Local steroid injection is commonly used as an adjunctive therapy in articular disease and soft tissue rheumatism. It may also be used as a bridge for earlier symptomatic relief in inflammatory arthritis, especially rheumatoid arthritis. In this article, we describe some of the general considerations of this procedure. In the next issues, we will describe specific techniques of injection of specific joints and soft tissue rheumatism lesions.published_or_final_versio

Ho, CTK

Lau, CS

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Title Intralesional steroid injection: General considerationsAuthor(s) Ho, CTK; Lau, CSCitation Hong Kong Practitioner, 1997, v. 19 n. 8, p. 425-429Issued Date 1997URL http://hdl.handle.net/10722/45064Rights Creative Commons: Attribution 3.0 Hong Kong LicenseCURRENT THERAPEUTICSIntralesional Steroid Injection: GeneralConsiderations+C T K Ho,* MBBS, MRCPC S Lau, MD, MRCPDepartment of MedicineThe University of Hong KongSummaryLocal steroid injection is commonly used as an adjunctive therapy in articular disease and soft tissuerheumatism. It may also be used as a bridge for earlier symptomatic relief in inflammatory arthritis, especiallyrheumatoid arthritis. In this article, we describe some of the general considerations of this procedure. In thenext issues, we will describe specific techniques of injection of specific joints and soft tissue rheumatismlesions. (HK Pract 1997; 19:425-429)*£ A;!IntroductionIn 1940, Thorn' injected l0 mghydrocortisone into the knee joint ofa patient with rheumatoid arthritis(RA). The knee improved locally,but the patient also improvedgenerally and it was concluded thatthe improvemen t resu l ted fromsystemic absorption of the intra-ar t icular ly injected material . Nofurther studies of intra-articularglucocorticoid injections were doneunt i l the early 1950s.2 In 1961,Hollander and associates3 reported aseries of more than 100,000injections of joints, bursae, or tendonsheaths in 4,000 pa t ien ts . Theresearchers called for attention tothe usefulness of in t ra les ionalglucocorticoids as temporary,p a l l i a t i v e , r e p e a t a b l e , l o c a ladjunctive treatment for a variety ofrheumatic conditions.Mechanism of action of in-tralesional glucocorticoidsThe anti- inflammatory mecha-nisms of systemically administeredglucocorticoids are s t i l l not ful lyunders tood . Even less is knowna b o u t t h e m e c h a n i s m s o fintralesional glucocorticoids. Afteran intralesional injection, a decreasein erythema, swe l l i ng , heat andtenderness of the tissues or joints isdemonstrated. An increase inviscosity and hyaluronate concentra-tion of the synovial f lu id is alsoobserved. In some s tudies ,i n t r a l e s i o n a l i n j ec t ion of g l u c o -corticoid has also been shown todecrease synovial pe rmeab i l i t y .Al though the disease process ofa r t h r i t i s may be suppressed to amajor degree, it is rarely "cured" by+ Editor's Note: This article is the first in a series of three articles on local steroid injection for rheumatic disorders.* Address for correspondence: Dr Carmen T K Ho, Registrar, Division of Rheumatology, Department of Medicine, The University of Hong Kong, QueenMary Hospital, Pokfulam Road, Hong Kong.425Intralesional Steroid InjectionCURRENT THERAPEUTICSthe corticosteroid injection. Otherconditions like capsulitis, bursitis, ortendinitis may sometimes be "cured"by single injections, but recurrenceof symptoms is not uncommon.Indications of intralesionalsteroid injectionsIntra-articular and soft tissueglucocorticoid injections areconsidered adjunctive therapy formost rheumatic conditions. Whenone or few peripheral jo in t s arei n f l a m e d or p a i n f u l f rom RA,osteoarthritis (OA) or gouty arthritis,glucocorticoid injections may providepalliation and facilitate physicaltherapy. Common soft t issuerheumatism, for example, bicipitaltendinitis, shoulder capsulitis, tenniselbow, de Querva in ' s disease(stenosing tenosynovitis of theextensor pollicis brevis and abductorpollicis longus) and sometimestrigger fingers can also be treatedwith intralesional glucocorticoidinjections. Table 1 summarises thecommon articular and non-articularlesions which may be amenable tolocal steroid injections.Precautions and contraindi-cationsStrict adherence to asepticprocedures is required when one isperforming intralesional injections.Because of potential tissue atrophywith glucocorticoids, one should useextreme caution when injecting nearperipheral nerves. Direct injectionof steroid to a nerve may result innecrosis or atrophy.There are no absolute contrain-dications for soft tissue injectionsexcept concurrent sepsis around thesite to be injected. However, morecautions are needed prior to infusingsteroid into a joint. It is prudent toexclude local or systemic sepsis. Ifin doubt, the joint fluid should firstbe examined for possible infection.Unstable joint, traumatic arthritiswith in t ra -a r t icu la r fractures, andsevere juxtaarticular osteoporosis areother important contraindications forintra-ar t icular steroid in jec t ions .Repeated steroid administration may,in some cases, result in jointinstabili ty and should be avoided.Table 2 shows the major con-traindications for in t ra -a r t i cu la rglucocorticoid injections.Table 1: Indications of intralesional steroid injectionsI. Articular disease:Rheumatoid arthritis (juvenile and adult)Crystal deposition disease (gout and pseudogout)Systemic lupus erythromatosus and mixed connective tissuedisease with frank arthritisOsteoarthritisShoulder periarthritis (adhesive capsulitis, frozen shoulder)Tietze's syndromeII. Nonarticular disease:ShoulderElbowWrist & Hand -HipKneePelvisBackFootbicipital tendinitissubacromial tendinitissupraspinatus tendinitisfrozen shoulderlateral epicondylitis - "tennis elbow"medial epicondylitis -"golfer's elbow"olecranon bursitisgangliondeQuervain's diseasetrigger (snapping) fingerscarpal tunnel syndrometrochanteric bursitisprepatellar bursitis and neuritisischial bursitisiliopectineal bursitisfibromyalgia trigger pointsAchilles tendinitisAchilles bursitiscalcaneal bursitis426Hong Kong Practitioner 19 (8) August 1997CURRENT THERAPEUTICSPeriarticular sepsisBacteriaemiaUnstable joints or severe joint destructionMost spinal jointsIntra-articutar fracturesSeptic arthritis: Do not forget the possibility of tuberculosisNondiarthrodial joints e.g. symphysis pubisMarked juxta-articular osteoporosisFailure to respond to prior injectionsMultiplicity of severe joint inflammationBleeding disorders e.g. haemophiliacsEfficacy of intralesionalsteroid injectionsA p p r o p r i a t e l y u sed , mostpatients show a good response tolocally administered glucocorticoids.However, the duration of symptomimprovement appears to be related tothe p r e p a r a t i o n u s e d . M e t h y l -prednisolone and triamcinolone arethe commonest preparations used.Table 3 s h o w s the l i s t ofglucocorticoid preparations available.Dramatic improvement in symptomsusual ly occurs within 12-24 hours,although responses among patientsare extremely varied. Soft t issueinflammatory conditions can be moreor less permanently eradicated byjudicious injections of steroids. Onthe other hand, if one or twoinjections prove ineffective or giveonly short-lived benefit, there is nologic in persis tent ly in jec t ing theIntralesional preparationsBetamethasone sodium phosphate and acetate suspension, 6mg/mlDexamethasone sodium phosphate, 4mg/mlDexamethasone acetate, 8mg/mlHydrocortisone acetate, 25mg/mlMethylprednisolone acetate, 20, 40, and 80 mg/ml (Depo-Medrol)Prednisolone terbutate, 20mg/mlTriamcinolone acetonide, 10 and 40mg/ml (Kenacort-10 and Kenacort-40)Triamcinolone hexacetonide, 20mg/ml (Aristospan)Prednisolone equivalents40mg30mg80mg5mg25mg, 50mg, and 100mg20mg12.5mg and 50mg25mg427Intralesional Steroid InjectionCURRENT THERAPEUTICSsame joint. A weight-bearing jointshould be rested as much as possibleafter an injection.Most clinicians will agree withthe fo l lowing dosage (in mgmethylprednisolone acetate):Small jointse.g. interphalangeal joints 4-20 mgMedium jointse.g. wrist 20-40 mgLarge jointse.g. knees, shoulders, ankles40-80 mgSoft tissue rheumatism:frozen shoulder 20-40 mgtennis/golfer's elbow 20-40 mgbursitis 20-40 mgIt is important to remember notto inject large volume of the agentinto a small joint which inthemselves can be painful.General techniques for in-tralesional steroid injectionIntralesional steroid injection isa safe and simple procedure that canbe carried out in the c l in ic setting.However, a no-touch technique andthe use of s teri le e q u i p m e n t andaqueous solut ion are mandatory.Prior to injection, it is important thatthe pa t ien t is reassured andpositioned correctly. The objectiveis to enter the selected injection siteand administer the steroid agent withthe minimal pain and trauma possibleto the structures. The use of localanaesthetics (LA) such as lignocaineprior to infiltration of steroid may be1. Position patient. Palpate the specific area and select an injectionsite.2. Mark the skin with firm pressure by the edge of a nail or aballpoint pen (that has its ink cartridge and point retracted). Thiswill leave a mark for 5-15 minutes.3. Draw up local anaesthetics and steroid agent. Cap the syringes toensure sterility.4. Wash hands and swab the skin with alcohol pads or a sterilesolution such as hibitane. Do not touch the skin after swabbing.5. Use 21-gauge needles for larger joints and 25-gauge needles forsmaller joints such as the finger joints.6. Inject local anaesthetics to the site. Spraying the site with ethylchloride may be an alternative as the cooling effects of the sprayhelps to numb the skin.7. Aspirate any excess fluid (for intra-articular injections). Sendfluid for microscopical examination.8. Take great care not to pull the needle out during changing of thesyringe after injection of local anaesthetics or aspiration of fluid.9. Infuse the steroid preparation into the site. Ensure that there isNO resistance during injection. The procedure MUST be haltedand the needle re-positioned if resistance is felt. Pain orparaesthesia remote from the injection site should also call a haltto the procedure.10. Apply sterile dressing and advise the patient to avoid excessiveuse of the limb in which the injection has taken place.Table 5: Potential sequelae of intralesional glucocorticoid injections1. Post-injection flare2. Iatrogenic infection-very low incidence3. Nerve damage4. Tissue atrophy, fat necrosis, calcification5. Tendon rupture6. Pancreatitis- extremely rare7. Radiological deterioration of joints: Charcot-like arthropathy8. Posterior subcapsular cataract428Hong Kong Practitioner 19 (8) August 1997useful as partial relief of symptomsfollowing injection of LA and alsoconfirms that the needle is correctlyplaced. Additionally, the use of LAmay help to prevent post-injectionpain which may be a localinflammatory reaction to steroidcrystals. Any excess joint fluidshould be aspirated and sent formicrobiology examination beforeinfiltration of the steroid preparation.Table 4 shows a step-by-stepprocedure for intralesional steroidinjections.Potential complications ofintralesional steroid injec-tions and recommendationsfor repeat injectionsTable 5 s u m m a r i s e s thepotential sequelae of intralesionalsteroid injections. It is important toremember to review the patient in 3-4 days' time to assess the efficacy orpossible complications of theinjection.As for repeat injections, a "ruleof 3" is highly recommended. Anylesion should not be injected morethan 3 times, and for arthritisconditions, repeat injections shouldpreferrably not be given within 3months. However, for soft t issuerheumatism, it may sometimes benecessary to repeat an injection after2-4 weeks.ConclusionIn conclusion, appropriate useof intralesional steroid injection is agood and safe adjunctive therapy formany art icular and soft tissuerheumatism disorders. It involvesonly simple techniques that can becarried out as a bedside procedure bymost general practitioners. With careto avoid sepsis, intralesional steroidinjection can be one of the mostgrat ifying procedures for bothphys ic ians and pat ients . Mostconditions improve after singletreatment although some patientsmay require to repeat administrationof the steroid agent to achievemaximum effects. •References1. Hollander JL. Arthrocentesis and intrasynovialtherapy. In: Arthritis and All ied Conditions9th edition. Philadelphia, Lea and Febiger,1979.2. Hollander JL. The local effects of compoundF (Hydrocortisone) injected into joints. BullRheum Dis. 1951;2:3.3. Hollander JL, Jesser RA, Brown EM Jr.Intrasynovial corticosteroid therapy: A decadeof use. Bull Rheum Dis. 1961;11:239.4. Hollander JL. Arthrocentesis Technique andInt rasynovia l Therapy. In: Arthritis andallied conditions llth edition. Eds: McCarty.5. Duncan S. Owen, Jr. Diagnostic tests andprocedures in Rheumatic diseases. In:Textbook of Rheumatology 5th edition. Eds:Kelley, Harris, Ruddy, Sledge.429

Intralesional steroid injection: General considerations

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Intralesional steroid injection: General considerations

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