Steroid Distancing in Interventional Pain Management During COVID-19 and Beyond: Safe, Effective and Practical Approach

Abstract

Background: 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. Purpose: 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. Methods: 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. Results: 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 2 groups for peripheral intraarticular injections. Limitations: 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. Conclusion: 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. Key words: Steroid distancing, chronic pain, steroids, epidural injections, local anesthetic alone, local anesthetic with steroid, steroid distancing, physical distancing

Is Epidural Injection of Sodium Chloride Solution a True Placebo or an Active Control Agent? A Systematic Review and Meta-Analysis

“…The results of this study, although in agreement with multiple systematic reviews (12,15,(22)(23)(24)(25)(27)(28)(29)(30)(31)(32)(33) performed in the past showing positive results of epidural injections, are in conflict with other assessments (21,26). In recent years, multiple systematic reviews have been performed in interventional pain management, which have been described as appropriate with positive results, not only applying principles of placebo control and active control trials, and conventional meta-analysis and single-arm meta-analysis (10,12,18,(22)(23)(24)(25)(28)(29)(30)(31)(32)(33)80,(87)(88)(89)(90)(91)(92)(93)(94)(95)(96). Further, interventional techniques have been recommended by the authors and multiple agencies to utilize as a deterrent to the opioid epidemic (97,98).…”

“…Multiple systematic reviews and other types of analyses have reached discordant conclusions in reference to the effectiveness of steroids in managing spinal pain (12,15,18,(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33). Discordant conclusions are based on various challenges faced in the performance of systematic reviews of randomized controlled trials, with seeming lack of understanding of placebo control and the differences between active-and placebo-controlled studies, misinterpretation of evidence, and finally, conflicts and confluence of interest (12,21,26,27,(34)(35)(36)(37)(38)(39).…”

“…Thus there is more than a theoretical probability that sodium chloride solution placed into the epidural space is not a true placebo, exerting significant effects on nerve conduction providing pain relief and improvement in functional status with epidural administration (68)(69)(70)(71)(72)(73)(74). Conversely, the evidence of efficacy is lacking for epidural steroids without the addition of local anesthetic (15,25,(27)(28)(29)(30).…”

Efficacy of Radiofrequency Neurotomy in Chronic Low Back Pain: A Systematic Review and Meta-Analysis

“…3,4,8 In addition, the COVID-19 pandemic and the opioid epidemic have affected all aspects of human life, especially those of chronic pain sufferers. 3,4,17,[22][23][24][25][26][27][28] The pandemic has resulted in reduced access with modifications in treatment modalities, with increased psychological stressors, and suffering. 4,17,[22][23][24][25][26][27][28] The use of interventional techniques for the treatment of spinal pain increased exponentially until 2009, at which point utilization began to decrease.…”

“…3,4,17,[22][23][24][25][26][27][28] The pandemic has resulted in reduced access with modifications in treatment modalities, with increased psychological stressors, and suffering. 4,17,[22][23][24][25][26][27][28] The use of interventional techniques for the treatment of spinal pain increased exponentially until 2009, at which point utilization began to decrease. [8][9][10][11][12] Among these, facet joint interventions showed an overall 1.9% annual increase from 2009 to 2018 compared to 17% annual increases from 2000 to 2009.…”