++
The use of systemic corticosteroids for the treatment of symptomatic
arthritis began shortly after the discovery and synthesis of cortisone
in the 1940s.1 Intra-articular steroid injections
followed shortly thereafter. In 1951, Hollander published the results
of a large series of patients treated with corticosteroid joint
injections. Since then, corticosteroid injections have played an
important role in the diagnosis and management of acute and chronic
joint and periarticular pain problems.
++
Intra-articular and periarticular injections are indicated for
diagnostic, prognostic, and therapeutic purposes (Table 67-1).
++
++
A careful history, physical examination, and supporting radiographic
studies are important in the evaluation of a patient with a pain
complaint, but often these three components of the evaluation fail
to identify the source or sources of the patient’s pain.
Despite some limitations, a series of accurately performed local
anesthetic injections often is the best diagnostic “test” we
have to identify the pain generator(s) contributing to the patients
pain problem.
++
Injection techniques may help to determine if a more definitive
therapeutic intervention is indicated. Pain relief following a local
anesthetic injection into an arthritic joint may lead to consideration
of viscosupplementation or may convince a surgeon that an operation
is indicated (Fig. 67-1). The decision to perform total joint replacements
or bursectomies frequently is guided by the response to one or more
diagnostic injections.
++
++
Prognostic injections may help to determine if a joint denervation
procedure is indicated. Chronic facet pain and discogenic pain often
are treated with denervation procedures (e.g., radiofrequency).
A denervation procedure is performed following a series of carefully
controlled prognostic local anesthetic blocks.
+++
Therapeutic
Injection
++
Injections are used to treat a variety of inflammatory and noninflammatory
joint and periarticular soft tissue pain problems.
++
Rheumatoid arthritis is a chronic systemic inflammatory disease
with polyarticular involvement. Because this is a systemic disease,
the principal therapeutic agents are systemic anti-inflammatory and/or
immune modulating drugs. Injection of isolated joint flare-ups with
local anesthetic and corticosteroid may help to quickly restore
function and allow participation in physical therapy. Studies have
demonstrated short-term pain relief and improved periarticular muscle
strength in patients following intra-articular corticosteroid injection
of a symptomatic rheumatoid joint.3,4 For a flare-up
of a single or a couple of joints, it is preferable to inject one
or two joints rather than ...