Cortizone infiltrations - Ortokinetic

Treatments

Cortizone infiltrations

 

 

The use of cortisone injections to treat joint and muscle inflammation is becoming increasingly popular. This type of injection, first discovered by Dr. Travell Janet, is an effective, safe and relatively easy to perform.

Mechanism of inflammation

Inflammation is one of the body’s first reactions to injury. A series of particles released by the cells and tissues affected by the injury function as antigens and stimulate a non-specific immune response (leukocyte proliferation). Local circulation increases, transporting leukocytes, macrophages and plasma proteins to the affected area. Redistribution of arteriolar flow produces stasis and tissue hypoxia. This accumulation of leukocytes, plasma proteins and fluid leads to the swelling and pain characteristic of the inflammatory process.

Causes of joint and muscle inflammation:

  • Muscle stretching
  • Trauma
  • Polyarthritis
  • Connective tissue disease
  • Degenerative joint disease
  • Tendinitis
  • Bursitis
  • Tumors

The influx of leukocytes facilitates the process of phagocytosis and elimination of affected cells. Pain and edema remind the patient to protect the affected area.

Corticosteroids mode of action

    The mechanism of action of corticosteriods includes reducing the inflammatory reaction by limiting capillary dilation and decreasing capillary permeability, which leads to decreased accumulation of leukocytes, macrophages and also reduces the release of vasoactive kinins.
   According to new studies, corticosteroids may also inhibit the release of arachidonic acid by phospholipids, thus decreasing the formation of prostaglandins involved in the inflammatory process.

Patient evaluation

The patient’s history and a good clinical examination are very important for treatment. Intense, severe pain suggests the presence of post-traumatic inflammatory reaction. Chronic, repetitive pain suggests moderate inflammation secondary to chronic disease or arthritis. Worsening pain or the appearance of neurological symptoms (paresthesias, burning sensations) also implies a neurological consultation.

Clinical examination is useful to identify the location and severity of inflammation. Painful muscle points are easily identified by clinical examination.

Radiography is generally not useful, the inflammatory process evolving without radiologic changes, but sometimes it is necessary to detect fractures with or without displacement.

EMG (electromyography) is useful when we have correlated neurological symptoms.
The usual blood tests are also important, changes in leukocytes may suggest an infection: increased erythrocyte sediment (ESH) may suggest myopathy or an arthritic process; increased rheumatoid factor may suggest rheumatoid atritis; increased uric acid may suggest a gout process.

The treatment

In anti-inflammatory treatment we can also use nonsteroidal anti-inflammatory drugs (aspirin) and oral prednisone. It is important to remember that the anti-inflammatory treatment should be carried out for the whole indicated period, as many patients stop treatment as soon as they start to feel better. During the acute period, rest, ice, immobilization with elastic bandaging, followed by physiotherapy and massage are also useful. Injectable corticosteroid therapy is generally a safe maneuver, but there are some possible risks such as infection, bleeding, tendon ruptures.
 

Indications for corticosteroid injections

  • Sinovita
  • Bursitis
  • Gouty arthritis
  • Frozen shoulder syndrome
  • Tendinitis
  • Rheumatoid arthritis
  • Trigger points/Puncte dureroase
  • Carpal tunnel syndrome
  • Wrap
  • Synovial cyst

Precautions in corticosteroid therapy:

  • Peripheral neuropathies
  • Infections
  • Tumors
  • Tuberculosis
  • Immunosuppressive diseases
  • Hypothyroidism
  • Blood clotting disorders
  • Insulin-dependent diabetes
  • Joint prosthesis
  • Marked osteoporosis
  • Achilles or patellar tendinopathies (risk of future rupture)

Corticosteroids have other important precautions and contraindications. The doctor should be familiar with all these restrictions before starting injectable corticosteroid treatment.

Local side effects of corticosteriods can be:

  • Infection
  • Subcutaneous atrophy
  • Skin depigmentation
  • Tendon tears

These complications often result from poor technique, too high or too frequent doses or failure to prepare and dissolve the preparation. Concerning injection for myofascial pain, some doctors prefer to inject at trigger points, while others prefer to inject local anesthetics at these points.

Procedure

Corticosteroid injection is a simple and well-defined procedure. The objective is to inject the preparation without pain and with as few complications as possible.The technique is identical for muscles, periarticular tissues or joints. Injections in the vicinity of nerve threads or arteries should be avoided. For example: injecting the lateral epicondyle is relatively straightforward, whereas injecting the medial epicondyle (in the vicinity of the ulnar nerve) carries an increased risk and special attention must be paid to identifying the nerve pathway and avoiding it.
A sterile technique is recommended in order to minimize the risk of iatrogenic infections especially in the case of intra-articular infiltrations.
There are 2 opinions about using one infiltration needle or two separate needles for anesthetic and cortisone. Using a single needle is less painful, but cortisone requires a thick needle for infiltration, which is why some doctors prefer a prior anesthesia.

It should be remembered that the iodine solutions used to sterilize the infiltration site must dry on the skin in order to have maximum antibacterial effect. Another recommendation would be to change the needle used to aspirate the drug from the vial into the syringe with a new needle used for injection.
The material used for infiltration depends on the doctor’s preference. Many doctors prefer a long-acting methylprednisolone preparation. We prefer a cocktail of equal parts of lidocaine, triamcinolone and dexamethasone.

For muscle trigger points the needle is inserted directly into the painful point. Suction is always necessary to confirm that the needle is not in a blood vessel. The needle can remain in place, but can be moved up and down without being removed. The needle should be oriented in 3-4 areas of the painful point.
It should be recalled that one benefit of infiltrations is scar tissue rupture. In the case of periarticular injections, they should not be made directly into the tendon, because of the risk of tendon rupture. Cor cortisone infiltrations are done in small amounts around the inflamed area. Several injections are needed to infiltrate several centimeters of tendon or muscle. Intra-articular infiltrations are performed by inserting the needle directly into the joint. Identification of the injection site can be found in the description of the technique for each individual joint.
After infiltrations cold local applications are often necessary. Injection is traumatic and can cause swelling and edema that may require treatment. Ice applied immediately can reduce the inflammatory response. In the first 2 hours the patient may feel quite comfortable due to the local anesthetic. However, this lasts for only 2 hours and is gradually replaced by a pain that is usually stronger than the pain before the injection. This pain disappears within 48 hours.

Other symptoms may occur (excessive bleeding, allergic reactions, chest pain), in which case urgent medical attention is necessary. Often several injections are needed to treat a patient. Usually patients have multiple painful points and 3 sets of injections are needed.

Infiltrations in tendons and joints are generally limited to 3/year
due to the potential for mechanical rupture of the injected structures.

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The long-term safety and efficacy of intra-articular steroid infiltration has been the subject of several studies. The findings of these studies support the clinical efficacy of repeated courses of corticosteroids on pain, especially in arthrosis (Raynauld JP, Buckland-Wright C, Ward R, Choquette D, Haraoui B, Martel-Pelletier J, Uthman I, Khy V, Tremblay JL, Bertrand C, Pelletier JP; Hopital Notre-Dame, Centre Hospitalier de l’Universite de Montreal, Quebec, Canada).

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