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Local anesthetics with glucocorticoids to treat chronic non-cancerous pain
Local anesthetics with glucocorticoids to treat chronic non-cancerous pain. Chronic non-cancer pain (CNCP) is widespread in the population, restricting people’s daily activities and reducing the quality of life.
Chronic non-cancer pain (CNCP) is widespread in the population, restricting people’s daily activities and reducing the quality of life. In 2012, an estimated 100 million adults in the United States were affected by CNCP, and related treatment costs ranged from US$560 to US$635 billion. Percutaneous injection therapy is often used to relieve pain and as an adjunct to medication and physical therapy.
Local anesthetics are usually used for the diagnosis of blockade, and the addition of steroid hormones to local anesthetics is often used to treat chronic pain. Although widely used, the biological theory and clinical efficacy of hormone therapy for chronic pain are still unclear. Shanthanna et al. conducted a comprehensive systematic review and meta-analysis of RCT to assess the benefits and risks of combined injection of steroid hormones and local anesthetics. The results of the study were published in the November 2020 issue of BJA.
The study searched the MEDLINE, EMBASE and CENTRAL databases, and the search time was from the establishment of the database to May 7, 2019. Adult patients with CNCP who were injected with local anaesthetic (LA) or steroid mixed with LA (SLA) were included.
If included patients have known inflammatory pain diseases, such as rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus or gouty arthritis, and systemic painful diseases such as fibromyalgia, they will be included in the study exclude.
The main research goal is to compare the effects of injection therapy with SLA and LA to relieve pain in patients with CNCP. The secondary research objectives refer to the “Clinical Experimental Research Methods, Monitoring and Pain Assessment Initiative IMMPACT”, including the effectiveness in physiological function, mood, overall patient satisfaction, side effects, and patient preferences, and compare the duration of pain relief, and Evaluate the effects of multiple injections and hormone doses on pain.
NRS pain score (0 painless, 10 severe pain), ODI dysfunction index (0% no dysfunction, 100% complete dysfunction) and QoL quality of life score (0 is the worst, 100 is the best). In the study, relative risk (RR) was used to indicate pain relief, the corresponding 95% confidence interval (CI) was used for dichotomous results, and the weighted mean difference (WMD) and corresponding 95% CI were used for continuous results. When the integrated results are meaningful, report the risk difference (RD) and the number of people requiring treatment (NNT).
A total of 73 trials were included in this study. According to different injection methods, they were divided into epidural and intrathecal injection group (n=26), spinal joint and intervertebral disc injection group (n=3), and peripheral intra-articular injection group (n= 7) Peripheral nerve injection group (n=12), soft tissue and peri-articular injection group (n=20), autonomic nerve/autonomic ganglion injection group (n=1) and pain point or intramuscular injection group (n=4). Of the 73 studies, 69 studies were included in the meta-analysis.
Although moderate-quality evidence indicates that SLA is slightly better than LA (42 trials enrolled 3586 patients, RR=1.14; 95% CI, 1.03-1.25; NNT: 13; Figure 1), but if 2 is removed In a study on intrathecal injection, the absolute risk difference will be reduced by nearly 50% (NNT: 22), and after SLA treatment, the decrease in NRS pain score has no clinical significance (MD=0.44 points; 95% CI, 0.24-0.65; figure 2).
Figure 1 Comparison of successful pain relief.
Figure 2 Comparison of pain relief with 11 points.
Medium-quality evidence showed that there was no significant difference in functional improvement between the groups (RR=1.04; 95%CI, 0.96-1.12);
SLA has a slight improvement in ODI score (WMD-1.77 points; 95% CI, -2.99 points to -0.56 points);
In terms of overall patient satisfaction (RR=1.16; 95%CI, 0.96-1.40) and QoL score (WMD2.59; 95%CI, -0.71 to 5.89), there were no significant differences between the groups.
Most studies did not report clinical side effects, and in the only report, there were no differences in side effects between groups.
According to the different injection methods, there was no difference in the pain relief effect between the subgroups (Figure 3). Meta regression shows that hormone dose or multiple injections are not related to pain relief.
Figure 3 Subgroup analysis of the comparison of successful pain relief in different clinical categories.
The addition of hormones to local anesthetics has little benefit and potential harm. Local anesthetic injection alone is not only a diagnosis, but also a treatment. The patient’s wishes should be taken into consideration during treatment, and decisions should be made jointly with the patient. Even with hormones, long-term or high-dose injections must be avoided.
Hormones have the effects of anti-inflammatory, stabilizing cell membranes, inhibiting the synthesis of neuropeptides and blocking ectopic discharge, which may be the mechanism of their treatment of CNCP. However, LA alone can also inhibit ectopic discharge and lower the pain threshold. In clinical practice, LA alone is mainly used for the diagnosis of CNCP, but its pain relief time often exceeds expectations. In the recently updated intervention guidelines, Huygen et al. pointed out that LA injection can be used for certain structures of the spine, with or without hormones.
Hormones have many side effects. Local effects include soft tissue atrophy and hair loss. High doses may cause long-term adrenal hypofunction and metabolic disorders, as well as abnormal vaginal bleeding, blood sugar changes, infections, skin lesions, weight gain, osteoporosis and fractures.
A large number of studies have shown that SLA is not better than LA in terms of pain relief and functional improvement, and the injection site is more important than whether to add hormones. Even so, doctors still tend to use hormones when injecting pain points, because hormones are not only powerful anti-inflammatory agents but also prolong the action time of local anesthetics. Inflammation is a common pathological manifestation of many painful diseases, so the traditional concept is that Adding hormones can increase the efficacy and prolong the analgesia time. But what is the truth? This research gave us the answer
The study showed that after adding hormones to local anesthetics, only 1/13 of the patients had pain relief. After removing 2 studies of intrathecal hormone injections, the curative effect dropped by nearly 50%, and only 1/22 of patients received It is beneficial, and usually considering the safety, rarely use hormones for intrathecal injection.
The NRS pain score also only dropped by 0.44 points, which is of no clinical significance. There were also no differences between LA and SLA in terms of physiological function, overall patient satisfaction, and QoL scores. The study also did not confirm that adding hormones can prolong the pain relief time, or the use of high-dose hormones can achieve better pain relief effects.
In a large observational study, Friedly et al. reported that patients receiving repeated injections may consume more opioids, which may be the reason for the reduced response to treatment. Therefore, the study showed that repeated injections did not help the patient’s prognosis. The study did not find side effects related to hormones, which may be related to the research method.
From the above research results, it can be seen that for patients with chronic non-cancer pain, the benefits of adding hormones to local anesthetics for injection therapy are minimal, and there are obvious potential harms. The local anesthetic is also effective by injection alone, not only for diagnosis, but also for treatment.
However, it is still challenging for physicians to formulate the best injection treatment plan. It is essential to clarify the treatment process and preparation selection for the implementation, supervision and billing of injection treatment. Physicians need to take all the above factors into consideration and combine them with patients. Preference for comprehensive judgment to make joint decisions.
This study represents an extensive and systematic review and attempts to cover more CNCP situations. However, despite the level 1 evidence, RCT data may still have limitations, such as small sample size and populations that do not represent clinical practice, and comfort The dose effect and blinding challenges cannot be ignored either.
(source:internet, reference only)