Regular Cortisone Injections

Cortisone is an anti-inflammatory medication that can be injected into joints and soft tissues with the help of fluoroscopic or ultrasound guidance. It works by treating local inflammation, thereby reducing pain. This can be helpful for a variety of conditions, including joint inflammation due to arthritis, inflammation of bursa, or of lining around a tendon (tenosynovitis). This is a safe first injection to confirm diagnosis, typically lasting 3 to 6 months.

Regular cortisone joint injections including lumbar facet require no protocol. Post injections patients will stay with the tech assistant to ensure there is no post procedure complications. Any physio, chiropractic and acupuncture for patients is recommended 7-10 days after injection.

Viscosupplementation (Hyaluronic Acid/HA) Injections

Hyaluronic acid (HA) is a molecule normally present in healthy cartilage. When injected into degenerated joints it can help improve mobility, reduce pain, and may even stimulate joints to regenerate HA. HA injections are used to treat osteoarthritis or stiff joints, and typically last up to 12 months. These products are ‘medical devices’ and may be covered by insurance plans. Mayfair Diagnostics offers them to patients at cost. These injections can help provide improved relief for chronic OA or prearthroplasty patients.

Platelet Rich Plasma (PRP) Injections

Platelet Rich Plasma is a safe and effective treatment used to speed the healing of new injuries, repair chronic injuries and arthritis. PRP is derived from the patient’s own blood and injected under image guidance to stimulate the body to heal itself. Helpful in treating chronic tendon and ligament injuries, and it speeds up healing of recent tendon or muscle injuries. Early studies suggest it may also relieve symptoms from arthritis. This is a fee-for-service offering. Patients report faster injury repair, improved mobility and decreased pain lasting for months. Joints require 3 injections, soft tissues a single injection. Pre & Post therapy instructions will be given to the patient at time of booking.

Tendon Fenestration

Tendon Fenestration aims to help the body heal by stimulating tissue with a process that is like acupuncture. A radiologist uses a small needle to make tiny ‘pokes’ in an inflamed tendon with the help of image guiding technology. Depending on the site, we may inject steroids into the nearby tissues to control inflammation after treatment. This speeds healing of tendinopathy and partial tendon tears, often recalcitrant to conservative therapy. This delicate technique can aid in repair of chronic or acute tendon pathology.

Therapy for Calcific Tendinopathy

Calcium can often build up in tendons and tissues near joints, which causes pain and makes movement difficult. Ultrasound guidance is used to try to remove or break up the excess calcium with a needle. After the treatment, an injection steroid in adjacent tissue to reduce inflammation and pain. Mayfair recommends patients have repeat ultrasound three months after first treatment for reassessment of calcium in area.

nStride

nSTRIDE autologous protein solution (APS), has been approved by Health Canada and the FDA for treatment of knee osteoarthritis (OA).  The treatment involves a single injection of prepared APS derived from the patient’s blood, which is concentrated anti-inflammatory cytokines. This has proven to be a safe and effective treatment designed to stimulate the body to protect and preserve joint cartilage from further destruction – the hallmark of OA. As a result, there is a decrease in pain and an improvement in joint function, often within a few weeks of the injection. In clinical studies, patients reported ~ 70% symptom improvement even 24 months after the treatment. If an injection does not help relieve symptoms after three months, then patients may need further evaluation.

This treatment has been evaluated most extensively in the knee and is most effective in treatment of mild to moderate OA. As APS promotes healing by recruiting the body’s own repair system, the process can take a few weeks. Most patients notice improvement after 1-2 weeks and should see continued improvement gradually over many months.

Mayfair does not offer N-Stride for soft tissue. The treatment fee is $1,250 set by the manufacturer (Zimmer Biomet) and includes a preparation kit. This procedure is not available for spinal procedures.

Procedures that need prior imaging and the reasoning behind it:

In general, tendons are at risk of tearing with excessive steroid injections. Ultrasound helps confirm the integrity of the tendon before injection and exclude other potential causes of pain. Our goal is to do no harm

Shoulder:

• Bicep Tendon: ultrasound prior to confirm tenosynovitis, safest place for injection and exclude tear.
• Tendon Calcification: Tendon calcific deposits are common, but not always the cause of pain (NB. Calcium is painful during initial deposition and resorptive stages). More commonly, the calcium causes local inflammation of the bursa. It is safer to inject the bursa and treat the symptoms than proceed directly to a needling of the tendon. An ultrasound is important to confirm and localize any calcium deposits amenable to procedure (we suggest > 8mm). We advise an initial Subacromial Bursa injection for all patients. If the patient has persistent or recurrent pain 4-6 weeks later, we will proceed to tendon fenestration to break up the calcium.

Elbow:

• Lateral/Medial Epicondyle: ultrasound prior to injection to confirm Tendonitis, evaluate for tears or tendon retraction and for bursa around the tendon
• Olecranon Bursa: Needs ultrasound prior to confirm there is fluid to safely aspirate/inject

Wrist & Hand:

• De Quervain’s Tenosynovitis: Needs ultrasound prior to confirm there is enough fluid in the tendon sheath to safely inject, and to exclude tendon tears or other causes of symptoms
• Trigger Finger/Ganglion Cyst: Needs ultrasound prior to confirm that a cyst is present and can be safely aspirated, and to exclude other causes (mass, hematoma, vessel, etc)

Knee:

• Baker Cyst: Needs ultrasound prior to injection to confirm there is a cyst and it is amenable to aspiration, and exclude other causes of swelling

Hip & Pelvis:

• Iliopsoas Bursa: Needs ultrasound prior to confirm hamstring tendons are intact, assess for bursitis or other causes of pain.

Ankle & Foot:

• Plantar Fascia and Achilles: Needs ultrasound prior to confirm the fascia/tendon are intact, exclude tears or retraction, evaluate for adjacent bursa, and exclude other causes of pain.
• Ganglion Cyst: Needs ultrasound prior to confirm that a cyst is present and can be safely aspirated, and to exclude other causes (mass, hematoma, vessel, etc)
• Morton’s Neuroma: ultrasound preferred to confirm Interdigital neuroma and evaluate for other causes such as bursitis or mass.

Special Spine:

• Medial Branch Blocks: Need prior Facet injections and preferably a Bone Scan with Spect/CT but not a prerequisite. This is strictly a diagnostic test to see if patient is a candidate for the Ablation.
• Selective Nerve Root Block OR Epidural: Needs MR or CT prior to see that there is enough Epidural Fat to safely perform either injection, exclude regional vessels, or other causes of regional pain.
• Radiofrequency Ablation: Patient will have to go through the Medial Branch Block of two successful outcomes to see if they are a candidate for the Ablation.

Helpful Booking Tips

• To order Pain Management, please fax all pain therapy requisition to 403.777.3001 and ensure all relevant history is included.
• Fluid analysis or send-to-lab requests must have a completed lab requisition along with the imaging requisition.
• If a translator is required for your patient, please come with a consent form.
• For facet injections, a SPECT/CT (covered by Alberta Health Care Plan) imaging is often used to provide guidance.

(this section can be added to the case studies for consideration – from Dr. Salat)

REFERENCES

Arthritis Foundation (2020) “What is Osteoarthritis?” www.arthritis.org. Accessed January 10, 2021.
Arthritis Society & Dr. J. Hochman. (2017) “Osteoarthritis.” www.arthritis.ca. Accessed January 10, 2021.
Healthwise Staff (2019) “Osteoarthritis.” www.MyHealth.Alberta.ca. Accessed January 10, 2021.
Kon, E., et al. (2018) “Clinical Outcomes of Knee Osteoarthritis Treated With an Autologous Protein Solution Injection: A 1-Year Pilot Double-Blinded Randomized Controlled Trial.” American Journal of Sports Medicine. Jan; 46(1):171-180.