Epidural corticosteroid injections (ESIs) have been used for several decades and now represent the most common intervention performed for the management of back pain with a radicular component. However, several reports have presented devastating complications and adverse effects, which fuelled concerns over the risk versus clinical effectiveness. The authors offer a comprehensive review of the available literature and analyse the data derived from studies and case reports.

To review the current literature to determine which injection technique and needle portal placement provide the greatest accuracy for intra-articular access to the knee.

In order to determine the exact localization (intra- vs intermuscular) in which a drug is injected when administered by a so-called intramuscular injection technique, a radiopaque test article (2 ml) was injected into the cervical musculature (2 sites), the loins and the gluteal mass in anaesthesized pigs. Immediately after this, the pigs were euthanized and deep-frozen. Then they were cut into slices, which were X-rayed to determine the exact localization of the test material. Semi-quantitative scores were given to each injection site according to the amount of test article found in or out of muscle mass and also to the absence or the presence of test article subcutaneously. The loins area obtained the highest score for intramuscular location, but in this site, injections were almost always followed by a flowing back of the test article to the subcutaneous' area. It was shown that an injection in the neck perpendicular to the skin surface just behind the base of the ear was the most appropriate site for intramuscular injection in pigs.

Endolymph movements and endocochlear potential (EP) changes were measured during disturbances of perilymphatic pressure. induced by injecting artificial perilymph into scala tympani (ST) or scala vestibuli (SV) of the guinea pig cochlea. Injections were performed either with or without an outlet made in the opposite perilymphatic scala. Injections into ST without an outlet induced large pressure changes but virtually no endolymph movement or EP change. Injection at the same rate into ST with an outlet in SV produced smaller pressure changes which were accompanied by a basally-directed displacement of endolymph and significant EP changes. The magnitude of endolymph displacements and EP changes varied as a function of injection rate. Injections into SV, either with or without an outlet in ST, produced apically-directed endolymph displacement and EP changes. For the SV injections without an outlet, the cochlear aqueduct and round window are likely to provide an outlet and compliance, permitting flow along the perilymphatic scalae to occur even when no ST outlet was provided. We conclude that endolymph movements are not dependent on the absolute pressure of the perilymph, but instead occur when small, sustained pressure gradients are present across the cochlear partition, corresponding to times when perilymph flow is induced. This study demonstrates that in the normal. sealed cochlea, endolymph and EP are insensitive to fluid injections into ST, but are sensitive to fluid injections into SV. Endolymph movements are therefore unlikely to be generated by cerebrospinal fluid pressure fluctuations (such as those produced by respiration, posture changes, coughing, sneezing, etc) which are transmitted to ST by the cochlear aqueduct.

The aim of the study was to propose a more efficient and safer botulinum toxin type A (BoNT-A) injection method for the masseter by comparing the conventional blind injection and a novel ultrasonography (US)-guided injection technique in a clinical trial. The 40 masseters from 20 healthy young Korean volunteers (10 males and 10 females with a mean age of 25.6 years) were included in this prospective clinical trial. The BoNT-A (24 U) was injected into the masseter of each volunteer using the conventional blind and US-guided injection techniques on the left and right sides, respectively, and analyzed by US and three-dimensional (3D) facial scanning. One case of PMB (paradoxical masseteric bulging) was observed on the side where a conventional blind injection was performed, which disappeared after the compensational injection. The reduction in the thickness of the masseter in the resting state differed significantly at 1 month after the injection between the conventional blind injection group and the US-guided injection group by 12.38 ± 7.59% and 17.98 ± 9.65%, respectively (t(19) = 3.059, p = 0.007). The reduction in the facial contour also differed significantly at 1 month after the injection between the conventional blind injection group and the US-guided injection group by 1.95 ± 0.74 mm and 2.22 ± 0.84 mm, respectively (t(19) = 2.908, p = 0.009). The results of the study showed that the US-guided injection method that considers the deep inferior tendon by visualizing the masseter can prevent the PMB that can occur during a blind injection, and is also more effective.

To investigate factors associated with pain intensity following intravitreal injection and factors that might be associated with changes in pain intensity in patients who received repeated injections.

Intravitreal injections have become the cornerstone of retinal care and one of the most commonly performed procedures across all medical specialties. The impact of hydrodynamic forces of intravitreal solutions when injected into vitreous or vitreous substitutes has not been well described. While computational models do exist, they tend to underestimate the starting surface area of an injected bolus of a drug. Here, we report the dispersion profile of a dye bolus (50 µL) injected into different vitreous substitutes of varying viscosities, surface tensions, and volumetric densities. A novel 3D printed in vitro model of the vitreous cavity of the eye was designed to visualize the dispersion profile of solutions when injected into the following vitreous substitutes-balanced salt solution (BSS), sodium hyaluronate (HA), and silicone oils (SO)-using a 30G needle with a Reynolds number (Re) for injection ranging from approximately 189 to 677. Larger bolus surface areas were associated with faster injection speeds, lower viscosity of vitreous substitutes, and smaller difference in interfacial surface tensions. Boluses exhibited buoyancy when injected into standard S1000. The hydrodynamic properties of liquid vitreous substitutes influence the initial injected bolus dispersion profile and should be taken into account when simulating drug dispersion following intravitreal injection at a preclinical stage of development, to better inform formulations and performance.

Intra-articular (IA) corticosteroid (CS) injections are the mainstay of treatment for symptomatic management in knee osteoarthritis (OA), particularly in the UK. IA platelet-rich plasma (PRP) injections are a promising alternative, but no systematic reviews to date have compared them to the current standard of care, IA CS injections. We aim to investigate the effect of IA PRP injections versus IA corticosteroid injections for the symptomatic management of knee OA.

Infectious keratitis is a major global cause of vision loss and blindness. Prompt diagnosis and targeted antibiotic treatment are crucial for managing the condition. Topical antimicrobials are the most effective therapy for bacterial keratitis, but they can lead to unsatisfactory results due to ocular perforation, scarring, and melting. Intrastromal injection is a newer technique for delivering antimicrobials directly to the site of infection and has been successful in treating severe, treatment-resistant infectious keratitis, especially when surgery is not recommended. In cases where deep stromal disease is resistant to topical treatment, intrastromal antimicrobial injections may be necessary to achieve higher drug concentration at the infection site. However, the use of intrastromal antibiotics is limited, as topical antibacterial agents have better penetration than antifungal agents. Bacterial and fungal keratitis have been extensively researched for intrastromal medication injections, while there is limited evidence for viral keratitis. This review emphasizes the potential of intrastromal antimicrobial injections as an alternative for managing severe refractory infectious keratitis. The technique offers direct targeting of the infection site and faster resolution in some cases compared to topical therapy. However, further research is needed to determine the safest antimicrobials options, minimal effective doses, and concentrations for various pathogens. Intrastromal injections may serve as a non-surgical treatment option in high-risk cases, with benefits including direct drug delivery and reduced epithelial toxicity. Despite promising findings, more studies are required to confirm the safety and efficacy of this approach.

No abstract available

Pre- and postcontrast scans of the same normal brain tissue layer were compared in 20 patients in order to evaluate postcontrast density response. The original purpose of this investigation was to explain a paradoxical phenomenon of density decrease, which has been regularly observed in our patients. Control phantom measurements revealed that the decrease of density values is a function of the time interval between the analysed and the previous scan. Prolonged interscan interval--due to contrast injection--enables a change in the sensitivity of CT detectors to be registered. It is probable that any study of cerebral blood volume could be unfavourably influenced by this phenomenon. Comparison between the postcontrast brain scan density decrease and density decrease of a phantom showed substantially no difference, so that we estimate the contrast response of the brain parenchyma in toto as insignificant. Further, a comparative analysis between contrast response of the white and gray matter has been made. The gray-white matter difference increased from precontrast 4.56 H to postcontrast 7.82 H. The relatively high difference of 3.26 H between the white and gray matter enhancement compared with negligible enhancement of the brain slice as a whole leads us to the hypothesis, that an absolute decrease of white matter density, as a biological reaction to the injected contrast solution, has to be presumed.

We review evidence regarding the use of 0.9% benzyl alcohol in 0.9% sodium chloride solution for periocular injections ('preserved saline') including botulinum toxin A injections and local anaesthesia. A literature search was undertaken using search terms 'bacteriostatic saline', 'benzyl-alcohol saline', 'benzyl alcohol sodium chloride' and 'preserved saline'. Bibliographies identified further sources. There have been 62 studies published on the subject of preserved-saline since 1928. Significantly lower injection-associated pain levels for periocular/facial botulinum toxin injections reconstituted with preserved-saline rather than preservative-free saline are reported by 5 studies. Significantly lower injection-associated pain with preserved-saline diluted lidocaine and epinephrine solution for eyelid anaesthesia compared with unmodified or buffered lidocaine with epinephrine, and adequate anaesthesia, was reported by one study. Thirty-one studies have explored preserved-saline for anaesthetic and seven for bacteriostatic properties, with very low infection rates after periocular botulinum toxin injections, and reduced rates of infection in indwelling catheters when preserved saline is used to flush. A meta-analysis concluded that lidocaine-containing solutions are more effective at reducing pain from insertion of intravenous catheters. Patient-perceived pain related to periorbital injections of local anaesthesia is reduced when the anaesthetic is diluted with benzyl alcohol-preserved saline compared with other dilution or buffering options. Pain is similarly reduced for periocular botulinum toxin injections reconstituted with preserved saline compared with unpreserved saline. Benzyl-alcohol preserved-saline is inexpensive but costlier than unpreserved-saline, with minimal reported complications, particularly with periocular administration, and offers the opportunity to improve the patient experience.

The injection of autologous blood (AB) is one of the methods of treatment of recurrent dislocations in the temporomandibular joints (TMJs). Due to the low invasiveness of this technique, it is reasonable to evaluate it in accordance with the standards of evidence-based medicine. The purpose of this systematic review is to identify primary studies on AB injection for the treatment of TMJ hypermobility and assess the therapy for effectiveness. This systematic review was conducted in accordance with the current "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" guidelines. Controlled randomized trials comparing dislocation episode rates, range of motion in the TMJ, or articular pain intensity were adopted as the eligibility criteria. Final searches were conducted on 11 June 2023 using Bielefeld Academic Search Engine, Elsevier Scopus, and the National Library of Medicine: PubMed. Trials were assessed using the "Oxford Center for Evidence-Based Medicine 2011 Levels of Evidence" scale and "A revised Cochrane risk-of-bias tool for randomized trials". The results of the individual studies were tabulated, syntheses were illustrated in graphs. Twenty two studies involving 982 patients were included in the qualitative analysis, of which seven studies involving 390 patients were subject to quantitative analysis. None of the included randomized controlled trials presented a high risk of bias, 75% of them raised some concerns. In a three-month observation, administration of AB was more efficient in limiting temporomandibular dislocations than hypertonic dextrose (1 study, 32 patients, relative risk = 0.33, odds ratio = 0.29) and no difference in outcomes was observed between intracavitary and pericapsular administration compared to pericapsular injection alone (2 studies, 70 patients, relative risk = 1.00, odds ratio = 1.00). Injections of AB into the temporomandibular joints are effective in preventing further TMJ dislocation episodes in 75-94% of patients. This study received no funding.

Facet joint injections (FJIs) of anesthetic and corticosteroids are useful for the diagnosis and treatment of low back pain (LBP). In the current study, we evaluated the efficacy of FJI on LBP treatment and the predictive variables of pain recurrence after FJI.

Even though chronic abdominal pain is 1 of the most common reasons for hospital visits, diagnostic testing is often time-consuming and treatment is inadequate. Abdominal myofascial pain syndrome (AMPS) is usually not included as a differential diagnosis, but it should be considered in cases of chronic abdominal pain. The purpose of this study was to investigate the clinical characteristics of AMPS and to assess the effect of sonography-guided trigger point injections (TPI).A total of 100 patients with AMPS from 2012 to 2018 were retrospectively evaluated for clinical characteristics and TPI effects. AMPS was diagnosed using Srinivasan and Greenbaum's criteria, and the TPIs were performed at intervals of 2 to 4 weeks. The Visual Analog Scale (VAS) ratio was calculated by subtracting the final VAS from the initial VAS score and dividing it by the initial VAS score after injections, and the patients were divided into 4 groups: non-responders, mild, moderate, and good responders.The median duration of pain was 12 months, and the median number of hospital visits before TPI was 2. Of the 100 patients, 66 (66%) were categorized as good responders, 11 (11%) as moderate responders, 7 (6.9%) as mild responders, and 16 (15.7%) as non-responders. When the initial and final VAS scores were compared, the sonography-guided injections were found to be effective in alleviating pain (P < .001). Moreover, patients who received the injections 2 or more times tended to have more significant pain reduction than those who received a single injection (P < .001).Patients with AMPS suffer from long-term pain and undergo many hospital visits and diagnostic tests. TPI with lidocaine can be an effective and safe treatment for patients with chronic AMPS.

Aspiration during any kind of injection is meant to ensure that the needle tip is at the desired location during this blind procedure. While aspiration appears to be a simple procedure, it has generated a lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration both make logically sound claims. However, due to scarcity of available data, there is no evidence that this procedure is truly beneficial or unwarranted. Keeping in view the huge number of injections given worldwide, it is important that we draw attention to key questions regarding aspiration that, up till now, remain unanswered. In this review, we have attempted to gather and present literature on aspiration both from published and non-published sources in order to provide not only an exhaustive review of the subject, but also a starting point for further studies on more specific areas requiring clarification. A literature review was conducted using the US National Institute of Health's PubMed service (including Medline), Google Scholar and Scopus. Guidelines provided by the World Health Organization, Safe Injection Global Network, International Council of Nursing, Center for Disease Control, US Federal Drug Agency, UK National Health Services, British Medical Association, Europe Nursing and Midwifery Council, Public Health Agency Canada, Pakistan Medical Association and International Organization of Standardization recommendations 7886 parts 1-4 for sterile hypodermics were reviewed for relevant information. In addition, curricula of several medical/nursing schools from India, Nigeria and Pakistan, the US pharmacopeia Data from the WHO Program for International Drug Monitoring network in regard to adverse events as a result of not aspirating prior to injection delivery were reviewed. Curricula of selected major medical/nursing schools in India, Nigeria and Pakistan, national therapeutic formularies, product inserts of most commonly used drugs and other possible sources of information regarding aspiration and injections were consulted as well.

To determine the safety of a surgeon's initial consecutive intravitreal injections using a specific protocol and to review the complications that may be attributed to the injection procedure.

Low back pain represents a significant socioeconomic burden. Several nonsurgical medical treatments have been proposed for the treatment of this disabling condition. Epidural steroid injections (ESIs) are commonly used to treat lumbosacral radicular pain and to avoid surgery. Even though it is still not clear which type of conservative intervention is superior, several studies have proved that ESIs are able to increase patients' quality of life, relieve lumbosacral radicular pain and finally, reduce or delay more invasive interventions, such as spinal surgery. The aim of this narrative review is to analyze the mechanism of action of ESIs in patients affected by low back pain and investigate their current application in treating this widespread pathology.

Sacroiliac joint (SIJ) pathology is typically diagnosed and treated with fluoroscopy-guided intraarticular injections. Most practitioners use only an anteroposterior (AP) or oblique view. Although injection into the periarticular space may yield adequate pain relief, intraarticular needle placement is imperative to identify SIJ pathology and plan future management. This study highlights the importance of obtaining an additional lateral view during fluoroscopy to better evaluate SIJ disease.

Intracisternal injections of hypocretin-1 (hcrt-1) have been shown to elicit sympathoexciatory responses. However, the location of central sites that may mediate these cardiovascular effects have not been clearly elucidated. This study was done in male Wistar rats to investigate the effects of microinjections of hcrt-1 into the rostral ventromedial medulla (RVMM) on mean arterial pressure (MAP), heart rate (HR) and the arterial baroreflex. An initial series of experiments was done to provide a detailed mapping of the location of hcrt-1- and hcrt-1 receptors (hcrtR-1)-like immunoreactivity (i.r.) in the RVMM region. Hcrt-1 and hcrtR-1 ir were found throughout the RVMM region, but primarily within the magnocellular reticular nucleus and the adjacent nucleus paragigantocellularis lateralis. In the second series, this region containing hcrt-1 and hcrtR-1 ir was explored for sites that elicited changes in MAP and HR in the anaesthetized rat. Microinjection of hcrt-1 (0.5-2.5 pmol) into the region of magnocellular reticular nucleus elicited a dose-dependent increase in HR, with little or no change in MAP. Administration (i.v.) of the muscarinic receptor antagonist atropine methyl bromide significantly attenuated ( approximately 62%) the HR response whereas, the total autonomic blockade abolished the HR response. Finally, unilateral or bilateral microinjection of hcrt-1 into the magnocellular reticular nucleus significantly attenuated the reflex bradycardia resulting from the activation of the baroreflex following the increase in MAP from an iv injection of phenylephrine. These data suggest that hcrt-1 in the RVMM region activates neuronal circuits that both inhibit vagal activity and increase sympathetic activity to the heart, and that it alters the excitability of central circuits that reflexly control the circulation.