Pain management requires comprehensive evaluation through physical exams, imaging, and diagnostic procedures, followed by multidisciplinary treatment including physical medicine, interventional procedures, medical/natural therapies, psychological care, and surgical options when needed. This integrated approach addresses both the physical and emotional components of pain for optimal outcomes.
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Key resources include American Academy of Pain Medicine (https://www.painmed.org/), International Association for the Study of Pain (https://www.iasp-pain.org/), American Academy of Orthopaedic Surgeons (https://www.aaos.org/), and National Alliance on Mental Illness (https://www.nami.org/) for comprehensive pain management guidance.
Head/Face: Occipital nerve block, Auriculotemporal nerve block, Supraorbital/Supratrochlear nerve block, Sphenopalatine ganglion block, Trigeminal nerve block, Glossopharyngeal nerve block
Neck/Cervical Spine: Cervical facet (medial branch) block, Cervical epidural steroid injection (interlaminar/transforaminal), Stellate ganglion block
Thorax/Upper Back: Intercostal nerve block, Paravertebral block, Thoracic epidural steroid injection, Costovertebral/Costotransverse joint injection
Lumbar Spine/Low Back: Lumbar facet (medial branch) block, Lumbar epidural steroid injection (interlaminar/transforaminal), Caudal epidural injection, Trigger point injections
Pelvis/Sacral: Sacroiliac joint injection, Ganglion impar block, Superior hypogastric plexus block, Pudendal nerve block
Upper Extremity: Glenohumeral joint injection, Subacromial bursa injection, AC joint injection, Lateral epicondyle injection, Medial epicondyle injection, Carpal tunnel injection, First CMC joint injection, Digital nerve block
Lower Extremity: Hip joint injection, Iliopsoas bursa injection, Knee intra-articular injection, Genicular nerve block/RFA, Pes anserine bursa injection, Tibiotalar joint injection, Plantar fascia injection, Morton’s neuroma injection, Subtalar joint injection
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Steroid Injection Quick Reference | Equivalence (Anti-inflammatory Potency)
Hydrocortisone 20 mg = Cortisone acetate 25 mg = Prednisone 5 mg = Methylprednisolone (DM) 4 mg = Triamcinolone (KENALOG) 4 mg = Dexamethasone 0.75 mg = Betamethasone 0.6–0.75 mg
Steroid Injection Quick Reference
Steroid Injection Quick Reference
Equivalence (Anti-inflammatory Potency)
Equivalence (Anti-inflammatory Potency)
Hydrocortisone 20 mg = Cortisone acetate 25 mg = Prednisone 5 mg = Methylprednisolone 4 mg = Triamcinolone 4 mg = Dexamethasone 0.75 mg = Betamethasone 0.6–0.75 mg
1. Depo-Medrol (Methylprednisolone acetate)
1. Depo-Medrol (Methylprednisolone acetate)
Common Dose: 40–80 mg (epidural, large joint); 20–40 mg (small joint).
Onset: 1–2 days.
Duration: 2–4 weeks.
Notes: Widely used for LESI and intra-articular injections. Not for adrenal replacement.
2. Kenalog (Triamcinolone acetonide)
2. Kenalog (Triamcinolone acetonide)
Common Dose: 40–80 mg (epidural/large joint); 10–40 mg (small joint).
Onset: 1–2 days.
Duration: 2–6 weeks (longer depot effect than methylpred).
Notes: Strong depot effect, more risk of local tissue atrophy.
3. Decadron (Dexamethasone sodium phosphate)
3. Decadron (Dexamethasone sodium phosphate)
Common Dose: 4–12 mg (epidural, nerve block, joints).
Onset: Immediate.
Duration: 1–2 weeks (shorter duration than depot steroids).
Notes: Non-particulate → preferred in cervical transforaminal injections (safer profile).
4. Celestone (Betamethasone acetate + sodium phosphate)
4. Celestone (Betamethasone acetate + sodium phosphate)
Common Dose: 6–12 mg (joint, epidural, soft tissue).
Onset: Rapid (phosphate) + sustained (acetate).
Duration: 2–4 weeks.
Notes: Dual formulation gives both quick and longer-lasting effect.
5. Hydrocortisone (Solu-Cortef, short-acting)
5. Hydrocortisone (Solu-Cortef, short-acting)
Common Dose: 25–100 mg (rarely used for MSK; more for systemic or diagnostic).
Onset: Immediate.
Duration: <1 week.
Notes: Shortest-acting; not ideal for long-term pain injections.
✅ Clinical Pearls
Depot steroids (Depo-Medrol, Kenalog): longer-lasting but particulate (risk in cervical TFESI).
Non-particulates (Decadron, Celestone phosphate): safer in high-risk areas.
Adrenal replacement: never use depot injections → use hydrocortisone or cortisone acetate in divided oral doses.
Effect on Blood Glucose
Effect on Blood Glucose
Steroid injections (local corticosteroid injections) cause a transient elevation in blood glucose in diabetic patients, typically peaking within the first 1–2 days and returning to baseline within 2–5 days.[1-3] The magnitude and duration of hyperglycemia after injection are generally less pronounced and shorter than with systemic oral steroid administration, which is associated with more sustained and higher elevations in blood glucose, especially with intermediate- and long-acting oral glucocorticoids such as prednisolone and dexamethasone.[4-7]
For example, epidural steroid injections in diabetic patients resulted in a mean increase of 126 mg/dL in blood glucose, with levels normalizing within 2 days [4, PMID: 21540770]. Hand injections with triamcinolone acetonide caused elevations lasting up to 5 days, with higher and more prolonged increases in those with poor baseline glycemic control (HbA1c ≥7%) [8, PMID: 26397266]. Knee injections may cause more pronounced increases than upper extremity injections, but still resolve within several days [10, PMID: 30077229].
In contrast, oral corticosteroids (e.g., prednisolone, dexamethasone) produce a more sustained hyperglycemic effect, with mean blood glucose increases persisting throughout the dosing period and showing a circadian pattern (afternoon/evening peaks) [1, PMID: 38061932].[5] The American Diabetes Association recommends close monitoring and tailored insulin regimens for patients receiving oral steroids due to the higher risk and duration of hyperglycemia.[5]
In summary, local steroid injections cause short-lived, moderate hyperglycemia, while oral steroid administration leads to more sustained and pronounced elevations in blood glucose. The clinical impact and management differ accordingly, with oral steroids requiring more intensive monitoring and intervention.
Would you like me to summarize the comparative risk of steroid-induced hyperglycemia leading to acute complications (such as diabetic ketoacidosis or hyperosmolar hyperglycemic state) between injection and oral routes, based on available literature?
1.
Effects of Epidural Steroid Injections on Blood Glucose Levels in Patients With Diabetes Mellitus.
Even JL, Crosby CG, Song Y, McGirt MJ, Devin CJ.
Spine. 2012;37(1):E46-50. doi:10.1097/BRS.0b013e31821fd21f.
2.
Kim N, Schroeder J, Hoffler CE, et al.
Plastic and Reconstructive Surgery. 2015;136(4):474e-479e. doi:10.1097/PRS.0000000000001624.
3.
Twu J, Patel N, Wolf JM, Conti Mica M.
The Journal of Hand Surgery. 2018;43(8):738-744. doi:10.1016/j.jhsa.2018.06.005.
4.
Limbachia V, Nunney I, Page DJ, et al.
Clinical Therapeutics. 2024;46(2):e59-e63. doi:10.1016/j.clinthera.2023.11.013.
5.
16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2025.
Diabetes Care. 2025;48(Supplement_1):S321-S334. doi:10.2337/dc25-S016.
Leading Journal New Research
6.
Radhakutty A, Burt MG.
European Journal of Endocrinology. 2018;179(4):R207-R218. doi:10.1530/EJE-18-0315.
7.
van Raalte DH, Diamant M, Ouwens DM, et al.
Diabetologia. 2013;56(11):2383-91. doi:10.1007/s00125-013-3016-8.
Effect on EMG/NCT
Effect on EMG/NCT
Epidural steroid injections and intramuscular steroid injections do not directly alter the results of electromyography (EMG) or nerve conduction studies (NCS), except in rare cases of procedural complications such as nerve injury or hematoma, which are uncommon and not a routine effect of these interventions.[1-4] The American Academy of Neurology and the American Society of Regional Anesthesia and Pain Medicine both note that the primary adverse effects of epidural steroid injections are related to procedural risks, not to changes in electrodiagnostic parameters.[1-2]
For intramuscular glucocorticoid injections, recent randomized controlled trial data show that while these injections can improve pain and disability in lumbar radicular pain, they do not produce significant changes in EMG or NCS findings compared to placebo. The only observed effect was the disappearance of fibrillation potentials in both treatment and placebo groups, likely reflecting clinical improvement rather than a direct pharmacologic effect on nerve conduction or muscle electrical activity.[5]
Epidural steroid injections may improve clinical symptoms in radiculopathy and spinal stenosis, but they do not acutely change EMG or NCS results. Electrodiagnostic findings are used for diagnosis and prognostication, not for monitoring response to steroid injections, and improvement in symptoms does not necessarily correlate with changes in EMG/NCS parameters.[6-9]
In summary, neither epidural nor intramuscular steroid injections are expected to directly affect EMG or nerve conduction study results, except in rare cases of procedural complications. Clinical improvement after these interventions may be reflected in symptom scores, but not in electrodiagnostic measurements.[1-7][9]
Would you like me to review the literature on how the timing of EMG/NCS relative to steroid injections might influence diagnostic accuracy or interpretation, particularly in cases of recent symptom improvement?
1.
Armon C, Narayanaswami P, Potrebic S, et al.
Neurology. 2025;104(5):e213361. doi:10.1212/WNL.0000000000213361.
New Research
2.
Anesthesiology. 2010;112(4):810-33. doi:10.1097/ALN.0b013e3181c43103.
Practice Guideline
3.
Rathmell JP, Benzon HT, Dreyfuss P, et al.
Anesthesiology. 2015;122(5):974-84. doi:10.1097/ALN.0000000000000614.
4.
Hwang B, Lee J, Park BJ.
The Clinical Journal of Pain. 2020;36(6):449-457. doi:10.1097/AJP.0000000000000816.
5.
Boga Vijdan E, Basaran S, Balal M.
BMC Musculoskeletal Disorders. 2025;26(1):650. doi:10.1186/s12891-025-08897-1.
New Research
6.
Role of Electrodiagnosis in Patients Being Considered for Epidural Steroid Injections.
Annaswamy TM, Bierner SM, Avraham R.
PM & R : The Journal of Injury, Function, and Rehabilitation. 2013;5(5 Suppl):S96-9. doi:10.1016/j.pmrj.2013.03.013.
7.
Are Electrodiagnostic Study Findings Related to a Patient's Response to Epidural Steroid Injection?.
Marchetti J, Verma-Kurvari S, Patel N, Ohnmeiss DD.
PM & R : The Journal of Injury, Function, and Rehabilitation. 2010;2(11):1016-20. doi:10.1016/j.pmrj.2010.07.002.
8.
Lin CK, Borresen A, Kroll M, Annaswamy TM.
PM & R : The Journal of Injury, Function, and Rehabilitation. 2020;12(7):663-670. doi:10.1002/pmrj.12272.
9.
Needle Electromyography Predicts Outcome After Lumbar Epidural Steroid Injection.
Annaswamy TM, Bierner SM, Chouteau W, Elliott AC.
Muscle & Nerve. 2012;45(3):346-55. doi:10.1002/mus.22320.
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Injeções nas facetas articulares
Visão geral As facetas articulares, encontradas em ambos os lados da parte posterior da coluna vertebral, podem ficar dolorosamente irritadas ou inflamadas. Uma injeção na faceta articular pode ajudar a diagnosticar a origem da dor do paciente. Ela também pode aliviar a dor e a inflamação.
Pele anestesiada Na preparação para o procedimento, o médico anestesia a pele e o tecido acima da faceta articular com uma injeção local.
Colocação confirmada Com a ajuda de um aparelho de raios-X chamado fluoroscópio, o médico insere uma agulha no tecido anestesiado até a faceta articular. O contraste é injetado na articulação para confirmar a colocação da agulha.
Medicamento injetado Depois que a agulha é posicionada corretamente, o médico injeta uma mistura anestésico e medicação esteroide anti-inflamatória. Uma ou mais facetas articulares podem ser tratadas. Se isso fizer com que a dor diminua, sugere que a faceta articular (ou facetas articulares) que recebeu a injeção era a causa da dor.
Fim do procedimento A dor nas costas ou no pescoço pode desaparecer imediatamente após uma injeção bem-sucedida devido ao anestésico administrado. Quando o efeito do anestésico passa, a dor pode voltar. O esteroide começará a fazer efeito nos dias após a injeção. O esteroide reduzirá a inflamação e a dor. A injeção pode proporcionar alívio por um período que varia de vários dias a vários meses. Podem ser aplicadas até três injeções por ano.
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