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CORTISONE INJECTIONS
What is a cortisone injection?
It is the
introduction of synthetic corticosteroid (cortisol) medication into
an affected area using a needle and syringe.
How does cortisone work in the
body?
Cortisol is a
hormone that occurs naturally in the body, secreted by the adrenal
glands. Cortisol (as well as the synthetic form given in cortisone
injections) has many important actions. Injections of cortisone are
most noted for it ability to suppress some parts of the immune
system that can lead to decreased inflammation and subsequent
reduction of pain in an affected area. Cortisone also affects the
metabolism of protein and glucose (sugar).
What is in a cortisone
injection?
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Cortisone:
Most cortisone that is injected into the body is synthetic analogue
of the body’s natural hormone, cortisol (hydrocortisone). There are
several kinds of corticosteroids that can be injected into the body
with various potencies, possible side effects, and length of time in
which they are expected to act and last. The amount of cortisone
chosen by your physician is determined by the amount estimated can
be held locally in that area.
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Novacaine:
This is a fast-acting numbing medication that is pre-mixed in the
syringe with the cortisone medication. It provides some immediate
relief while also serving to dilute the cortisone and help it reach
the entire problem area. For these reasons, more numbing medication
is used in proportion to cortisone. Your physician will choose the
appropriate amount of numbing medication for the given area to be
injected.
What kinds of orthopedic
problems can be helped with cortisone injections?
Cortisone
injections are used for inflammatory problems that can cause pain
and loss of function.
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Many kinds of arthritis can be helped with cortisone
injections, including rheumatoid arthritis, osteoarthritis
(“wear-and-tear” arthritis), gout, and pseudogout.
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Some inflammatory conditions in the tendons of the forearm,
wrist, and hand can be helped with cortisone, such as
epicondylitis (“tennis elbow”), trigger finger and de
Quervain’s tenosynovitis.
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Cortisone has also proven helpful for inflamed bursas, the
fluid-filled cushioning sacs present in joints, especially in the
hip (trochanteric bursitis) and shoulder (subacromial
bursitis or impingement syndrome).
How long does it take to get
relief from an injection and how long will it last?
Each patient has
a variable sensitivity to cortisone, and so it is impossible to
predict how well or long a cortisone injection will work for each
patient. Generally, cortisone used in an orthopedic setting starts
to take effect within one week, but may take up to two weeks for
maximal effect. It is important to note that cortisone injections
may not work at all for your problem because either your problem is
not primarily an inflammatory condition or your inflammatory
condition might be too advanced or far along in its course.
Cortisone injections are often an important “intermediary” treatment
option before more extensive treatment options are tried, and so it
is important to determine if they are helpful for you or not.
What are the potentially
negative side effects of cortisone injections?
Cortisone
injections are overall very safe and effective when used
appropriately. However, like any medication, cortisone can have
potentially negative side effects on the body in addition to their
positive effects.
Locally,
cortisone injections can cause post-injection flaring of pain, loss
of skin pigmentation, bleeding or bruising at the injection site, or
even infection in the soft tissues or within the joint. These side
effects may occur if too potent, too high of volume, or too
frequently injected medication is used, but more commonly occur as a
result of individual reaction to the medication. For example, it is
known that dark-skinned persons are more susceptible to
depigmentation side effects. Also, certain types of cortisone are
linked with more post-injection pain than others. Regarding
infections, these are rare, but if an infection occurs, it is
usually because cortisone works to suppress the immune system in
that area, and can make that area more vulnerable to the spread of
an already existing infection elsewhere in the body.
Cortisone
injections can also have systemic (whole body process) effects.
Flushing in the face can occur one to two days after an injection,
lasting for another one to two days, and is usually not concerning.
Diabetics receiving injections should be aware that administered
cortisone can temporarily suppress the production of the natural
cortisol hormone in the body. This can keep sugar from being
absorbed normally in the tissues, thus causing transient increased
blood sugar levels (hyperglycemia). Injections in diabetic patients
should not be feared with normal injection amounts, but nonetheless,
the possibility of impaired blood sugar control should be
considered.
Other more
concerning systemic side effects are the impaired ability to monitor
inflammation markers in the blood for patients with inflammatory
arthritis taking medications (an effect that can last up to six
months and make monitoring palliative drugs difficult), and rare
effects such as pancreatitis, uterine bleeding, or anaphylactic
shock (severe allergic reaction).
When should cortisone
injections not be used?
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Nerve injection.
Care should be taken to avoid injecting nerves. The results of
introducing cortisone into a nerve can be very damaging to that
nerve’s function, depending on how far into the nerve the cortisone
goes and what kind of cortisone is used. The effects can range from
“twinges” of pain from hitting the nerve with the needle, to altered
sensation and/ or transient inability to move an area the affected
nerve controls. The risk of nerve injection is a primary reason why
some conditions that might theoretically benefit from an injection
that can decrease inflammation (e.g. carpal tunnel syndrome), might
not be done routinely.
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Tendon
injection.
Care should be taken to avoid injection directly into a tendon or
ligament. Injections in these areas are not only extremely painful,
but can weaken and predispose these structures to rupture.
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Injection into
an infected area.
For reasons
already discussed above, cortisone suppresses the immune response in
the injected area, leading to decreased inflammation, but also a
increased vulnerability to the spread of existing infections in the
body.
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Too many
injections.
See below.
How many injections can I have?
We recommend
that a patient have no more than three cortisone injections a
year in a given body area with at least three months in between each
injection. Although it is known that cortisone decreases
inflammation in joints, there is still debate on its direct effects
on the cartilage and joint surfaces in the injected area. In
addition to the uptake of the cortisone into the bloodstream that
can lead to greater risks of systemic effects, the accumulation of
too much cortisone in a joint has been linked to actually
degenerate the cartilage on joint surfaces, which can lead to
increased rate of arthritis progression.
What are Synvisc/ Hyalgen
injections & what are they used to treat?
Synvisc or
Hyalgen injections are two different brands of similar medications.
These preparations are considered joint lubricants and are one of
the methods that can be used to treat early osteo-arthritis
conditions.
How does this type of injection
work?
The normal joint
has fluid called synovial fluid that flows throughout the joint
capsule. The synovial fluid has a naturally occurring substance
called hyaluronic acid (hyaluronan) that gives it lubricating and
shock absorbing properties in the joints. In osteo-arthritis, it is
believed that hyaluronic acid is decreased in the synovial fluid,
making the joint more prone to wear and tear arthritis. Synvisc/
Hyalgen are preparations with derivatives of the naturally occurring
hyaluronic acid that, when injected, are thought to stimulate the
formation of more natural hyaluronic acid and thereby decrease
inflammation in the arthritic joint.
What is the “dosing schedule”
for these injections? Can I have more than one course?
Both brands of
injections stay in the joint cavity for only a few days and
therefore need to be given weekly once started. Synvisc is given
once weekly for three weeks for a total of three injections and
Hyalgen is for five weeks for a total of five injections. Synvisc
requires at least four weeks between courses and no more than two
courses should be given in a six-month period. Hyalgen should not
be given more than six times in one month.
How likely will these
injections help my arthritis and for how long?
Synvisc/ Hyalgen
injections are an alternative conservative treatment method for
early osteo-arthritis. They provide one more option for patients
with arthritis, often when lifestyle modifications,
anti-inflammatory medications, and/ or cortisone injections have
already proven unsuccessful but surgery is not yet recommended.
Studies on Synvisc injections have shown that approximately 60% of
patients with early arthritis will receive relief from a full course
of three injections.
Who should not receive these
injections?
The medication
that is injected is derived from natural sources such as rooster
combs and should not be used in anyone allergic to feathers, eggs,
poultry, or vaccines that use products derived from eggs (including
yellow fever, influenza, rabies, and measles/ mumps/ rubella
vaccinations). In addition, these medications have not been tested
in children or pregnant women.
What is an epidural steroid
injection & what is it used to treat?
Epidural steroid
injections are injections of corticosteroid medication and local
anesthesia (numbing medication) into the lower back by means of a
syringe and needle. These type of injections are aimed at providing
relief from lower back pain conditions.
Where exactly in the back is
the medication injected?
Your physician
will specify the “level” of the spine where the medication needs to
be injected. Usually, this corresponds with the results found on
your physical examination or MRI scan. The medication is injected
into the epidural space around the nerve roots that exit the spine
and provide sensory and motor ability to the lower extremities.
Where will my epidural steroid
injection be done and who will perform the procedure?
Epidural steroid
injections are not performed in the office, but rather in an
outpatient setting in a hospital, pain clinic associated with a
hospital, or a diagnostic center. An anesthesiologist or
radiologist will perform these injections.
How does an epidural injection
work to help my symptoms?
ESI’s work
similarly to a cortisone injection in other joints
because the same medications are used. Local anesthetic and
cortisone medications are injected into the epidural space
surrounding the nerves within the spinal canal or injected directly
onto a specific nerve root to reduce inflammation (swelling and
irritation).
When are epidural steroid
injections not recommended?
ESI’s are not
recommended for patients who are pregnant or who are on blood
thinner medications (see recommended instructions below).
How often and how many epidural
steroid injections can be given?
If an initial
epidural steroid injection is found to be beneficial, up to a course
of three injections might be recommended. These will be spaced out
at least a week a part according to the recommendations by the
treating anesthesiologist or radiologist. Patients may receive more
than one course of three injections in their lifetime, but the
timing of all subsequent courses should be determined by the
treating physician.
Are there special instructions
I need to follow before receiving my injection?
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Patients who are on blood thinner medications should stop
these medications a minimum of five days prior to receiving an ESI
to avoid an increased risk for bleeding.
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Though not required, it is a good idea to eat a light
breakfast or avoid solid food for about three hours before the
procedure.
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It is important to have a driver present to take you home
after the injection procedure, or else the procedure might be
cancelled.
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