Comparing the Effectiveness and Safety of Dexamethasone, Methylprednisolone and Betamethasone in Lumbar Transforaminal Epidural Steroid Injections.

BACKGROUND: Particulate steroids are thought to exert their effects for long durations at injection sites. However, these types of steroids carry higher risks when used in epidural steroid injections. Catastrophic spinal cord complications, including sudden-onset paraplegia, have been reported due to intravascular particulate steroid preparations that cause embolisms and occlusion of blood vessels, resulting in spinal cord infarctions. Clinicians, therefore, recommend nonparticulate steroids to mitigate these adverse events. To our knowledge, this is the first retrospective study that addresses the effectiveness and safety of methylprednisolone, dexamethasone, and betamethasone when used in transforaminal epidural steroid injections (TFESIs) for the treatment of lumbar radiculopathy. OBJECTIVES: The primary goal of this study was to compare the proportion of patients who received injections of particulate steroids and required zero repeat injections within 12 months of their initial injection to the proportion of patients who received injections of nonparticulate steroids and also required zero repeat injections, as well as to compare the number of patients in the particulate cohort who required one or more repeat injections within 12 months of their initial injection to the number of patients in the nonparticulate cohort who required the same. The secondary goal was to evaluate the proportion of patients ultimately requiring surgery. STUDY DESIGN: This is a single-center, IRB-approved, retrospective study evaluating the safety and effectiveness of nonparticulate as compared to particulate steroid medications when used in TFESIs as minimally invasive treatments for chronic lumbar radiculopathy. SETTING: This study captured data (n = 1717) over a 4-year time frame (01/15/2018 to 01/15/2022). METHODS: The following data were collected from each patient's chart: age, gender, BMI, race, date of initial injection, number of repeat injections at the same lumbosacral level and on the same side within 12 months of the initial injection, and lumbar surgery date (if applicable). Inclusion criteria included: 1) having chronic low back pain of radicular etiology; 2) being at least 18 years old; 3) having experienced the failure of conservative therapy after 12 weeks (including physical therapy and/or medications); 4) having positive physical exam findings supporting nerve impingement (straight leg raise, slump test); and 5) showing lumbar MRI evidence of nerve impingement from disc herniation. Exclusion criteria included: 1) having received prior lumbar surgery at any level (L1-S1); 2) having been given prior TFESIs fewer than 6 months prior to initial injection; 3) having contracted a systemic infection at the proposed injection site; 4) undergoing active cancer treatment; and 5) having gotten any other spine injections. RESULTS: A significantly greater proportion of patients in the nonparticulate steroid cohort received 0 repeat injections (87.5% vs 71.4%, P < 0.001). The particulate steroid cohort demonstrated a significantly greater proportion of patients who received repeat injections within 12 months after the initial injections (12.5% vs 29.6%, P < 0.001). There were no significant differences among patients requiring surgery between the 2 cohorts. Other outcome measures included the identification of risk factors significantly associated with repeat injections. There was a statistically significant weak positive correlation between age and repeat injections (Pearson corr = 0.102; P < 0.001) and a weak negative correlation between ethnicity/race and repeat injections (point-biserial corr = -0.093; P < 0.001).  No adverse events were reported. LIMITATIONS: Not all clinicians included in this study used each of the 3 steroid types, and all clinicians used either particulate or nonparticulate steroids exclusively. CONCLUSIONS: Our study demonstrates that the clinical outcomes associated with TFESIs of nonparticulate steroids are superior to those associated with TFESIs of particulate steroids when either variety of medication is used to treat lumbar radiculopathy. This is the first study to include a clinically useful predictive model using information on laterality, age, and steroid type.

Comparison of Long-Term Healthcare Cost and Utilisation of Nonoperative and Surgical Management of Thumb CMC Arthritis.

Background: Thumb carpometacarpal joint (CMC) osteoarthritis is the most symptomatic hand arthritis but the long-term healthcare burden for managing this condition is unknown. We sought to compare total healthcare cost and utilisation for operative and nonoperative treatments of thumb CMC arthritis. Methods: We conducted a retrospective longitudinal analysis using a large nationwide insurance claims database. A total of 18,705 patients underwent CMC arthroplasty (trapeziectomy with or without ligament reconstruction tendon interposition) or steroid injections between 1 October 2015 and 31 December 2018. Primary outcomes, healthcare utilisation and costs were measured from 1 year pre-intervention to 3 years post-intervention. Generalised linear mixed effect models adjusted for potentially confounding factors such as the Elixhauser comorbidity score with propensity score matching were applied to evaluate the association between the primary outcomes and treatment type. Results: A total of 13,646 patients underwent treatment through steroid injections, and 5,059 patients underwent CMC arthroplasty. At 1 year preoperatively, the surgery group required $635 more healthcare costs (95% CI [594.28, 675.27]; p < 0.001) and consumed 42% more healthcare utilisation (95% CI [1.38, 1.46]; p < 0.0001) than the steroid injection group. At 3 years postoperatively, the surgery group required $846 less healthcare costs (95% CI [-883.07, -808.51], p < 0.0001) and had 51% less utilisation (95% CI [0.49, 0.53]; p < 0.0001) annually. Cumulatively over 3 years, the surgical group on average was $4,204 costlier than its counterpart secondary to surgical costs. Conclusions: CMC arthritis treatment incurs high healthcare cost and utilisation independent of other medical comorbidities. At 3 years postoperatively, the annual healthcare cost and utilisation for surgical patients were less than those for patients who underwent conservative management, but this difference was insufficient to offset the initial surgical cost. Level of Evidence: Level III (Therapeutic).

Cost-effectiveness of Transforaminal epidural steroid injections for patients with ACUTE sciatica: a randomized controlled trial.

BACKGROUND: Transforaminal epidural injections with steroids (TESI) are increasingly being used in patients sciatica. The STAR (steroids against radiculopathy)-trial aimed to evaluate the (cost-) effectiveness of TESI in patients with acute sciatica (< 8 weeks). This article contains the economic evaluation of the STAR-trial. METHODS: Participants were randomized to one of three study arms: Usual Care (UC), that is oral pain medication with or without physiotherapy, n = 45); intervention group 1: UC and transforaminal epidural steroid injection (TESI) 1 ml of 0.5% Levobupivacaine and 1 ml of 40 mg/ml Methylprednisolone and intervention group 2: UC and transforaminal epidural injection (TEI) with 1 ml of 0,5% Levobupivacaine and 1 ml of 0.9% NaCl (n = 50). The primary effect measure was health-related quality of life. Secondary outcomes were pain, functioning, and recovery. Costs were measured from a societal perspective, meaning that all costs were included, irrespective of who paid or benefited. Missing data were imputed using multiple imputation, and bootstrapping was used to estimate statistical uncertainty. RESULTS: None of the between-group differences in effects were statistically significant for any of the outcomes (QALY, back pain, leg pain, functioning, and global perceived effect) at the 26-weeks follow-up. The adjusted mean difference in total societal costs was €1718 (95% confidence interval [CI]: - 3020 to 6052) for comparison 1 (intervention group 1 versus usual care), €1640 (95%CI: - 3354 to 6106) for comparison 2 (intervention group 1 versus intervention group 2), and €770 (95%CI: - 3758 to 5702) for comparison 3 (intervention group 2 versus usual care). Except for the intervention costs, none of the aggregate and disaggregate cost differences were statistically significant. The maximum probability of all interventions being cost-effective compared to the control was low (< 0.7) for all effect measures. CONCLUSION: These results suggest that adding TESI (or TEI) to usual care is not cost-effective compared to usual care in patients with acute sciatica (< 8 weeks) from a societal perspective in a Dutch healthcare setting. TRIAL REGISTRATION: Dutch National trial register: NTR4457 (March, 6th, 2014).

Neuropsychiatric Side Effects After Lumbosacral Epidural Steroid Injections: A Prospective Cohort Study.

BACKGROUND: The central nervous system contains steroid receptors, particularly in the hypothalamic and limbic systems. These systems are responsible for driving certain emotions in humans, especially stress, anxiety, motivation, energy levels, and mood. Thus, corticosteroids may precipitate patients to experience these emotions. Most existing studies report neuropsychiatric side effects after oral or intravenous corticosteroids rather than epidural. OBJECTIVES: This study examines the neuropsychiatric side effects after epidural steroid injections (ESIs), with a focus on whether certain factors in patients' histories further exacerbate symptomatology. STUDY DESIGN: Prospective observational cohort study. SETTING: Fluoroscopy suite at an urban academic teaching hospital. METHODS: Patients were called 24 hours and one week after their ESIs and asked if they experienced certain neuropsychiatric symptoms more than usual compared to baseline. PATIENTS: Seventy-four patients undergoing a lumbosacral ESI (interlaminar (ILESI), caudal or transforaminal (TFESI)) were invited to take part in the study the day of his or her procedure. INTERVENTION/MEASUREMENT: Assessed whether psychiatric history, gender, race, type of ESI, or the number of levels injected affected frequency and duration of neuropsychiatric symptoms at one day and one week after an ESI. RESULTS: Significantly (P < 0.05) more patients with a psychiatric history experienced restlessness and irritability at day one than those without a psychiatric history. At week one, male gender (IRR 2.29, 95% CI 1.37, 3.83, P = 0.002), ILESI (IRR 7.75, 95% CI 1.03, 58.6, P = 0.047), and 2-level injections (IRR 2.14, 95% CI 1.13, 4.06, P = 0.019) were significantly associated to more total symptoms. LIMITATIONS: Single center study, reliance on subjective responses from patients, lack of follow-up after one week post-ESI. CONCLUSION(S): This study demonstrates that neuropsychiatric symptoms are rare overall after an ESI, though certain factors may influence patients experiencing these symptoms. Restlessness and irritability were more likely to occur one day after an ESI in those with a psychiatric history. Those who had a 2-level injection were more likely to keep experiencing most symptoms by week one, suggesting a possible correlation between corticosteroid dose and neuropsychiatric symptoms.

Outcomes of Eyes Lost to Follow-up After Treatment With Intraocular or Periocular Steroid Injections.

Purpose: To evaluate the visual, intraocular pressure (IOP), and anatomic outcomes of eyes with loss to follow-up (LTFU) after intravitreal or periocular steroid injections. Methods: Patients receiving intraocular or periocular steroid injections and with LTFU for at least 180 days were included in this retrospective cohort study. Charts were reviewed for the visual acuity (VA), IOP, and central foveal thickness at the visit before LTFU, the first return visit, and 3, 6, and 12 months after return. Results: Fifty-three eyes of 47 patients were identified. The mean (±SD) age was 62.3 ± 14.9 years, the mean LTFU time was 295 ± 181.2 days (range, 182-1101), and the mean follow-up after return was 354 ± 339.3 days (range, 32-1141). The overall mean number of steroid injections was 5.2 ± 3.9 (range, 1-18). Compared with the mean logMAR VA at the visit before LTFU (0.59 [Snellen 20/77]), the mean VA remained stable at all timepoints after return as follows: return visit (0.62 [20/83]; P = .6), month 3 (0.55 [20/70]; P = .6), month 6 (0.55 [20/70]; P = .5), month 12 (0.64 [20/87]; P = .6), and final visit (0.69 [20/97]; P = .2). At the first return visit, 8 (15%) of 53 patients had an IOP of 21 mm Hg or higher (range, 21-31); 2 required treatment with a new antihypertensive medication (latanoprost and timolol, respectively). Conclusions: Patients with LTFU after receiving steroid injections maintained their VA. No patient required incisional glaucoma surgery. Compared with other etiologies, eyes with diabetic macular edema had a greater increase in IOP.

Efficacy and Safety of Triamcinolone Acetonide Injections Following Rhinoplasty: A Systematic Review of Recommended Doses, Complications, and Outcomes.

BACKGROUND: Triamcinolone acetonide injections (TAIs) have been suggested to decrease complications following rhinoplasty. This systematic review aimed to assess the efficacy and safety of TAIs following rhinoplasty. METHODS: We performed a systematic literature search on Medline, Embase, Google Scholar, and Cochrane Central Register of Controlled Trials from inception to May 2023, without any timeframe limitations. The following terms were used: (Triamcinolone OR steroid injections OR triamcinolone acetonide) AND (Skin thickness OR supratip edema OR supratip deformity OR Pollybeak deformity) AND (rhinoplasty OR external rhinoplasty). We included randomized controlled trials and observational studies (prospective, retrospective, and case series). RESULTS: In total, six of the 1604 articles met our inclusion criteria. A total of 1524 patients were included in this study. Our results included patient demographics, type of rhinoplasty, post-injection follow-up period, site of injection, type of syringe used, timing of the first dose, volume and concentration used, time interval between doses, response to the injection, and complications of injection. CONCLUSION: To our knowledge, this is the first systematic review to address this issue. Our results demonstrate the ease and safety of TAIs as a first-line treatment, with positive outcomes and limited complications. TAIs can be used early postoperatively to minimize the need for revision surgery. Despite the limited number of studies on TAIs, this study provides the best available evidence that can help surgeons decide when to use the injection, the intervals between doses, and the duration of use. Further randomized controlled trials are required to confirm our findings. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Transforaminal epidural steroid injection for radiculopathy and the evolution to surgical treatment: a pragmatic prospective observational multicenter study.

Aim: The aim of this study is to analyze the real-world outcomes of transforaminal epidural steroid injections (TFESIs) in all patients with radiculopathy and their long-term outcomes. Methods: Patients with radiculopathy and failure of conservative treatment were included in a prospective, multicenter, observational cohort study. Results: In total, 117 patients were treated with one or two TFESIs. The mean duration of follow-up was 116 (±14) weeks. In total 19,6% (95% CI: 12.9-28.0%) patients were treated with surgery after insufficient symptom improvement. The evolution to surgery was not associated with etiology, symptom duration or previous spine surgery. Conclusion: Real-world data confirms that TFESIs is an effective treatment with satisfactory results in about 80% of patients for a period of 2 years.

This study focusses on evaluating the real-world effectiveness of transforaminal epidural steroid injections (TFESIs) in treating radiculopathy, a condition characterized by back and leg pain due to compressed spinal nerves. This nerve compression can originate from different problems.A total of 117 patients with radiating leg pain were included in this study. The infiltrations were administered, and the primary outcome was the need for spinal surgery within 2 years. The findings revealed that approximately 20% of patients eventually required surgery due to unsatisfactory results after injections. However, for patients with satisfactory outcomes, there was a notable reduction in back and leg pain, disability and pain medication usage, along with an improved quality of life.Importantly, the results suggested that TFESIs could be considered as a treatment option in daily clinical practice, also after a prolonged duration of symptoms.Despite certain limitations, such as the absence of a control group undergoing immediate surgical treatment, the real-world data supported the effectiveness of TFESIs in treating radiculopathy. This information provides valuable insights for spine surgeons and pain physicians in understanding the prognosis of TFESIs across diverse patient scenarios.

Musculoskeletal injections for palliative treatment of neuromuscular hip dysplasia patients: how I do it.

This review describes our institution's standardized technique as well as potential pitfalls for therapeutic steroid injections in children with symptomatic neuromuscular hip dysplasia. Symptomatic, painful neuromuscular hip dysplasia can dramatically affect quality of life. Steroid injections are used to identify the source of perceived pain, temporarily treat pain while awaiting surgical intervention, or for therapeutic management for nonoperative hip joints.

A systematic review and network meta-analysis comparing different epidural steroid injection approaches.

BACKGROUND: Low back pain (LBP) and lumbosacral radiculopathy are frequent disorders that cause nerve root injury, resulting in a variety of symptoms ranging from loss of sensation to loss of motor function depending on the degree of nerve compression. OBJECTIVES: The goal of this study was to investigate the effectiveness of various epidural injection procedures in adult LBP patients. STUDY DESIGN: Systematic review and network meta-analysis. SETTING: Egypt. METHODS: PubMed, Scopus, Web of Science, Cochrane Database, and Embase were used to conduct an electronic literature search. We included RCTs, cohorts, case controls, patients 30 years old with a clinical presentation of low back pain, and comprehensive data on the effects of the intervention on patients with lumbosacral radicular pain who got epidural steroid injections via various techniques. Only papers written in English were eligible. RESULTS: Our analysis showed that parasagittal intralaminar (PIL) was the most effective approach in decreasing VAS (0-10) in the short term (< 6 months) (MD = -1.16 [95% CI -2.04, -0.28]). The next significant approach was transforaminal (TF) (MD = -0.37 [95% CI -1.14, -0.32]) in the long term; TF was the most effective approach (MD = -0.56 [95% CI -1, -0.13]). According to VAS (0-100) in the short term (< 6 months), our analysis showed an insignificant difference among the injection approaches and in the long term; TF was the most effective approach (MD = -24.20 [95% CI -43.80, -4.60]) and the next significant approach was PIL (MD = -23.89 [95% CI -45.78, -1.99]). LIMITATIONS: The main limitations are the heterogeneity encountered in some of our analyses in addition to studies assessed as high risk of bias in some domains. CONCLUSION: TF was the most effective steroid injection approach. In decreasing VAS for short-term PIL and TF were the most significant approaches, but TF was the most effective approach in decreasing VAS for the long term. Also, TF was the most effective approach in decreasing ODI for the long term.

The Subglottic Stenosis 6 Questionnaire: A Novel Quality-of-Life Survey Validated to Predict Need for Intervention in Patients With Idiopathic Subglottic Stenosis.

BACKGROUND: Idiopathic subglottic stenosis (iSGS) is a recurrent, chronic disease defined by fibroinflammatory narrowing of the subglottic airway. A key challenge in treatment is monitoring disease progression, which may be debilitating and unpredictable in its timing. RESEARCH QUESTION: Can the Subglottic Stenosis 6 (SGS-6) questionnaire be validated as a novel quality-of-life (QOL) instrument to monitor breathing, disease progression, and disease severity proactively in patients with iSGS? STUDY DESIGN AND METHODS: Panel data from 51 patients with iSGS were collected from January 2012 through June 2022, representing 1,684 patient encounters including routine office visits and treatment encounters. Subjective QOL scores (including the novel SGS-6 and established RAND-36 and EuroQol Five Dimensions [EQ-5D] Visual Analog Scale) and objective pulmonary function test (PFT) results were collected at each visit. Subjective SGS-6 QOL scores were repeated within 1 week of initial reporting. Panel regression analyses were performed to assess the relationship between SGS-6 scores, PFT results, and a patient's need for intervention. Minimal clinically important differences (MCIDs) for SGS-6 and peak expiratory flow percentage (PEF%) were assessed using receiver operating characteristic (ROC) curve analysis and a patient's need for intervention as the external anchor. RESULTS: Each one-point increase in SGS-6 score (of a maximum of 27) was associated with a 3.26% decrease in PEF%, a 1.93-point decrease in RAND-36 Physical Health composite score, a 1.27-point decrease in RAND-36 Mental Health composite score, and a 0.88-point decrease in EQ-5D Visual Analog Scale score. The intracorrelation coefficient for the SGS-6 composite score is 0.838 (95% CI, 0.770-0.888). Compared with patient baselines, SGS-6 scores were 4.66 points greater at the time of intervention with an MCID of 2.25 from a patient's baseline. The area under the ROC curve for SGS-6 and a patient's intervention point was 0.81. INTERPRETATION: iSGS disease severity can be modeled using the SGS-6 questionnaire, offering physicians and patients a potentially new method of tracking disease progression and need for intervention remotely.

Framework and guide for intralesional steroid injections in idiopathic granulomatous mastitis.

PURPOSE: Literature on how to perform intralesional steroid injections, a valuable therapy for idiopathic granulomatous mastitis (IGM), is limited. This technical note offers a detailed technical guide on intralesional steroid injections for IGM and provides a framework for long-term follow-up. METHODS: Ultrasound characterization of IGM severity considering breadth, depth, and ancillary findings was used to guide steroid dosing and injection frequency. Clinical and sonographic breast diagrams were designed for accurate longitudinal tracking of IGM. A step-by-step guide for ultrasound-guided IGM aspirations and intralesional steroid injections was developed. RESULTS: A detailed approach for ultrasound-guided IGM interventions with clinical and sonographic breast diagrams for longitudinal follow-up is now in practice. CONCLUSIONS: The treatment approach described provides a framework for multidisciplinary treatment of IGM and offers insights that may contribute to the ongoing development and improvement of management strategies for this challenging disease.

Efficacy of Caudal Epidural Steroid Injections in Chronic Low Backache Patients.

Background: Caudal epidural steroid injections are the popular treatment for patients with chronic low back aches (LBA) and radiculopathy, pain that radiates down the legs. These injections are typically given in the lower back, and their purpose is to reduce inflammation and pain caused by a herniated disc or other issues in the lumbosacral spine. Studies have generally found that caudal epidural steroid injections effectively manage chronic LBP, although they may not provide long-term relief in all cases. It is essential to remember that these injections should be combined with other forms of conservative management, such as physical therapy, before considering more invasive interventions. Materials and Methods: A prospective analysis is performed at the Orthopedics Department At The Hind Institute Of Medical Sciences In Sitapur, Uttar Pradesh, India, over two years. In the study, 80 patients with chronic low back pain and symptoms that did not improve with conservative therapies. The patients are clinically examined before and after receiving a cervical epidural steroid injection (CESI) based on their ability to perform daily activities and work using the Oswestry disability index (ODI) and visual analog scale (VAS). Results: The experiment was conducted with 165 CESI administered to 120 patients. A single injection is given to 85 patients; two injections are given to 25 patients, and 10 patients receive three injections. Of the 120 patients, 50 were male, and 70 were female, all of whom had chronic LBA. Of the 120 cases of LBA, 37 were diagnosed with lumbar disc herniation, 11 with lumbar canal stenosis, and 22 with degenerative disc disease. The remaining 50 cases were classified as non-specific LBA. Follow-up evaluations were conducted 1 week, 1 month, and 3 months after that, till 12 months of treatment. The mean pre-CESI VAS score was 7.11, and the mean post-CESI VAS score was 4.82 after one year of treatment. The mean ODI score before CESI treatment was 59.12; after CESI treatment for a full year, it was 44.64. We observed excellent outcomes in 27.5% of patients, good outcomes in 38.33%, fair outcomes in 21.67%, and bad outcomes in 12.5% of patients. Conclusion: Patients who experience chronic function aches can dramatically reduce their discomfort with the help of CESIs.

Posterior pedicle screw fixation combined with local steroid injections for treating axial eosinophilic granulomas and atlantoaxial dislocation: A case report.

BACKGROUND: Eosinophilic granuloma (EG) is a proliferative condition that affects the cells of bone tissue. There are no specific clinical signs or imaging manifestations in the early stages of the disease, making it simple to overlook and misdiagnose. Because of the disease's rarity, there is presently no standardized treatment principle. There are few accounts of such occurrences affecting the axis among children. We discovered a case of a child whose EG resulted in atlantoaxial joint dislocation and destruction of the axial bone. CASE SUMMARY: After having pharyngeal discomfort for more than six months without a clear explanation, a 6-year-old boy was brought to our hospital. Following a careful evaluation, the pathology indicated a strong likelihood of an axial EG. Ultimately, we decided to treat the boy with posterior pedicle screw fixation and local steroid injections. CONCLUSION: EGs of the upper cervical spine are quite uncommon in children, and they are exceedingly easy to overlook or misdiagnose. Posterior pedicle screw fixation and local steroid injections are effective treatments for patients with axial EGs affecting the atlantoaxial junction.

A Change in Global Sagittal Alignment after Transforaminal Epidural Steroid Injections in Lumbar Spinal Stenosis.

Patients' functional adaptation to pain can affect global sagittal alignment. This study evaluated the short-term spinal sagittal alignment change after transforaminal epidural steroid injection (TFESI) in lumbar spinal stenosis patients. Patients with lumbar spinal stenosis who underwent TFESI were retrospectively examined. Clinical outcomes were assessed using the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). Before and two weeks after the intervention, whole-spine lateral standing view radiographs were taken. Radiographic parameters including the Sagittal Vertical Axis (SVA), C2C7 Cobb, Thoracic Kyphosis (TK), Lumbar Lordosis (LL), Pelvic Incidence (PI), Pelvic Tilt (PT), Sacral Slope (SS), and Lumbopelvic Mismatch (PI-LL) were measured. Ninety-nine patients (mean age 64.3 ± 9.2 years) were included in this study. Both VAS and ODI outcomes were statistically improved after two weeks of intervention. Radiographic parameters showed that SVA, PT, and PI-LL mismatch were significantly decreased, while C2C7 Cobb, TK, SS, and LL were significantly increased after the intervention. SVA was improved by 29.81% (52.76 ± 52.22 mm to 37.03 ± 41.07 mm, p < 0.001). PT also decreased significantly from 28.71° ± 10.22° to 23.84° ± 9.96° (p < 0.001). Transforaminal epidural steroid injection (TFESI) significantly improves VAS, ODI, and global sagittal parameters in lumbar spinal stenosis patients.

MANIFESTATIONS AND TREATMENT OF LOWER BACK PAIN SYNDROME IN WARTIME.

OBJECTIVE: The aim: To improve treatment of patients with lower back pain through identification of pathogenetic factors in its formation. PATIENTS AND METHODS: Materials and methods: The early results of treatment of 84 patients with lower back pain (main group) were analysed. Patients of the main group were divided into two subgroups: one group involved patients with mental disorders, the other - patients not suffering from such disorders (the Spielberger-Hanin Anxiety Test used). The patients of the main group with mental disorders (49 patients) were administered with epidural steroid injections and antidepressants. The patients with no mental disorders (35 patients) were administered with epidural steroid injections only. The control group involved 36 patients with lower back pain who did not undergo any psychological testing and were administered with epidural steroid injections only. The Visual Analog Scale (VAS) and the Oswestry Disability Index questionnaire were used to assess pain syndrome. The assessment was carried out twice: in the pre-operative period and in three months after the treatment. RESULTS: Results: A significant difference in the early treatment results between the main and control groups was established according to both the Visual Analog Scale and the Oswestry Disability Index in favour of the main group patients, who were differentiated by pathogenetic factors of the pain syndrome formation. CONCLUSION: Conclusions: Lower back pain syndrome necessitates clarification of its components in order to develop pathogenically based treatment.

Prognostic factors related to recurrence of trigger finger after open surgical release in adults.

INTRODUCTION: Recurrent trigger finger after surgery is one of the major adverse events. However, studies to identify factors associated with recurrence after open surgical release in adult trigger finger patients are still limited. PURPOSE: To identify factors associated with recurrent trigger finger after open surgical release. METHODS: This 12-year retrospective observational study included 723 patients with 841 trigger fingers who underwent open A1 pulley release. Patients were categorized into 2 groups: those with recurrent trigger finger after surgery and those without. Associations between potential predictors including age, sex, duration of symptoms, occupation status, active smoker status, number of steroid injections before surgery, and types of comorbidities and the outcome of interest, recurrence of trigger finger, were examined using univariable and multivariable analyses. The results are presented as hazard ratios (HR) with a 95% confidence interval (95% CI). RESULTS: The recurrence rate after trigger finger release was 2.39% (20 of 841 fingers). After adjusting for confounders, more than 3 steroid injections before surgery and manual labor were the independent predictors of recurrent trigger finger (HR = 4.87, 95%CI = 1.06-22.35 and HR = 3.43, 95%CI = 1.15-10.23, respectively). CONCLUSIONS: More than 3 steroid injections before surgery and manual labor increase the risk of recurrent trigger finger after an open A1 pulley release. There may be limited benefit in administering a fourth steroid injection.

Cost-Effectiveness of Steroids for Prolonging the Surgery-Free Interval in Subglottic Stenosis.

OBJECTIVES: Repeat endoscopic dilation (ED) in the operating room for subglottic stenosis (SGS) remains an economic burden to patients. The cost-effectiveness (CE) of adjuvant serial intralesional steroid injections (SILSI) to prolong the surgery-free interval (SFI) in SGS patients requiring ED has yet to be studied. METHODS: Details of the cost of SILSI and ED were received from our tertiary academic center. SFI, cost of intervention, and the effect of SILSI on prolonging SFI were collected from a systematic review by Luke et al. SGS etiologies in the review included idiopathic, iatrogenic, or autoimmune. A break-even analysis, comparing the cost of SILSI alone with the cost of repeat ED, was performed to determine if SILSI injections were cost-effective in prolonging the SFI. RESULTS: Average extension of the SFI with SILSI was an additional 219.3 days compared to ED alone based on a systematic review of the literature. 41/55 (74.5%) cases did not require further ED once in-office SILSI management began. SILSI administered in a 4-dose series in 3-to-7-week intervals (~$7,564.00) is CE if the reported recurrence rate of SGS requiring ED (~$39,429.00) has an absolute risk reduction (ARR) of at least 19.18% with the use of SILSI. Based on the literature, SILSI prevents ~3 out of every 4 cases of SGS at sufficient follow-up from undergoing repeat ED, resulting in an ARR of ~75%. CONCLUSIONS: SILSI is economically reasonable if it prolongs the SFI of at least one case of recurrence out of 5. SILSI, therefore, can be CE in extending the interval for surgical ED. LEVEL OF EVIDENCE: NA Laryngoscope, 133:3436-3442, 2023.

The Benefit of Early Epidural Corticosteroid Injections for Acute Sciatica-Associated Lower Back Pain: A Four-Year Case Series in Lebanon.

Background Early epidural steroid injections are currently widely used for patients experiencing lumbago. However, there is uncertainty about their efficacy, such as the limitation of continuous drug infusion and the need for well-trained physicians on this technique. The main objective of this study was to evaluate the effectiveness of early epidural steroid injections in treating patients with acute sciatica in the lower back in terms of symptom relief and recurrence rate. Methods A case series was conducted in Lebanon from 2015 to 2019. We recruited 98 patients suffering from sciatica due to disc disease over three-time intervals: two weeks, one, and three months. The immediate results accounted for the intensity of various symptoms (numerical rating scale (NRS) for pain) and the assessment of patient satisfaction (Macnab criteria). Results The clinical results showed at least a three-point pain relief according to Numerical Rating Scale (NRS) and a good grade according to MacNab (P <0.001), with only 10.4% of the total population having a positive leg raise test post-injection. The maximum benefit was noted after two weeks from the injection with a 5.7 mean change in NRS (p<0.001) with a good/excellent response in MacNab and a 4.9 change with only a good response after one month. This study noticed a rebound phenomenon where around half of the patients needed two steroid injections after three months (39.6 % after three months and 17.9 % after six months). Conclusion Even though current guidelines worldwide may suggest the use of conservative treatment for low back pain with acute sciatica, our study has demonstrated the effectiveness of epidural steroid injections in the Lebanese population with a significant outcome.

Intralesional steroid injections for inflammatory nail dystrophies in the pediatric population.

Intralesional injections of triamcinolone acetonide are widely used to successfully treat several inflammatory nail conditions. This procedure is well described in adults, but less frequently reported in children and teenagers, being largely considered too invasive and fear-provoking for pediatric patients. Our report shows how this procedure is feasible and successful in children, even without a digital block. The step-by-step technique and tips to reduce pain should encourage clinicians to offer it as an alternative option to children with inflammatory nail disorders.

Long-Term Follow-up of 64 Patients With Idiopathic Subglottic Stenosis: Treatment Pathways, Outcomes, and Impact of Serial Intralesional Steroid Injections.

OBJECTIVE: To describe treatment pathways and long-term outcomes in 64 patients with idiopathic subglottic stenosis (iSGS), including the impact of serial intralesional steroid injection (SILSI) on degree of stenosis, need for subsequent operation, and patient-reported outcome measures. METHODS: Retrospective review of 64 female patients with iSGS undergoing varied management approaches, 57 of whom underwent SILSI as at least part of their care. Treatment pathways included SILSI only, endoscopic intervention followed by SILSI only, endoscopic interventions only, endoscopic intervention followed by SILSI followed by need for repeat endoscopic intervention, open surgery, and tracheotomy. Outcomes assessed included subjectively estimated percent airway stenosis, dyspnea index (DI), modified medical research council (MMRC) dyspnea scale, voice handicap index-10 (VHI-10), number of operative and office-based procedures performed, need for subsequent operative intervention, and inter-operative interval. RESULTS: Treatment pathways included SILSI alone (n = 6), endoscopic intervention(s) followed by SILSI only (n = 31), SILSI followed by additional endoscopic or office-based procedures (n = 16), open surgery (n = 3), and tracheostomy (n = 4). 57 of 64 patients underwent SILSI as at least part of their treatment. Inter-operative interval was increased after starting SILSI. Of patients undergoing SILSI, those with more procedures or shorter inter-operative interval prior to SILSI were more likely to return to the operating room. Estimated stenosis, DI, MMRC, and VHI-10 decreased with SILSI. Stenosis was not correlated with DI, MMRC, or VHI-10, though DI was correlated with both MMRC and VHI-10 score. CONCLUSION: Of 57 patients undergoing SILSI, 37 did not require further operative intervention. Improvements in inter-operative interval, dyspnea, and voice were observed across patients. Randomized trials to identify which patients may benefit most from SILSI are warranted.