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Lee JH, Lee SH, Suh HS, Hwang MS, Jang S, Choi S, Lim YS, Byun SH, Yoon SH, Park S, Park TY. Effectiveness of Acupotomy Combined with Epidural Steroid Injection for Lumbosacral Radiculopathy: A Randomized Controlled Pragmatic Pilot Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:175. [PMID: 38276054 PMCID: PMC10818306 DOI: 10.3390/medicina60010175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/04/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024]
Abstract
Background and Objectives: This pilot study aimed to evaluate the clinical effectiveness, cost-effectiveness, and safety of acupotomy combined with epidural steroid injection (ESI) in lumbosacral radiculopathy and examine its feasibility for the main study. Materials and Methods: This randomized, controlled, two-arm, parallel, assessor-blinded, pragmatic study included 50 patients with severe lumbosacral radiculopathy who had insufficient improvement after an ESI. Patients were randomized (1:1 ratio) into a combined treatment (acupotomy + ESI, experimental) and an ESI single treatment (control) group. Both groups underwent a total of two ESIs once every 2 weeks; the experimental group received eight additional acupotomy treatments twice a week for 4 weeks. Types of ESI included interlaminar, transforaminal, and caudal approaches. Drugs used in ESI comprised a 5-10 mL mixture of dexamethasone sodium phosphate (2.5 mg), mepivacaine (0.3%), and hyaluronidase (1500 IU). The primary outcome was the difference in changes from baseline in the Oswestry Disability Index (ODI) scores between the groups at weeks 4 and 8. The incremental cost-utility ratio (ICUR) was calculated to evaluate the cost-effectiveness between the groups. Adverse events (AEs) were assessed at all visits. Results: Mean ODI scores for the experimental and control groups were -9.44 (95% confidence interval [CI]: -12.71, -6.17) and -2.16 (95% CI: -5.01, 0.69) at week 4, and -9.04 (95% CI: -12.09, -5.99) and -4.76 (95% CI: -7.68, -1.84) at week 8, respectively. The difference in ODI score changes was significant between the groups at week 4 (p = 0.0021). The ICUR of the experimental group versus the control group was as economical as 18,267,754 won/quality-adjusted life years. No serious AEs were observed. Conclusions: These results demonstrate the potential clinical effectiveness and cost-effectiveness of acupotomy combined with ESI for lumbosacral radiculopathy and its feasibility for a full-scale study. Larger, long-term follow-up clinical trials are needed to confirm these findings.
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Affiliation(s)
- Jin-Hyun Lee
- Institute for Integrative Medicine, International St. Mary’s Hospital, Catholic Kwandong University, Incheon 22711, Republic of Korea;
| | - Sang-Hyun Lee
- Department of Korean Medicine, Graduate School, Pusan National University, Yangsan 50612, Republic of Korea;
| | - Hae Sun Suh
- College of Pharmacy, Kyung Hee University, Seoul 02453, Republic of Korea
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul 02453, Republic of Korea
- Institute of Regulatory Innovation through Science, Kyung Hee University, Seoul 02453, Republic of Korea
| | - Man-Suk Hwang
- Department of Korean Medicine Rehabilitation, Spine and Joint Center, Pusan National University Korean Medicine Hospital, Yangsan 50612, Republic of Korea
- Third Division of Clinical Medicine, School of Korean Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Semin Jang
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul 02453, Republic of Korea
- Institute of Regulatory Innovation through Science, Kyung Hee University, Seoul 02453, Republic of Korea
| | - Sooil Choi
- Department of Anesthesiology and Pain Medicine, International St. Mary’s Hospital, Catholic Kwandong University, Incheon 22711, Republic of Korea; (S.C.)
| | - Young-Soo Lim
- Department of Anesthesiology and Pain Medicine, International St. Mary’s Hospital, Catholic Kwandong University, Incheon 22711, Republic of Korea; (S.C.)
| | - Sang Hyun Byun
- SAGAJEONG Pain and Korean Medicine Clinic, Seoul 02238, Republic of Korea
| | - Sang-Hoon Yoon
- Department of Applied Korean Medicine, Graduate School, Kyung Hee University, Seoul 02453, Republic of Korea
| | - Sukhee Park
- Department of Anesthesiology and Pain Medicine, International St. Mary’s Hospital, Catholic Kwandong University, Incheon 22711, Republic of Korea; (S.C.)
| | - Tae-Yong Park
- Institute for Integrative Medicine, International St. Mary’s Hospital, Catholic Kwandong University, Incheon 22711, Republic of Korea;
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Delaney FT, MacMahon PJ. An update on epidural steroid injections: is there still a role for particulate corticosteroids? Skeletal Radiol 2023; 52:1863-1871. [PMID: 36171350 DOI: 10.1007/s00256-022-04186-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 02/02/2023]
Abstract
Epidural steroid injections (ESIs) play an important role in the multifaceted management of neck and back pain. Corticosteroid preparations used in ESIs may be considered "particulate" or "non-particulate" based on whether they form a crystalline suspension or a soluble clear solution, respectively. In the past two decades, there have been reports of rare but severe and permanent neurological complications as a result of ESI. These complications have principally occurred with particulate corticosteroid preparations when using a transforaminal injection technique at cervical or thoracic levels, and only rarely in the lumbosacral spine. As a result, some published clinical guidelines and recommendations have advised against the use of particulate corticosteroids for transforaminal ESI, and the FDA introduced a warning label for injectable corticosteroids regarding the risk of serious neurological adverse events. There is growing evidence that the efficacy of non-particulate corticosteroids for pain relief and functional improvement after ESI is non-inferior to particulate agents, and that non-particulate injections almost never result in permanent neurological injury. Despite this, particulate corticosteroids continue to be routinely used for transforaminal epidural injections. More consistent clinical guidelines and societal recommendations are required alongside increased awareness of the comparative efficacy of non-particulate agents among specialists who perform ESIs. The current role for particulate corticosteroids in ESIs should be limited to caudal and interlaminar approaches, or transforaminal injections in the lumbar spine only if initial non-particulate ESI resulted in a significant but short-lived improvement.
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Affiliation(s)
- Francis T Delaney
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - Peter J MacMahon
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
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MacLean E, Garber G, Barbosa K, Liu R, Verge A, Mukhida K. Lessons learned from examination of Canadian medico-legal cases related to interventional therapies for chronic pain management. Can J Anaesth 2023; 70:1504-1515. [PMID: 37523142 DOI: 10.1007/s12630-023-02531-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/10/2023] [Accepted: 02/20/2023] [Indexed: 08/01/2023] Open
Abstract
PURPOSE Chronic pain is a common condition affecting almost one in five Canadians. One of the methods used to treat chronic pain is injection therapies. While they are considered relatively safe procedures, they do carry inherent risk that can result in adverse events. Our goal was to investigate these patient safety events to identify themes that could be used to shape practice guidelines and standards and improve patient safety. METHODS We looked at closed civil legal actions and regulatory college complaints associated with injection therapies for chronic pain in the Canadian Medical Protection Association database from 2015 to 2019. Injury was defined as that arising from, or associated with, plans or actions taken during the provision of health care, rather than an underlying disease or injury. RESULTS Of the 91 cases identified, the most common reported complications were neurologic-related symptoms, injury, and infection. Fifty-eight percent (53/91) of patients experienced health care-related harm that had a negative effect on their health or quality of life. Peer experts were critical of the clinical care provided in 74% (67/91) of the cases. Provider-related (60%, 40/67), team-related (75%, 50/67), and system-related factors (21%, 14/67) were identified as contributing factors in these cases. Common examples of provider-related factors were deficiencies in clinical decision-making (48%, 19/40), failure to follow established procedures (43%, 17/40), and situational awareness (38%, 15/40). Common examples of team-related factors were deficiencies in medical record keeping (80%, 40/50) and communication breakdowns (56%, 28/50). All system-related factors were related to inadequate office procedures. CONCLUSION We recommend that clinicians conduct appropriate physical examinations, keep up-to-date with clinical standards, and ensure their documentation reflects their assessment, the patient's condition, and the treatment rationale.
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Affiliation(s)
- Emma MacLean
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Gary Garber
- Department of Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kate Barbosa
- Department of Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, ON, Canada
| | - Richard Liu
- Department of Safe Medical Care Research, Canadian Medical Protective Association, Ottawa, ON, Canada
| | - Allison Verge
- Department of Anesthesia, Pain Management & Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Karim Mukhida
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.
- Department of Anesthesia, Pain Management & Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.
- Pain Management Unit, Queen Elizabeth II Health Sciences Centre, 4th Floor Dickson Building, Halifax, NS, B3H 1K5, Canada.
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Peene L, Cohen SP, Brouwer B, James R, Wolff A, Van Boxem K, Van Zundert J. 2. Cervical radicular pain. Pain Pract 2023; 23:800-817. [PMID: 37272250 DOI: 10.1111/papr.13252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Cervical radicular pain is pain perceived in the upper limb, caused by irritation or compression of a cervical spine nerve, the roots of the nerve, or both. METHODS The literature on the diagnosis and treatment of cervical radicular pain was retrieved and summarized. RESULTS The diagnosis is made by combining elements from the patient's history, physical examination, and supplementary tests. The Spurling and shoulder abduction tests are the two most common examinations used to identify cervical radicular pain. MRI without contrast, CT scanning, and in some cases plain radiography can all be appropriate imaging techniques for nontraumatic cervical radiculopathy. MRI is recommended prior to interventional treatments. Exercise with or without other treatments can be beneficial. There is scant evidence for the use of paracetamol, nonsteroidal anti-inflammatory drugs, and neuropathic pain medications such as gabapentin, pregabalin, tricyclic antidepressants, and anticonvulsants for the treatment of radicular pain. Acute and subacute cervical radicular pain may respond well to epidural corticosteroid administration, preferentially using an interlaminar approach. By contrast, for chronic cervical radicular pain, the efficacy of epidural corticosteroid administration is limited. In these patients, pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered. CONCLUSIONS There is currently no gold standard for the diagnosis of cervical radicular pain. There is scant evidence for the use of medication. Epidural corticosteroid injection and pulsed radiofrequency adjacent to the dorsal root ganglion may be considered. [Correction added on 12 June 2023, after first online publication: The preceding sentence was corrected.].
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Affiliation(s)
- Laurens Peene
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
| | - Steven P Cohen
- Pain Medicine Division, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, USA
| | - Brigitte Brouwer
- Department of Anesthesiology, Pain Medicine and Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rathmell James
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Leroy D. Vandam Professor of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Andre Wolff
- Department of Anesthesiology, UMCG Pain Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Koen Van Boxem
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
- Department of Anesthesiology, Pain Medicine and Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
- Department of Anesthesiology, Pain Medicine and Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
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Interaction between Dexamethasone, Ropivacaine, and Contrast Media Used in Interventional Pain Treatment: Considerations in Safety. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121871. [PMID: 36557073 PMCID: PMC9788574 DOI: 10.3390/medicina58121871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/15/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
Background and Objectives: Although epidural steroid injections are used as an effective treatment, this technique is associated with rare but serious ischemic complications, especially when particulate steroids are used. However, recent studies have reported that even if non-particulate steroids are used, particulates are formed by the interaction with some local anesthetics (LA), causing ischemic complications. This observational study evaluated commonly used combinations of non-particulate steroids and LA with contrast media via microscopic analysis and analyzed the chemical properties of each mixture to identify the correlation of particulate formation. Materials and Methods: Commonly used clinical non-particulate and particulate steroids, contrast media, and LA agent combinations were evaluated macroscopically and microscopically. The pH values were also measured at both room temperature (26 °C) and body temperature (36 °C). Where particulates were observed, the particulate size was measured. Results: Macroscopically, the mixture of non-particulate steroid and ropivacaine had a slightly cloudy appearance at all concentrations, but there was no visible particulate. However, when observed under a microscope, the pH-dependent particulate formation was observed at all concentration combinations tested. (0.1% ropivacaine: from 19 μm to 70 μm, and 0.2% ropivacaine: from 37 μm to 108 μm at room temperature (26 °C)). When contrast media was mixed or the temperature was raised to body temperature (36 °C), the number and size of the particulates decreased or dissolved. Conclusions: The combination of ropivacaine and dexamethasone, a non-particulate steroid, mainly used in epidural injections, forms particulates. However, when mixed with contrast media, particulates are dissolved because of changes in pH and factors affecting particulate formation. In fluoroscopy-guided injections, the use of contrast media could resolve particulate formation.
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Lee SY, Kim IY, Jeong KW, Ryu T, Kwak SK, Jung JY. Comparison between the coronal diameters of the cervical spinal canal and spinal cord measured using computed tomography and magnetic resonance imaging in Korean patients. Korean J Anesthesiol 2022; 75:323-330. [PMID: 35272447 PMCID: PMC9346277 DOI: 10.4097/kja.22006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Cervical epidural block could cause spinal cord injury if the epidural needle is over-inserted and punctures the spinal cord. However, if the proportion of the spinal cord in the epidural space can be determined under C-arm fluoroscopy, a safe entry point for the epidural needle can be established. Methods We retrospectively evaluated the imaging data of 100 patients (50 men and 50 women) who underwent both cervical computed tomography (CT) and cervical magnetic resonance imaging (MRI) at our hospital. We measured the diameters of the spinal canal and spinal cord from the 3rd cervical vertebra to the 1st thoracic vertebra (T1) at each level by using the patients' cervical CT and MR images. The spinal cord and spinal canal diameters were measured in the transverse plane of cervical MR and CT images, respectively. Results The spinal cord to spinal canal diameter ratio was the highest at the 4th and 5th cervical vertebrae (0.64 ± 0.07) and the lowest at T1 (0.55 ± 0.06, 99% confidence interval : 0.535 - 0.565). Conclusions Our findings suggest that the cord to canal transverse diameter ratio could be used as a reference to reduce direct spinal cord injuries during cervical epidural block under C-arm fluoroscopy. In the C-arm fluoroscopic image, if an imaginary line connecting the left and right innermost lines of the pedicles of T1 is drawn and if the needle is inserted into the outer one-fifth of the left and right sides, the risk of puncturing the spinal cord would be relatively reduced.
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Affiliation(s)
- So Young Lee
- Department Anesthesiology and Pain Medicine, School of Medicine Daegu Catholic University, Daegu, Korea
| | - In Young Kim
- Department Anesthesiology and Pain Medicine, School of Medicine Daegu Catholic University, Daegu, Korea
| | - Kyung Wook Jeong
- Department Anesthesiology and Pain Medicine, School of Medicine Daegu Catholic University, Daegu, Korea
| | - Taeha Ryu
- Department Anesthesiology and Pain Medicine, School of Medicine Daegu Catholic University, Daegu, Korea
| | - Sang Kyu Kwak
- Department of Medical Statistics, School of Medicine Daegu Catholic University, Daegu, Korea
| | - Jin Yong Jung
- Department Anesthesiology and Pain Medicine, School of Medicine Daegu Catholic University, Daegu, Korea
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Ultrasound-Guided Caudal Epidural Steroid Injection for Back Pain: A Case Report of Successful Emergency Department Management of Radicular Low Back Pain Symptoms. J Emerg Med 2021; 61:293-297. [PMID: 34183200 DOI: 10.1016/j.jemermed.2021.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Radicular low back pain is difficult to treat and commonly encountered in the Emergency Department (ED). Pain associated with acute radiculopathy results in limited ability to work, function, and enjoy life, and is associated with increased risk of chronic opioid therapy. In this case report, we describe the first ED-delivered ultrasound-guided caudal epidural steroid injection (ESI) used to treat medication-refractory lumbar radiculopathy, which resulted in immediate and sustained resolution of pain. CASE REPORT A 56-year old man with a past medical history of chronic lumbar radiculopathy presented to the ED with acute low back and right lower-extremity pain. Based on history and physical examination, a right L5 radiculopathy was suspected. His pain was poorly controlled despite multimodal analgesia, at which point he was offered admission or an ultrasound-guided caudal ESI. The procedure was performed using dexamethasone, preservative-free normal saline, and preservative-free 1% lidocaine solution, after which the patient reported 100% resolution of his pain and requested discharge from the ED. Why Should an Emergency Physician Be Aware of This? The safety and efficacy of ultrasound-guided caudal ESIs have been established, but there is a paucity of literature exploring their application in the ED. We present a case of a refractory lumbar radiculopathy successfully treated with an ultrasound-guided caudal ESI. ED-performed epidurals can be one additional tool in the emergency physician arsenal to treat acute or chronic lumbar radiculopathy.
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Hadzimuratovic B, Mittelbach A, Bahrami A, Zwerina J, Kocijan R. Confluent abscesses in autochthonous back muscles after spinal injections : A case report and narrative review of the literature on low back pain and spinal injections. Wien Med Wochenschr 2020; 172:247-255. [PMID: 32748365 DOI: 10.1007/s10354-020-00773-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/01/2020] [Indexed: 12/13/2022]
Abstract
Injection therapy is a frequently used method for the treatment of subacute and chronic low back pain (LBP) despite scant evidence for its effectiveness. To date there are relatively few studies comparing this method with other treatments. Moreover, there are many possible side effects associated with injection therapies, some of which are potentially life threatening. We present the case of a 59-year-old woman admitted to the emergency department with confluent abscess formations of autochthonous back muscles and staphylococcal sepsis caused by injection therapy performed by a general practitioner for LBP. The findings of this case report emphasize a careful selection of patients for this type of treatment and a multidisciplinary approach to treatment of LBP.
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Affiliation(s)
- Benjamin Hadzimuratovic
- Ludwig Boltzmann Institute of Osteology, I. Medizinische Abteilung, Mein Hanusch-Krankenhaus, Heinrich Collin-Straße 30, 1140, Vienna, Austria
| | - Andreas Mittelbach
- Institut für Physikalische Medizin und Rehabilitation, Mein Hanusch-Krankenhaus, Heinrich Collin-Straße 30, 1140, Vienna, Austria
| | - Arian Bahrami
- Zentralröntgeninstitut mit Fachbereich Nuklearmedizin, I. Medizinische Abteilung, Mein Hanusch-Krankenhaus, Heinrich Collin-Straße 30, 1140, Vienna, Austria
| | - Jochen Zwerina
- Ludwig Boltzmann Institute of Osteology, I. Medizinische Abteilung, Mein Hanusch-Krankenhaus, Heinrich Collin-Straße 30, 1140, Vienna, Austria
| | - Roland Kocijan
- Ludwig Boltzmann Institute of Osteology, I. Medizinische Abteilung, Mein Hanusch-Krankenhaus, Heinrich Collin-Straße 30, 1140, Vienna, Austria.
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He Z. Pathogenic Mechanisms of a Stroke-like attack Elicited by Epidural Steroid Injection Therapy. Curr Neurovasc Res 2020; 17:312-318. [PMID: 32294038 DOI: 10.2174/1567202617666200415143201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 03/09/2020] [Accepted: 03/12/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The pathogenic mechanisms involved in a disastrous scenario, following epidural steroid injections (ESI), remain unclarified. Intra-arterial injection of steroids with needlepenetrating vascular injury would be the culprit, as particulate medicine elicits a brain or spinal cord stroke-like attack. METHODS On the other hand, the limited experimental approaches simulating an accidental steroid intra-arterial injection for ESI conflicted in their results: hemorrhage vs. ischemia. RESULTS This article dissects the potential pathogenic mechanisms at a neurovascular unit. Noticeably, a schematic representation provides an explanation of how emboli formed by particulate steroids elicit either hemorrhagic, or ischemic lesion. CONCLUSION In addition, the development of a rat model with intravertebral artery steroid injection is a proposal to address the unmet need in evaluating steroids and vascular injury in ESI.
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Affiliation(s)
- Zhen He
- Division of Neurotoxicology, National Center for Toxicological Research, Food and Drug Administration, Jefferson, AR 72079, United States
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Neurological Complication Rates of Epidural Injections and Selective Nerve Blocks: A Comparison of Steroid Use Patterns. Clin J Pain 2020; 36:449-457. [PMID: 32068540 DOI: 10.1097/ajp.0000000000000816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Epidural injections and selective nerve blocks are widely used for pain relief, but steroid usage is controversial due to safety concerns. We carried out this retrospective cohort study to estimate the incidence rates of neurological complications associated with epidural and selective nerve blocks, in relation to steroid use patterns. MATERIALS AND METHODS Using a national insurance claims database, we identified patients who received at least one epidural injection or nerve block from 2009 to 2013. We estimated incidence rates and hazard ratios in propensity score-matched cohorts stratified by steroids, using the Charlson comorbidity index, age, sex, anesthetics, and antithrombotics as variables. We included cases attending hospital within 24 hours after injection and treated for neurological complications. RESULTS Incidence rates of neurological complications per 100,000 person-days for injections with and without steroids were 1.48 (95% confidence interval [CI]: 1.25-1.65) and 0.86 (95% CI: 0.66-1.30), respectively; rates for particulate steroid injections and nonparticulate steroid injections were 1.73 (95% CI: 1.41-1.95) and 0.90 (95% CI: 0.43-1.47), respectively. The adjusted hazard ratio (aHR) of neurological complications for injections with versus without steroids was 1.71 (95% CI: 0.96-2.49). The aHR of particulate versus nonparticulate steroid injections was 4.98 (95% CI: 1.01-262.35), at the cervicothoracic level. The aHR of neurological complications for nonparticulate steroids compared with nonsteroidal injections was 0.97 (95% CI: 0.46-3.01). DISCUSSION At the cervicothoracic level, the incidence rate of neurological complications with particulate steroid injections was higher than that with nonparticulate steroid injections. Injections with nonparticulate steroids and without steroids were equally safe.
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A Contemporary Medicolegal Analysis of Outpatient Interventional Pain Procedures: 2009-2016. Anesth Analg 2020; 129:255-262. [PMID: 30925562 DOI: 10.1213/ane.0000000000004096] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Closed malpractice claim studies allow a review of rare but often severe complications, yielding useful insight into improving patient safety and decreasing practitioner liability. METHODS This retrospective observational study of pain medicine malpractice claims utilizes the Controlled Risk Insurance Company Comparative Benchmarking System database, which contains nearly 400,000 malpractice claims drawn from >400 academic and community medical centers. The Controlled Risk Insurance Company Comparative Benchmarking System database was queried for January 1, 2009 through December 31, 2016, for cases with pain medicine as the primary service. Cases involving outpatient interventional pain management were identified. Controlled Risk Insurance Company-coded data fields and the narrative summaries were reviewed by the study authors. RESULTS A total of 126 closed claims were identified. Forty-one claims resulted in payments to the plaintiffs, with a median payment of $175,000 (range, $2600-$2,950,000). Lumbar interlaminar epidural steroid injections were the most common procedures associated with claims (n = 34), followed by cervical interlaminar epidural steroid injections (n = 31) and trigger point injections (n = 13). The most common alleged injuring events were an improper performance of a procedure (n = 38); alleged nonsterile technique (n = 17); unintentional dural puncture (n = 13); needle misdirected to the spinal cord (n = 11); and needle misdirected to the lung (n = 10). The most common alleged outcomes were worsening pain (n = 26); spinal cord infarct (n = 16); epidural hematoma (n = 9); soft-tissue infection (n = 9); postdural puncture headache (n = 9); and pneumothorax (n = 9). According to the Controlled Risk Insurance Company proprietary contributing factor system, perceived deficits in technical skill were present in 83% of claims. CONCLUSIONS Epidural steroid injections are among the most commonly performed interventional pain procedures and, while a familiar procedure to pain management practitioners, may result in significant neurological injury. Trigger point injections, while generally considered safe, may result in pneumothorax or injury to other deep structures. Ultimately, the efforts to minimize practitioner liability and patient harm, like the claims themselves, will be multifactorial. Best outcomes will likely come from continued robust training in procedural skills, attention paid to published best practice recommendations, documentation that includes an inclusive consent discussion, and thoughtful patient selection. Limitations for this study are that closed claim data do not cover all complications that occur and skew toward more severe complications. In addition, the data from Controlled Risk Insurance Company Comparative Benchmarking System cannot be independently verified.
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Smith GA, Pace J, Strohl M, Kaul A, Hayek S, Miller JP. Rare Neurosurgical Complications of Epidural Injections: An 8-Yr Single-Institution Experience. Oper Neurosurg (Hagerstown) 2019; 13:271-279. [PMID: 28927205 DOI: 10.1093/ons/opw014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 10/22/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Neurosurgical complications from epidural injections have rarely been reported. OBJECTIVE To define the spectrum of complications from these procedures in order to identify risk factors and strategies for prevention. METHODS A prospectively maintained database of 14 247 neurosurgical admissions over 8 yr was screened to identify patients who had suffered procedural complications associated with 1182 cervical and 4617 lumbar interlaminar epidural injection procedures performed at a single institution. Patients who developed new neurological symptoms or deficits were included. A retrospective analysis of demographic and procedural features was performed. RESULTS Thirteen patients experienced complications requiring neurosurgical treatment, accounting for an overall procedural complication rate of 0.22% (0.51% and 0.15% for cervical and lumbar injections, respectively), and representing 0.09% of all neurosurgical admissions over 8 yr. There were 3 categories: hemorrhage (n = 7), infection (n = 3), and inadvertent dural penetration (n = 3). There was significant association with anticoagulation use among patients with hemorrhagic vs nonhemorrhagic complications ( P < .01, Fisher's exact test). Six patients who developed epidural hematoma had been managed in accordance with current guidelines, either after prolonged cessation of anticoagulation (n = 3) or taking only aspirin (n = 3); all were decompressed promptly with good long-term outcome. All infections were associated with lumbar injection. Dural penetration resulted in diffuse pneumocephalus (n = 1), intramedullary air at the site of injection (n = 1), and acutely symptomatic colloid cyst (n = 1). CONCLUSION A majority of neurosurgical complications from epidural injections are hemorrhagic and associated with anticoagulation, although infection and inadvertent dural penetration also occur. Prompt treatment of compressive lesions is associated with good outcome.
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Affiliation(s)
- Gabriel A Smith
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Jonathan Pace
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Madeleine Strohl
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Anand Kaul
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Salim Hayek
- Division of Pain Medicine, Depart-ment of Anesthesiology, University Hospi-tals Case Medical Center, Cleveland, Ohio
| | - Jonathan P Miller
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
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Affram KO, Reddy TL, Osei KM. A Rare Case of Thyrotoxic Periodic Paralysis After Epidural Steroid Injection: A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:1453-1458. [PMID: 30531678 PMCID: PMC6293861 DOI: 10.12659/ajcr.911270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Patient: Male, 36 Final Diagnosis: Epidural steroid induced thyrotoxic periodic paralysis Symptoms: Paralysis Medication: — Clinical Procedure: Epidural steroid injection Specialty: Endorinology and Metabolic
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Affiliation(s)
- Kwame Ofori Affram
- Department of Internal Medicine, Piedmont Athens Regional Medical Center, Athens, GA, USA
| | - Tanya Luke Reddy
- Department of Internal Medicine, Piedmont Athens Regional Medical Center, Athens, GA, USA
| | - Kofi M Osei
- Department of Internal Medicine, Piedmont Athens Regional Medical Center, Athens, GA, USA
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14
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Marcia S, Zini C, Hirsch JA, Chandra RV, Bellini M. Steroids Spinal Injections. Semin Intervent Radiol 2018; 35:290-298. [PMID: 30402012 DOI: 10.1055/s-0038-1673421] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Spinal pain is a common condition leading to significant disability and high cost. Spinal injections have been demonstrated to be effective short-term treatments with cost-utility superior to numerous other treatments, including surgical procedures. Appropriate patient selection-based on clinical and imaging finding-and the use of image guidance associated with technical precautions improve the safety and effectiveness of spinal injection and overall patient outcomes.
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Affiliation(s)
- Stefano Marcia
- Chief of Diagnostic and Interventional Radiology, Ospedale "Santissima Trinità", Cagliari, Italy
| | - Chiara Zini
- Department of Radiology, Ospedale "Santa Maria Annunziata", Azienda Ospedaliera Toscana Centro, Firenze, Italy
| | - Joshua A Hirsch
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Ronil V Chandra
- Diagnostic and Interventional Neuroradiology, Monash Imaging, Monash Health, Melbourne, Australia.,Chief of Stroke Imaging and Endovascular Clot Retrieval, Monash Imaging, Monash Health, Melbourne, Australia.,Neurovascular Surgery, Monash Health, Melbourne, Australia.,Chief of Neurovascular Imaging Research, Monash Health, Melbourne, Australia.,Departments of Surgery and Medicine, Monash Health, Melbourne, Australia
| | - Matteo Bellini
- Chief of Minimal Invasive Spinal Treatment Unit.,Neuroimaging and Neurointerventional Unit.,Department of Neurological and Neurosensorial Sciences.,Ospedale "Santa Maria alle Scotte", Azienda Ospedaliera Universitaria Senese, Siena, Italy
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15
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Simon JI, O'Donnell HK, Broyer Z. To the Editor. PAIN MEDICINE 2018; 19:412-413. [PMID: 29016898 DOI: 10.1093/pm/pnx150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Jeremy I Simon
- Department of Physical Medicine, Rothman Institute, Philadelphia, Pennsylvania
| | - Harla K O'Donnell
- Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Zachary Broyer
- Department of Physical Medicine, Rothman Institute, Philadelphia, Pennsylvania
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16
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Schneider BJ, Maybin S, Sturos E. Safety and Complications of Cervical Epidural Steroid Injections. Phys Med Rehabil Clin N Am 2018; 29:155-169. [DOI: 10.1016/j.pmr.2017.08.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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17
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Manchikanti L, Pampati V, Kaye AD, Hirsch JA. Therapeutic lumbar facet joint nerve blocks in the treatment of chronic low back pain: cost utility analysis based on a randomized controlled trial. Korean J Pain 2018; 31:27-38. [PMID: 29372023 PMCID: PMC5780212 DOI: 10.3344/kjp.2018.31.1.27] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 10/03/2017] [Accepted: 10/12/2017] [Indexed: 12/29/2022] Open
Abstract
Background Related to escalating health care costs and the questionable effectiveness of multiple interventions including lumbar facet joint interventions, cost effectiveness or cost utility analysis has become the cornerstone of evidence-based medicine influencing coverage decisions. Methods Cost utility of therapeutic lumbar facet joint nerve blocks in managing chronic low back pain was performed utilizing data from a randomized, double-blind, controlled trial with a 2-year follow-up, with direct payment data from 2016. Based on the data from surgical interventions, utilizing the lowest proportion of direct procedural costs of 60%, total cost utility per quality adjusted life year (QALY) was determined by multiplying the derived direct cost at 1.67. Results Patients in this trial on average received 5.6 ± 2.6 procedures over a period of 2 years, with average relief over a period of 2 years of 82.8 ± 29.6 weeks with 19 ± 18.77 weeks of improvement per procedure. Procedural cost for one-year improvement in quality of life showed USD $2,654.08. Estimated total costs, including indirect costs and drugs with multiplication of direct costs at 1.67, showed a cost of USD $4,432 per QALY. Conclusions The analysis of therapeutic lumbar facet joint nerve blocks in the treatment of chronic low back pain shows clinical effectiveness and cost utility at USD $2,654.08 for the direct costs of the procedures, and USD $4,432 for the estimated overall cost per one year of QALY, in chronic persistent low back pain non-responsive to conservative management.
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Affiliation(s)
| | | | - Alan D Kaye
- LSU Health Science Center, New Orleans, LA, USA
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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18
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Schneider BJ, Sturos E. Safety and Risk Mitigation for Cervical Interlaminar Epidural Steroid Injections. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2017. [DOI: 10.1007/s40141-017-0166-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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19
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Filippiadis DK, Rodt T, Kitsou MC, Batistaki C, Kelekis N, Kostopanagiotou G, Kelekis A. Epidural interlaminar injections in severe degenerative lumbar spine: fluoroscopy should not be a luxury. J Neurointerv Surg 2017; 10:592-595. [DOI: 10.1136/neurintsurg-2017-013288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 08/21/2017] [Accepted: 08/24/2017] [Indexed: 12/27/2022]
Abstract
ObjectiveTo assess technical efficacy, accuracy, and safety of epidural (interlaminar) injections performed blindly in patients with a severely degenerated lumbar spine.MethodsOver 12 consecutive months, 138 patients with a severe degenerative lumbar spine underwent epidural (interlaminar) injection as therapy for low back pain and neuralgia. Patients had already undergone a blind epidural infiltration with minimum or no pain reduction. The session was repeated in the angiography suite. Patients were placed in the lateral decubitus position. The injection was performed without image guidance by an anaesthesiologist; the target level was defined before the beginning of the procedure. Once air resistance loss was felt it was presumed that the needle was inside the epidural space. Verification of needle position was performed by injection of 1–3 mL of iodinated contrast medium under fluoroscopy in a lateral projection.ResultsCorrect needle position inside the epidural space was documented in 82/138 cases (59.4%); unexpected extraepidural location was seen in 56/138 cases (40.6%). Target level was reached in 96/138 cases (69.6%); in 42/138 cases (30.4%) the needle was positioned in a non-target level. In 5/138 (3.6%) cases, there was inadvertent intradural position of the needle. Image guidance was subsequently used for correct positioning of the needle, which was feasible in all cases.ConclusionBlind interlaminar epidural injections lack the accuracy of exact needle location that imaging guidance offers in approximately 40% of cases, when there is difficult spine anatomy and the initial epidural approach has failed to provide pain relief. Image guidance for interlaminar epidural injection ensures accurate needle placement, enhancing the safety and efficacy of the procedure.
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20
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Schneider BJ, Maybin S. Safety and Risk Mitigation for Cervical Transforaminal Epidural Steroid Injections. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2017. [DOI: 10.1007/s40141-017-0165-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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21
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Ter Meulen BC, Maas ET, Vyas A, van der Vegt M, de Priester K, de Boer MR, van Tulder MW, Weinstein HC, Ostelo RWJG. Treatment of acute sciatica with transforaminal epidural corticosteroids and local anesthetic: design of a randomized controlled trial. BMC Musculoskelet Disord 2017; 18:215. [PMID: 28545491 PMCID: PMC5445356 DOI: 10.1186/s12891-017-1571-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 05/11/2017] [Indexed: 12/28/2022] Open
Abstract
Background Transforaminal epidural injections with steroids (TESI) are used increasingly for patients with sciatica. However there is much debate about their safety and effectiveness. It is important to identify patients that benefit most from TESI and only few trials have yet evaluated the effects in patients with acute sciatica. Methods We describe a prospective, randomized controlled trial (RCT), with the aim to evaluate the hypothesis that TESI plus Levobupivacaine (TESI-plus) added to oral pain medication is more effective compared to pain medication alone or compared to transforaminal injection with a local anesthetic of short duration among patients with acute sciatica. We will recruit a total of 264 patients with sciatica (<8 weeks) caused by a herniated disc, from two clinical sites. Participants are randomly assigned one of three study groups: 1) oral pain medication (control group), 2) oral pain medication and TESI-plus (intervention group one), 3) oral pain medication and transforaminal epidural injection (TEI) with Levobupivaine and saline solution (intervention group two). Primary outcomes are functional status (Roland-Morris Disability Questionnaire), pain intensity for both leg and back, (100 mm visual analogous scale (VAS)), and global perceived recovery (GPR, reported on a 7-point Likert scale, dichotomized into ‘recovered’ and ‘not recovered’). The secondary outcomes are health-related quality of life (EQ5D-5 L) and patient satisfaction (7-point Likert scale). We will also collect information on healthcare utilization and costs, to perform an economic evaluation. All outcomes are measured at three and six weeks, three and six months after randomization. We defined a minimal clinically relevant difference between groups as a difference between both intervention groups and the control group of 20 points for pain (100-point VAS), four points for functional status (24-point RDQ) and a 20% difference on dichotomized GPR (recovered versus not recovered). Discussion A clinically relevant outcome in favor of TESI-plus implies that future patients with acute sciatica should be recommended TESI-plus within the first few weeks rather than being treated with pain medication alone in order to relieve pain and improve their functioning. In case of a negative result (no relevant differences in outcome between the three study arms), pain medication will remain the mainstay of treatment in the acute stages of sciatica. Trial registration Dutch National trial register: NTR4457 (March, 6th, 2014)
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Affiliation(s)
- Bastiaan C Ter Meulen
- Department of Neurology, Zaans Medisch Centrum, Zaandam and Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
| | - Esther T Maas
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Amrita Vyas
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | - Koo de Priester
- Department of Radiology Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Michiel R de Boer
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands.,Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Henry C Weinstein
- Department of Neurology, Zaans Medisch Centrum, Zaandam and Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Raymond W J G Ostelo
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands.,Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
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22
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Meir A, Bush K. Successful outcomes following transforaminal epidural steroid injections for C4/5 cervical disc prolapse associated with profound neurological deficit. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:207-212. [DOI: 10.1007/s00586-017-5031-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 03/04/2017] [Indexed: 10/19/2022]
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23
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Facet joint injection versus epidural steroid injection for lumbar spinal stenosis: intra-individual study. Clin Radiol 2017; 72:96.e7-96.e14. [DOI: 10.1016/j.crad.2016.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 07/26/2016] [Accepted: 08/09/2016] [Indexed: 12/19/2022]
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24
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Manchikanti L, Pampati V, Hirsch JA. Retrospective cohort study of usage patterns of epidural injections for spinal pain in the US fee-for-service Medicare population from 2000 to 2014. BMJ Open 2016; 6:e013042. [PMID: 27965254 PMCID: PMC5168679 DOI: 10.1136/bmjopen-2016-013042] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 10/28/2016] [Accepted: 11/10/2016] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To assess the usage patterns of epidural injections for chronic spinal pain in the fee-for-service (FFS) Medicare population from 2000 to 2014 in the USA. DESIGN A retrospective cohort. METHODS The descriptive analysis of the administrative database from Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) master data from 2000 to 2014 was performed. The guidance from Strengthening the Reporting of Observational studies in Epidemiology (STROBE) was applied. Analysis included multiple variables based on the procedures, specialties and geography. RESULTS Overall epidural injections increased 99% per 100 000 Medicare beneficiaries with an annual increase of 5% from 2000 to 2014. Lumbar interlaminar and caudal epidural injections constituted 36.2% of all epidural injections, with an overall decrease of 2% and an annual decrease of 0.2% per 100 000 Medicare beneficiaries. However, lumbosacral transforaminal epidural injections increased 609% with an annual increase of 15% from 2000 to 2014 per 100 000 Medicare population. CONCLUSIONS Usage of epidural injections increased from 2000 to 2014, with a decline thereafter. However, an escalating growth has been seen for lumbosacral transforaminal epidural injections despite numerous reports of complications and regulations to curb the usage of transforaminal epidural injections.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, Kentucky, USA
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky, USA
| | | | - Joshua A Hirsch
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Introduction of a predictive model for epidural steroid injections leads to inappropriate and inaccurate conclusions. Spine J 2016; 16:905-6. [PMID: 27480023 DOI: 10.1016/j.spinee.2016.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 02/16/2016] [Indexed: 02/03/2023]
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26
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Manchikanti L, Boswell MV, Hirsch JA. Innovations in interventional pain management of chronic spinal pain. Expert Rev Neurother 2016; 16:1033-42. [DOI: 10.1080/14737175.2016.1194204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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27
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Manchikanti L, Hirsch JA. In Response to Risks and Pitfalls of Epidural Injections during Management of Lumbar Disc Herniation: Few Comments. Korean J Pain 2015; 28:219-20. [PMID: 26175884 PMCID: PMC4500788 DOI: 10.3344/kjp.2015.28.3.219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 04/03/2015] [Indexed: 12/04/2022] Open
Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, and University of Louisville, Louisville, KY, USA
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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28
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Manchikanti L, Benyamin RM. Key safety considerations when administering epidural steroid injections. Pain Manag 2015; 5:261-72. [PMID: 26059467 DOI: 10.2217/pmt.15.17] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Neurological and other complications of epidural steroid injections have been widely discussed in recent years. Consequently, the US FDA issued a warning about serious neurological events, some resulting in death, and consequently is requiring label changes. Neurological adverse events numbering 131, including 41 cases of arachnoiditis, have been identified by the FDA, and 700 cases of fungal meningitis following injection of contaminated steroids. A review of the literature reveals an overwhelming proportion of the complications are related to transforaminal epidural injections, with the majority of them to cervical transforaminal epidural injections. This perspective describes the prevalence of administering epidural injections, complications, pathoanatomy, mechanism of injury and various preventive strategies.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, KY 42003, USA.,Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY, 40292, USA
| | - Ramsin M Benyamin
- Millennium Pain Center, Bloomington, IL 61701, USA.,Department of Surgery, College of Medicine, University of Illinois, Urbana-Champaign, IL 61801, USA
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