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Consent for Steroid Injection

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What is Cortisone?

Cortisone is the name used to describe a group of drugs correctly known as corticosteroids.   Cortisone is used to treat pain in various parts of the body where inflammation is felt to be the root cause of the pain. Cortisone is effective in treating such pain is because it is a powerful anti-inflammatory. The types of cortisone used at our office are Dep-Medrol, Kenalog, and aristospan.  The cortisone we use is NOT an illegal steroid medication such as those steroids used by some body builders and athletes.

Why inject Cortisone?

Cortisone injections provide anti-inflammatory components directly into the area of inflammation and/or pain, as opposed to a systemic distribution.  In regard to musculoskeletal problems, cortisone injections are performed in order to reduce or even eliminate pain associated with a variety of disorders, such as:

• Bursitis (most commonly subacromial and trochanteric bursitis)
• Arthritis (any joint may be injected, including joints of the spine)
• Nerve pain (most commonly for sciatica and carpal tunnel)
• Tendinitis and Tenosynovitis (such as plantar fasciitis, trigger finger, DeQuervain's tenosynovitis, Tennis and Golfer's elbow)
• Other miscellaneous conditions where inflammation is a contributor to the pain,
(frozen shoulder/ adhesive capsulitis, Morton's neuroma, ganglion cyst injections and Dupuytren's contracture).

What is involved?

• The skin is prepared using an antiseptic agent and the superficial dermal and soft tissue layers anesthetized with a numbing agent.
• The cortisone filled syringe with needle is then guided into the relevant body part with or without the aid of Ultrasound. The guidance, at times, provides a more accurate  visualization and administration of cortisone to be more  accurately delivered into the area of suspected/proven pain.
• The degree of discomfort during the procedure is generally mild as the needle used is fine and local anaesthetic is also mixed in with cortisone◦.
• A greater degree of discomfort may occur if:

▪ Underlying tissue is severely inflamed or painful
▪ the area to be injected is severely painful
• the needle tip requires to be repositioned several times in order to distribute the cortisone effectively
▪ a previous bad experience has resulted in a fear of needles, or there is a general anxiety/phobia of needles and other medical procedures.

In cases where a cyst, ganglion, bursa or joint is distended with fluid, the cortisone will be injected after an attempt to aspirate (remove) the fluid in order to improve patient comfort.

Benefits, Risks, Complications and Side-Effects

As for all medical procedures, there are risks associated with the administration of any medication, including cortisone. However this procedure is more likely to provide you with a benefit, such as pain relief.  This benefit outweighs the small risk, but of course it will be based on your specific case and with the providers consideration of your full medical history.

The decision to inject cortisone is not taken lightly and is carefully made by your provider based on your signs, symptoms and past medical history, as well as the suspected diagnosis. Frequently, a trial injection is made where the diagnosis is not clear, however the body region injected is suspected of causing your pain.

The risks of a cortisone injection include:

• Allergy to any of the substances utilised during the procedure, such as the cortisone,  dressing, local anaesthetic or antiseptic. This is usually minor and self limiting.
• The cortisone may result in palpitations, hot flushes and mild mood disturbance. This usually resolves within 24 hours and no treatment is necessary.
• Infection. Infection is a rare but serious complication, especially if injected into a joint. Most infections take at least a day or two to manifest, so pain at the injection site after 48 hours is considered to be due to an infection until proven otherwise. Even if not definitively proven, you may be commenced on empirical antibiotic treatment.
• Local bruising.
• Localized skin and subcutaneous fat atrophy (thinning resulting in dimpling).
• Hypopigmentation (whitening of the skin) at the injection site. This most commonly     happens in injections of the palm of the hand or sole of the foot.
• Mild increase in blood sugar levels in diabetic patients for several days.
• Transient increase in pain at the injection site before the cortisone takes effect.
Occasionally this pain may be severe, however usually lasts only 4–24 hours and is treated with a cold pack, Tylenol and anti-inflammatory medication. If this occurs and you are concerned, especially if the pain is not settling despite the above treatment, then please call your provider  to discuss your situation.
• Cortisone injection administered directly into a tendon has been reported to weaken and damage the collagen fibers thus carrying a risk of delayed rupture. For this reason,     cortisone is only injected around the tissue surrounding a tendon and the tendon is rested for one week.
• An extremely rare complication is avascular necrosis (bone death) which some doctors   suspect may rarely occur when cortisone is injected into a joint, though this has not been proven.

Remember that the side effects of cortisone that are commonly reported in the media, such as osteoporosis, weight gain, acne and diabetes only occur when taking cortisone tablets for at least several weeks. These side effects do not occur with the careful use of infrequent cortisone injections.

Are there any alternatives?

Of course there are. Since a cortisone injection is used for treating pain, it is an optional procedure.  Other options should be discussed with your provider and may include anti inflammatory medications, exercise, physiotherapy and surgery.