Short-term Pain Relief Research Articles

Efficacy of epidural injection of steroid in treatment of lumber disc prolapse: article review

"Chronic low back and lower extremity pain is mainly caused by lumbar disc herniation (LDH) and radiculitis. Various surgery and nonsurgical modalities, including epidural injections, have been used to treat LDH or radiculitis. Caudal epidural injection of local anesthetics with or without steroids is one of the most commonly used interventions in managing chronic low back and lower extremity pain. To describe the indications, rationale, techniques, alternatives, contraindications, complications, and efficacy of lumbar and caudal epidural corticosteroid injections. Interventions: Three reviewers with formal training and certification in evidence-based medicine searched the literature on non–image guided lumbar interlaminar epidural steroid injections. A larger team of seven reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented. A systematic literature search was performed, in the Medline Case reports and retrospective and prospective studies were extensively reviewed to provide detailed descriptions of the clinical features of lumbar and caudal epidural corticosteroid injections. Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE , and manual searches of bibliographies of known primary and review articles. Epidural corticosteroid injections are commonly requested treatments for patients with various low-back or lower-extremity pain syndromes (or both). Most of the reports on the use of this type of treatment are retrospective and noncontrolled. These studies indicate benefit; however, the prospective controlled studies provide varied results about the efficacy of lumbar and caudal epidural corticosteroid injections. In conclusions: In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical practice, these procedures should be restricted to the rare settings where fluoroscopy is not available."

Impact of educational level and employment status on short-term and long-term pain relief from supervised exercise therapy and education: an observational study of 22 588 patients with knee and hip osteoarthritis

ObjectivesTo investigate the impact of educational level and employment status on change in pain intensity after treatment among patients with knee and hip osteoarthritis (OA).DesignA prospective cohort study.Setting and participantsWe...

Comparative Efficacy of Nonoperative Treatments for Greater Trochanteric Pain Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials.

An evolved understanding of the pathophysiology of greater trochanteric pain syndrome has led to a number of proposed nonoperative management strategies. The objective of this review was to compare the efficacy of the various nonoperative treatments for greater trochanteric pain syndrome (GTPS). Systematic review and network meta-analysis. PubMed, Embase, CENTRAL, SCOPUS, and Web of Science were searched to January 2020. Patients undergoing nonoperative treatment for GTPS. Nonoperative treatment strategies for GTPS including injections of corticosteroids, platelet-rich plasma, hyaluronic acid, dry needling, and structured exercise programs and extracorporeal shockwave therapy. Pain and functional outcomes. Bayesian random-effects model was performed to assess the direct and indirect comparison of all treatment options. Thirteen randomized controlled trials and 1034 patients were included. For pain scores at 1 to 3 months follow-up, both platelet-rich plasma (PRP) and shockwave therapy demonstrated significantly better pain scores compared with the no treatment control group with PRP having the highest probability of being the best treatment at both 1 to 3 months and 6 to 12 months. No proposed therapies significantly outperformed the no treatment control group for pain scores at 6 to 12 months. Structured exercise had the highest probability of being the best treatment for improvements in functional outcomes and was the only treatment that significantly improved functional outcome scores compared with the no treatment arm at 1 to 3 months. Current evidence suggests that PRP and shockwave therapy may provide short-term (1-3 months) pain relief, and structured exercise leads to short-term (1-3 months) improvements in functional outcomes.

Dry Needling for the Treatment of Tension-Type, Cervicogenic, or Migraine Headaches: A Systematic Review and Meta-Analysis.

Dry needling is a treatment technique used by clinicians to relieve symptoms in patients with tension-type headache (TTH), cervicogenic headache (CGH), or migraine. This systematic review's main objective was to assess the effectiveness of dry needling on headache pain intensity and related disability in patients with TTH, CGH, or migraine. Medline/PubMed, Scopus, Embase, PEDro, Web of Science, Ovid, Allied and Complementary Medicine Database/EBSCO, Cochrane Central Register of Controlled Clinical Trials, Google Scholar, and trial registries were searched until April 1, 2020, along with reference lists of eligible studies and related reviews. Randomized clinical trials or observational studies that compared the effectiveness of dry needling with any other interventions were eligible for inclusion. Three reviewers independently selected studies, extracted data, and assessed risk of bias. Random-effects meta-analyses were performed to produce pooled-effect estimates (Morris dppc2) and their respective CIs. Of 2715 identified studies, 11 randomized clinical trials were eligible for qualitative synthesis and 9 for meta-analysis. Only 4 trials were of high quality. Very low-quality evidence suggested that dry needling is not statistically better than other interventions for improving headache pain intensity in the short term in patients with TTH (SMD -1.27, 95%CI=-3.56 to 1.03, n=230), CGH (SMD -0.41, 95% CI=-4.69 to 3.87, n=104), or mixed headache (TTH and migraine; SMD 0.03; 95% CI=-0.42 to 0.48, n=90). Dry needling provided significantly greater improvement in related disability in the short term in patients with TTH (SMD -2.28, 95% CI=-2.66 to -1.91, n=160) and CGH (SMD -0.72, 95% CI=-1.09 to -0.34, n=144). The synthesis of results showed that dry needling could significantly improve headache frequency, health-related quality of life, trigger point tenderness, and cervical range of motion in TTH and CGH. Dry needling produces similar effects to other interventions for short-term headache pain relief, whereas dry needling seems to be better than other therapies for improvement in related disability in the short term. Although further high-methodological quality studies are warranted to provide a more robust conclusion, our systematic review suggested that for every 1 or 2 patients with TTH treated by dry needling, 1 patient will likely show decreased headache intensity (number needed to treat [NNT]=2; large effect) and improved related disability (NNT=1; very large effect). In CGH, for every 3 or 4 patients treated by dry needling, 1 patient will likely exhibit decreased headache intensity (NNT=4; small effect) and improved related disability (NNT=3; medium effect).

The effectiveness of preoperative assessment using a patient-specific three-dimensional pseudoarticulation model for minimally invasive posterior resection in a patient with Bertolotti\u2019s syndrome: a case report

BackgroundBertolotti’s syndrome is widely known to cause low back pain in young patients and must be considered as a differential diagnosis. Its treatment such as conservative therapy or surgery remains controversial. Surgical procedure is recommended for intractable low back pain. The three-dimensional (3D) lumbosacral transitional vertebrae anatomy should be completely understood for a successful surgery. Using an intraoperative 3D navigation and preoperative preliminary surgical planning with a patient-specific 3D plaster model contribute for safe surgery and good outcome.Case presentationA case of a 22-year-old Japanese male patient with intractable left low back pain due to lumbosacral transitional vertebrae with Bertolotti’s syndrome. The symptom resisted the conservative treatment, and anesthetic injection at pseudoarticulation only provided a short-term pain relief. Posterior resection using intraoperative three-dimensional (3D) navigation has been performed through microendoscopic view. Pseudoarticulation was totally and successfully resected in a safe manner.ConclusionsPreoperative surgical planning and rehearsal using a patient-specific 3D plaster model was greatly useful and effective for surgeons in performing accurate and safe pseudoarticulation resection.

\u201cAn apple pie a day does not keep the doctor away\u201d: Fictional depictions of gout in contemporary film and\xa0television

BackgroundFictional portrayals of illness and medical management in film and television can reflect and perpetuate cultural stereotypes about illness. The aim of this study was to analyse fictional depictions of gout in contemporary film and television.MethodsWe conducted a search for English language depictions of gout in film and television since 1990 using the Internet Movie Database (IMDb), other internet media databases, and member suggestions from the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN). Film and television episodes with gout content were analysed for depictions of characters with gout, causal factors, and management strategies (n=44).ResultsGout was used to denote royalty or nobility in historical settings, and as a plot device to explain the absence of characters from key events. The most commonly depicted causes of gout were overindulgence of food and alcohol (61%), and portrayals of biological causes were infrequent (12%). Common management strategies were change in diet (36%) and short-term pain relief (32%), with only one mention of urate-lowering therapy (5%). The majority of films and television episodes depicted gout as humorous (59%) and embarrassing (50%).ConclusionsIn contemporary film and television, gout is portrayed as a humorous and embarrassing condition, caused by dietary indulgence. These depictions may reinforce inaccurate beliefs about the causes of gout and its management.

Hydrodilatation with corticosteroids is the most effective conservative management for frozen shoulder.

The purpose of this overview is to summarise the findings of meta-analyses of randomised controlled trialsthat compare conservative treatment options for frozen shoulder. The authors conducted an electronic literature search for meta-analyses published using PubMed, Web of Science and the Cochrane Library. Two researchers independently applied selection criteria and assessed quality of meta-analyses using A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2). Short-, medium- and long-term outcomes were synthesised narratively. A total of 319 studies were identified, of which 8 meta-analyses were eligible for inclusion. All included meta-analyses were judged to be low or critically low quality according to AMSTAR-2, however, their data synthesis and interpretation was considered valid. Physiotherapy, intra-articular and subacromial corticosteroid injection (CSI), and arthrographicdistension/hydrodilatation with corticosteroid were reported with sufficient evidence. Intra-articular CSI and arthrographic distension/hydrodilatation with corticosteroid provide advantages over placebo in short-term pain relief, range of motion (ROM) and shoulder function, with improvements in ROM continuing into the medium and long term. Arthrographic distension/hydrodilatation with corticosteroid provides medium-term and long-term improvements in ROM over intra-articular CSI and physiotherapy. Proprioceptive neuromuscular facilitation provides advantages over conventional physiotherapy for pain improvement and external rotation in the short term. Arthrographic distension/hydrodilatation with corticosteroid provides superior pain relief in the short term and improvement in range of motion across all time frames for frozen shoulder when compared to CSI or physiotherapy. Level IV.

Efficacy and predictive factors of response to intra-articular corticosteroids in knee osteoarthritis.

In knee osteoarthritis (KOA), synovial inflammation is linked with pain, swelling and structural abnormalities. Intra-articular corticosteroids (IACS) have been considered for pain relief in subjects who are non-responders to standard therapy. However, the results vary across different studies. This review aims to determine efficacy of IACS in KOA by review of the existing data.In several randomized controlled trials (RCTs), meta-analyses and uncontrolled studies a single IACS resulted in pain relief from 1 to a few weeks. In a few studies repeated IACS every three months provided a longer duration of pain relief and functional improvement in a proportion of patients. Baseline synovitis was predictor of treatment response in some but not all studies.Based upon the existing data, IACS provides a short-term pain relief in a proportion of patients. Given, anti-inflammatory properties of IACS, it is likely to be more effective in subgroups of KOA who display inflammatory phenotype.

Incobotulinum toxin type A for treatment of chronic myofascial pain.

This study assessed the effectiveness of incobotulinum toxin type A (IBTx) for chronic myofascial pain affecting the masseter and temporal muscles. Twenty two patients who received a diagnosis of chronic masseter and temporalis myofascial pain were evaluated by using a visual analog pain scale (VAS), digital pressure algometry, and the SF-36 Health Survey at baseline (T0), before IBTx injection. Patients were again evaluated at 2 months (T1) and 7 months (T2) after IBTx injection. VAS scores for pain significantly differed (P = 0.029, Friedman test). Post-hoc tests showed a significant reduction in pain at 2 months (T0-T1) and 7 months (T0-T2) (P = 0.011 and P = 0.028, respectively; Wilcoxon test) but not between 2 and 7 months (P = 0.676; Wilcoxon test). There was no significant difference in pressure algometry values (P = 0.385, Friedman test). Quality of life (QOL) assessment showed a significant difference (P = 0.002, Friedman test). Post-hoc tests showed a significant improvement in QOLat 2 months, but no significant difference at 7 months (P = 0.004 and P = 0.260, Wilcoxon test). IBTx injection resulted in safe, effective short-term pain relief for patients with chronic facial pain affecting the masseter and temporalis muscles.

Analgesic efficacy of morphine sulfate immediate release vs. oxycodone/acetaminophen for acute pain in the emergency department.

Previous research demonstrated that administration of Morphine Sulfate Immediate Release (MSIR) results in similar analgesic efficacy to Oxycodone but with significantly lesser degrees of euphoria and reward. The purpose of this study sit to investigate if MSIR combined with Acetaminophen can serve as an opioid analgesic alternative to Oxycodone combined with acetaminophen (Percocet) for acute pain in the Emergency Department (ED). A prospective, randomized, double-blind trial of ED patients aged 18 to 64years presenting with moderate to severe acute pain as defined by an 11-point numeric rating scale (NRS) with an initial score of ≥5 (0=no pain and 10=very severe pain). Patients were randomized to receive either 15mg MSIR combined with 650mg of Acetaminophen or 10mg Oxycodone combined with 650mg Acetaminophen. Patients were assessed at baseline, 30, 45 and 60min. The primary outcome was reduction in pain at 60min. Secondary outcomes include drug likeability and adverse events. 80 patients were enrolled in the study (40 per group). Demographic characteristics were similar between the groups (P>0.05). Mean NRS pain scores at baseline were 8.44 for the MSIR group and 8.53 for the Percocet group (P=0.788). Mean pain scores decreased over time but remained similar between the groups: 30min (6.03 vs. 6.43; P=0.453), 45min (5.31 vs. 5.48; P=0.779), and 60min (4.22 vs. 4.87; P=0.346). Reduction in mean NRS pain scores were statistically significant from baseline to 30, 45 and 60min within each group (P<0.0001 at each time point for both groups). The largest NRS mean difference was from baseline to 60min: 4.2 (95% CI: 3.43 to 5.01) for MSIR group and 3.61 (95% CI: 2.79 to 4.43) for Percocet group. No clinically significant changes or any serious adverse events were observed in either group. MSIR provides similar analgesic efficacy as Percocet for short-term pain relief in the ED, similar rates of nausea/vomiting, and lower rates of likeability of the drug.

Platelet-Rich Plasma in Patients With Partial-Thickness Rotator Cuff Tears or Tendinopathy Leads to Significantly Improved Short-Term Pain Relief and Function Compared With Corticosteroid Injection: A Double-Blind Randomized Controlled Trial

To perform a randomized controlled trial comparing platelet-rich plasma (PRP) with standard corticosteroid (CS) injection in providing pain relief and improved function in patients with rotator cuff tendinopathy and partial-thickness rotator cuff tears (PTRCTs). This double-blind randomized controlled trial enrolled patients with ultrasound-proven or magnetic resonance imaging-proven PTRCTs who received either an ultrasound-guided PRP or CS injection. Patients completed patient-reported outcome assessments at baseline and at 6 weeks, 3 months, and 12 months after injection. The primary outcome was improvement in the visual analog scale (VAS) score for pain. Secondary outcomes included changes in American Shoulder and Elbow Surgeons (ASES) and Western Ontario Rotator Cuff Index (WORC) scores. Treatment failure was defined as subsequent injection, consent to undergo surgery, or operative intervention. We followed up 99 patients (47 in the PRP group and 52 in the CS group) until 12 months after injection. There were no differences in baseline patient demographic characteristics including age, sex, or duration of symptoms. Despite randomization, patients in the PRP group had worse baseline VAS (46.0 vs 34.7, P= .01), ASES (53.9 vs 61.8, P= .02), and WORC (42.2 vs 49.5, P= .03) scores. At 3 months after injection, the PRP group had superior improvement in VAS (-13.6 vs 0.4, P= .03), ASES (13.0 vs 2.9, P= .02), and WORC (16.8 vs 5.8, P= .03) scores. There were no differences in patient-reported outcomes at 6 weeks or 12 months. There was no difference in the rate of failure (P= .31) or conversion to surgery (P= .83) between groups. Patients with PTRCTs or tendinopathy experienced clinical improvement in pain and patient-reported outcome scores after both ultrasound-guided CS and PRPinjections. Patients who received PRP obtained superior improvement in pain and function at short-term follow-up (3months). There was no sustained benefit of PRP over CS at longer-term follow-up (12 months). Level I, randomized controlled trial.

Acupuncture and Chronic Musculoskeletal Pain.

Chronic musculoskeletal pain (CMP) attributable to conditions such as osteoarthritis, rheumatoid arthritis, fibromyalgia, and chronic low back pain is the most common cause of disability globally, for which no effective remedy exists. Although acupuncture is one of the most popular sensory stimulation therapies and is widely used in numerous pain conditions, its efficacy remains controversial. This review summarizes and expands upon the current research on the therapeutic properties of acupuncture for patients with CMP to better inform clinical decision-making and develop patient-focused treatments. We examined 16 review articles and 11 randomized controlled trials published in the last 5years on the clinical efficacy of acupuncture in adults with CMP conditions. The available evidence suggests that acupuncture does have short-term pain relief benefits for patients with symptomatic knee osteoarthritis and chronic low back pain and is a safe and reasonable referral option. Acupuncture may also have a beneficial role for fibromyalgia. However, the available evidence does not support the use of acupuncture for treating hip osteoarthritis and rheumatoid arthritis. The majority of studies concluded the superiority of short-term analgesic effects over various controls and suggested that acupuncture may be efficacious for CMP. These reported benefits should be verified in more high-quality randomized controlled trials.

The role of acupuncture in the treatment of chronic pain.

Acupuncture is a practice based on traditional Chinese medicine, in which needles are used to restore the body's internal balance. Recently, there has been growing interest in the use of acupuncture for various pain conditions. Acupuncture's efficacy in five pain conditions-low back pain (LBP), migraines, fibromyalgia, neck pain, and abdominal pain-was evaluated in this evidence-based, comprehensive review. Based on the most recent evidence, migraine and fibromyalgia are two conditions with the most favorable outcomes after acupuncture. At the same time, abdominal pain has the least evidence for the use of acupuncture. Acupuncture is efficacious for reducing pain in patients with LBP, and for short-term pain relief for those with neck pain. Further research needs to be done to evaluate acupuncture's efficacy in these conditions, especially for abdominal pain, as many of the current studies have a risk of bias due to lack of blinding and small sample size.

Radiofrequency denervation for chronic back pain: a systematic review and meta-analysis

ObjectivesTo assess the effectiveness of radiofrequency denervation (RD) of lumbosacral anatomical targets for the management of chronic back pain.DesignSystematic review and meta-analysis of randomised controlled trials (RCTs).MethodsA database search (Medline,...

Neuromodulation, Specialized Proresolving Mediators, and Resolution of Pain.

The current crises in opioid abuse and chronic pain call for the development of nonopioid and nonpharmacological therapeutics for pain relief. Neuromodulation-based approaches, such as spinal cord stimulation, dorsal root ganglion simulation, and nerve stimulation including vagus nerve stimulation, have shown efficacy in achieving pain control in preclinical and clinical studies. However, the mechanisms by which neuromodulation alleviates pain are not fully understood. Accumulating evidence suggests that neuromodulation regulates inflammation and neuroinflammation-a localized inflammation in peripheral nerves, dorsal root ganglia/trigeminal ganglia, and spinal cord/brain-through neuro-immune interactions. Specialized proresolving mediators (SPMs) such as resolvins, protectins, maresins, and lipoxins are lipid molecules produced during the resolution phase of inflammation and exhibit multiple beneficial effects in resolving inflammation in various animal models. Recent studies suggest that SPMs inhibit inflammatory pain, postoperative pain, neuropathic pain, and cancer pain in rodent models via immune, glial, and neuronal modulations. It is noteworthy that sham surgery is sufficient to elevate resolvin levels and may serve as a model of resolution. Interestingly, it has been shown that the vagus nerve produces SPMs and vagus nerve stimulation (VNS) induces SPM production in vitro. In this review, we discuss how neuromodulation such as VNS controls pain via immunomodulation and neuro-immune interactions and highlight possible involvement of SPMs. In particular, we demonstrate that VNS via auricular electroacupuncture effectively attenuates chemotherapy-induced neuropathic pain. Furthermore, auricular stimulation is able to increase resolvin levels in mice. Thus, we propose that neuromodulation may control pain and inflammation/neuroinflammatioin via SPMs. Finally, we discuss key questions that remain unanswered in our understanding of how neuromodulation-based therapies provide short-term and long-term pain relief.

A randomized control trial to compare the efficacy of intralesional platelet rich plasma vs steroid in lateral epicondylitis: A prospective interventional study

Background: lateral epicondylitis most commonly known as tennis elbow is not a rare entity. Most commonly seen in working population causing many work hour losses and thus leads to loss of income. Severity ranges from occasional pain to continuous dull aching leading to frustration and hindering the daily activities. It’s a common practice to treat this condition with intralesional steroids. However, the recent developments in treatment advocates use of PRP in place of steroids. Hence, we conducted this study to compare and see the efficacy of both.Methods: This is a prospective interventional study of 40 cases of lateral epicondylitis visited to our tertiary care private hospital during 2019 to 2020. Patients not amenable to analgesic were treated with intralesional steroid and PRP. 20 patients of each group received the treatment in double blinded randomised control fashion. Each patient assessed at regular interval for a period of 24 weeks and pain analysed with the help of VAS, FPS scoring and functional improvement with DASH score. Results were analysed with appropriate statistical method.Results: In our study pre injection VAS score was comparable in both groups. The difference of pre injection VAS score was not much significant statistically. Both group of patients showed improvement in pain and functionality, reflected by decreasing VAS, FPS and DASH scores at 4 and 8 weeks. However, at 12- and 24-weeks improvement achieved with PRP was much better than the steroid. In the steroid group they cease to improv after 12 months and some patients even started experiencing pain again at 24 weeks. There is a significance difference between the two groups outcome seen at 24 weeks. Percentage of effect along with effect size achieved is also large in PRP group.Conclusions: Both steroid and PRP are good for short term pain relief in management of lateral epicondylitis. However, in long term and sustained pain control PRP showed better outcome than steroid. Risk of recurrence is high with steroid than with the PRP.

Short-Term Pain Relief by Repetitive Peripheral Magnetic Stimulation in Patients with Musculoskeletal Pain: A Pilot Study

Short-Term Pain Relief by Repetitive Peripheral Magnetic Stimulation in Patients with Musculoskeletal Pain: A Pilot Study

Does meloxicam provide adequate pain management as a post-operative analgesic in canine ovariohysterectomy patients?

Background: Meloxicam is an analgesic agent with anti-inflammatory properties, commonly used in veterinary practices to treat a variety of different long-term medical conditions and is also used as a short-term pain relief following particularly traumatic surgeries. Aims: An observational study was conducted to determine whether meloxicam provides adequate pain management as a post-operative analgesic for canine ovariohysterectomies. Methods: 13 canines were admitted for ovariohysterectomy. Each patient was assessed using the Glasgow composite pain scale (CMPS) prior to surgery during the admission procedure, 15 minutes post-operatively, at discharge and at their post-operative check (POC) 3–5 days after surgery. Results: Data were statistically analysed to determine the overall effectiveness of meloxicam in reducing pain following canine ovariohysterectomy. The results showed a statistically significant difference (Kruskal-Wallis test: H3 =12.98, p=0.005) in pain scores between admission, 15 minutes post operatively, discharge and 3–5 days POC. The greatest decrease in pain score was between 15 minutes post-operatively and POC (Mann-Whitney U test: W=236, n=13, 13, p=0.0014) and between discharge and POC (Mann-Whitney U test: W=227, n=13, 13, p=0.0060). Overall, this demonstrated that there was an improvement in pain suggesting meloxicam is effective between these time frames. In addition, 69.2% (n=9) of patients in the study showed a pain score of 0, indicating an absence of pain, on their final POC. Statistical analysis was also used to determine if there was any difference in pain score between the 3, 4 or 5 day POC pain score. The results show there was no significant difference (Kruskal-Wallis test: H2 =0.090, p=0.638) suggesting that meloxicam's effectiveness was similar across this range of time post surgery. Conclusion: The results from the study indicate that meloxicam is an effective post-operative analgesic for canine patients undergoing an ovariohysterectomy.

Impact of fluoroscopic injection location on immediate and delayed pain relief in patients with greater trochanteric pain syndrome.

The purpose of this study was to assess whether fluoroscopically guided corticosteroid injections into the extrabursal tissues, trochanteric (subgluteus maximus) bursa, or subgluteus medius bursa provide better immediate and short-term pain relief. All fluoroscopically guided corticosteroid injections performed over a 67-month period for greater trochanteric pain syndrome were retrospectively reviewed. Procedural images were reviewed by two musculoskeletal radiologists to determine the dominant injection site based on final needle positioning and contrast spread pattern, with discrepancies resolved by consensus. Statistical analysis of the association between pain score reduction and dominant injection site was performed. One hundred forty injections in 121 patients met the inclusion criteria. The immediate and 1-week post-injection pain reduction was statistically significant for trochanteric bursa, subgluteus medius bursa, and non-bursal injections. However, there was no statistically significant difference in the degree of pain reduction between the groups. There was statistically significant increase in the 1-week post-injection mean pain score compared with immediate post-injection mean pain score in the subgluteus medius bursa and non-bursal injection groups (p < 0.01) but not in the trochanteric bursa group. Fluoroscopy is frequently chosen over blind injection or ultrasound guidance for trochanteric steroid injections in patients with a high body mass index. Our results indicate that fluoroscopically guided steroid injections into the trochanteric bursa and subgluteus medius bursa significantly reduced immediate and 1-week post-injection pain scores, as do non-bursal injections. Steroid injection into the subgluteus medius bursa and non-bursal sites may be less effective in maintaining pain reduction at 1-week post-injection.

Intra-articular corticosteroids for knee and hip OA: a systematic review of serious adverse joint outcomes

Purpose: Intra-articular corticosteroids (IACS) are proven to provide short-term pain relief and functional improvement in individuals with knee and hip osteoarthritis (OA). However, the potential for serious adverse joint outcomes resulting from long-term use of IACS has been cause for concern. We conducted a systematic review of all RCT data comparing IACS to intra-articular saline to explore the incidence of accelerated OA progression, subchondral insufficiency fracture, complication of osteonecrosis, and/or rapid destruction of joint tissue among individuals with knee and hip OA. Methods: Medline, PubMed Central, Google Scholar, and the Cochrane Databases were systematically searched from inception to November, 2019. Reference lists of relevant reviews were searched by hand, and we sought additional data within supplements of conference proceedings that had been published up until November, 2019. Randomized controlled trials comparing IACS to intra-articular saline in participants with knee or hip OA were included. Two reviewers screened potentially relevant references and independently assessed study quality using the Cochrane Risk of Bias tool. Relevant data were independently extracted from included studies by the same two reviewers. Outcomes of interest included incidence of any one of four target serious adverse joint outcomes: accelerated OA progression, subchondral insufficiency fracture, complication of osteonecrosis, and/or rapid destruction of joint tissue. Analysis of dichotomous outcomes using the Mantel-Haenszel method was planned a priori, and effect estimates were to be reported as risk ratios (RR) with 95% confidence intervals. Results: Our search returned 516 potentially relevant references. Of these, 28 references were deemed to be potentially eligible for inclusion. Twenty two RCTs met our inclusion criteria, but 12 of them did not report safety outcomes. Ten RCTs incorporating a total of 538 patient-years of follow-up reported on safety in sufficient detail to confirm absence or incidence of the target serious adverse joint outcomes. Seven RCTs (N= 728) involved participants with knee OA, and 3 RCTs focused on hip OA (N= 162). Follow-up of the included RCTs ranged from 5 weeks to 2 years, with the most common (40% of RCTs) study duration being 6 months. 60% of RCTs involved a single IACS injection; two trials involved 8 injections total over 12 week intervals, while two other RCTs involved 3 and 5 total injections over intervals of 2 weeks and 1 week, respectively. Study quality was overall assessed to be of Low to Very Low Quality. None of the included RCTs involving participants with knee or hip OA documented incidence of accelerated OA progression, subchondral insufficiency fracture, complication of osteonecrosis, or rapid destruction of joint tissue over the course of the study follow-up. Due to a complete absence of events, statistical comparison of IACS with placebo was not possible. Conclusions: The results of our study suggest that the use of IACS is unlikely to lead to serious adverse joint outcomes in a controlled clinical setting. These findings are limited by the short follow-up and low number of total IACS injections, and may not be generalizable to patients with repeated injections over longer time periods. High-quality, long-term observational data are needed to confirm the safety of long-term use of IACS in knee or hip OA.