To assess the predictive variables after sonographically guided corticosteroid injection in carpal tunnel syndrome.
A prospective, observational study was carried out on 25 wrists of 20 consecutive patients with carpal tunnel syndrome, confirmed by the American Association of Neuromuscular and Electrodiagnostic Medicine criteria, which includes clinical history, symptoms, and evidence of slowing of distal median nerve conduction. Visual analogue scale (VAS) and Boston Carpal Tunnel Questionnaire (BCTQ) were asked to the patients before and 4 weeks after the procedure. On a basis of VAS difference before and after the procedure, we divided the patients into two groups: more than 50% of VAS improving (good response group) and less than 50% of VAS improving (poor response group). Also, nerve conduction studies and ultrasound evaluations were performed prior to sonographically guided corticosteroid injection and at 4 weeks after the procedure. The cross-sectional area (CSA) of median nerve at maximal swelling point around wrist was measured by manual tracing using ultrasonography. With assessments mentioned above, we tried to assess predictive variables for prognosis after sonographically guided corticosteroid injection in carpal tunnel syndrome.
The CSA of median nerve at wrist measured before the procedure was significantly larger in good response group than in poor response group. Furthermore, the CSA of median nerve at wrist, symptom severity scale of BCTQ, motor/sensory latency and sensory amplitude were correlated with VAS improving.
The CSA of median nerve at wrist is the strongest predictive value for sonographically guided corticosteroid injection in mild-to-moderate carpal tunnel syndrome.
Citations
To evaluate at which pH level various local anesthetics precipitate, and to confirm which combination of corticosteroid and local anesthetic crystallizes.
Each of ropivacaine-HCl, bupivacaine-HCl, and lidocaine-HCl was mixed with 4 different concentrations of NaOH solutions. Also, each of the three local anesthetics was mixed with the same volume of 3 corticosteroid solutions (triamcinolone acetonide, dexamethasone sodium phosphate, and betamethasone sodium phosphate). Precipitation of the local anesthetics (or not) was observed, by the naked eye and by microscope. The pH of each solution and the size of the precipitated crystal were measured.
Alkalinized with NaOH to a certain value of pH, local anesthetics precipitated (ropivacaine pH 6.9, bupivacaine pH 7.7, and lidocaine pH 12.9). Precipitation was observed as a cloudy appearance by the naked eye and as the aggregation of small particles (<10 µm) by microscope. The amount of particles and aggregation increased with increased pH. Mixed with betamethasone sodium phosphate, ropivacaine was precipitated in the form of numerous large crystals (>300 µm, pH 7.5). Ropivacaine with dexamethasone sodium phosphate also precipitated, but it was only observable by microscope (a few crystals of 10–100 µm, pH 7.0). Bupivacaine with betamethasone sodium phosphate formed precipitates of non-aggregated smaller particles (<10 µm, pH 7.7). Lidocaine mixed with corticosteroids did not precipitate.
Ropivacaine and bupivacaine can precipitate by alkalinization at a physiological pH, and therefore also produce crystals at a physiological pH when they are mixed with betamethasone sodium phosphate. Thus, the potential risk should be noted for their use in interventions, such as epidural steroid injections.
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To evaluate effects of subacromial bursa injection with steroid according to dosage and to investigate whether hyaluronidase can reduce steroid dosage.
Thirty patients with periarticular shoulder disorder were assigned to receive subacromial bursa injection once a week for two consecutive weeks. Ten patients (group A) underwent subacromial bursa injection with triamcinolone 20 mg; another group of ten patients (group B) with hyaluronidase 1,500 IU and triamcinolone 20 mg; and the other ten patients (group C) with triamcinolone 40 mg. We examined the active range of motion (AROM) of the shoulder joint, visual analogue scale (VAS), and shoulder disability questionnaire (SDQ) at study entry and every week until 1 week after the 2nd injection.
All groups showed statistically significant improvements in VAS after 1st and 2nd injections. When comparing the degree of improvement in VAS, there were statistically significant differences between groups C and A or B, but not between groups A and B. SDQ was statistically significantly improved only in groups B and C, as compared to pre-injection. There were statistically significant differences in improvement of SDQ after the 2nd injection between groups C and A or B. Statistically significant improvements in AROM were shown in abduction (groups B and C) and in flexion (group C only).
Repeated high-dose (40 mg) steroid injection was more effective in terms of pain relief and functional improvements of shoulder joint than medium-dose (20 mg) steroid injection in periarticular disorder. Hyaluronidase seems to have little additive effect on subacromial bursa injection for reducing the dosage of steroid.
Citations
Objective: The purpose of this study is to find out what is the effect of epidural corticosteroid injection on bone metabolism.
Method: We have assessed the systemic effects of a single epidural triamcinolone acetonide injection on biochemical indices of bone formation and resorption in patients with lumbosacral radiculopathy. Twenty patients who had lumbosacral radiculopathy and free from exposure to corticosteroid for at least 6 weeks were selected for this study. Patients were classifed as two groups; 1) epidural block with 2% lidocaine 3 ml and 0.9% normal saline 15 ml (4 men, 5 women; mean age 47.2⁑7.6 years) and 2) combination of triamcinolone acetonide 40 mg (5 men, 6 women; mean age 49.6⁑8.2 years). Fasting serum and the second voided urine were collected at 0, 1, 3, 7 and 14 days after the single epidural injection for bone-related biochemical
markers measurements.
Results: 1) Level of serum osteocalcin showed a significant time trend in the epidural corticosteroid injection group. Osteocalcin decreased dramatically from 11.2⁑3.4 ng/ml on day 0 to 5.9⁑2.8 ng/ml on day 1, 6.1⁑1.5 ng/ml on day 3 (p＜0.05). After the initial drop, the level recovered to 9.8⁑3.7 ng/ml by day 7, and returned to preinjection level on day 14, at 10.9⁑4.1. 2) Urinary deoxypyridinoline levels did not show any significant changes.
Conclusion: According to the above results, the epidural injection of corticosteroid may be a better therapeutic mode, with less potential for harmful effects to bone metabolism, in providing effective relief of symptoms to patients with lumbosacral radiculopaties. (J Korean Acad Rehab Med 2002; 26: 203-207)
Objective: This study was designed to evaluate the effect of growth hormone on bone mineral density of corticosteoid-induced osteoporosis in male rat.
Method: Twenty Sprague-Dwaley male rats was studied, divided into four group, each group has 5 rats. The group 1 was treated with saline. The group 2 was treated with corticosteroid (Methylprednisolone 10 mg/kg). The group 3 was treated with corticosteroid and growth hormone (recombinant human growth hormone 0.5 IU/kg). The group 4 was treated with growth hormone after corticosteroid treatment. The treatment duration was 6 weeks for each group. After six weeks of hormone administration, the animals were sacrificed, the bilateral femur were removed and tested for bone mineral density using dual energy X-ray absorptiometry and examined histomorphometrically.
Results: Administration of growth hormone after corticosteroid therapy, the growth hormone could reverse the decrease in body weight and bone mineral density induced by corticosteroid therapy (p＜0.05).
Conclusion: When growth hormone is administrated after corticosteroid therapy, the growth hormone can protect the osteoporosis in male rats induced by a high dose of corticosteroid.
Local steroid injection in carpal tunnel syndrome(CTS) is widely practised for the relief of symptoms such as pain and paresthesias. We evaluated the effects of the injection with electrophysiologic changes and improvement in pain and paresthesias.
27 patients, 40 cases with carpal tunnel syndrome diagnosed clinically and electrophysiologically were injected with 40mg of triamcinolone acetonide. Patients were reevaluated with the visual analogue scale and electrophysiologic parameters after 2 to 4 weeks. Then we split up the patients into "excellent", "good" ,"poor" group by the degree of responses to the injections. In order to predict the injection effect, we analyzed several clinical and electrophysiologic factors: duration of symptoms, Phalen test, prolongation of distal motor latency of the median nerve, denervation evidence of the abductor pollicis brevis muscle.
Symptom relief was noted in the 89% of the cases[excellent(75%), good(14%)], and there was no statistically significant correlation between any of the above four factors and the degree of the symptom responses. Among the electrophysiologic parameters motor distal latency, motor residual latency, sensory onset and peak latency, median to radial sensory onset and peak latency difference reflected the clinical improvements(p＜0.05). But there was some cases that improved clinically but deteriorated electrophysiologically(2 cases in motor distal latency, 5 cases in motor residual latency, 1 case in sensory peak latency, none in sensory onset latency).
In conclusion we find that local steroid injection in CTS is an effective therapeutic modality for the symptom remission and it also showed changes in electrophysiologic parameters. And among these parameters sensory distal latency seems to be the most appropriate electrophysiologic parameter which best reflects the improvement of pain and paresthesias.
In 12 Reflex Sympathetic Dystrophy(RSD) patients(13 cases) after the acute stroke, Three- phase Bone Scintigraphy(TBS) was performed to evaluate whether the amount of radioisotope reflects the disease activity of RSD. The diagnosis of RSD was based on Kozin's criteria(definite or probable group) and scintigraphic findings(increased radioisotope uptake in all three phases). Initial TBS was performed within 10 days after the onset of clinical symptoms and it was followed up within 5days after the short term steroids therapy. Before and after the steroids therapy, patients were evaluated with respect to pain, swelling and allodynia. Radioisotope uptake of ROI(Regions Of Interest) of all three images was calculated semiquantitatively in initial and follow up scintigraphy.
Pain, swelling and allodynia of the affected hand were improved in all patients after short-term oral corticosteroids therapy. Radioisotope uptake in blood flow image(11 patients, 12 cases) and blood pool image(11 patients, 12 cases) were decreased(p＜0.05), but radioisotope uptake in delayed image was not decreased(p＞0.05).
We concluded that radioisotope uptake in blood flow and blood pool images could reflect disease activity of RSD. It was suggested that decreased capillary vascular permeability by corticosteroids resulted in decreased blood flow and blood pool. The semiquantitative evaluation of TBS may be useful for monitoring the response to therapeutic intervention.
The role of inflammatory mediators in RSD and pharmacologic effect of corticosteroids were also discussed.
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