RESUMEN
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.
RESUMEN
PURPOSE: To assess the IOP-lowering effect of adding a mattress suture (Ahmed's suture) to non-penetrating deep sclerectomy (NPDS), in patients with open angle glaucoma over a 12-month follow-up period. METHODS: This is a randomized controlled study comparing 52 eyes with a sub-flap Ahmed's suture modified NPDS (group A) and 51 with a conventional NPDS (group B). Success of surgery was categorized as complete success if the IOP remained between 6 and 18 mmHg without medications and as qualified if topical medications were required. RESULTS: The post-operative IOP at the 1st week, 3rd, 6th, 9th & 12th months follow ups in group A were significantly lower (7.3 ± 2.1, 12.0 ± 2.3, 12.6 ± 2.7, 13.6 ± 3.4 & 13.8 ± 3.8 mmHg) than in B (9.2 ± 1.9, 14.0 ± 3.1, 14.8 ± 2.9, 15.4 ± 2.6 & 15.7 ± 2.7 mmHg) (p = 0.001, p = 0.001, p = 0.002, p = 0.027 & p = 0.029 respectively). The percentage of IOP reduction after 1 year was significantly higher in group A than in group B (49% vs. 36.5%). At the end of the 12-month follow-up, 81% of group A and 69% of group B were considered as complete success. Multivariate regression analysis showed lower 1st week post-operative IOP was associated with better outcome. CONCLUSION: In conclusion, the Ahmed's suture, a simple, novel and economic modification, maintains lower IOP levels and has a higher success rate over conventional DS, as it is 30% more effective in reducing the IOP.