agreement) using a modified Delphi process. The United States Preventive Services Task Force grading of evidence and strength of recommendation was followed. RESULTS This guideline deals with the use and safety of corticosteroid injections for sympathetic, peripheral nerve blocks and trigger point injections for adult chronic pain conditions. All the statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Board of Directors of the participating societies also approved all the statements and recommendations. The safety of some procedures, including stellate blocks, lower extremity peripheral nerve blocks and some sites of trigger point injections, is improved by imaging guidance. The addition of non-particulate corticosteroid to the local anesthetic is beneficial in cluster headaches but not in other types of headaches. Corticosteroid may provide additional benefit in transverse abdominal plane blocks and ilioinguinal/iliohypogastric nerve blocks in postherniorrhaphy pain but there is no evidence for pudendal nerve blocks. There is minimal benefit for the use of corticosteroids in trigger point injections. CONCLUSIONS In this practice guideline, we provided recommendations on the use of corticosteroids in sympathetic blocks, peripheral nerve blocks, and trigger point injections to assist clinicians in making informed decisions.
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Affiliation(s)
- Honorio T Benzon
- Anesthesiology, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dalia Elmofty
- Department of Anesthesia, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Hariharan Shankar
- Anesthesiology, Clement Zablocki VA Medical Center/Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Maunak Rana
- Department of Anesthesia, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Andrea L Chadwick
- Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Shalini Shah
- University of California Irvine, Orange, California, USA
| | - Dmitri Souza
- Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Ameet S Nagpal
- Orthopaedics and PM&R, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Salahadin Abdi
- Pain Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Christian Rafla
- Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Alaa Abd-Elsayed
- University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Tina L Doshi
- Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Maxim S Eckmann
- Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Thanh D Hoang
- Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | - Carlos A Pino
- Anesthesiology, Naval Medical Center San Diego, San Diego, California, USA
| | | | - Byron J Schneider
- PM&R, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Angela Stengel
- American Society of Regional Anesthesia and Pain Medicine, Pittsburgh, Pennsylvania, USA
| | - Maged Mina
- Anesthesiology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | | | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ajay D Wasan
- University of Pittsburgh Health Sciences, Pittsburgh, Pennsylvania, USA
| | | | | | - Samer Narouze
- Anesthesia, Division of Pain Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Steven P Cohen
- Anesthesiology, Feinberg School of Medicine, Chicago, Illinois, USA
- Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | - Ariana M Nelson
- Department of Anesthesiology and Perioperative Medicine, University of California Irvine, Irvine, California, USA
- Department of Aerospace Medicine, Exploration Medical Capability, Johnson Space Center
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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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