What are Knee Steroid Injections?

Knee steroid injections involve administration of medicine through a needle into your hip to relieve pain and inflammation. Cortisol is a hormone that is naturally produced in the human body and functions to reduce stress and inflammation. Steroids are synthetic drugs that resemble cortisol and are used in treating joint pain. Steroid injections are often combined with other treatment options such as physical therapy, other medications, and occupational therapy.

Indications

Steroid injections are recommended by your doctor if you suffer from painful knee conditions including:

• Knee osteoarthritis
• Rheumatoid arthritis
• Gout
• Knee Bursitis

Preparation 

Talk to your doctor about the medicines you are taking, especially blood-thinners. Inform your doctor if you are allergic to any medicines or anesthesia. A small amount of joint fluid may be extracted and sent for diagnosis prior to the procedure.

Technique

A joint injection usually involves the following steps:

• Your doctor may draw a few lines on the skin to mark the injection site. 
• Your skin at the injection site is cleaned with an antiseptic solution.
• The needle is injected into the soft tissue and advanced towards the joint and the drug is injected into the joint. Imaging guidance such as ultrasound or fluoroscopy may be used to accurately inject the drugs into the joint.
• The steroids may be injected into a vein, muscle, soft tissue, bursa or tendon.
• After the injection, the pressure is applied to the injection site and a bandage applied.

After the Procedure

You will need to spend some time in the recovery room under observation. At home:
You may be asked to ice the injection site.
Avoid heat exposure and any work that may stress your affected leg for a few days.
Take medications as prescribed.

Frequency of Injections

Joint injections may be effective for a few weeks to 6 months or longer. Treatment may involve one or more injections spread over a few weeks. Your doctor may schedule repeated treatments if necessary.

Complications

Complications are rare, but can involve:

• Allergic reactions
• Discoloration of skin
• Infection
• Bleeding
• Tendon Rupture

Advantages

Knee steroid injections have numerous advantages including:

• Helps restore the structure and function of the hip
• Reduces inflammation and pain
• May make oral medications unnecessary
• Avoids high doses of medicines which could cause side-effects

Contraindications

Knee steroid injections are not recommended if you:

• Are allergic to steroids
• Have diabetes or any hormone disorder
• Have a knee infection or any other infection in the body
• Have bleeding problem

What are Hip Steroid Injections?

Hip steroid injections involve administering medication through a needle into your hip joint to relieve pain and inflammation. Cortisol is a hormone that is naturally produced in the human body and functions to reduce stress and inflammation. Steroids are synthetic drugs that resemble cortisol and are used in treating joint pain. Steroid injections are often combined with other treatment options such as physical therapy, other medications, and occupational therapy.

Indications for Hip Steroid Injections

Hip steroid injections are recommended by your doctor if you have painful hip conditions including:

• Hip osteoarthritis
• Rheumatoid arthritis
• Gout
• Hip bursitis

Preparation

Talk to your doctor about the medicines you are taking, especially blood-thinners. Inform your doctor if you are allergic to any medicines or anesthesia. A small amount of joint fluid may be extracted and sent for diagnosis prior to the procedure.

Technique

A joint injection usually involves the following steps:

• Your doctor may draw a few lines on the skin to mark the injection site. 
• Your skin at the injection site is cleaned with an antiseptic solution.
• The needle is injected into the soft tissue and advanced towards the joint and the drug is injected into the joint. Imaging guidance such as ultrasound or fluoroscopy may be used to accurately inject the drugs into the joint.
• The steroids may be injected into a vein, muscle, soft tissue, bursa or tendon.
• After the injection, the pressure is applied to the injection site and a bandage applied.

After the Procedure

You will need to spend some time in the recovery room under observation.

At home:

• You may be asked to ice the injection site.
• Avoid heat exposure and any work that may stress your hip for a few days.
• Take medications as prescribed.

Frequency of Injections

Joint injections may be effective for a few weeks to 6 months or longer. Treatment may involve one or more injections spread over a few weeks. Your doctor may schedule repeat treatments if necessary.

Complications

Complications are rare, but can involve:

• Allergic reactions
• Discoloration of skin
• Infection
• Bleeding
• Tendon Rupture

Advantages

Hip steroid injections have numerous advantages including:

• Helps restore the structure and function of the hip
• Reduces inflammation and pain
• May eliminate the need for oral medications
• Avoids high doses of medicines which could cause side-effects

Contraindications

Hip steroid injections are not recommended if you:

• Are allergic to steroids
• Suffer from diabetes or any hormone disorder
• Have a hip infection or any other infection in the body
• Have bleeding problems

Disease Overview

Degenerative conditions of the spine such as a herniated disc and spinal stenosis may compress associated spinal nerves and cause back pain. This pain or numbness may extend to the parts of the body that the nerve supplies such as hips, buttocks, and legs. 

What is an Epidural Spinal Injection?

An epidural spinal injection is a non-surgical treatment option for relieving back pain. Your doctor usually suggests a non-surgical method to treat back pain, and epidural spinal injection is one of these preferences. In cases where you find no relief from this and other non-surgical methods, surgery is recommended.

What does the Epidural Spinal Injection Compose of?

Epidural spinal injections contain a strong anti-inflammatory agent called corticosteroid and an anesthetic for pain relief. It is not the same as epidural anesthesia given before childbirth to decrease labor pain. 

Epidural injections are administered into the epidural space of the spine. The epidural space is the space between the outermost covering of the spinal cord (dura mater) and the wall of the spinal canal. It is approximately 5 mm wide and is filled with spinal nerve roots, fat and small blood vessels.

Indications for Epidural Steroid Injection

Pain management in different conditions such as spinal stenosis, disc herniation, and arthritis can be performed through epidural injection. An epidural spinal injection may be employed both for diagnostic and therapeutic reasons.
Diagnostic purpose: Medication is administered to determine the specific nerve root involved in the spinal problem.
Therapeutic purpose: Medication is administered for inducing short- or long-term relief from pain and inflammation.

It is to be noted that epidural spinal injection is not a curative intervention; rather, it is a treatment tool to reduce discomfort so that rehabilitation programs such as physical therapy may be well executed.

Procedure of Epidural Steroid Injection

Epidural spinal injection is usually performed on an outpatient basis. The procedure involves the following steps: 

• You will be taken to the pre-op area where trained nursing staff prepares you for the procedure by measuring your vitals and reviewing your medications. Blood sugar and coagulation status may also be checked if needed. 
• You will then be taken to the procedure room and made to lie face down on a table. 
• The injection site is then cleansed and an injection of a local numbing agent is administered in the area so that you don’t feel pain during the procedure. 
• A thin hollow needle is then inserted into the epidural space, guided by fluoroscopic X-ray to place the needle in the correct position. This system provides real-time X-ray images of the position of the needle in the spine on a monitor for your surgeon to view.
• A contrast material is then injected through the accurately-placed hollow needle to confirm that the drug flows to the affected nerve when injected.
• When your doctor is satisfied with the position of the needle, the anesthetic drug and corticosteroid are injected through the same needle inserted in the spine.
• Finally, the needle is removed, and the injection site is covered with a dry, sterile bandage.

What can you Expect after Epidural Spinal Injection?

You may feel some pressure during the administration of the injection, but the procedure is generally painless. The procedure takes about 15-30 minutes to complete. After the injection, you are advised not to drive or return to work. You should rest and avoid any vigorous activities. Your surgeon may give specific post-care instructions. Please follow the instructions to recover faster.

Recovery Time following Epidural Spinal Injection

Patients may feel numbness in the arms or legs just after the procedure along with other side effects related to the anesthetic component that usually settles down within 1-8 hours. Patients may continue to feel some back pain, epidural spinal injections take about 24-72 hours before showing their pain-relieving action. In some cases, if the desired effect is not obtained, then reinjection may be recommended. The standard guidelines for steroid injections state a maximum of 3 injections per year. In case no relief is obtained from spinal injection, then surgery is considered as the final option. 

Risks and Complications following Epidural Spinal Injection

With any procedure, some risk factors will always be there. Likewise, epidural spinal injections have complications such as bleeding or infection at the injection site, pain during or after injection, post-injection headache, nerve injury, bladder dysfunction, fluid retention, respiratory arrest, epidural hematoma, and spinal cord infarction. Discuss with your doctor if you have any concerns prior to the procedure.

What are Peripheral Joint Injections?

Peripheral joint injections are injections administered into the joints of the limbs such as the shoulder, elbow, hip, knee, and joints of the hands and feet. They help diagnose and treat joint pain and inflammation and improve mobility.

When are Peripheral Joint Injections Recommended?

Peripheral joint injections are recommended when you have significant joint pain which does not respond to medications and you are not willing or able to undergo surgery.

Types of Peripheral Joint Injections

Corticosteroid Injections

Corticosteroid injections are used to treat symptoms of osteoarthritis by reducing inflammation in the treated joint. A local anesthetic may also be combined with the corticosteroid to provide immediate pain relief.

Hyaluronic acid injections

Hyaluronic acid is naturally present in joint fluid and acts as a lubricant and shock absorber. Osteoarthritis can result in depletion of this substance, thinning the joint fluid and increasing friction. Hyaluronic acid injections provide a natural supplement allowing the joint to function smoothly. It is usually recommended for the knee joint. Hyaluronic acid injections also have anti-inflammatory effects and may even promote the production of natural hyaluronic acid in the knee.

Platelet Rich Plasma (PRP) Injections

This injection contains a fluid rich in platelets which are prepared from your own blood. Platelets contain a lot of growth factors that promote healing. Studies show that PRP even reduces inflammation.

Placental Tissue matrix Injections

This is an injection prepared from donated placental tissue following a healthy delivery. Placental tissue does not trigger the immune system and is hence found to be effective in many patients. The growth factors in the placental tissue promote healing.

Arthrocentesis

Arthrocentesis is the removal of excess fluid that has accumulated in the joint using a hollow needle. This can bring immediate relief of symptoms. The fluid removed may be tested in the laboratory to evaluate your condition. Removal of excess fluid creates space so that injections can be administered, usually through the same site.

Talk to your doctor to learn which type of injection is best for your condition.

Peripheral Joint Injection Technique

A joint injection usually involves the following steps:

• Your doctor may draw a few lines on the skin to mark the injection site. 
• Your skin is cleaned with an antiseptic at the infection site.
• The needle is injected into the soft tissue and advanced towards the joint. The drug is injected into the joint. 
• Imaging guidance such as ultrasound or fluoroscopy may be used to accurately inject the drugs into the joint.
• A band-aid is usually placed over the injection site

Following a corticosteroid injection, you will experience immediate relief for a few hours due to the local anesthetic. Once this wears off, your joint may feel sore for about 3-5 days. Ice may be applied to the injection site. You can usually return to work the next day but should avoid strenuous activity for a day or two. The effect of the corticosteroid is more gradual and long-lasting. 

Joint injections may be effective for a few weeks to 6 months or longer. A single treatment may involve one or more injections spread out over a few weeks. Your doctor may schedule repeat treatments if indicated. 

Side Effects of Peripheral Joint Injections

Although peripheral joint injections are found to be effective in many patients, a few may experience pain, infection or an allergic reaction.

Corticosteroid injections given repeatedly over a long duration can result in the breakdown of cartilage so your doctor will limit the number of injections you receive. They are also known to increase blood glucose levels and may not be suitable for diabetic patients. Hyaluronic acid is considered a better option for diabetic patients. Oral anti-inflammatory medications are contraindicated while taking PRP injections.

Advantages of Peripheral Joint Injection

Peripheral joint injections are beneficial as they can provide better relief than other conservative methods often delaying or avoiding the need for surgery.

Advanced pain management techniques may be recommended for severe chronic pain.

What is chronic pain? 

Pain may be temporary or persistent. Pain which lasts several months is called chronic pain. 

Some conditions causing chronic pain include:

• Arthritis
• Lower back pain
• Cancer
• Nerve damage
• Multiple sclerosis
• Shingles
• Fibromyalgia
• Headache
• Fractures

Pain Management Interventions

Pain is usually managed by:

Drugs: These include over-the-counter analgesic and anti-inflammatory medications (NSAIDs), corticosteroids, opioids, muscle relaxants, antidepressant, and anticonvulsant medications.

Physical therapy: Including specific exercises for pain relief and improved function and physical modalities such as heat and cold application, electric current, and manual therapy

Alternative therapies: Including acupuncture, massage, and chiropractic treatments.

Advanced Pain Management Interventions 

To treat severe chronic pain your doctor may recommend advanced interventions such as:

Patient-controlled analgesia

This technique is useful for patients recovering from surgery. A computerized pump is activated by the patient at the press of a button when increased pain is felt and delivers analgesics through an IV line.  

Nerve blocks

A nerve or group of nerves transmitting pain impulses are blocked by drugs or radiation.

Trigger point injections

In certain conditions, muscles do not relax properly forming “knots” and may be associated with pain. Your doctor injects the site of the muscle knot to relieve pain. Trigger point injections are useful for muscle pain in the arms, legs, and back associated with conditions such as fibromyalgia and myofascial pain syndrome.

Surgical implants

An implant may be surgically placed to provide pain management. Commonly used implants include:
Intrathecal pumps: They are implanted in the skin and deliver pain medication to the intrathecal space in the spine to control pain

Spinal Cord Stimulation: This implant delivers electric signals to block pain impulses traveling through the spine to the brain. You can start and stop and control the intensity of the electrical impulses through a remote-control device.

Transcutaneous Electric Nerve Stimulation (TENS): Low-voltage electric current is delivered to the site of pain through electrodes on the skin. This stimulates nerves in the area to send impulses other than pain impulses which results in diminished pain.

Bioelectric Therapy: Bioelectric therapy involves the application of electrodes to the skin through which electric currents are delivered, preventing the transmission of pain impulses. It is also believed to stimulate the production of endorphins in your body which naturally relieves pain.

Psychological Therapy: When pain is associated with a psychological illness such as feelings of increased sadness, hopelessness and anger, your doctor may suggest various forms of psychological therapy to help you manage your pain. You will be taught various life skills and how to tackle difficult situations.

Multimodal Pain Management

The American Pain Society (APS) has proposed the use of multimodal pain management strategies to treat chronic pain and overcome the dangers of opioid addiction. 
This strategy of pain management is reported to be successful in many patients particularly during or after orthopedic surgery and has minimal side effects. 

Multimodal analgesic techniques target various pain pathways by the administration of two or more analgesic agents along with other nonpharmacologic pain management techniques.

Advantage of Multimodal Pain Management

Medications used to treat pain are often associated with side effects such as decreased energy level, impaired mobility, memory loss, etc. During multimodal pain management, the medications are combined to retain the analgesic effect and minimize their side effects.

What is Selective Nerve Block?

A selective nerve block is the injection of an anesthetic and steroid medication around the spinal nerve root to diagnose or treat pain. It is indicated to relieve pain, weakness, numbness and tingling sensation in your neck, back and extremities due to nerve injuries such as a pinched nerve and spinal stenosis (narrowing).

Procedure of Selective Nerve Block

A selective nerve block is an outpatient procedure during which you will lie on your stomach on an X-ray table and your doctor will administer a sedative intravenously to help you relax during the procedure. Your vitals will be constantly monitored. Your doctor locates the target site with the help of X-ray imaging. A contrast dye is used to ensure that the needle is accurately placed and the medication is then delivered to the target site to help relieve pain and inflammation. If the nerve block is performed as a diagnostic procedure, you will be instructed to note any changes in the levels of pain at different intervals. This helps your doctor evaluate which nerve is causing pain. The entire procedure takes approximately 15 to 30 minutes. 

Post-Procedure for Selective Nerve Block

You may have pain relief immediately after the injection, but pain may return after a few hours as the anesthesia wears off. The effects of the treatment will be usually noticed 2 or 3 days after the treatment. If you respond well to the first injection, you may be advised to have another injection after a period of time for better relief. 

Risks and Complications of Selective Nerve Block

With any procedure there may be risks, complications or side effects. The most common side effects of selective nerve block are pain (temporary), bruising, infection at the site of the injection and nerve damage. 
 

What is Cortisone?

Cortisone is a corticosteroid released by the adrenal gland in response to stress and is a potent anti-inflammatory agent. 

Indications for Cortisone Injections

Cortisone injections are recommended for injuries that cause pain and inflammation, and those that don’t require surgical treatment. 

Cortisone Injection Procedure

Artificial preparations containing cortisone are injected directly into the affected joint to relieve pain and reduce inflammation. The effects of cortisone injections may last for several weeks. 

Risks and Complications of Cortisone Injections

Cortisone injections offer significant relief in pain and inflammation; however, they may be associated with certain adverse effects. The most common side effect is a cortisone flare, a condition where cortisone crystallizes and causes severe pain for a brief period that lasts for a day or two. A cortisone flare can be minimized by applying ice to the injected area. Other adverse effects include whitening of the skin and infection at the injection site, or a transient elevation in blood sugar if you are diabetic.

Complex Pain

Complex pain may be caused due to multiple factors that are not always clearly understood. It may be secondary to malignant (cancerous) or non-malignant conditions.

Causes of Complex Pain 

Complex pain may occur because of:

• Nerve injury from surgery, infection, herniated discs or infections
• Bone and soft tissue injury that may occur because of accidents falls or trauma
• Organ pain such as pancreatic pain or abdominal pain
• Malignancy
• Stroke or heart attack

Management of Complex Pain Secondary to Non-Malignant Conditions

A combination of different treatments is generally provided to relieve complex pain conditions. The various treatment options for the management of complex pain secondary to non-malignant conditions include:

• Pain Relievers: Over-the-counter pain medications may be recommended to help ease mild pain. If the pain is severe, opioid medications at the appropriate doses may be prescribed by your doctor. The medications may be administered on the skin, orally or as injections.
• Antidepressants and anticonvulsants: These medications have proven to be effective in relieving pain caused due to nerve injury.
• Corticosteroid medication: These medications reduce inflammation and pain as well as promote healing of tissue.
• Bone-loss medication: These medications help prevent or reduce bone loss and can be effective in treating complex pain due to the chronic bone and joint conditions.
• Nerve-block injections: These injections block the transmission of pain signals through the nerves.
• Intrathecal drug pumps: Special pumps are attached to an implanted catheter, which delivers pain medications directly into your spinal fluid.
• Spinal cord stimulation: Tiny electrodes are inserted along your spine through which electrical current is delivered to the spinal cord to relieve pain.
• Transcutaneous electrical nerve stimulation: A special device called the TENS unit is used to stimulate nerve endings and reduce the perception of pain. 
• Physical therapy: Physical therapy improves your strength and mobility, which will help in the management of complex pain.
• Biofeedback: These are special techniques that help increase the awareness of your body sensations to better control your response to pain.

Management of Complex Pain Secondary to Malignant Conditions

Pain secondary to malignant conditions may be due to cancer itself, which may cause bone pain or spinal cord compression, or the treatments for cancer such as surgery, chemotherapy or radiation therapy. 

Pain medication may be prescribed by your doctor to be taken in the form of pills, skin patches, rectal suppositories, injections, or patient-controlled analgesia. When pain is severe, strong opioid medications will be prescribed by your doctor. You must strictly follow the instructions provided by your doctor regarding the dosage and how often you should take these medications to avoid side effects. Other medications and methods of pain relief as mentioned above may also be provided for the management of complex pain secondary to malignant conditions.