What is the role of corticosteroids in therapeutic injections for pain management?

Updated: Jun 19, 2018
  • Author: Anthony H Wheeler, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Injectable corticosteroids have been traditionally advocated to treat pain and inflammation associated with a myriad of musculoskeletal conditions, except when infection or skin breakdown is present at the target site, or in patients with poorly controlled diabetes. [3] Several therapeutic actions have been proposed for their beneficial effects. [4] They reduce inflammation by inhibiting the synthesis or release of a number of proinflammatory substances, including arachidonic acid and its metabolites (eg, prostaglandins, leukotrienes), some cytokines (eg, interleukins 1 and 6, tumor necrosis factor-α), and other acute phase reactants. [5] Other proposed mechanisms of action include a direct membrane-stabilization effect, reversible inhibition of nociceptive C-fiber transmission, and modulation of nociceptive input within the dorsal horn substantia gelatinosa neurons.

Continuous large doses of a corticosteroid adversely affect collagen synthesis, and, therefore, connective tissue strength. [6, 7] Frequency of injections and dosages must be monitored by the practitioner to prevent generalized or focal immune suppression such as infection or impaired soft tissue healing. [3] Therefore, the amount of corticosteroids that can be applied over time to a specific tissue area can be detrimental, although the exact dose/time curve remains unknown. [3] Concomitant use of medications that alter corticosteroid effects or clearance is usually not salient when injections are provided intermittently.

Practitioner preference among commonly used injectable corticosteroids is often arbitrary. Corticosteroid esters have long been preferred because of their relative safety and efficacy. The relative solubility of these solutions is considered a factor when determining the appropriate injectate. [3] Highly soluble steroids such as betamethasone sodium phosphate-acetate are rapidly absorbed and pose a lower risk for connective tissue injury, such as tendon rupture, fat atrophy, and muscle wasting. Relatively insoluble steroid esters have a longer duration of action. [3]

Corticosteroids are among the most commonly used active substances for spinal intervention. Particulate steroids should not be placed into the cervical foramina, because foraminal arteries, specifically the radiculomedullary artery, can be occluded by the injection. Foraminal artery occlusion is also a consideration between spinal levels T10 to L4. Particulate steroids, when injected into a foraminal spinal artery, can cause paralysis, even death. [8]

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