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What steroids can we inject?

Quick history of injectable steroids

Hench in 1950 was awarded the Nobel Prize in Physiology for discovering that corticosteroids have important anti-inflammatory effects. 

Corticosteroids can be classified as mineralocorticoids (eg, aldosterone), which control water and electrolyte physiology, and glucocorticoids (egcortisol), which control metabolism and inflammation.

Initially Hydrocortisone was injected in joints by Hollander in 1951 who established the practice

A number of corticosteroid-like molecules have been synthesized to be used in drug therapy

Steroids used in musculoskeletal conditions:

Corticosteroids used in MSK injection therapy are synthetic derivatives of prednisolone​. Methylprednisolone is the methyl derivative of prednisolone.

Commonly injected steroids such as: Betamethasone, Dexamethasone, and Triamcinolone Acetonide are all fluorinated derivatives of prednisolone.

This modification decreases solubility and therefore increases duration of action​. They have been shown to be more highly associated with tendon rupture and subcutaneous atrophy compared with non-fluorinated compounds. Most clinicians recommend only using fluorinated corticosteroids for intra-articular injections, where there is minimal risk to soft tissues.

Water soluble steroids 

Betamethasone sodium phosphate and betamethasone acetate. Dexamethasone sodium phosphate SPC (Summary of Product Characteristics) for Betamethasone and Dexamethasone indicates for systemic usage only.​

The above freely water soluble preparations are taken up rapidly by cells and have a quicker onset of effect​. The disadvantage is that they also have a reduced duration of action.​

Depot Steroids

Most corticosteroid preparations contain corticosteroid esters, which are highly insoluble in water and form microcrystalline suspensions. The potential advantage of corticosteroid ester preparations is that they require hydrolysis by cellular ester-ases to release the active component and consequently should last longer in the joint than do non-ester preparations.

Steroid Particulates and injection therapy

Compounds with low solubility are well suited for intra-articular injections, they may not be appropriate for soft-tissue injections because of associated side effects, particularly atrophy of surrounding tissues.​

Particulate preparations are thought to act as a depot, which increases the duration of action through a continuous and slow release of the drug. It has been shown that particulate formulations offer a small but statistically significant clinical benefit (Brennan, 2019)

 

Common (long acting) particulate steroids on the market:

Common particulate preparations on the market:

Betamethasone sodium phosphate/ betamethasone acetate (Celestone Soluspan), Methylprednisolone acetate (DEPO-Medrol), Triamcinolone acetonide (Kenalog).

Common side effects of particulate steroids

Hypopigmentation:

Hypopigmentation is characterised by a lightening in skin colour, mostly affecting the peripheral cutaneous regions possibly due to thinner dermal layers.
It appears to affect people with darker skin (Ghunawat, 2018) and affects
Incidence: 1 to 4% of adults following local corticosteroid injection (Papadopoulos, 2009; Park, 2013)
The hypothesized etiology of hypopigmentation with corticosteroids relates to decreased melanocyte function. and the linear or streaky pattern often characteristic of hypopigmentation is due to lymphatic spread (Schwartz, 2012)
Re-pigmentation has been reported to occur as early as 1 month but may take up to 1 year for significant improvement (Kaur 2002, Saour, 2009)

Lymphatic spread

In the presence of low concentration of steroids it is bound to plasma proteins. When steroid concentration suddenly increases a small fraction of steroid is in a free state and allowed to enter cells.

It is thought that steroid molecules (Triamcinolone Acetonide) can then enter the lymphatic system causing a linear ray distribution of depigmentation (Schwartz, 2012)

Subcutaneous fat atrophy

Subcutaneous fat atrophy (lipoatrophy) is a serious adverse event that may occur following corticosteroid injection into soft tissue. It may be more common in women (Kim, Lee, & Lee, 2015).
Lymphatic spread into the dermal and subdermal tissues has been hypothesized as the mechanism the but cause still remains unknown.
High doses of corticosteroids have been implicated with Triamcinolone acetonide due to its larger molecular size and longer half-life (Kim et al., 2015). Although there are also reports of this occurring with Depomedrone.

Example of fat atrophy:

Summary:

  • Particulate steroids due to depots are thought to be more effective due to steroid releasing slowly over time.
  • Depomedrone is most suitable for superficial soft tissues.
  • Depomedrone is generally considered to cause fewer side effects in superficial soft tissue structures. Triamcinolone Acetonide has larger particulates and shows more aggregation than Depomedrone it is associated with more frequent side effects in soft tissue such as depigmentation and lipodystrophy (Kaur, 2002; Kikuchi, 1975).
  • Triamcinolone is generally recommended for larger joints and deeper located soft tissue structures
  • Triamcinolone Acetonide was shown in 2 out of 4 level 1 studies to be more effective than other steroids (Hepper: 2009).
  • Triamcinolone Hexacetonide is recommended in inflammatory joint conditions where it is more potent than other steroids (Blyth, 1994, Zulian, 2003) but the evidence does not show it to be superior for osteoarthritic knee conditions. (Dieppe, 1980, Friedman; 1980 and Gaffney; 1995)

 


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Carpal tunnel syndrome- is steroid injection helpful?

Carpal tunnel syndrome, what is it?

The carpal tunnel is located underneath the wrist crease overlying the wrist joint. The carpal tunnel is a protective tunnel of bone and has a ligament overlying the anatomical structures (Fig. 1). The transverse ligament is a thick ligament very much like a cable tie and keeps all the structures in place.

Carpal tunel graphic

Carpal tunnel syndrome

Many critical structures are tightly packed together within a small tunnel. The carpal tunnel syndrome can be caused by the tunnel becoming strained which can affect the structures running in the carpal tunnel. Nerve tissue is sensitive to small changes in pressure. This can cause nerve irritation and cause symptoms of carpal tunnel syndrome. The main symptoms are pain and numbness in the distribution of the median nerve (see Fig. 2). Compression of the nerve can also cause significant weakness of the musculature if more advanced.

If left untreated compression of the median nerve can cause lasting nerve damage. This can lead to permanent weakness and numbness and pain in the hand. It is therefore important to diagnose this problem early on and to treat it promptly.

We be discussing treatment options and pose the question what conservative treatments are helpful and especially injection therapy. So we can hopefully answer the question in the title of this article: Carpal tunnel injection- is it helpful?

 

Causes of carpal tunnel syndrome

There is still a lot unknown about carpal tunnel syndrome. We know that there are several factors that play a role in developing carpal tunnel syndrome.Physical repetitive activity could be a factor. There are other factors such as diabetes, hormonal changes such as during pregnancy and an underactive thyroid. These can all be contributing factors. A direct injury to the wrist can also cause damage to the median nerve the wrist joint. This in turn can also cause problems with the median nerve.

Treatment of carpal tunnel syndrome

The correct treatment of carpal tunnel syndrome depends on the accuracy of the diagnosis. The most important way to evaluate the carpal tunnel is simply by doing a thorough physical assessment. The Sonoscope ultrasound guided injection clinic has experts with many years of experience. They have successfully managed many hundreds of people with carpal tunnel syndrome.

The use of diagnostic ultrasound provides another level of information and often confirms the diagnosis made by physical examination. Ultrasoujd can detect nerve caliber changes along the nerve path which is commonly found in Carpal tunnel syndrome and can help to confirm the diagnosis.

If left untreated compression of the median nerve can cause lasting nerve damage. This can lead to permanent weakness and numbness and pain in the hand. It is therefore important to diagnose this problem early on and to treat it promptly.

Ultrasound guided injection

Carpal tunnel injection- is it helpful?

We would always advocate for this procedure to be done under ultrasound guidance. This will improve the accuracy of the procedure as well as the safety. Only those with a high level of diagnostic ultrasound and ultrasound guided injection expertise and who perform a significant number of these injections regularly should be performing ultrasound-guided injection for carpal tunnel syndrome as it is technically demanding.

Evidence:

Eslamian (et al, 2017) comparing both landmark guided with ultrasound guided injections concludes: that the evidence Both US-guided and LM-guided steroid injections were effective in reducing the symptoms, improving the function and electrodiagnostic findings of CTS. Although there was better symptomatic improvement with US-guided injections.

Safety:

In the hands of a highly trained expert in diagnostic ultrasound and ultrasound guided procedures the needle tip can be accurately monitored and steered to inject in the exact accurate location. This will reduce the risk of inadvertent nerve or vascular injury.

Comfort:

Accuracy and needle monitoring will also result in significantly less discomfort as it will allow the operator to avoid as much as possible pain sensitive structures.

 

Carpal tunnel decompression surgery: 

If the numbness and pain and or weakness don’t improve with other treatments, then surgery might be required. The surgery, known as carpal tunnel release or decompression surgery relieves pain by reducing the pressure on the median nerve. 

References:

Recovery from the surgery is usually less than a month, although it may take longer to get all the feeling back in your hand, especially if you’ve had the condition for a long time. 

Eslamian, F., Eftekharsadat, B., Babaei-Ghazani, A., Jahanjoo, F. and Zeinali, M., 2017. A randomized prospective comparison of ultrasound-guided and landmark-guided steroid injections for carpal tunnel syndrome. Journal of Clinical Neurophysiology34(2), pp.107-113.

References:

Eslamian, F., Eftekharsadat, B., Babaei-Ghazani, A., Jahanjoo, F. and Zeinali, M., 2017. A randomized prospective comparison of ultrasound-guided and landmark-guided steroid injections for carpal tunnel syndrome. Journal of Clinical Neurophysiology34(2), pp.107-113.


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How much does a steroid injection cost privately UK?

What is the cost of corticosteroid injections?

If you are in pain, and you don’t want to wait forever in the hospital queue, you might be considering a private ultrasound guided cortisone injection in the UK and you want to know exactly how much a steroid injection cost privately.

Unfortunately, there is no quick answer. Well, there is, but the answer is “it depends on where you live and the medical establishment you choose for your treatment”.

Researching the price of cortisone joint injections online, we found that there is a wide span of prices, starting from as low as £200 to more than £900.

What is the cost of joint injection procedures at Sonoscope?

Sonoscope offers a one stop clinic which includes:  Deatiled Initial clinical assessment with physical examination and diagnostic ultrasound and ultrasound guided injection all in a single appointment.

The One-Stop clinic model is not the norm. In other settings and in other clinics often times multiple visits are required. First a consultation then an ultrasound scan and in some cases yet another appointment for an ultrasound guided injection.

This is not just an inefficient practice but it is also far more costly, as every visit comes with a significant price tag, and three separate sessions can become very expensive!

At the same time having often multiple separate practitioners involved can lead to the potential missing of crucial clinical details that would not be missed if one expert clinician who is highly competent in all these disciplines  carries out the entire examination including ultrasound and injection all in one session!

Our price of ultrasound guided injections incluse your consulation fee your examination and ultrasound diagnosis as well as the injection itself!.

Find all our competitive treatment prices on the treatment cost page.

If during the diagnostic tests we find out your condition is not suitable for the injection shot treatment you will only be charged for the consultation and ultrasound scan and a report will be provided to you with our recommendations.

Are there any hidden costs?

No. We have a clear and transparent pricing policy and our quoted treatment price is all-inclusive with no hidden additional charges.

Which locations can I have an injection?

Sonoscope injection clinics are conveniently based in Hertfordshire, easily accessible and offer an efficient patient journey.

You can find more information about our clinics as well as how to book your appointment.

Contact us

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How long does a steroid injection take to work?

What steroids are commonly injected?

Many patients ask the question: How long does a steroid injection take to work? To answer that question we need to first look at the kind of type of steroid injected. This is one of the reasons that these are now commonly not used very much for joint and soft tissue conditions.

Highly soluble steroid injections such as hydrocortisone, were commonly injected for joint and soft tissue conditions years ago. they are very fast acting but unfortunately not very long lasting. This is why these type of steroids are now no longer commonly used to treat joint and soft tissue conditions.

The steroid injections administered for joint or soft tissues are usually longer-acting steroids such as: Triamcinolone Acetonide (Kenalog) and Methylprednisolone (Depo-Medrone). These steroids are highly insoluble in water. That means that they tend to form a depot in the injected structure and the active steroid is released more gradually. This means that they are seen as longer-acting steroids. One of the downsides of longer acting steroids is that they do not work immediately.

How long does it take before steroids to start working?

It Is generally accepted that Depomedrone and Kenalog steroids take at least several days to start working, in some cases people report that they notice the benefit after only one day or so. In many cases it can take as long as 5 to 10 days after injection for the benefits to show. In a minority of cases, it could take as long as two weeks before these steroids start working.

How long will the steroid injection last for?

There is no quick answer to this question. This will largely depend on your condition and the severity of your condition. For example, it is likely that in a degenerative condition such as osteoarthritis eventually when the steroid has stopped working the symptoms return. The evidence for how long steroid injection can last as long as 10 weeks or so. Although most studies do not look at longer term outcomes. Anecdotally it is not uncommon for people to report pain relief for many more months following steroid injection.

However, in non-degenerative conditions the success can be longer lasting. For example in steroid injection for De Quervains tenosynovitis (a very common and often debilitating tendon condition at the wrist) at four year follow up 90 % of patients completely recovered following steroid injection (Anderson, Manthey and Brouns, 1991).

Conclusion:

So hopefully this summary goes some way to answer the question we posed at the beginnning of this blog: How long does a steroid injection take to work?

  • Steroid injections generally take up to a week to start working. A small number of people  report benefit as soon as one day after the injection. A minority of people might not see any benefit for up to two weeks following a steroid injection.
  • Most injections if succesfull will last for at least a few months. But In degenerative conditions such as  (osteoarthritis)  the benefits are generally temporary. In non degenerative conditions such as a number of soft tissue conditions the benefits can be much longer lasting and for certain conditions (de quervains tenosynovitis) for example the recovery can be permanent.

Looking for an expertly delivered and pinpoint accurate injection?

You are in the right place!

With thousands of successful ultrasound guided injections behind him contact our lead clinician Rob Mast for a free telephone consulation.

We are proud to bring our highly specialist ultrasound guided procedures to a physiotherapy practice in your local area !

 

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