Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections - guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, the International Pain and Spine Intervention Society, and the North American Spine Society

Honorio T. Benzon, Northwestern University Feinberg School of Medicine
Dalia Elmofty, The University of Chicago Medicine
Hariharan Shankar, Medical College of Wisconsin
Maunak Rana, The University of Chicago Medicine
Andrea L. Chadwick, University of Kansas Medical Center
Shalini Shah, University of California, Irvine
Dmitri Souza, Western Reserve Hospital
Ameet S. Nagpal, Medical University of South Carolina
Salahadin Abdi, The University of Texas MD Anderson Cancer Center
Christian Rafla, Loma Linda University Medical Center
Alaa Abd-Elsayed, University of Wisconsin School of Medicine and Public Health
Tina L. Doshi, Johns Hopkins Medicine
Maxim S. Eckmann, The University of Texas Health Science Center at San Antonio
Thanh D. Hoang, Walter Reed National Military Medical Center
Christine Hunt, Mayo Clinic in Jacksonville, Florida
Carlos A. Pino, Naval Medical Center San Diego
Jessica Rivera, LSU Health Sciences Center - New OrleansFollow
Byron J. Schneider, Vanderbilt University Medical Center
Alison Stout, Cleveland Clinic Foundation
Angela Stengel, American Society of Regional Anesthesia and Pain Medicine
Maged Mina, The University of Texas Health Science Center at San Antonio
John D. FitzGerald, University of California, Los Angeles
Joshua A. Hirsch, Massachusetts General Hospital
Ajay D. Wasan, University of Pittsburgh
Laxmaiah Manchikanti, University of Louisville Health Sciences Center
David Anthony Provenzano
Samer Narouze, University Hospitals Case Medical Center
Steven P. Cohen, Northwestern University Feinberg School of Medicine

Document Type

Article

Publication Date

8-7-2024

Publication Title

Regional Anesthesia and Pain Medicine

Abstract

Background There is potential for adverse events from corticosteroid injections, including increase in blood glucose, decrease in bone mineral density and suppression of the hypothalamic–pituitary axis. Published studies note that doses lower than those commonly injected provide similar benefit. Methods Development of the practice guideline was approved by the Board of Directors of American Society of Regional Anesthesia and Pain Medicine with several other societies agreeing to participate. The scope of guidelines was agreed on to include safety of the injection technique (landmark-guided, ultrasound or radiology-aided injections); effect of the addition of the corticosteroid on the efficacy of the injectate (local anesthetic or saline); and adverse events related to the injection. Based on preliminary discussions, it was decided to structure the topics into three separate guidelines as follows: (1) sympathetic, peripheral nerve blocks and trigger point injections; (2) joints; and (3) neuraxial, facet, sacroiliac joints and related topics (vaccine and anticoagulants). Experts were assigned topics to perform a comprehensive review of the literature and to draft statements and recommendations, which were refined and voted for consensus (≥75% agreement) using a modified Delphi process. The United States Preventive Services Task Force grading of evidence and strength of recommendation was followed. Results This guideline deals with the use and safety of corticosteroid injections for sympathetic, peripheral nerve blocks and trigger point injections for adult chronic pain conditions. All the statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Board of Directors of the participating societies also approved all the statements and recommendations. The safety of some procedures, including stellate blocks, lower extremity peripheral nerve blocks and some sites of trigger point injections, is improved by imaging guidance. The addition of non-particulate corticosteroid to the local anesthetic is beneficial in cluster headaches but not in other types of headaches. Corticosteroid may provide additional benefit in transverse abdominal plane blocks and ilioinguinal/iliohypogastric nerve blocks in postherniorrhaphy pain but there is no evidence for pudendal nerve blocks. There is minimal benefit for the use of corticosteroids in trigger point injections. Conclusions In this practice guideline, we provided recommendations on the use of corticosteroids in sympathetic blocks, peripheral nerve blocks, and trigger point injections to assist clinicians in making informed decisions.

PubMed ID

39019502

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