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Macedo F, Annaswamy T, Coller R, Buelt A, Glotfelter MA, Heideman PW, Kang D, Konitzer L, Okamoto C, Olson J, Pangarkar S, Sall J, Spacek LC, Steil E, Vogsland R, Sandbrink F. Diagnosis and Treatment of Low Back Pain: Synopsis of the 2021 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline. Am J Phys Med Rehabil 2024; 103:350-355. [PMID: 37903622 DOI: 10.1097/phm.0000000000002356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
ABSTRACT Low back pain is a significant issue in the US Department of Veterans Affairs and Department of Defense populations as well as the general US population at large. This type of pain can be distressing to those who experience its effects, leading patients to seek relief of their symptoms. In 2022, leadership within the US Department of Veterans Affairs and US Department of Defense approved a joint clinical practice guideline for the management of low back pain. The guideline provides evidence-based recommendations for assessing and managing low back pain. Development of the guideline included a systematic evidence review, which was guided by 12 key questions. A multidisciplinary team, which included clinical stakeholders, reviewed the evidence that was retrieved and developed 39 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. The scope of the clinical practice guideline is broad; however, the authors have focused on key recommendations that are important for clinicians in the evaluation and nonoperative treatment of low back pain, including pharmacologic therapies and both noninvasive and invasive nonpharmacologic treatments.
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Affiliation(s)
- Franz Macedo
- From the Comprehensive Pain Center, VA Health Care System, Minneapolis, Minnesota (FM); PM&R Service, VA North Texas Health Care System, Dallas, Texas (TA); Naval Medical Center (NMCSD), San Diego, California (RC); VA Medical Center, Bay Pines, Florida (AB); Eielson Medical Treatment Facility, Fairbanks, Alaska (MAG); Comprehensive Pain Center, VA Medical Center, Minneapolis, Minnesota (PWH); Orthopedic Surgery Residency, Madigan Army Medical Center, Tacoma, Washington (DK); Department of Rehabilitation Medicine, Madigan Army Medical Center, Tacoma, Washington (LK); Chiropractic Care, VA Healthcare System (HCS), Minneapolis, Minnesota (CO); Acupuncture, Chinese Medicine, and Chiropractic Care, Pain Clinic, VA Central Iowa HCS, Des Moines, Iowa (JO); David Geffen School of Medicine at UCLA, Los Angeles, California (SP); Veterans Administration Central Office, Washington, District of Colombia (JS); Internal Medicine and Sports Medicine, South Texas Veterans HCS, San Antonio, Texas (LCS); Defense Health Agency, Healthcare Risk Management, Regional Health Command Europe, Primary Care Service Line, Sembach, Germany (ES); Comprehensive Pain Center, VA Health Care System, Minneapolis, Minnesota (RV); and Department of Neurology, VA Medical Center, Washington, District of Colombia (FS)
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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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Manchikanti L, Pampati V, Knezevic NN, Kaye AD, Abdi S, Sanapati MR, Abd-Elsayed A, Kosanovic R, Soin A, Beall DP, Shah S, Hirsch JA. The Influence of COVID-19 on Utilization of Epidural Procedures in Managing Chronic Spinal Pain in the Medicare Population. Spine (Phila Pa 1976) 2023; 48:950-961. [PMID: 36728775 DOI: 10.1097/brs.0000000000004574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/19/2022] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN A retrospective cohort study of utilization patterns and variables of epidural injections in the fee-for-service (FFS) Medicare population. OBJECTIVES To update the utilization of epidural injections in managing chronic pain in the FFS Medicare population, from 2000 to 2020, and assess the impact of COVID-19. SUMMARY OF BACKGROUND DATA The analysis of the utilization of interventional techniques also showed an annual decrease of 2.5% per 100,000 FFS Medicare enrollees from 2009 to 2018, contrasting to an annual increase of 7.3% from 2000 to 2009. The impact of the COVID-19 pandemic has not been assessed. METHODS This analysis was performed by utilizing master data from the Centers for Medicare and Medicaid Services, physician/supplier procedure summary from 2000 to 2020. The analysis was performed by the assessment of utilization patterns using guidance from Strengthening the Reporting of Observational Studies in Epidemiology. RESULTS Epidural procedures declined at a rate of 19% per 100,000 Medicare enrollees in the FFS Medicare population in the United States from 2019 to 2020, with an annual decline of 3% from 2010 to 2019. From 2000 to 2010, there was an annual increase of 8.3%. This analysis showed a decline in all categories of epidural procedures from 2019 to 2020. The major impact of COVID-19, with closures taking effect from April 1, 2020, through December 31, 2020, will be steeper and rather dramatic compared with April 1 to December 31, 2019. However, monthly data from the Centers for Medicare and Medicaid Services is not available as of now. Overall declines from 2010 to 2019 showed a decrease for cervical and thoracic transforaminal injections with an annual decrease of 5.6%, followed by lumbar interlaminar and caudal epidural injections of 4.9%, followed by 1.8% for lumbar/sacral transforaminal epidurals, and 0.9% for cervical and thoracic interlaminar epidurals. CONCLUSION Declining utilization of epidural injections in all categories was exacerbated to a decrease of 19% from 2019 to 2020, related, in part, to the COVID-19 pandemic. This followed declining patterns of epidural procedures of 3% overall annually from 2010 to 2019.
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Affiliation(s)
| | | | - Nebojsa Nick Knezevic
- Advocate Illinois Masonic Medical Center and College of Medicine, University of Illinois, Chicago, IL
| | - Alan D Kaye
- LSU Health Sciences Center, Shreveport, Ochsner Shreveport Hospital and Interventional Pain Clinic Feist-Wieller Cancer Center, Shreveport, LA
| | - Salahadin Abdi
- University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | - Alaa Abd-Elsayed
- UW Health Pain Services and University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Amol Soin
- Ohio Pain Clinic, Centerville, OH, Wright State University, Dayton, OH
| | | | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Manchikanti L, Kaye AD, Latchaw RE, Sanapati MR, Pampati V, Gharibo CG, Albers SL, Hirsch JA. Impact of the COVID-19 Pandemic on Utilization Patterns of Facet Joint Interventions in Managing Spinal Pain in a Medicare Population. Pain Ther 2023; 12:505-527. [PMID: 36723804 PMCID: PMC9890434 DOI: 10.1007/s40122-023-00476-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/10/2023] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic resulted in major disruptions in all aspects of human life including a decline of medical services utilized during 2020. An analysis of the impact of COVID-19 pandemic showed an 18.7% reduction in utilization patterns of interventional techniques in managing chronic pain in the Medicare population from 2019 to 2020. However, specific changes in utilization patterns of facet joint interventions have not been studied. Thus, we sought to assess the utilization patterns including an update of facet joint interventions from 2018 to 2020, with analysis of the impact of COVID-19 pandemic in managing chronic spinal pain utilizing facet joint interventions in the fee-for-service Medicare population of the United States. METHODS The present investigation was designed to assess utilization patterns and variables of facet joint interventions, in managing chronic spinal pain from 2010 to 2020 in the fee-for-service (FFS) Medicare population in the United States (US), and how the COVID-19 pandemic impacted these utilization patterns. Data for the analysis were obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2020. RESULTS Results of this analysis showed significant impact of COVID-19 with overall decrease of 18.5% of all facet joint interventions per 100,000 Medicare population compared to 20.2 and 20.5% decrease for lumbar and cervical facet joint injections, 15 and 13.1% decrease per 100,000 Medicare population of lumbosacral and cervicothoracic facet joint neurolysis procedures. The results are significant in that comparative analysis from 2000 to 2010 and 2010 to 2019 showing an annual increase of 14.4 vs. 2.2%, illustrating a decelerating pattern. There were also significant growth patterns noted with decreases in facet joint injections and nerve blocks compared to facet joint neurolytic procedures. CONCLUSIONS This analysis shows a significant effect of COVID-19 producing an overall decrease in utilization of facet joint interventions relative to pre-COVID data. Further, the analysis demonstrates continued deceleration of utilization patterns of facet joint interventions compared to the periods of 2000-2010 and 2010-2019.
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Affiliation(s)
- Laxmaiah Manchikanti
- grid.419960.30000 0004 0649 0485Pain Management Centers of America, 67 Lakeview Drive, Paducah, KY 42001 USA
- grid.266623.50000 0001 2113 1622University of Louisville, Louisville, KY USA
- grid.411417.60000 0004 0443 6864Department of Anesthesiology, School of Medicine, LSU Health Sciences Center, Shreveport, LA USA
| | - Alan D. Kaye
- grid.411417.60000 0004 0443 6864Louisiana State University Health Sciences Center, Shreveport, LA USA
| | - Richard E. Latchaw
- grid.416958.70000 0004 0413 7653Department of Radiology, University of California at Davis Health System, Sacramento, CA USA
| | - Mahendra R. Sanapati
- grid.419960.30000 0004 0649 0485Pain Management Centers of America, Evansville, IN USA
| | - Vidyasagar Pampati
- grid.419960.30000 0004 0649 0485Pain Management Centers of America, 67 Lakeview Drive, Paducah, KY 42001 USA
| | - Christopher G. Gharibo
- grid.137628.90000 0004 1936 8753NYU Langone Health and NYU School of Medicine, New York, NY USA
- grid.137628.90000 0004 1936 8753NYU Grossman School of Medicine, New York, NY USA
| | | | - Joshua A. Hirsch
- grid.38142.3c000000041936754XMassachusetts General Hospital and Harvard Medical School, Boston, MA USA
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Manchikanti L, Knezevic NN, Knezevic E, Abdi S, Sanapati MR, Soin A, Wargo BW, Navani A, Atluri S, Gharibo CG, Simopoulos TT, Kosanovic R, Abd-Elsayed A, Kaye AD, Hirsch JA. A Systematic Review and Meta-analysis of the Effectiveness of Radiofrequency Neurotomy in Managing Chronic Neck Pain. Pain Ther 2022; 12:1-48. [PMID: 36465720 PMCID: PMC9686245 DOI: 10.1007/s40122-022-00455-0] [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: 08/23/2022] [Accepted: 10/28/2022] [Indexed: 11/25/2022] Open
Abstract
Background Extensive research into potential sources of neck pain and referred pain into the upper extremities and head has shown that the cervical facet joints can be a potential pain source confirmed by precision, diagnostic blocks. Study Design Systematic review and meta-analysis utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, quality assessment of the included studies, conventional and single-arm meta-analysis, and best evidence synthesis. Objective The objective of this systematic review and meta-analysis is to evaluate the effectiveness of radiofrequency neurotomy as a therapeutic cervical facet joint intervention in managing chronic neck pain. Methods Available literature was included. Methodologic quality assessment of studies was performed from 1996 to September 2021. The level of evidence of effectiveness was determined. Results Based on the qualitative and quantitative analysis with single-arm meta-analysis and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system of appraisal, with inclusion of one randomized controlled trial (RCT) of 12 patients in the treatment group and eight positive observational studies with inclusion of 589 patients showing positive outcomes with moderate to high clinical applicability, the evidence is level II in managing neck pain with cervical radiofrequency neurotomy. The evidence for managing cervicogenic headache was level III to IV with qualitative analysis and single-arm meta-analysis and GRADE system of appraisal, with the inclusion of 15 patients in the treatment group in a positive RCT and 134 patients in observational studies. An overwhelming majority of the studies produced multiple lesions. Limitations There was a paucity of literature and heterogeneity among the available studies. Conclusion This systematic review and meta-analysis shows level II evidence with radiofrequency neurotomy on a long-term basis in managing chronic neck pain with level III to IV evidence in managing cervicogenic headaches. Supplementary Information The online version contains supplementary material available at 10.1007/s40122-022-00455-0.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, 67 Lakeview Drive, Paducah, KY 42001 USA
- Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY USA
- Department of Anesthesiology, School of Medicine, LSU Health Sciences Center, Shreveport, LA USA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL USA
- College of Medicine, University of Illinois, Chicago, IL USA
| | - Emilija Knezevic
- College of Liberal Arts and Sciences, University of Illinois at Urbana-Champaign, Champaign, IL USA
| | - Salahadin Abdi
- Department of Pain Medicine, University of Texas, MD Anderson Cancer Center, Houston, TX USA
| | | | - Amol Soin
- Ohio Pain Clinic and Wright State University, Dayton, OH USA
| | - Bradley W. Wargo
- Interventional Pain Management, Mays & Schnapp Neurospine & Pain, Memphis, TN USA
| | - Annu Navani
- Comprehensive Spine & Sports Center and Le Reve Regenerative Wellness, Campbell, CA USA
| | | | | | - Thomas T. Simopoulos
- Department of Anesthesiology, Critical Care and Pain Medicine, Arnold Warfield Pain Management Center, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA USA
| | | | - Alaa Abd-Elsayed
- UW Health Pain Services and UW Pain Clinic, Chronic Pain Medicine, Department of Anesthesiology, and University of Wisconsin School of Medicine and Public Health,, Madison, WI USA
| | - Alan D. Kaye
- Anesthesiology and Pharmacology, Toxicology, and Neurosciences, LSUHSC, Shreveport, LA USA
| | - Joshua A. Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA USA
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Carassiti M, Pascarella G, Strumia A, Russo F, Papalia GF, Cataldo R, Gargano F, Costa F, Pierri M, De Tommasi F, Massaroni C, Schena E, Agrò FE. Epidural Steroid Injections for Low Back Pain: A Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:ijerph19010231. [PMID: 35010492 PMCID: PMC8744824 DOI: 10.3390/ijerph19010231] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/19/2021] [Accepted: 12/22/2021] [Indexed: 05/03/2023]
Abstract
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.
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Affiliation(s)
- Massimiliano Carassiti
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
- Correspondence:
| | - Giuseppe Pascarella
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Alessandro Strumia
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Fabrizio Russo
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.R.); (G.F.P.)
| | - Giuseppe Francesco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.R.); (G.F.P.)
| | - Rita Cataldo
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Francesca Gargano
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Fabio Costa
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
| | - Michelangelo Pierri
- Integrated Sleep Surgery Team UCBM, Unit of Otolaryngology, Integrated Therapies in Otolaryngology, Campus Bio-Medico University of Rome, 00128 Rome, Italy;
| | - Francesca De Tommasi
- Unit of Measurements and Biomedical Instrumentation, Department of Engineering, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.D.T.); (C.M.); (E.S.)
| | - Carlo Massaroni
- Unit of Measurements and Biomedical Instrumentation, Department of Engineering, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.D.T.); (C.M.); (E.S.)
| | - Emiliano Schena
- Unit of Measurements and Biomedical Instrumentation, Department of Engineering, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (F.D.T.); (C.M.); (E.S.)
| | - Felice Eugenio Agrò
- Unit of Anaesthesia, Intensive Care and Pain Management, Department of Medicine, Campus Bio-Medico University of Rome, 00128 Rome, Italy; (G.P.); (A.S.); (R.C.); (F.G.); (F.C.); (F.E.A.)
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Knezevic NN, Candido KD, Vlaeyen JWS, Van Zundert J, Cohen SP. Low back pain. Lancet 2021; 398:78-92. [PMID: 34115979 DOI: 10.1016/s0140-6736(21)00733-9] [Citation(s) in RCA: 416] [Impact Index Per Article: 138.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 12/23/2020] [Accepted: 02/16/2021] [Indexed: 12/31/2022]
Abstract
Low back pain covers a spectrum of different types of pain (eg, nociceptive, neuropathic and nociplastic, or non-specific) that frequently overlap. The elements comprising the lumbar spine (eg, soft tissue, vertebrae, zygapophyseal and sacroiliac joints, intervertebral discs, and neurovascular structures) are prone to different stressors, and each of these, alone or in combination, can contribute to low back pain. Due to numerous factors related to low back pain, and the low specificity of imaging and diagnostic injections, diagnostic methods for this condition continue to be a subject of controversy. The biopsychosocial model posits low back pain to be a dynamic interaction between social, psychological, and biological factors that can both predispose to and result from injury, and should be considered when devising interdisciplinary treatment plans. Prevention of low back pain is recognised as a pivotal challenge in high-risk populations to help tackle high health-care costs related to therapy and rehabilitation. To a large extent, therapy depends on pain classification, and usually starts with self-care and pharmacotherapy in combination with non-pharmacological methods, such as physical therapies and psychological treatments in appropriate patients. For refractory low back pain, a wide range of non-surgical (eg, epidural steroid injections and spinal cord stimulation for neuropathic pain, and radiofrequency ablation and intra-articular steroid injections for mechanical pain) and surgical (eg, decompression for neuropathic pain, disc replacement, and fusion for mechanical causes) treatment options are available in carefully selected patients. Most treatment options address only single, solitary causes and given the complex nature of low back pain, a multimodal interdisciplinary approach is necessary. Although globally recognised as an important health and socioeconomic challenge with an expected increase in prevalence, low back pain continues to have tremendous potential for improvement in both diagnostic and therapeutic aspects. Future research on low back pain should focus on improving the accuracy and objectivity of diagnostic assessments, and devising treatment algorithms that consider unique biological, psychological, and social factors. High-quality comparative-effectiveness and randomised controlled trials with longer follow-up periods that aim to establish the efficacy and cost-effectiveness of low back pain management are warranted.
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Affiliation(s)
- Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA; Department of Anesthesiology, University of Illinois, Chicago, IL, USA; Department of Surgery, University of Illinois, Chicago, IL, USA.
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA; Department of Anesthesiology, University of Illinois, Chicago, IL, USA; Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Johan W S Vlaeyen
- Research Group Health Psychology, University of Leuven, Leuven, Belgium; Research Group Experimental Health Psychology, Maastricht University, Maastricht, Netherlands; TRACE Center for Translational Health Research, KU, Leuven-Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Jan Van Zundert
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium; Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Neurology, Physical Medicine and Rehabilitation, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Psychiatry and Behavioral Sciences, Johns Hopkins Medical Institutions, Baltimore, MD, USA; Department of Physical Medicine and Rehabilitation and Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
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Manchikanti L, Vanaparthy R, Atluri S, Sachdeva H, Kaye AD, Hirsch JA. COVID-19 and the Opioid Epidemic: Two Public Health Emergencies That Intersect With Chronic Pain. Pain Ther 2021; 10:269-286. [PMID: 33718982 PMCID: PMC7955940 DOI: 10.1007/s40122-021-00243-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 02/08/2021] [Indexed: 02/06/2023] Open
Abstract
The COVID-19 pandemic has affected the entire world and catapulted the United States into one of the deepest recessions in history. While this pandemic rages, the opioid crisis worsens. During this period, the pandemic has resulted in the decimation of most conventional medical services, including those of chronic pain management, with the exception of virtual care and telehealth. Many chronic pain patients have been impacted in numerous ways, with increases in cardiovascular disease, mental health problems, cognitive dysfunction, and early death. The epidemic has also resulted in severe economic and physiological consequences for providers. Drug deaths in America, which fell for the first time in 25 years in 2018, rose to record numbers in 2019 and are continuing to climb, worsened by the coronavirus pandemic. The opioid epidemic was already resurfacing with a 5% increase in overall deaths from 2018; however, the preliminary data show that prescription opioid deaths continued to decline, while at the same time deaths due to fentanyl, methamphetamine, and cocaine climbed, with some reductions in heroin deaths. The health tracker data also showed that along with an almost 88% decline in elective surgeries, pain-related prescriptions declined 15.1%. Despite increases in telehealth, outpatient services declined and only began returning towards normal at an extremely slow pace, accompanied by reduced productivity and increased practice costs. This review, therefore, emphasizes the devastating consequences of concurrent epidemics on chronic pain management and the need to develop best practice efforts to preserve access to treatment for chronic pain.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY, USA.
- Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA.
- Department of Anesthesiology, School of Medicine, LSU Health Sciences Center, New Orleans, LA, USA.
| | | | | | - Harsh Sachdeva
- Pain Division and Fellowship Program, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alan D Kaye
- Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Pain Management Fellow Program Director, LSU School of Medicine, Shreveport, LA, USA
- Anesthesiology and Pharmacology, LSU School of Medicine, New Orleans, LA, USA
- Anesthesiology and Pharmacology, Tulane School of Medicine, New Orleans, LA, USA
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Choi EJ, Kim DH, Han WK, Lee HJ, Kang I, Nahm FS, Lee PB. Non-Particulate Steroids (Betamethasone Sodium Phosphate, Dexamethasone Sodium Phosphate, and Dexamethasone Palmitate) Combined with Local Anesthetics (Ropivacaine, Levobupivacaine, Bupivacaine, and Lidocaine): A Potentially Unsafe Mixture. J Pain Res 2021; 14:1495-1504. [PMID: 34079364 PMCID: PMC8166310 DOI: 10.2147/jpr.s311573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/03/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose Particulate steroids used in epidural steroid injections have been suspected as a cause of post-procedural embolic events. Some particulate steroids have been suspended only when the transforaminal approach is used for an epidural block of the spine. In contrast, non-particulate steroids are generally accepted for safety during epidural steroid injections. However, the safety of using a mixture of non-particulate steroids and local anesthetics is unknown. This study analyzed whether mixtures of commonly used non-particulate steroids and local anesthetics form crystals in solution. Methods We mixed non-particulate steroids (betamethasone sodium phosphate, dexamethasone sodium phosphate, and dexamethasone palmitate) and local anesthetics (ropivacaine, levobupivacaine, bupivacaine, and lidocaine) at different ratios. We used fluorescence microscopy to observe whether crystals formed in mixed solutions; we also measured the pH of each steroid, local anesthetic, and the mixtures. Results Ropivacaine or levobupivacaine and betamethasone sodium phosphate produced large crystals (>50 µm). Ropivacaine or levobupivacaine and dexamethasone sodium phosphate produced small crystals (<10 µm). Lidocaine and all non-particulate steroids produced no identifiable crystals; dexamethasone palmitate and all local anesthetics did not form significant particulates. Betamethasone sodium phosphate and dexamethasone sodium phosphate demonstrated basic pH, while all local anesthetics demonstrated acidic pH. Mixtures showed a wide pH range. Conclusion Non-particulate steroids can form crystals upon combination with local anesthetics. Crystal formation may be caused by alkalinization of steroids. The mixing of ropivacaine or levobupivacaine and betamethasone sodium phosphate may require caution during an epidural steroid injection. Lidocaine or bupivacaine is recommended as a local anesthetic. Dexamethasone palmitate is a candidate for a mixture, but additional studies on its safety and effectiveness are needed.
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Affiliation(s)
- Eun Joo Choi
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong-Hyun Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Woong Ki Han
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Imhong Kang
- Department of Anesthesiology and Pain Medicine, Bundang Chuk Hospital, Seongnam, Korea
| | - Francis Sahngun Nahm
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Pyung-Bok Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
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Shanthanna H, Busse J, Wang L, Kaushal A, Harsha P, Suzumura EA, Bhardwaj V, Zhou E, Couban R, Paul J, Bhandari M, Thabane L. Addition of corticosteroids to local anaesthetics for chronic non-cancer pain injections: a systematic review and meta-analysis of randomised controlled trials. Br J Anaesth 2020; 125:779-801. [PMID: 32798067 DOI: 10.1016/j.bja.2020.06.062] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Despite common use, the benefit of adding steroids to local anaesthetics (SLA) for chronic non-cancer pain (CNCP) injections is uncertain. We performed a systematic review and meta-analysis of English-language RCTs to assess the benefit and safety of adding steroids to local anaesthetics (LA) for CNCP. METHODS We searched MEDLINE, EMBASE, and CENTRAL databases from inception to May 2019. Trial selection and data extraction were performed in duplicate. Outcomes were guided by the Initiative in Methods, Measurements, and Pain Assessment in Clinical Trials (IMMPACT) statement with pain improvement as the primary outcome and pooled using random effects model and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CIs). RESULTS Among 5097 abstracts, 73 trials were eligible. Although SLA increased the rate of success (42 trials, 3592 patients; RR=1.14; 95% CI, 1.03-1.25; number needed to treat [NNT], 13), the effect size decreased by nearly 50% (NNT, 22) with the removal of two intrathecal injection studies. The differences in pain scores with SLA were not clinically meaningful (54 trials, 4416 patients, MD=0.44 units; 95% CI, 0.24-0.65). No differences were observed in other outcomes or adverse events. No subgroup effects were detected based on clinical categories. Meta-regression showed no significant association with steroid dose or length of follow-up and pain relief. CONCLUSIONS Addition of cortico steroids to local anaesthetic has only small benefits and a potential for harm. Injection of local anaesthetic alone could be therapeutic, beyond being diagnostic. A shared decision based on patient preferences should be considered. If used, one must avoid high doses and series of steroid injections. CLINICAL TRIAL REGISTRATION PROSPERO #: CRD42015020614.
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Affiliation(s)
- Harsha Shanthanna
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada.
| | - Jason Busse
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - Li Wang
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada; Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - Alka Kaushal
- Department of Family Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Prathiba Harsha
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Erica A Suzumura
- Department of Preventive Medicine, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Varun Bhardwaj
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Edward Zhou
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Rachel Couban
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - James Paul
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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11
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Urits I, Hasegawa M, Orhurhu V, Peck J, Kelly AC, Kaye RJ, Orhurhu MS, Brinkman J, Giacomazzi S, Foster L, Manchikanti L, Kaye AD, Viswanath O. Minimally Invasive Treatment of Chronic Ankle Instability: a Comprehensive Review. Curr Pain Headache Rep 2020; 24:8. [PMID: 32020393 DOI: 10.1007/s11916-020-0840-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Chronic ankle pain is a prevalent and significant cause of chronic pain. While the definition of chronic ankle pain is heterogeneous and poorly defined in the literature, systematic reviews and meta-analyses have estimated this condition to be a prevalent and debilitating source of chronic pain. The most identifiable and prominent cause of chronic ankle pain is chronic ankle instability (CAI), a condition defined by instability of the ankle-joint complex. It is a common consequence of lateral ankle sprains or ligamentous injuries and can be described as a failure of the lateral ankle joint complex after an acute, or recurring, ankle injury. The objective of this manuscript is to provide a comprehensive review of CAI diagnosis and our current understanding of minimally invasive treatment options. RECENT FINDINGS First-line treatment is conservative management, some of which includes neuromuscular rehabilitation, balance training, nonsteroidal anti-inflammatory drugs (NSAIDs), manual mobilization, ice therapy, and compression. While conservative management is effective, additional treatments for those who fail conservative management, or who seek alternative options also have been explored. Recent advances and modern techniques have expanded available treatment options, many of which are becoming less invasive, and have shown improving functionality, recovery, and patient satisfaction. Minimally invasive treatments highlighted in this review include: arthroscopic surgery, steroid injections, plasma-rich plasma injections, hyaluronic acid (HA) injections, medicinal signaling cell injections, radiofrequency therapies, and shockwave therapies. This review will discuss some of these current treatments for minimally invasive treatment of CAI, as well as suggest novel treatments for clinical trials and further investigation.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Morgan Hasegawa
- Creighton University School of Medicine at Regional Campus St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Vwaire Orhurhu
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Jacquelin Peck
- Mount Sinai Medical Center of Florida, Department of Anesthesiology, Miami Beach, FL, USA
| | - Angele C Kelly
- Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, USA
| | - Rachel J Kaye
- Medical University of South Carolina, Charleston, SC, USA
| | - Mariam Salisu Orhurhu
- Department of Anesthesia, Critical Care, and Pain Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Joseph Brinkman
- Creighton University School of Medicine at Regional Campus St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Stephen Giacomazzi
- Creighton University School of Medicine at Regional Campus St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Lukas Foster
- Creighton University School of Medicine at Regional Campus St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | | | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Phoenix, AZ, USA.,Department of Anesthesiology, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
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