Recently, SpineUniverse spoke with Doctor Lawrence Kamhi, an Interventional Pain Management specialist who practices in Middletown, NY. Although the focus of the discussion was cortisone, Dr. Kamhi also provided us with his clinical experience in the nonsurgical treatment of back and neck pain using spinal epidural corticosteroid injections and related minimally invasive techniques.

SpU: What is cortisone?
Dr. Kamhi:
This is a common question patients ask. Cortisone is a close analogue of cortisol, the body's natural anti-inflammatory hormone. Chemically, cortisone is a steroid hormone made by the adrenal glands from the precursor molecule cholesterol. The sex hormones, estrogen and testosterone, are also steroid hormones made by the gonads and, to a lesser extent, by the adrenal glands, from cholesterol.

The chemical structure of a steroid (illustration above), which includes cholesterol, is characterized by four fused rings plus side chains. The ring structure stays constant. Differences in the side chains account for the different properties of steroid molecules.

There are two small adrenal glands in both males and females located atop the kidneys. The pituitary gland, through the release of ACTH (adrenocorticotropic hormone) regulates the release of cortisol from the adrenal glands into the bloodstream. When the body encounters stress (physical or mental) in response to a trauma, cortisol is released, which in turn regulates the body's inflammatory response.

Other effects of cortisol release include:

1) Stimulation of the liver to produce carbohydrates; the short-term fuel for the musculature.
2) Temporary elevation of blood glucose levels.
3) Mobilization of fatty acids from adipose tissue into the bloodstream.

These added effects of cortisol appear to prepare the organism for a "fight or flight" response. The inflammatory response by the body's tissues to trauma or injury is very complex, but may be divided into five principle stages:

Stage 1: Release of vasoactive substances from the bloodstream into the injured body tissues including histamine, bradykinin, proteolytic enzymes, prostaglandins, and leukotrienes;

Stage 2: A marked increase in blood flow to the trauma location producing erythema (redness);

Stage 3: Leakage of large quantities of plasma fluid from the capillary beds to the damaged tissue causing edema (swelling);

Stage 4: Infiltration of the traumatized region by large numbers of white blood cells and, after days to weeks;

Stage 5: The ingrowth of fibroblasts which form a healed scar.

Among the vasoactive substances cited in Stage 1, are chemicals that keenly stimulate sensory nerve endings causing the highly unpleasant - yet tissue protective -- sensation we know as pain.

This inflammatory response has evolved in man and most higher animals as protection from further injury and to effect healing. Nevertheless, the inflammatory response itself sometimes imposes considerable stress on the organism and in certain diseases (for example, rheumatoid arthritis) the inflammatory response itself is actually responsible for causing tissue injury to bone and joints. Thus, humans and most higher animals have evolved an internal homeostatic system designed to modulate the inflammatory response. The pituitary-adrenal ACTH-cortisol release system is a critical component of that system.

A number of diseases are caused by disorders or dysregulation within the inflammatory response. Besides the familiar rheumatoid arthritis, psoriasis and even Crohn's disease are, to a large extent, disorders of the inflammatory (immune) system.

Steroids are among the most potent anti-inflammatory drugs. More properly, steroid compounds are closely related, chemically speaking, to cortisol and the proper terms corticosteroids or glucocorticoids. These are the drugs used by physicians to modulate excessive inflammatory response.