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Chronic and interventional pain
Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections - guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, the International Pain and Spine Intervention Society, and the North American Spine Society
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  1. Honorio T Benzon1,
  2. Dalia Elmofty2,
  3. Hariharan Shankar3,
  4. Maunak Rana2,
  5. Andrea L Chadwick4,
  6. Shalini Shah5,
  7. Dmitri Souza6,
  8. Ameet S Nagpal7,
  9. Salahadin Abdi8,
  10. Christian Rafla9,
  11. Alaa Abd-Elsayed10,
  12. Tina L Doshi11,
  13. Maxim S Eckmann12,
  14. Thanh D Hoang13,
  15. Christine Hunt14,
  16. Carlos A Pino15,
  17. Jessica Rivera16,
  18. Byron J Schneider17,
  19. Alison Stout18,
  20. Angela Stengel19,
  21. Maged Mina20,
  22. John D FitzGerald21,
  23. Joshua A Hirsch22,
  24. Ajay D Wasan23,
  25. Laxmaiah Manchikanti24,
  26. David Anthony Provenzano25,
  27. Samer Narouze26,
  28. Steven P Cohen1,27,
  29. Timothy P Maus28,
  30. Ariana M Nelson29,30 and
  31. Harsha Shanthanna31
  1. 1 Anesthesiology, Feinberg School of Medicine, Chicago, Illinois, USA
  2. 2 Department of Anesthesia, University of Chicago Medical Center, Chicago, Illinois, USA
  3. 3 Anesthesiology, Clement Zablocki VA Medical Center/Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  4. 4 Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
  5. 5 University of California Irvine, Orange, California, USA
  6. 6 Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
  7. 7 Orthopaedics and PM&R, Medical University of South Carolina, Charleston, South Carolina, USA
  8. 8 Pain Medicine, MD Anderson Cancer Center, Houston, Texas, USA
  9. 9 Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
  10. 10 University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
  11. 11 Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
  12. 12 Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
  13. 13 Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
  14. 14 Pain Medicine, Mayo Clinic, Jacksonville, Florida, USA
  15. 15 Anesthesiology, Naval Medical Center San Diego, San Diego, California, USA
  16. 16 Orthopedic Surgery, LSUHSC, New Orleans, Louisiana, USA
  17. 17 PM&R, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  18. 18 PM&R, Cleveland Clinic, Cleveland, Ohio, USA
  19. 19 American Society of Regional Anesthesia and Pain Medicine, Pittsburgh, Pennsylvania, USA
  20. 20 Anesthesiology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
  21. 21 Medicine (Rheumatology), UCLA, Los Angeles, California, USA
  22. 22 Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
  23. 23 University of Pittsburgh Health Sciences, Pittsburgh, Pennsylvania, USA
  24. 24 University of Louisville Health Sciences Center, Louisville, Kentucky, USA
  25. 25 Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania, USA
  26. 26 Anesthesia, Division of Pain Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
  27. 27 Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
  28. 28 Radiology, Mayo Clinic, Rochester, Minnesota, USA
  29. 29 Department of Anesthesiology and Perioperative Medicine, University of California Irvine, Irvine, California, USA
  30. 30 Department of Aerospace Medicine, Exploration Medical Capability, Johnson Space Center
  31. 31 Anesthesia, McMaster University, Hamilton, Ontario, Canada
  1. Correspondence to Dr Honorio T Benzon, Anesthesiology, Feinberg School of Medicine, Chicago, IL 60611, USA; hobenzon{at}nm.org

Abstract

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.

  • Pain Management
  • CHRONIC PAIN
  • Neuralgia
  • Nerve Block

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

https://doi.org/10.1136/rapm-2024-105593

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Footnotes

    • AMN and HS are joint senior authors.

    • X @ShaliniShahMD, @dr_tinadoshi, @eckmann_max, @NarouzeMD, @ANels_MD, @harshamd5

    • Contributors All the authors were involved in the Delphi process, approval of the statements and recommendations, and approval of the manuscript. The primary author, HTB, guarantees the contributorship statement.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests HTB, MD: NIH NIAMS P30AR072579. AC, MD: Research Funding: RM1NS128956-01A1; Consultant: Swing Therapeutics, Scilex Pharmaceuticals. SS, MD: Consultant: SPR Therapeutics, Allergan, Inc. DS, MD: Advisory Board, Funded research: Scilex; Speaker: AbbVie. AN, MD: Speaker: Averitas Pharmaceuticals; Research: Saol Therapeutics. AA-E, MD: Consultant: Curonix. TD, MD: Research support: Biohaven, NIH; Consultant: Guidepoint Global; Speaker honorarium: Remedy Health Media. MSE, MD: Funded research: SPR Therapeutics; Consultant: Avanos, Abbott. TH, MD: Acella: Advisory board, speaker: Acella. CH, MD: Research grant: Nevro, Inc. CP, MD: Consulting: Mainstay Medical; Royalties, UpToDate. BS, MD: Consultant: State Farm, Carelon. AS, MD: NIH R34AR080279. MM, MD: Consultant: Juris Medicus. JAH, MD: Grants: Neiman Health Policy Institute (there is no number associated with this foundation grant; Consulting (last 12 months): Medtronic, Relievant, Persica; DMC Chair: Balt, Rapid Medical, Arsenal. AW, MD: Investigator-initiated grant, Goodblends, PA. DAP, MD: Consulting: Avanos, Boston Scientific, Medtronic, Nevro, and SI Bone. Research support: Avanos, Boston Scientific, Medtronic, Nevro, Stimgenics, Abbott. SPC, MD: Consulting (past 2 years): Avanos, Scilex, SPR, SWORD, Releviate (ended), Clearing (ended), Persica (inactive); Research funds paid to institution: Scilex, Avanos. TM, MD: Consultant, Interventional AnalgesiX. The remaining authors declare no competing interests.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.