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

Honorio T Benzon; Dalia Elmofty; Hariharan Shankar; Maunak Rana; Andrea L Chadwick; Shalini Shah; Dmitri Souza; Ameet S Nagpal; Salahadin Abdi; Christian Rafla; Alaa Abd-Elsayed; Tina L Doshi; Maxim S Eckmann; Thanh D Hoang; Christine Hunt; Carlos A Pino; Jessica Rivera; Byron J Schneider; Alison Stout; Angela Stengel; Maged Mina; John D FitzGerald; Joshua A Hirsch; Ajay D Wasan; Laxmaiah Manchikanti; David Anthony Provenzano; Samer Narouze; Steven P Cohen; Timothy P Maus; Ariana M Nelson; Harsha Shanthanna

doi:10.1136/rapm-2024-105593

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

Reg Anesth Pain Med. 2024 Aug 7:rapm-2024-105593. doi: 10.1136/rapm-2024-105593. Online ahead of print.

Authors

Honorio T Benzon¹, Dalia Elmofty², Hariharan Shankar³, Maunak Rana², Andrea L Chadwick⁴, Shalini Shah⁵, Dmitri Souza⁶, Ameet S Nagpal⁷, Salahadin Abdi⁸, Christian Rafla⁹, Alaa Abd-Elsayed¹⁰, Tina L Doshi¹¹, Maxim S Eckmann¹², Thanh D Hoang¹³, Christine Hunt¹⁴, Carlos A Pino¹⁵, Jessica Rivera¹⁶, Byron J Schneider¹⁷, Alison Stout¹⁸, Angela Stengel¹⁹, Maged Mina²⁰, John D FitzGerald²¹, Joshua A Hirsch²², Ajay D Wasan²³, Laxmaiah Manchikanti²⁴, David Anthony Provenzano²⁵, Samer Narouze²⁶, Steven P Cohen^{27

28}, Timothy P Maus²⁹, Ariana M Nelson^{30

31}, Harsha Shanthanna³²

Affiliations

¹ Anesthesiology, Feinberg School of Medicine, Chicago, Illinois, USA hobenzon@nm.org.
² Department of Anesthesia, University of Chicago Medical Center, Chicago, Illinois, USA.
³ Anesthesiology, Clement Zablocki VA Medical Center/Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
⁴ Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA.
⁵ University of California Irvine, Orange, California, USA.
⁶ Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA.
⁷ Orthopaedics and PM&R, Medical University of South Carolina, Charleston, South Carolina, USA.
⁸ Pain Medicine, MD Anderson Cancer Center, Houston, Texas, USA.
⁹ Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA.
¹⁰ University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA.
¹¹ Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA.
¹² Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
¹³ Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
¹⁴ Pain Medicine, Mayo Clinic, Jacksonville, Florida, USA.
¹⁵ Anesthesiology, Naval Medical Center San Diego, San Diego, California, USA.
¹⁶ Orthopedic Surgery, LSUHSC, New Orleans, Louisiana, USA.
¹⁷ PM&R, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
¹⁸ PM&R, Cleveland Clinic, Cleveland, Ohio, USA.
¹⁹ American Society of Regional Anesthesia and Pain Medicine, Pittsburgh, Pennsylvania, USA.
²⁰ Anesthesiology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
²¹ Medicine (Rheumatology), UCLA, Los Angeles, California, USA.
²² Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA.
²³ University of Pittsburgh Health Sciences, Pittsburgh, Pennsylvania, USA.
²⁴ University of Louisville Health Sciences Center, Louisville, Kentucky, USA.
²⁵ Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania, USA.
²⁶ Anesthesia, Division of Pain Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.
²⁷ Anesthesiology, Feinberg School of Medicine, Chicago, Illinois, USA.
²⁸ Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
²⁹ Radiology, Mayo Clinic, Rochester, Minnesota, USA.
³⁰ Department of Anesthesiology and Perioperative Medicine, University of California Irvine, Irvine, California, USA.
³¹ Department of Aerospace Medicine, Exploration Medical Capability, Johnson Space Center.
³² Anesthesia, McMaster University, Hamilton, Ontario, Canada.

PMID: 39019502
DOI: 10.1136/rapm-2024-105593

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.

Keywords: CHRONIC PAIN; Nerve Block; Neuralgia; Pain Management.