Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA.
Pain Management Centers of America.
Pain Physician. 2020 Aug;23(4S):S319-S350.
Since the late 1940s, corticosteroids have been a mainstay class of agents in multiple interventional techniques and intra-articular injections. Exogenous glucocorticoids are structurally and pharmacologically similar to the endogenous hormones. As such, multiple actions of corticosteroids are exhibited, including those of anti-inflammatory and immunosuppressive effects. Epidural injections, with or without steroids, have been extensively used throughout the world. There are reports of epidural injections starting in 1901, with steroids being added to the local anesthetic since 1952, when steroids were administered into the sacral foramen.
Due to the extensive side effects of steroids in various injections, some have proposed limiting their use in epidurals and intraarticular injections. With the COVID-19 pandemic, the multiple side effects of the steroids have elevated the level of concern and recommendations have been made to utilize local anesthetic alone or the lowest dose of steroids. Fashioned from common expressions of the day, the term "steroid distancing" began to be used and proposed for intraarticular injections of the knee. Consequently, we sought to evaluate the evidence and feasibility of steroid distancing in interventional pain management.
This focused review of local anesthetics and steroids utilized in interventional pain management for epidural injections, peripheral nerve blocks, and intraarticular injections by multiple database searches. This is a focused narrative review and not a systematic review. Consequently, evidence synthesis was not performed traditionally, but was based on an overview of the available evidence.
No significant difference was identified based on whether steroids are added to local anesthetic or not for epidural as well as facet joint injections. However, there was not enough evidence to compare these two groups for peripheral intraarticular injections.
The present review is limited by the paucity of literature with bupivacaine alone or bupivacaine with steroids local anesthetic alone or with steroids of intraarticular injections of knee, hip, shoulder and other joints, and intraarticular facet joint injections.
This review shows an overall lack of significant difference between lidocaine alone and lidocaine with steroids in epidural injections. However, available evidence is limited for bupivacaine alone or with steroids. Evidence is also not available comparing local anesthetic alone with steroids for facet joint or peripheral joint intraarticular injections. Thus, it is concluded that local anesthetic with lidocaine may be utilized for epidural injections, with appropriate patient selection and steroids reserved for non-responsive patients with local anesthetic and with significant radiculitis.
自 20 世纪 40 年代末以来，皮质类固醇一直是多种介入技术和关节内注射的主要药物类别。外源性糖皮质激素在结构和药理学上与内源性激素相似。因此，皮质类固醇表现出多种作用，包括抗炎和免疫抑制作用。硬膜外注射（有或没有类固醇）在世界各地得到了广泛应用。有报道称，1901 年开始进行硬膜外注射，1952 年开始将类固醇加入局部麻醉剂中，当时将类固醇注入骶孔。
由于各种注射中类固醇的广泛副作用，有人建议限制其在硬膜外和关节内注射中的使用。随着 COVID-19 大流行，类固醇的多种副作用引起了人们的关注，并建议单独使用局部麻醉剂或使用最低剂量的类固醇。从当时常见的表达方式中，“类固醇隔离”一词开始被用于膝关节的关节内注射，并被提议使用。因此，我们试图评估在介入性疼痛管理中使用类固醇隔离的证据和可行性。
通过对多个数据库进行搜索，对硬膜外注射、周围神经阻滞和关节内注射中使用的局部麻醉剂和类固醇进行了局部麻醉剂和类固醇的重点综述。这是一项重点叙述性综述，而不是系统综述。因此，传统上没有进行证据综合，而是基于对现有证据的概述。
无论是否在硬膜外以及关节突关节注射中加入类固醇，都没有发现局部麻醉剂中加入类固醇与不加入类固醇之间有显著差异。然而，对于外周关节内注射，没有足够的证据来比较这两组。
本综述受到文献缺乏的限制，文献中仅有布比卡因单独或布比卡因加类固醇用于膝关节、髋关节、肩部和其他关节的关节内注射以及关节内关节突关节注射。
本综述显示，利多卡因单独使用与利多卡因加类固醇在硬膜外注射中的总体差异不显著。然而，单独使用布比卡因的证据有限，或与类固醇一起使用的证据也有限。也没有证据表明单独使用局部麻醉剂与关节内或关节突关节内注射时使用类固醇进行比较。因此，结论是，在适当的患者选择下，可在硬膜外注射中使用含有利多卡因的局部麻醉剂，并将类固醇保留给对局部麻醉剂和神经根炎无反应的患者。
