Comparison of surgical decompression and local steroid injection in the treatment of carpal tunnel syndrome: 2-year clinical results from a randomized trial.

OBJECTIVE: To compare the efficacy of surgical decompression vs local steroid injection in the treatment of idiopathic CTS. METHODS: This is an open, prospective, randomized clinical trial. We studied the effects of surgical decompression vs local steroid injection in 163 wrists with a clinical diagnosis and neurophysiological confirmation of CTS, with an extended follow-up of 2 years. The primary end point was the percentage of wrists that reached a ≥ 20% improvement in the visual analogue scale score for nocturnal paraesthesias. Statistical analysis was done by Student's t-test for continuous variables and by chi-square test for categorical variables. Analyses were performed on an intent-to-treat basis. P < 0.05 were considered statistically significant. RESULTS: Both treatment groups had comparable severity of CTS at baseline. Eighty wrists were randomly assigned to surgical decompression and 83 wrists to local steroid injection. Fifty-five wrists in the surgery group and 48 wrists in the injection group completed the 2-year follow-up. In the intent-to-treat analysis, at 2-year follow-up, 60% of the wrists in the injection group vs 69% in the surgery group reached a 20% response for nocturnal paraesthesias (P < 0.001). CONCLUSION: Our findings suggest that both local steroid injection and surgical decompression are effective treatments in alleviating symptoms in primary CTS at 2-year follow-up. Surgery has an additional benefit in the 2-year follow-up, although clinical relevance of those differences remains to be defined. TRIAL REGISTRATION: Current Controlled Trials, www.controlled-trials.com, ISRCTN26264638.

Epidural dextran-40 and paramethasone injection for treatment of spontaneous intracranial hypotension.

PURPOSE: This report describes treatment with epidural dextran-40 and paramethasone injection of postural headache resulting from spontaneous intracranial hypotension in a pregnant patient. CLINICAL FEATURES: A 39-yr-old pregnant woman consulted the pain clinic for the assessment of a debilitating postural headache which was non-responsive to conventional analgesic treatment. Clinical findings and cranial magnetic resonance imaging indicated the diagnosis of spontaneous intracranial hypotension syndrome. Treatment with an epidural blood patch was not undertaken for several reasons. A lumbar epidural injection with dextran-40 and paramethasone led to a significant improvement in the symptoms and allowed a progressive discontinuation of adjuvant treatment with oral steroids, with complete resolution of symptoms. CONCLUSION: We report a case of spontaneous intracranial hypotension in a pregnant patient successfully treated by epidural injection of dextran-40 and paramethasone, with adjuvant oral steroid therapy. Clinical trials are warranted to establish the efficacy of this treatment as an alternative to the epidural blood patch administration.

Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial.

OBJECTIVE: Optimal treatment of carpal tunnel syndrome (CTS) has not been established. This study compared the effects of local steroid injection versus surgical decompression in new-onset CTS of at least 3 months' duration. METHODS: In a 1-year, prospective, randomized, open, controlled clinical trial, we studied the effects of surgical decompression versus local steroid injection in 163 wrists with a clinical and neurophysiologic diagnosis of CTS. Clinical assessments were done at baseline and at 3, 6, and 12 months after treatment. The primary end point was the percentage of wrists that reached a >or=20% improvement in the visual analog scale score for nocturnal paresthesias at 3 months of followup. Statistical analysis was done by Student's t-test for continuous variables and by chi-square test for categorical variables. Analyses were performed on an intent-to-treat basis. P values less than 0.05 were considered statistically significant. RESULTS: Both treatment groups had comparable severity of CTS at baseline. Eighty wrists were randomly assigned to the surgery group and 83 wrists to the local steroid injection group. In the intent-to-treat analysis, at 3 months of followup, 94.0% of the wrists in the steroid injection group versus 75.0% in the surgery group reached a 20% response for nocturnal paresthesias (P = 0.001). At 6 and 12 months, the percentages of responders were 85.5% versus 76.3% (P = 0.163) and 69.9% versus 75.0% (P = 0.488), for local steroid injection and surgical decompression, respectively. CONCLUSION: Over the short term, local steroid injection is better than surgical decompression for the symptomatic relief of CTS. At 1 year, local steroid injection is as effective as surgical decompression for the symptomatic relief of CTS.

[Capsular retraction of shoulder: prospective study of imaging benefits in 20 patients]. / Capsulites rétractiles de l'épaule: étude prospective de l'apport de l'imagerie chez 20 patients.

PURPOSE: To evaluate the contribution of principal imaging techniques in diagnosis and treatment in adhesive capsulitis of the shoulder. MATERIALS AND METHODS: In 20 patients presenting adhesive capsulitis of shoulder since mean of 6,7 months, the following examinations were performed: radiographies, angioscintigraphy, MRI as well as an opaque arthrography and a bursography associated with corticosteroid injection. Patients were followed during one year. RESULTS: The opaque arthrography was to affirm the adhesive capsulitis for the inclusion of the patients. Radiographies (patchy demineralization) and scintigraphy (hyperfixation) were often pathological. In MRI, T1 fat-saturated sequences after contrast injection almost always showed enhancement of the articular capsula, the synovia, the miscellaneous bone or the sub-acromial bursa. The latter was often modified and retracted at bursography. In 19 of 20 cases, a functional improvement was observed after the opacifications. CONCLUSION: Therapeutic effect of both arthrography and bursography is almost proved. Post contrast MRI confirms presence of vascular troubles in all the shoulder structures even at this advanced stage.

Two cases of specific adverse reactions to systemic corticosteroids.

Although true allergic reactions due to systemic corticosteroid therapy are not frequent, they should be kept in mind since allergic reactions to this kind of therapy are possible. We report two cases of specific adverse reactions resulting from systemic corticosteroid therapy which were diagnosed by provocation tests. The corticosteroids involved in each case were paramethasone and betamethasone, and methyl-prednisolone in both of them. Additives and other corticosteroids were studied by skin tests and challenges, with negative results. The structures of paramethasone and betamethasone are similar, with a 16 carbon methyl group in both, and with a fluoride in the alpha position of the 6 carbon in paramethasone, and a fluoride in the beta position of the 9 carbon and a 6 carbon methyl group in betamethasone. Methyl-prednisolone differs from that of other corticosteroids in its 6 carbon methyl group. We report two cases of specific adverse reactions caused by corticosteroids. Positive challenge tests showed a possible immunologic hypersensitivity mechanism in both cases. The patients' reactions demonstrated cross-reactivity between methyl-prednisolone and the corticosteroids having a 16 carbon methyl group, and fluoride or methyl radicals on the 6 carbon.

Anaphylactic shock following povidone.

OBJECTIVE: To report a patient with an anaphylactic reaction related to povidone administration. CASE SUMMARY: A 37-year-old man with a history of allergic rhinitis presented with urticaria, dyspnea, wheezing, rhinorrhea, and dysphonia 20 minutes after the intraarticular administration of mepivacaine hydrochloride and paramethasone acetate in his right knee. Two months after this episode, he was admitted for controlled provocation tests. Tests on mepivacaine were negative. The preparation of paramethasone contained the excipients benzalkonium chloride, polysorbate 80, and povidone. In vitro tests and provocation were negative with polysorbate 80 and benzalkonium chloride, but positive with povidone. DISCUSSION: Povidone, a mixture of synthetic polymers, is commonly used as an excipient in pharmaceutical products, an additive in food products, and a dispersant and stabilizer in hairsprays. Although it is well tolerated when used topically or parenterally, local and systemic effects have been reported. Furthermore, multiorgan involvement resulting from accumulation of the drug in the reticuloendothelial system has been described. The immunologic properties of povidone have not been explored in humans, but have been in animals. In fact, the capacity of povidone to release histamine and its immunogenicity are proportional to its molecular weight. An immunoglobulin (Ig) E-mediated hypersensitivity reaction in asthma has been reported. In our case, povidone was responsible for the syndrome. However, we cannot determine the exact mechanism. An unspecific histamine release and/or an IgE-mediated hypersensitivity could be involved. CONCLUSIONS: Povidone was responsible for a severe anaphylactic reaction in our patient. The possibility of an iatrogenic adverse effect caused by the excipient but not by the active ingredient should be considered in patients exhibiting similar symptoms. We believe that the excipients used in the preparation of all medicines should be disclosed.

Pseudo-allergic reactions to corticosteroids: diagnosis and alternatives.

Two patients treated with parenteral paramethasone (Triniol) and dexamethasone (Sedionbel) are described. A few minutes after administration of the drugs, they presented urticaria (patients 1 and 2) and conjunctivitis (patient 1). The purpose of our study was to determine the cause of the patients' reactions, the immunological mechanisms involved and whether these patients would be able to tolerate any kind of corticoid. Clinical examinations and skin, oral and parenteral challenges with different corticosteroids and ELISA tests were performed. In the two patients, skin and ELISA tests with paramethasone were negative, as was the prick test with each of its excipients. A single-blind parenteral challenge with Triniol was positive in both patients after the administration of 1 ml of the drug, and negative with its excipients. We also carried out oral and parenteral challenges with other corticosteroids and found intolerance to some of them. These results suggest that paramethasone caused pseudoallergic reactions in our patients. Corticosteroids different from paramethasone also produced hypersensitivity reactions in these patients; however, a few of them were tolerated. The basic mechanisms of those reactions are not yet fully understood. To our knowledge, this is the first report of a pseudo-allergy caused by paramethasone.

Urticaria y conjuntivitis aguda causadas por corticoides

Presentamos el caso de dos sujetos sometidos a tratamiento parenteral con los corticoides dexametasona y parametasona (Triniol). A los pocoso minutos de su administración desarrollaron un cuadro urticariforme y uno de ellos ademas una inyeccion conjuntival en el ojo derecho. Fueron sometidos a pruebas cutáneas con todos los componentes del Triniol. Por separado, siendo esta positiva tras la administración intramuscular de 1 ml de la sustancia y negativa con cada uno de los excipientes del preparado. las pruebas "in vitro" destinadas a detectar IgE especifica frente a la parametasona, fueron negativas. Adicionalmente realizamos provocaciones orales y parenterales con otros corticoides encontrando intolerancia a varios de ellos

[Epidural infiltrations in the treatment of lumbar radiculopathy. Apropos of 200 cases]. / Infiltrations épidurales dans le traitement de la radiculopathie lombaire. A propos de 200 cas.

INTRODUCTION: The authors report a prospective study on the treatment of radicular compression using epidural infiltrations. MATERIAL AND METHODS: An open study was performed on 200 patients suffering from radicular compression due to either herniated lumbar discs (124 cases), lumbar stenosis (32 cases) or segmental lumbar stenosis (44 cases) and treated by epidural infiltrations. RESULTS: Of the 200 patients studied, 74 per cent did not need subsequent surgical treatment. Therapeutic effect was influenced by several parameters: etiology of radicular compression: 65 per cent favorable results in herniated discs; 69 per cent in lumbar stenosis; and 91 per cent favorable results in segmental lumbar stenosis; age of patients: 100 per cent favorable in patients > 70 years, while only very few favorable results in patients < 20 years of age. Chronic or acute radicular pain: among the patients who had herniated discs requiring subsequent surgery, 65 per cent presented with acute lesions (pain for < 4 months). In patients with lumbar stenosis requiring surgery, 80 per cent had acute lesion and in patients with segmental lumbar stenosis, no patients complained of acute pain. DISCUSSION: Avoiding surgical treatment is not the only parameter which should be studied in evaluating the effectiveness of treatment. Lassale's pre and postoperative evaluation with a minimum 1 year follow up showed improvement in all non surgical cases. When compared to the literature, this study shows favorable long term results.

A case of necrobiosis lipoidica treated with systemic corticosteroid.

A 43-year-old woman had asymptomatic eruptions on the anterior sides of both legs for 5 years. Biopsy specimens revealed the typical findings of necrobiosis lipoidica. An immunofluorescence study demonstrated no deposits of immunoglobulins, complement, or fibrinogen in vessel walls. Immunohistochemical staining revealed CD4 positive lymphocytes dominating in the lesion and strong expression of ICAM-1 on the endothelial cells, giant cells, lymphocytes and dermal fibroblasts in the lesion. The eruptions resolved remarkably with oral corticosteroid therapy.

Effect of corticosteroids on indomethacin-induced intestinal ulceration in the rat.

A single dose of indomethacin induces a severe gastrointestinal syndrome in the rat, characterized by intestinal ulceration, perforation, and death. The mechanism by which indomethacin induces this syndrome is unclear, although it has been suggested that a loss of mucosal integrity leads to inflammation and necrosis of the intestinal wall. The purpose of the present investigation was to study the effect of corticosteroids on indomethacin-induced ulceration. Prednisolone administered orally, even as a single dose (10 mg/rat), significantly reduced the severity of ulceration following indomethacin. This protective effect was most pronounced when prednisolone was administered 1 hr postindomethacin and decreased as the period between indomethacin and prednisolone administration increased. Of the steroids studied, the rank order of efficacy in reducing the severity of indomethacin-induced ulceration was paramethasone acetate > betamethasone > prednisolone. Hydrocrotisone was not significantly effective at the doses ultilized. Our results suggest that corticosteroids exert a cytoprotective effect on intestinal mucosa similar to that produced by prostaglandins.

Naproxen: corticosteroid-sparing effect in rheumatoid arthritis.

Ambulatory patients with a diagnosis of "classical" or "definite" active adult rheumatoid arthritis were selected. They had been stabilized for at least six months previously with oral administration of paramethasone acetate plus various analgesics and/or nonsteroidal anti-inflammatory agents. During an initial period of two to five weeks, the paramethasone dosage was adjusted and other medications replaced by placebo to find the minimum required to keep the patient at a level similar to the one at the beginning of the study. Subsequently, with the double-blind method, the effect of 400 mg naproxen daily was compared with placebo, making periodic and progressive reductions in the corticosteroid dosage, unknown to the patient, until a tolerable minimum was found. The average total observation time was 14 weeks. Results obtained in the first 28 patients showed an average reduction of 57 per cent in paramethasone dose for the group treated with naproxen, versus 21 per cent for the control group. One patient experienced euphoria which could possibly have been related to the test drug. It is concluded that naproxen possesses a significant corticosteroid-sparing effect with negligible toxicity.