Citations
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
Spinal dural arteriovenous fistulas (SDAVFs) are the most common type of spinal vascular malformations. However, SDAVFs are still underdiagnosed entities because their clinical symptoms are usually non-specific, as they include low back pain or radiating pain to the limb. There have been several reports of acute paraplegia after lumbar epidural steroid injections in patients with SDAVFs. We present 4 patients with SDAVFs who received lumbar steroid injection. Among the 4 cases, acute paraplegia developed in 2 cases that received a larger volume of injectate than the other cases. Thus, we are suggesting that the volume of injectate may be a contributing factor for acute paraplegia after lumbar steroid injection in patients with SDAVFs.
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.
Citations
To compare the long-term effect and safety of an epidural steroid injection in spinal stenosis patients, with or without local anesthetics.
Twenty-nine patients diagnosed with spinal stenosis were included and randomly divided into two groups. Translaminar epidural and selective nerve root spinal injection procedures were performed using steroids mixed with local anesthetics or normal saline. The effects of spinal injection procedures were measured with visual analogue scale (VAS) and functional rate index (FRI). These measurements were performed before injection, at 1 month after injection and at 3 months after injection. The occurrence of side effects was investigated each time.
The VAS and FRI scores were significantly reduced in both the local anesthetics group and normal saline group at 1 and 3 months after the injection. However, there was no significant difference in VAS and FRI score reduction between the two groups each time. Side effects are not noted in both groups.
The spinal injection procedures using steroids mixed either with local anesthetics or normal saline have an effect in reducing pain and improving functional activities. However, there was no significant difference between the two groups in relation to side effects and the long-term effects of pain and function.
Citations
To evaluate the effects of repeated steroid injection at subacromial bursa with different interval for patient with periarticular shoulder disorder.
Group A (n=10) received subacromial bursa injection only on their first visit, group C (n=10) received the injection on their first visit and one week later, and group B (n=10) received the injection on their first visit and two weeks later. All injections were done with a combination of 40 mg (1.0 mL) of triamcinolone and 5.0 mL 0.5% lidocaine (6 mL total). We examined the active range of motion (AROM) of the shoulder joint, visual analogue scale (VAS), and shoulder disability questionnaire (SDQ) at baseline at 1, 2, and 4 weeks after the initial injection.
In VAS, comparing the changes in VAS between groups, group B showed significant improvements compared with group A or C at 4 weeks after the initial injection (p<0.05). In SDQ, comparing the changes in SDQ between the groups, group B and C showed more improvement than group A at 4 weeks after the initial injection, but these results were not statistically significant (p>0.05). In AROM, comparing the changes in AROM of external rotation between groups, group B and C showed significant improvement compared with group A at 4 weeks after the initial injection (p<0.05).
It may be more effective in pain relief for patients with periarticular disorder to receive subacromial bursa injections twice with 2-week interval, as opposed to once.
Citations
To compare the treatment effects of epidural neuroplasty (NP) and transforaminal epidural steroid injection (TFESI) for the radiating pain caused by herniated lumbar disc.
Thirty-two patients diagnosed with herniated lumbar disc through magnetic resonance imaging or computed tomography were included in this study. Fourteen patients received an epidural NP and eighteen patients had a TFESI. The visual analogue scale (VAS) and functional rating index (FRI) were measured before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment.
In the epidural NP group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.00±1.52, 4.29±1.20, 2.64±0.93, 1.43±0.51 and those of FRI were 23.57±3.84, 16.50±3.48, 11.43±2.44, 7.00±2.15. In the TFESI group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.22±2.05, 4.28±1.67, 2.56±1.04, 1.33±0.49 and those of FRI were 22.00±6.64, 16.22±5.07, 11.56±4.18, 8.06±1.89. During the follow-up period, the values of VAS and FRI within each group were significantly reduced (p<0.05) after the treatment. But there were no significant differences between the two groups statistically.
Epidural NP and TFESI are equally effective treatments for the reduction of radiating pain and for improvement of function in patients with a herniated lumbar disc. We recommend that TFESI should be primarily applied to patients who need interventional spine treatment, because it is easier and more cost-effective than epidural NP.
Citations
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
To evaluate the effectiveness of initial extracorporeal shock wave therapy (ESWT) for patients newly diagnosed with lateral or medial epicondylitis, compared to local steroid injection.
An analysis was conducted of twenty-two patients who were newly confirmed as lateral or medial epicondylitis through medical history and physical examination. The ESWT group (n=12) was treated once a week for 3 weeks using low energy (0.06-0.12 mJ/mm2, 2,000 shocks), while the local steroid injection group (n=10) was treated once with triamcinolone 10 mg mixed with 1% lidocaine solution. Nirschl score and 100 point score were assessed before and after the treatments of 1st, 2nd, 4th and 8th week. And Roles and Maudsley score was assessed one and eight weeks after the treatments.
Both groups showed significant improvement in Nirschl score and 100 point score during the entire period. The local steroid injection group improved more in Nirschl score at the first week and in 100 point score at the first 2 weeks, compared to those of the ESWT group. But the proportion of excellent and good grades of Roles and Maudsley score in the ESWT group increased more than that of local steroid injection group by the final 8th week.
The ESWT group improved as much as the local steroid injection group as treatment for medial and lateral epicondylitis. Therefore, ESWT can be a useful treatment option in patients for whom local steroid injection is difficult.
Citations
To evaluate the additive effects of hyaluronidase combined with steroids in patients with peri-articular shoulder disorder.
Thirty patients with peri-articular shoulder disorder were given subacromial bursa injections once a week for three consecutive weeks. Fifteen patients (Group A) underwent subacromial bursa injections with hyaluronidase 1,500 IU, triamcinolone 40 mg and 0.5% lidocaine (total 6 ml). Another fifteen patients (Group B) underwent the same injections with triamcinolone 40 mg and 0.5% lidocaine (total 6 ml). We examined the active range of motion (AROM) in the shoulder, used a visual analogue scale (VAS) for measurement, and administered a shoulder disability questionnaire (SDQ) at the commencement of the study and then every week until one week after the third injection.
There were no significant difference between group A and B before the injections took place (p>0.05). Statistically significant improvement was seen in the VAS, SDQ, and AROM of flexion, abduction, internal rotation at one week after the first and second injections compared with the parameters measured at previous visits in both groups (p<0.05), except the SDQ between one week after the first and second injections in group B (p>0.05). Improvement in all parameters measured at one week after the third injection compared with the measurement values at one week after the second injection were not statistically significant in both groups (p>0.05). However, group A (the hyaluronidase group) showed significantly greater improvements than group B in terms of their SDQ and AROM of internal rotation scores one week after the three injections had taken place (p<0.05).
Peri-articular shoulder disorder patients who underwent subacromial bursa injections using hyaluronidase and steroids showed greater functional improvements than those who were given only steroid injections.
Citations
To investigate the additive effect of sono-guided subacromial bursa injection of hyaluronate with steroid in patients with peri-articular shoulder disorders.
This prospective randomized controlled trial involved 26 patients who had shoulder pain. Group A, consisting of 13 patients, was treated with a sono-guided subacromial bursa injection containing a mixture of 0.5% lidocaine (5 ml) and triamcinolone 40 mg (1 ml), followed by injection with sodium hyaluronate (2 ml) once a week for 3 weeks. The other 13 patients (Group B) were treated with a sono-guided subacromial bursa injection containing a mixture of 0.5% lidocaine (5 ml) and triamcinolone 40 mg (1 ml) once a week for 3 weeks. The effects were assessed using a visual analogue scale (VAS) of shoulder pain, active range of motion (AROM), shoulder function assessment scale (SFA), shoulder disability questionnaire (SDQ) at study entry and every week from first injection until 4 weeks after the 1st injection (= 2 weeks after 3rd injection).
(1) Demographic features and all parameters measured before injection did not show a significant difference between the 2 groups. (2) Statistically significant improvements were shown in VAS, SFA, SDQ during the 1st, 2nd, and 4th week after the first injection in both groups (p<0.05). (3) SFA showed significant improvement at 1 week after injection only in group A (p<0.05). (4) AROM of internal rotation showed significant improvement at week 4 after the 1st injection only in group A (p<0.05).
Subacromial bursa injection of hyaluronate with steroid in patients with peri-articular shoulder disorders has additive effects on functional improvement of the affected shoulder, including the AROM of internal rotation.
Citations
The objectives of this study were to clarify the short-term effects of transforaminal epidural steroid injection (TFESI) for degenerative lumbar scoliosis combined with spinal stenosis (DLSS), and to extrapolate factors relating to the prognosis of treatment.
Thirty-six patients with lumbar radicular pain from DLSS were enrolled. Subjects were randomly assigned to one of two groups (steroid or lidocaine group). We compared the effect of pain suppression at 2, 4 and 12 weeks after the procedure between the two groups. Radiographic analysis included measurement of the Cobb's angle, the upper endplate obliquities of L3 and L4, and maximal lateral olisthy between two adjacent lumbar vertebrae. Sagittal plane measurement included lumbar lordosis, and thoracolumbar kyphosis. Statistical analysis of both radiographic and clinical parameters along with treatment outcome was performed to determine any significant correlations between the two.
There were no significant differences in the demographic data, initial visual analogue scale (VAS) or Oswestry disability index (ODI) between the steroid group (n=17) and the lidocaine group (n=19). Two, 4, and 12 weeks after injection VAS, ODI showed a significantly greater improvement in the steroid group compared to the lidocaine group (p<0.05). The radiographic and clinical parameters were not significantly correlated with treatment outcome.
Our findings suggest that fluoroscopic transforaminal epidural steroid injections appear to be an effective non-surgical treatment option for patients with degenerative lumbar scoliosis combined with spinal stenosis (DLSS) and radicular pain.
Citations
Method: Thirteen patients (24 hands) with CTS diagnosed clinically and electrophysiologically were included. All subjects were examined by ultrasonography with high-resolution linear array transducer and injected with 40 mg of triamcinolone acetonide. The ultrasonography was evaluated with regard to cross-sectional area and the flattening ratio of the median nerve and cross-sectional area of the flexor pollicis longus tenon at pisiform and hamate bone. After 4 weeks, the patients were re-evaluated with electrophysiologic study and ultrasonography. Results: Most patients (11/13) showed improvement of clinical symptoms and electrophysiologic parameters after the local steroid injection. The cross-sectional area of median nerve at pisiform using ultrasonography significantly decreased after the local steroid injection. However, flexor pollicis longus tendon did not show significant change after the injection. Conclusion: Local steroid injection in the patients with CTS caused improvement in ultrasonographic findings of median nerve. (J Korean Acad Rehab Med 2008; 32: 189-193)
Method: Seventeen patients with lumbar discogenic pain who have not received other interventional procedures were studied. After confirmation of needle placement into the discs by C-arm fluoroscopy, discogram was done. And 40 mg of triamcinolone and 0.5 cc of 2% lidocaine were injected into the nucleus. Correlation between degeneration and Visual Analogue Scale (VAS) was analyzed. The effects of steroid injection were evaluated using VAS and limitation of lumbar flexion at pre-injection, 1 week post-injection, 1 month post-injection, and 3 months post-injection. Changes over time were assessed statistically using ANOVA and chisquare.
Results: Correlation between degeneration and VAS was high (r=0.7). The averages of VAS reduced significantly from 6.1⁑1.6 at pre-injection, to 2.4⁑1.8 at 1 week post- injection, to 1.8⁑1.2 at 3 months post-injection, respectively (p＜0.05). The number of group of highly or moderately limited lumbar flexion was decreased from 10 at pre- injection to 4 at 1 day post-injection. Fourteen of 17 patients (82.4%) had a successful outcome reporting at least 50% reduction between pre and 3 months post-injection in VAS.
Conclusion: Intradiscal steroid injection was an effective treatment for patients with lumbar discogenic pain. (J Korean Acad Rehab Med 2003; 27: 240-244)
Method: We used 15 mdx and 15 control mice. To grade exercise loading, control and mdx mice were divided into free-living, exercise and immobilization groups. Free-living and exercise groups were further divided into steroid-treated and sham-treated groups to evaluate the effect of steroid administration. We measured the apoptotic changes using in situ DNA nick-end labling (TUNEL), DNA fragmentation assay and western blots for Bcl-2 and BAX.
Results: With TUNEL method, the largest number of myonuclei became positive in sham-treated exercise group while apoptosis was significantly reduced in steroid-treated exercise group in mdx mice. Steroid-treated free-living group showed higher rate of apoptotic change than sham-treated free-living group. With western blots for Bcl-2 and BAX, the value of BAX/Bcl-2 ratio was highest in sham-treated exercise group and among free living mdx mice, it was higher in steroid-treated group than sham-treated one.
Conclusion: Apoptosis can be minimized in free living condition while exercise loading or immobilization can cause apoptotic change in muscular dystrophy animal model. Steroid administration induces apoptosis in free living muscle and it alleviates apoptotic damage caused by exercise loading in mdx mice. (J Korean Acad Rehab Med 2003; 27: 232-239)
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: To investigate dose-related effects of repeated intraarticular steroid injection on the experimental arthritis.
Method: Twenty-four adult male rabbits received Zymosan A into their right knee joint for experimental arthritis. After a week, they were injected with 2 mg (group I; n=9), 10 mg (group II; n=7) or 20 mg (group III; n=8) triamcinolone acetonide into their right knee weekly interval for 4 weeks. We measured weekly changes of the weight and the mediolateral diameter of both knees for the calculation of edema index. 99mTechnetium pertechnate (99mTc) uptake measurement were performed before the first steroid injection and a week after the final steroid injection. All rabbits were sacrificed and histologic examinations of their proximal tibia were performed.
Results: A progressive weight loss and changes of edema index were evident for all rabbits (p＜0.05) and difference among the groups was not found (p＞0.05). 99mTc uptake significantly decreased after the steroid injection in group I (p＜0.05) but it was not profound in others (p＞0.05). In the histological findings, fibrillation-frayings and fissures of the surface were similar in all rabbits, but loss of nuclear stains and cyst formations were increased prominently in group III than group I (p＜0.05).
Conclusion: Low-dose repeated steroid intraarticular injections are safe and effective treatment in arthritis though no definite evidence of chondroprotection, and high-dose steroid injections accelerate degeneration of the arthritic cartilage.
Objective: To compare intraarticular steroid injection with and without capsular distension in the treatment of adhesive capsulitis of the shoulder
Method: Fifty-five cases those were clinically diagnosed as adhesive capsulitis of the shoulder were randomly assigned to one of two treatment groups. 28 cases were treated by intraarticular steroid injection with capsular distension (group 1) and 27 cases by steroid injection alone (group 2). They were evaluated by visual analogue scales, Cyriax stages of arthritis, and active shoulder range of motion (flexion, abduction, external rotation and internal rotation). Follow up assessments were made one week and one month after injection.
Results: There were no statistically significant differences in Cyriax stages and VAS between two groups. But in the group 1, shoulder range of motion showed significant improvement in flexion and internal rotation at one week, and flexion at one month.
Conclusion: Intraarticular steroid injection with cspsular distension had no advantage over steroid injection alone in pain reduction, but can help the patients to achieve better range of motion, especially flexion and internal rotation, in treatment of adhesive capsulitis of the shoulder.
Objective: The purpose of this study was to evaluate the anti-inflammatory effect of steroid in the neuroma plays a key role in the development of neuropathic pain.
Method: Materials consisted of 21 male Sprague-Dawley rats (8 weeks old, 180∼200 g), which were divided into a steroid (n=9) and control group (n=12). Neuropathic pain was produced by unilateral transection of the superior caudal trunks at the level between the S3 and S4 spinal nerves. We compared two groups of rats, the steroid group injecting 1 ml (40 mg) of Methylprednisolone (Depo-Medrol), and the control group injecting 1 ml of nomal saline on operation site just after operation.
Behavioral reactions to mechanical allodynia were checked using a von Frey hairs of 2.0 g (19.6 mN) bending force at pre-operation, post-operative 1, 4, 7, 10 & 14 day to evaluate the steroid effect on the development of neuropathic pain.
Results: The steroid group exhibited less tail-flick frequencies to mechanical stimulation: 14.8⁑17.0%, 28.1⁑18.3%, 38.1⁑28.3% at post-operative 4, 7, 10 days respectively in control group; 30.3⁑21.2% 43.6⁑21.3%, 47.2⁑20.8% at post-operative 4, 7, 10 days, respectively. But there was no significant difference between both groups at post-operative 14 days. The steriod reduced the pain at early stage of neuropathic pain development, but failed to decrease the pain level in late stage.
Conclusion: These results suggest that the steroid induced anti-inflammatory effect in the injured neuroma is not a key factor in the development of neuropathic pain.
Objective: To determine the therapeutic effect of transforaminal epidural injections in patients with refractory lumbar radicular pain.
Method: Thirty-five patients with lumbar radicular pain who did not receive any other interventional procedures were studied. Transforaminal epidurograms and epidural steroid injections via eighty-nine intervertebral foramens were performed under C-arm fluoroscopic visualization. After confirmation of proper needle placement, 20∼40 mg of triamcinolone and 1 cc of 2% lidocaine hydrochloride were injected into each safe triangle of the intervertebral foramen. Patients were evaluated for visual analogue scale (VAS) and straight leg raising (SLR) test at pre-injection, 1 week post-injection and 3 months post-injection. Changes over time were assessed statistically using ANOVA.
Results: The averages of VAS reduced significantly (p＜0.05) from 5.6⁑1.8 at pre-injection, to 3.5⁑1.7 at 1 week pos-tinjection, to 2.1⁑2.0 at 3 months post-injection, respectively. The averages of SLR augmented significantly (p＜0.05) from 51.6o⁑16.7o at pre-injection, to 66.6o⁑16.0o at 1 week post-injection, to 77.2o⁑15.1o at 3 months post-injection, respectively. Twenty-six out of thirty-five patients (74.3%) had a successful long-term outcome, reporting at least an over 50% reduction between pre-injection and 3 months post-injection in VAS.
Conclusion: Transforaminal epidural injection is an effective treatment for patients with lumbar radicular pain when evaluated after 1 week and 3 months post-injection.
Objective: The purpose of this study was to evaluate therapeutic effect of local steroid injection in carpal tunnel syndrome, and to make a comparison between therapeutic effect in patients with and without diabetic neuropathy.
Method: 30 patients (40 hands) with carpal tunnel syndrome diagnosed clinically and electrophysiologically were injected with 40mg of methylprednisone. Patients were evaluated with the visual analogue scale after 4 weeks and 8 weeks. According to the therapeutic responses, the patients were grouped into: excellent; good; poor; failed; recurrent.
Results: After 4 weeks, symptom relief was noted in the 95% of all cases: 100% of the patients without diabetic neuropathy; 82% of the patients with diabetic neuropathy. After 8 weeks, symptom relief was noted in the 82.5% of all cases: 86% of the patients without diabetic neuropathy; 73% of the patients with diabetic neuropathy. There was no statistically significant difference between the patients with and without diabetic neuropathy (p＞0.05).
Conclusion: We concluded that local steroid injection in carpal tunnel syndrome was an effective therapeutic modality for a short term and local steroid injection in the carpal tunnel syndrome with diabetic neuropathy diagnosed by palmar test also had a good effect.
Objective: To evaluate the efficacy of growth hormone in reversing glucocorticoid-induced musculoskeletal changes including osteoporosis and myopathy in rats.
Method: Experimental rats were divided into five groups and each group was composed of 10 rats. The group 1 was administered with saline, group 2 with growth hormone, group 3 with glucocorticoid, group 4 with combined dosages of growth hormone and glucocorticoid, and group 5 with glucocorticoid for 4 weeks and then growth hormone for another 4 weeks. All injections were carried out every other day for 8 weeks. The half of animals were sacrificed after 4 weeks and another half after 8 weeks in each group. The triceps surae muscle was biopsied and examined histologically for the evaluation of mean area of muscle fiber. The femur was removed and dissected for the measurement of its weight, length, and diameter. The bone mineral density of the femur was measured by a dual energy X-ray absorptiometer.
Results: Administration of growth hormone partially reversed the complications of steroid such as decrease in body weight, decrease in weight, length, diameter, and bone mineral density of femur, and decrease in mean area of muscle fiber.
Conclusion: This study indicated that growth hormone could be applied for the management of steroid-induced osteoporosis and myopathy.
Objective: To evaluate the efficacy of intra-articular hyaluronic acid and steroid injection in osteoarthritis of the knee.
Method: Among 653 patients with osteoarthritis, 531 patients were participated in this study. They were divided to three groups; A, treated with hyaluronic acid 2.5 ml intra-articular injection once a week for 5 times; B, hyaluronic acid 2.5 ml once a week for 5 times with triamcinolone 20 mg once at the first time; C, only triamcinolone 20 mg at the first time. Before injection, X-ray with standing view were checked and divided according to Kellgren's grade of osteoarthritis. The amount of pain relief was assessed by pain rating score (PRS) and visual analogue scale (VAS) 1 week before and 1 month after the treatment.
Results: The degree of pain relief by PRS and VAS were all improved at 1 month after injection compared with pre-injection status (p＜0.001). Intra-articular hyaluronic acid injection was more effective in Kellgren's grade I, II than in III, IV in pain relief and hyaluronic acid with steroid injection was more effective in III, IV.
Conclusion: The results suggest that intra-articular hyaluronic acid injection would be effective for the treatment of patients with osteoarthritis.
Objective: The goal of this study was to compare the therapeutic and the functional value between translaminar approach and transforaminal approach of epidural steroid injection in patient with refractory radicular pain.
Method: Among 31 patients with unilateral herniated nucleus pulposus (HNP) which was confirmed by physical examination and magnetic resonance imaging (MRI), 17 patients received a transforaminal approach and 14 patients received a translaminar approach. All patients were evaluated by independent observer and were checked by visual analogue scale (VAS), functional score before and 1 day, 2 weeks and 4 weeks after injection.
Results: The VAS of transforaminal approach was significantly lower than that of translaminar approach after 2 weeks and after 4 weeks (p＜0.05), although there were no statistical difference before and 1 day after injection. The functional score of transforaminal approach was significantly higher than that of translaminar approach after 4 weeks (p＜0.05), although there were no statistical difference before and 1 day, 2 weeks after injection. The translaminar approach needs more frequent injection (p＜0.05).
Conclusion: This study suggests that both translaminar approach and transforaminal approach could be valuable to the initial management of refractory radicular pain, but the duration of therapeutic effects was relatively short in translaminar approach. Transforaminal approach will be the promising treatment of refractory radicular pain, because it has better therapeutic efficacy, safety and longer duration of therapeutic effects than translaminar approach.
Objective: To determine the therapeutic efficacy of fluoroscopic and electrical stimulation guided perineural selective nerve root injection in cervical radiculopathy patients.
Method: The gold standard of the diagnosis of cervical radiculopathy was based on clinical features, MRI and electrodiagnostic findings. Considering the natural regression of pain in cervical radiculopathy, only patients (n=27, 14 male and 13 female) who had suffered from persisting or aggravating pain for at least 6 weeks or longer duration after the onset of symptoms, were received a selective nerve root injection (SNRI) of steroids to a target nerve root.
Patients were followed up at 2 weeks and 2 months, and interviewed via telephone or re-examined at an average of 37.8 weeks 68 weeks after injection by a independent physician. Criteria for a successful outcome were greater than 50% reduction of pain on visual analogue scale and an ability to return to previous level of function.
Results: High proportion of patients reported a successful outcome at 2 weeks (88.9%, 24 of 27 patients). Twenty-two of twenty-four patients reported the outcome at 2 months and 20 of 22 patients were followed up for an averrge period of 37.3 weeks. Among these 20 patients 19 patients satisfied with the result of SNRI at an average follow up period of 68 weeks. There was no significant difference of the efficacy according to the duration of the symptoms. There were no complications in any of the patients after injections.
Conclusion: Fluoroscopic and electrical stimulation guided selective nerve root injections of corticosteroids were an effective and safe treatment modality in cervical radiculopathy. These could be considered as a first line treatment before a surgical intervention in whom another conservative treatments are not effective.
Objective: The purpose of this study is to assess the changes of skin temperature quantitatively in the stroke patients with reflex sympathetic dystrophy syndrome (RSDS) using thermography according to their clinical phases as well as changes after treatment.
Method: Patient group was consisted of 17 stroke patients with RSDS. Mean onset time of RSDS after stroke was 10.6 weeks. All patients were assessed by triphasic bone scan and clinically classified by phase I, II, and III. Control group was consisted of 9 stroke patients without RSDS. Temperature difference between affected side and unaffected side in wrist and hand regions were assessed in all subjects using Thermovision 570 (Agema Infrared Systems, USA) when initial clinical diagnosis was made. Seven patients were reassessed after high dose steroid and physical therapy.
Results: In patients with phase I RSDS, affected wrist and hand showed higher temperature distribution than the unaffected side. On the other hand, patients with phase II and III showed lower temperature in the affected side. The mean temperature difference in patients with phase I RSDS was significantly greater than control group. After treatment, skin temperature of affected side was decreased in phase I patients, but increased in phase II patients. Skin temperature difference tended to be normalized after successful treatment.
Conclusion: Using thermography, temperature change of affected hand can be assessed quantitatively in stroke patients with RSDS. The thermography is considered to be a useful tool for evaluation of clinical phases and treatment effect in these patients.
For the management of refractory radicular pain, traditional injection techniques such as transcaudal or translumbar epidural steroid injection may be indicated. This epidural injection, done blindly, may result in improper needle placement. Fluoroscopically guided transforaminal epidural steroid injection and computerized tomography-controlled periganglionic foraminal steroid injection are selective nerve blocks. These procedures are useful for the diagnosis. The advantages of these procedures are precise anatomic location provided by fluoroscope or CT.
Intraforaminal or periganglionic steroid injection is useful in the treatment of radicular pain. Thus we introduce a case of selective epidural steroid injection in a patient with refractory radicular pain.
Objective: To observe histological changes of the intervertebral disc injected with intradiscal steroid and mollification of discogenic pain.
Method: A study group of 25 Sprague-Dawely rats was divided into five subgroups. A control group of 10 Sprague-Dawely rats was divided into five subgroups. The rats' intervertebral discs were exposed by an anterior surgical approach. For study group, the rats were injected intradiscally methylprednisolone acetate 4 mg (Depomedrol, 40 mg/ml) to the L4-L5 intervertebral disc, methylprednisolone sodium succinate 4 mg (Solumedrol, 40 mg/ml) to the L5-L6 intervertebral disc, and triamcinolone acetonide 4 mg (Triamcinolone, 40 mg/ml) to the L6-S1 intervertebral disc. For control group, the rats were injected intradiscally 0.1 ml of saline to the L5-L6 intervertebral disc and a needle was inserted in the L6-S1 intervertebral disc. The intervertebral discs were extracted after 1 week, 2 weeks, 3 weeks, 4 weeks, and 16 weeks. The extracted intervertebral discs were stained with Hematoxylin-Eosin and examined histomorphometrically.
Results: There is no significant histological change in either group until 4 weeks after the different types of steroid were injected. Focal fibrotic change was present in the Solumedrol and Triamcinolone injection subgroups after 16 weeks.
Conclusion: We concluded that rapid mollification of discogenic pain following intradiscal steroid injection may not result from histological change of the disc. Further biochemical study will be neccessary to clarify mollification mechanism of discogenic pain by intradiscal steroid injection.
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.
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