Musculoskeletal injections: a review of the evidence

Injections are valuable procedures for managing musculoskeletal conditions commonly encountered by family physicians. Corticosteroid injections into articular, periarticular, or soft tissue structures relieve pain, reduce inflammation, and improve mobility. Injections can provide diagnostic information and are commonly used for postoperative pain control. Local anesthetics may be injected with corticosteroids to provide additional, rapid pain relief. Steroid injection is the preferred and definitive treatment for de Quervain tenosynovitis and trochanteric bursitis. Steroid injections can also be helpful in controlling pain during physical rehabilitation from rotator cuff syndrome and lateral epicondylitis. Intra-articular steroid injection provides pain relief in rheumatoid arthritis and osteoarthritis. There is little systematic evidence to guide medication selection for therapeutic injections. The medication used and the frequency of injection should be guided by the goal of the injection (i.e., diagnostic or therapeutic), the underlying musculoskeletal diagnosis, and clinical experience. Complications from steroid injections are rare, but physicians should understand the potential risks and counsel patients appropriately. Patients with diabetes who receive periarticular or soft tissue steroid injections should closely monitor their blood glucose for two weeks following injection.     

Joint and soft tissue injection

Injection techniques are helpful for diagnosis and therapy in a wide variety of musculoskeletal conditions. Diagnostic indications include the aspiration of fluid for analysis and the assessment of pain relief and increased range of motion as a diagnostic tool. Therapeutic indications include the delivery of local anesthetics for pain relief and the delivery of corticosteroids for suppression of inflammation. Side effects are few, but may include tendon rupture, infection, steroid flare, hypopigmentation, and soft tissue atrophy. Injection technique requires knowledge of anatomy of the targeted area and a thorough understanding of the agents used. In this overview, the indications, contraindications, potential side effects, timing, proper technique, necessary materials, pharmaceuticals used and their actions, and post-procedure care of patients are presented.     

Glucocorticoids]

Recent years have witnessed the reassessment of cotherapy with steroid preparations and antirheumatic agents for the treatment of rheumatoid arthritis. However, in addition to desirable anti-inflammatory and immunosuppressive properties, the pharmacological spectrum of glucocorticoids includes diverse activities which may result in numerous adverse reactions. Antirheumatic therapy therefore requires strict adherence to the prescribed indications and careful selection of the specific drug type and dosage regimen. Based on the patient's response, dose reduction or withdrawal of any steroid preparations should be attempted. Although antirheumatic and non-steroidal anti-inflammatory agents are the mainstay treatment for rheumatoid arthritis, steroid therapy is usually employed when these drugs are not sufficiently effective.     

Osteoarthritis and rheumatoid arthritis in elderly patients. Differentiation and treatment

Osteoarthritis is differentiated from rheumatoid arthritis by age at onset, duration of morning stiffness, pattern of joint involvement, and radiographic findings. Distinguishing between the diseases can be challenging, because they have some symptoms in common. Therapy for osteoarthritis is aimed at relief of symptoms; treatment of active rheumatoid arthritis is more aggressive, aimed at controlling or modifying the disease. Both diseases may cause great pain and disability in elderly patients, so prompt diagnosis and treatment are essential.     

Alternative therapies for arthritis treatment. Part 2

Although modern medicine has been successful in managing infection and saving victims of multiple trauma, healthcare providers have offered little relief to individuals with chronic diseases, such as arthritis. Many patients with arthritis are seeking help with disease management from alternative therapies. When used along with allopathic medicine, these therapies may, in fact, increase quality of life for patients with arthritis. This article, second in a two-part series on alternative therapies, returns to the seven fields of practice identified by the National Institutes of Health (NIH) to explore additional treatment options for individuals with arthritis. Part 1 in this series was published in the September/October 2003 issue of Orthopaedic Nursing.     

Bilateral patellar tendon rupture secondary to repeated local steroid injections.

A case is reported of bilateral patellar tendon rupture in a fit man after a fall. He had a history of repeated local steroid injections into both tendons and histology confirmed steroid-induced changes. The history of repeated local steroid administration has to be implicated as the cause of this extremely rare injury in this patient, which can also be associated with hyperparathyroidism, systemic lupus erythematosus, diabetes and rheumatoid arthritis. All doctors performing repeated local steroid injections into the patellar tendon should be aware of the possible dangers of inducing tendon rupture and should ensure that the steroids are not delivered into its substance.     

Rheumatoid arthritis. New developments in treatment

If a patient with active rheumatoid arthritis does not obtain significant relief from nonsteroidal anti-inflammatory drugs, prompt institution of disease-modifying antirheumatic drugs (DMARDs) is recommended. If one agent fails, another may be tried. At present, hydroxychloroquine (Plaquenil) sulfate is one of the most widely used and best tolerated. Careful follow-up is essential with all DMARDs, however, because toxic effects may be severe and sometimes unpredictable.     

Disease-modifying anti-rheumatic drugs: strategies for screening.

Rheumatoid arthritis, a disease of unknown aetiology, has a multifactorial pathogenesis which may result in irreversible connective tissue destruction and loss of joint function. The search for drugs which offer more than symptomatic relief is a long term, largely unachieved aim of many pharmaceutical companies. This review briefly outlines those features of the aetiopathogenesis which appear to offer targets for therapeutic intervention and the structured strategy and test systems that can be used to detect drugs which may be capable of halting disease progression.     

Total joint arthroplasty. The wrist.

Total wrist arthroplasty, which has been performed in 101 patients, has proved to be a satisfactory procedure for the relief of pain and provision of mobility in the deformed wrist involved with rheumatoid arthritis. This procedure should not be performed after traumatic conditions in patients who expect to make heavy use of the wrist. Early cases were associated with technical problems in the development of the concept, but at present the procedure is reliable and is most often preferred to arthrodesis inpatients with rheumatoid arthritis.     

Rheumatoid arthritis in pregnancy.

For many women with rheumatoid arthritis, pregnancy can bring a welcome, temporary relief from symptoms. The baby's birth, however, can end the remission and coping with the infant and the return of difficulties associated with the disease can cause particular problems. In this article, the author highlights potential difficulties both before and after the birth of the baby, including the complexities of drug therapy during pregnancy, and offers practical advice to assist in their resolution.     

Intermittent interpleural injection of bupivacaine and methylprednisolone for analgesia in metastatic thoracic neoplasm.

Three patients with intractable chest wall pain due to diffusely metastatic thoracic neoplasm were successfully treated with intermittent interpleural steroid injections. Intermittent administration of 0.5% bupivacaine mixed with methylprednisolone suspension (Depo-Medrol) was effective in controlling intractable pain due to metastatic cancer. Pain relief with this technique lasted for periods in excess of 3 weeks between injections. Intermittent interpleural block may be a useful addition to the therapeutic armamentarium in dealing with chronic pain due to metastatic neoplasm.     

Retrospective Comparison of Ultrasound and Fluoroscopic Image Guidance for Intercostal Steroid Injections

Introduction: Steroid injection around the intercostal nerves is one of the treatment options for intercostal neuralgia. The technique may be performed blindly, under fluoroscopic guidance (FSG) or with the use of ultrasound guidance (USG). This study is a retrospective comparison of image guidance for intercostal steroid injections. Methods: After Institutional Review Board approval, a retrospective review of all patient charts who received intercostal steroid injections from 2005 to 2009 was performed. A total of 39 blocks were performed in that period. Of that 12 were USG blocks and 27 FSG blocks. The preprocedure visual analog scale (VAS) and postprocedure VAS and the duration of pain relief were compared between the 2 techniques. A Mann–Whitney test and Kruskal–Wallis test were performed looking for differences between the techniques. Results: The median change in the VAS for FSG and USG were ?5.000 and ?4.000, respectively, and duration of pain relief with a median difference of 2 weeks (95% confidence interval of ?4, 7). There were 2 occasions of intravascular spread noticed with the FSG although this should not affect the study result as the needle was repositioned and steroid injected only after contrast dye confirmation. Conclusion: With similar change in VAS scores and duration of pain relief between the 2 guidance methods based on this retrospective study, both image guidance techniques may offer similar pain relief.     

Systemic corticosteroids in rheumatoid arthritis: to use or not to use?

Systemic corticosteroids(steroids) were initially introduced after the dramatic efficacy in individual patients with rheumatoid arthritis(RA). Since the outcome of steroid therapy in RA turned to be awesome, steroids had been put at the apex of the therapeutic pyramid for a long time. However, most rheumatologists have subscribed steroids for the treatment of early active RA because they can provide rapid and significant clinical response. Moreover, recent several studies have shown that low dose(5 to 10 mg/day) of prednisolone retard joint destruction in a few years. However, the demonstrated negatives(opportunistic infections, osteoporosis, metabolic disorders, atherosclerotic vascular events etc.) of steroids may outweigh these advantages in the longterm clinical course of RA.     

Rheumatology. Part 2: The role of medication

Rheumatoid arthritis is a chronic, long-term inflammatory disease. Symptom relief can be achieved with analgesia and NSAIDs. The only way to influence its progress is by administering disease-modifying anti-rheumatic drugs.     

Ear Pain Due to Cervical Spine Arthritis: Treatment With Cervical Facet Injection

Two patients with cervical spine arthritis and ear pain were recently evaluated at our clinic. Injection of the C1-2 facet joints with local anesthetic plus corticosteroid resulted in relief of the pain. Therapeutic cervical facet injections may be indicated in cases of recalcitrant head and neck pain due to cervical spine arthritis.     

The rheumatoid vasculitis and malignant rheumatoid arthritis(MRA)

The inflammatory process characteristic of rheumatoid arthritis is typically targeted to the synovial membrane. In a subset of patients, rheumatoid disease is complicated by an inflammatory destruction of blood vessels, rheumatoid vasculitis. Rheumatoid vasculitis has been understood to be the result of severe disease extending beyond the joint, possibly caused by immune complex deposition. However, in Japan malignant rheumatoid arthritis(MRA) is designated as rheumatoid arthritis with vasculitis. Rheumatoid arthritis patients can be separated into two groups: individuals with synovial disease and individuals with synovial plus extra-articular disease, MRA. The model is supported by immunogenetic analysis describing an accumulation of vasculitis patients with rheumatoid arthritis among HLA-DRB10401 homozygotes. Therapy depends upon the clinical manifestation of rheumatoid vasculitis. Then, MRA is usually treated with steroid, and steroid pulse therapy and immunosuppressants are useful for severe MRA.     

Poncet's disease: An unusual presentation of tuberculosis in a diabetic lady

Authors describe a 53-year-old woman who presentedto their diabetes clinic with a three week history of multiple painful and swollen joints. She had been diagnosed with type 2 diabetes 5 years back. On examination, both knee joints and left ankle were swollen. A soft tissue swelling appeared over the medial end of the left clavicle few days later. Rheumatoid arthritis, collagen vascular diseases and other common causes of polyarthritis were ruled out by appropriate investigations. Non steroidal anti-inflammatory drugs failed to give satisfactory pain relief and the arthritis persisted. Conventional cultures of synovial fluid samples including cultures for tuberculosis were negative. Computed tomography showed a space occupying lesion involving the left sternoclavicular joint. Fine needle aspiration from the lesion was performed and acidfast bacilli were demonstrated in the smear using ZiehlNeelsen stain. The explanation of her arthritis was therefore tuberculous arthritis in left sternoclavicular joint and reactive arthritis in the rest of the joints. A diagnosis of Poncet's disease was considered in her case. We treated her with standard anti-tuberculosis drugs and the arthritis resolved within a few days. She remained symptom-free at her 2 years' follow-up.     

Neurophysiology of Arthritis Pain

Arthritis pain is a complex phenomenon involving intricate neurophysiological processing at all levels of the pain pathway. The treatment options available to alleviate joint pain are fairly limited and most arthritis patients report only modest pain relief with current treatments. A better understanding of the neural mechanisms responsible for musculoskeletal pain and the identification of new targets will help in the development of future pharmacological therapies. This article reviews some of the latest research into factors which contribute to joint pain and covers areas such as cannabinoids, proteinase activated receptors, sodium channels, cytokines and transient receptor potential channels. The emerging hypothesis that osteoarthritis may have a neuropathic component is also discussed.     

The Role of Adding Hyaluronidase to Fluoroscopically Guided Caudal Steroid and Hypertonic Saline Injection in Patients with Failed Back Surgery Syndrome: A Prospective,Double‐Blinded,Randomized Study

Background: Failed back surgery syndrome (FBSS) has been reported to account for up to 40% of patients with chronic low back pain. Epidural fibrosis may be responsible for up to 30% of all cases of FBSS. Perineural fibrosis can interfere with cerebrospinal fluid‐mediated nutrition, rendering the nerve root hyperesthetic and hypersensitive to compression. Traditionally, steroid injection has been used to treat low back pain and radiculopathy. The addition of hyaluronidase to the injectate has been reported to reduce the degree of fibrosis. Aim: To evaluate the role of hyaluronidase when added to fluoroscopically guided caudal steroid and hypertonic saline in patients with FBSS. Methods: Thirty‐eight patients with back pain because of FBSS were studied. Twenty patients received fluoroscopically guided caudal epidural steroid, local anesthetic, and hypertonic saline in combination (group 1), and 18 patients received fluoroscopically guided caudal epidural steroid, hypertonic saline, local anesthetic, and hyaluronidase (group 2). Patients were asked to rate their pain using a verbal scale of 0 to 4 (0 = none, 1 = mild, 2 = moderate, 3 = severe, and 4 = extremely severe). Lumbar spine range of motion and opioid intake were measured. Result: Significant improvement in short‐term pain relief was noted in both groups, while significant long‐term pain relief was only achieved in group 2 patients. Conclusion: The addition of hyaluronidase to fluoroscopically guided caudal epidural steroid and hypertonic saline combination improved long‐term pain relief in patients with FBSS.     

Facet joint injection and facet nerve block: a randomised comparison in 86 patients with chronic low back pain.

Eighty-six patients with refractory chronic low back pain were randomly assigned to receive either facet joint injection or facet nerve block, using local anaesthetic and steroid. There was no significant difference in the immediate response. The duration of response after facet joint injection was marginally longer than after facet nerve block (P less than 0.05 1 month after infiltration), but for both groups the response was usually short-lived; by 3 months only 2 patients continued to report complete pain relief. Patients who had complained of pain for more than 7 years were more likely to report good or excellent pain relief than those with a shorter history (P less than 0.005), but no other clinical feature was of value in predicting the response to infiltration. Facet joint injections and facet nerve blocks may be of equal value as diagnostic tests, but neither is a satisfactory treatment for chronic back pain.