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Liu D, Li G, Wang S, Liu Z, Wang Y, Connolly L, Usevitch DE, Shen G, Cleary K, Iordachita I. A magnetic resonance conditional robot for lumbar spinal injection: Development and preliminary validation. Int J Med Robot 2024; 20:e2618. [PMID: 38536711 PMCID: PMC10982612 DOI: 10.1002/rcs.2618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/27/2023] [Accepted: 12/12/2023] [Indexed: 04/04/2024]
Abstract
PURPOSE This work presents the design and preliminary validation of a Magnetic Resonance (MR) conditional robot for lumbar injection for the treatment of lower back pain. METHODS This is a 4-degree-of-freedom (DOF) robot that is 200 × 230 × 130 mm3 in volume and has a mass of 0.8 kg. Its lightweight and compact features allow it to be directly affixed to patient's back, establishing a rigid connection, thus reducing positional errors caused by patient movements during treatment. RESULTS To validate the positioning accuracy of the needle by the robot, an electromagnetic (EM) tracking system and a needle with an EM sensor embedded in the tip were used for the free space evaluation with position accuracy of 0.88 ± 0.46 mm and phantom mock insertions using the Loop-X CBCT scanner with target position accuracy of 3.62 ± 0.92 mm. CONCLUSION Preliminary experiments demonstrated that the proposed robot showed improvements and benefits in its rotation range, flexible needle adjustment, and sensor protection compared with previous and existing systems, offering broader clinical applications.
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Affiliation(s)
- Depeng Liu
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
- Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Gang Li
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, District of Columbia, USA
| | - Shuyuan Wang
- Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Zixuan Liu
- Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Yanzhou Wang
- Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Laura Connolly
- The Department of Electrical and Computer Engineering, Queen's University, Kingston, Ontario, Canada
| | - David E Usevitch
- Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Guofeng Shen
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Kevin Cleary
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, District of Columbia, USA
| | - Iulian Iordachita
- Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
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Gharu EMP, Singh NS, Paul R, Osahan NK. Comparing Functional Efficacy of Transforaminal vs Interlaminar Epidural Steroid Injection for Lumbar Disc Disease!! Do We Really Need Transforaminal Epidural Route Injections? JOURNAL OF PHARMACY AND BIOALLIED SCIENCES 2024; 16:S437-S439. [PMID: 38595425 PMCID: PMC11000967 DOI: 10.4103/jpbs.jpbs_658_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 04/11/2024] Open
Abstract
This study compared the functional efficacy of therapeutic transforaminal versus interlaminar epidural steroid injection. Adult patients were selected and randomized using an online research randomizer website and assigned into two groups and were given epidural injection either via transforaminal route or interlaminar route. The outcome was measured based on the Modified Japanese Orthopedic Association back index score (mJOA), Oswestry disability index (ODI), and visual analog scale (VAS) over a follow-up on 1st, 3rd, and 6th month postinjection period. It was found that there was no significant difference seen in m JOA, ODI, and VAS score at 1 month, 3 months, and 6 months between transforaminal and interlaminar epidural steroid injection. Pain management in the epidural route was comparable to the interlaminar route. Even though the transforaminal epidural route has the advantage of being a selective nerve route block, it has similar results as the interlaminar route at 6 months follow-up.
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Affiliation(s)
- Eman M. P. Gharu
- Department of Orthopedics, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Noel S. Singh
- Department of Orthopedics, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Rajesh Paul
- Department of Orthopedics, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Narjeet K. Osahan
- Department of Anaesthesia, Christian Medical College and Hospital, Ludhiana, Punjab, India
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Mohammadi N, Sedlak CA. Physiatry for Treating Hip, Knee, and Back Pain. Orthop Nurs 2024; 43:23-31. [PMID: 38266261 DOI: 10.1097/nor.0000000000000999] [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] [Indexed: 01/26/2024] Open
Abstract
Physical Medicine and Rehabilitation (PM&R) is a rapidly expanding field. Physicians who practice PM&R are known as physiatrists and provide care primarily for patients who have disabilities or physical impairments affecting the musculoskeletal system, brain, and spinal cord. Physiatrists may work in an inpatient or outpatient setting, with outpatient physiatrists being an invaluable resource in treating patients experiencing pain. It is worthwhile to refer patients experiencing hip, knee, or back pain to a PM&R specialist because of their skill in making specific and accurate diagnoses, as well as providing a wide range of modalities to treat pain and augment function such as management of pain medications, osteopathic manipulative therapy, trigger point injections, intra-articular steroid injections, orthobiologic therapy, and interventional spinal procedures. Emphasis is on the use of the least invasive modality before employing more invasive treatments. The need for physiatrists to help individuals maximize function and enhance quality of life is increasing with the aging population, expanding workforce of older adults, and a growing population of people with a disability, especially since the COVID-19 pandemic.
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Affiliation(s)
- Neema Mohammadi
- Neema Mohammadi, DO, Chief Resident Physician, Physical Medicine and Rehabilitation, University Hospitals, Cleveland, OH
- Carol A. Sedlak, PhD, RN, FAAN, Professor Emeritus, College of Nursing, Kent State University, Kent, OH
| | - Carol A Sedlak
- Neema Mohammadi, DO, Chief Resident Physician, Physical Medicine and Rehabilitation, University Hospitals, Cleveland, OH
- Carol A. Sedlak, PhD, RN, FAAN, Professor Emeritus, College of Nursing, Kent State University, Kent, OH
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Zhong D, Wang Y, Lin L, Cheng S, Zhao GS, Wang LY, Liu Y, Ke ZY. Development and Validation of a Nomogram to Predict the Risk of Recurrent Lower Extremity Radiating Pain Within 1 Week Following Full-Endoscopic Lumbar Discectomy. World Neurosurg 2023; 179:e348-e358. [PMID: 37634669 DOI: 10.1016/j.wneu.2023.08.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 08/22/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Accurately predicting the risk of lower extremity (LE) radiating pain after surgery is an important endeavor for spinal surgeons. Our study aimed to identify risk factors for LE radiating pain after decompression with full-endoscopic lumbar discectomy (FELD) and develop a nomogram. METHODS We retrospectively reviewed the medical data of patients with lumbar disc herniation who underwent FELD. Two hundred thirty-five patients diagnosed at our hospital from January 2015 to December 2020 were used for model development. The independent risk factors for LE radiating pain after surgery were determined by least absolute shrinkage and selection operator logistic regression and multivariate logistic regression analysis. A nomogram was developed to predict the risk of LE radiating pain based on independent risk factors. Receiver operating characteristic curve, calibration curve, and decision curve analyses were used to evaluate the predictive performance. The nomogram was further verified by an independent cohort. RESULTS Three hundred seventy-five patients were enrolled in this study, with 102 patients in the training cohort reporting LE radiating pain after FELD, while 133 patients did not. In the validation cohort, 57 patients reported LE radiating pain after FELD, while 83 patients did not. The model was established by multivariate logistic regression analysis. The risk factors included a higher Michigan State University classification of herniated discs, increased disease course, increased time of surgery, reduced lateral recess width, and an interlaminar surgical approach, compared to transforaminal approach. The C-indices and the area under the receiver operating characteristic curve of the predictive model demonstrated good discrimination. Good predictive performance and accuracy were also observed in the validation cohort. CONCLUSIONS A novel nomogram for predicting recurrent LE radiating pain within 1 week after FELD was established and validated. More aggressive pain management strategies should be considered for patients at high risk of LE radiating pain after surgery, as predicted by this model.
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Affiliation(s)
- Dian Zhong
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Wang
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| | - Lu Lin
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Si Cheng
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guo Sheng Zhao
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Yuan Wang
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Liu
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhen Yong Ke
- Department of Spine Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Bise S, Langlet B, Pesquer L, Poussange N, Silvestre A, Dallaudiere B. Transforaminal versus interlaminar CT-guided lumbar epidural steroid injections: prospective study of 237 patients with unilateral radicular pain and up to 5 years of follow-up. Skeletal Radiol 2023; 52:1959-1967. [PMID: 36729210 DOI: 10.1007/s00256-023-04290-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/25/2023] [Accepted: 01/25/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare the efficacy of the transforaminal approach (TFA) versus the interlaminar approach (ILA) for CT-guided epidural steroid injection (CTESI) in the treatment of persistent lumbosacral radicular pain (LRP > 6 weeks) with long-term follow-up. METHODS Patients were prospectively assessed for pain by visual analogue scale (VAS) and functional disability (Oswestry Disability Index, (ODI)) before treatment, then 6 weeks (6W), 6 months (6 M), and 5 years (5Y) after CTESI. RESULTS Overall, n = 237 patients (TFA, n = 71 and ILA, n = 166) were included, and 96 patients had 5 years of follow-up. Both groups showed a statistically significant improvement in VAS and ODI values at 6W (TFA, n = 60 and ILA, n = 146, P < 0.001 for both), at 6 M (TFA, n = 34 and ILA, n = 96, P < 0.001 for both), and at 5Y (TFA, n = 32 and ILA, n = 64, P < 0.001 for both). No significant differences were observed between the two approaches in VAS or ODI decreases at 6W (P = 0.38 and P = 0.33 respectively), 6 M (P = 0.13 and P = 0.51 respectively), or 5Y (P = 0.15 and P = 0.57 respectively). No major complications were noted. CONCLUSION Outcomes after CTESI by ILA approaches are similar to those by TFA for the treatment of persistent LRP.
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Affiliation(s)
- Sylvain Bise
- Centre d'imagerie ostéo-articulaire, Clinique du sport de Bordeaux, 2 Rue Georges-Negrevergne, 33700, Mérignac, France
- Département d'imagerie musculo-squelettique, centre hospitalier universitaire Pellegrin, Place Amélie-Léon-Rabat, 33000, Bordeaux, France
| | - Benjamin Langlet
- Centre d'imagerie ostéo-articulaire, Clinique du sport de Bordeaux, 2 Rue Georges-Negrevergne, 33700, Mérignac, France
| | - Lionel Pesquer
- Centre d'imagerie ostéo-articulaire, Clinique du sport de Bordeaux, 2 Rue Georges-Negrevergne, 33700, Mérignac, France
| | - Nicolas Poussange
- Centre d'imagerie ostéo-articulaire, Clinique du sport de Bordeaux, 2 Rue Georges-Negrevergne, 33700, Mérignac, France
| | - Alain Silvestre
- Centre d'imagerie ostéo-articulaire, Clinique du sport de Bordeaux, 2 Rue Georges-Negrevergne, 33700, Mérignac, France
| | - Benjamin Dallaudiere
- Centre d'imagerie ostéo-articulaire, Clinique du sport de Bordeaux, 2 Rue Georges-Negrevergne, 33700, Mérignac, France.
- Département d'imagerie musculo-squelettique, centre hospitalier universitaire Pellegrin, Place Amélie-Léon-Rabat, 33000, Bordeaux, France.
- Centre de Résonance Magnétique des Systèmes Biologiques, UMR 5536, CNRS, Univ. Bordeaux, 146 Rue Léo Saignat, 33076, Bordeaux, France.
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6
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Kim HJ, Cho YB, Bae J, Kim SH. Relationship between Time Elapsed Since Pain Onset and Efficacy of Pain Relief in Patients Undergoing Lumbar Percutaneous Epidural Adhesiolysis. Yonsei Med J 2023; 64:448-454. [PMID: 37365739 DOI: 10.3349/ymj.2023.0029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/15/2023] [Accepted: 05/15/2023] [Indexed: 06/28/2023] Open
Abstract
PURPOSE The aim of this study was to investigate the relationship between pain duration and pain relief after epidural adhesiolysis. MATERIALS AND METHODS Patients with low back pain who underwent lumbar epidural adhesiolysis were enrolled. A clinically significant reduction in pain score was defined as a ≥30% reduction at 6-month follow-up evaluation. Variables were compared based on pain duration categories. Changes in pain scores and pain outcome were also compared. Logistic regression analysis was conducted to identify factors associated with pain relief after adhesiolysis. RESULTS A total of 169 patients, including 77 (45.6%) patients with a favorable pain outcome, were included for analysis. Patients with a pain duration ≥3 years reported lower baseline pain scores and showed more frequent severe central stenosis. Pain scores significantly decreased over time after the procedure except in patients with a pain duration ≥3 years. Most patients who experienced pain for ≥3 years showed poor pain relief (80.8%), unlike other pain duration categories (pain duration <3 months=48.1%, 3 months-1 year=51.8%, 1-3 years=48.6%). A pain duration ≥3 years and lower baseline pain score were independent factors associated with an unfavorable pain outcome. CONCLUSION Pain lasting ≥3 years prior to lumbar epidural adhesiolysis was associated with worse outcomes in terms of pain relief. Therefore, this intervention should be considered early before pain chronification in patients with low back pain.
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Affiliation(s)
- Hee Jung Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - You Been Cho
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jungbin Bae
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Shin Hyung Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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7
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Sayed D, Grider J, Strand N, Hagedorn JM, Falowski S, Lam CM, Tieppo Francio V, Beall DP, Tomycz ND, Davanzo JR, Aiyer R, Lee DW, Kalia H, Sheen S, Malinowski MN, Verdolin M, Vodapally S, Carayannopoulos A, Jain S, Azeem N, Tolba R, Chang Chien GC, Ghosh P, Mazzola AJ, Amirdelfan K, Chakravarthy K, Petersen E, Schatman ME, Deer T. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res 2022; 15:3729-3832. [PMID: 36510616 PMCID: PMC9739111 DOI: 10.2147/jpr.s386879] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. Objective The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. Methods The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. Results After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. Conclusion The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA,Correspondence: Dawood Sayed, The University of Kansas Health System, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA, Tel +1 913-588-5521, Email
| | - Jay Grider
- University of Kentucky, Lexington, KY, USA
| | - Natalie Strand
- Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Steven Falowski
- Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Christopher M Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nestor D Tomycz
- AHN Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry, Henry Ford Health System, Detroit, MI, USA
| | - David W Lee
- Physical Medicine & Rehabilitation and Pain Medicine, Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | - Hemant Kalia
- Rochester Regional Health System, Rochester, NY, USA,Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Soun Sheen
- Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Mark N Malinowski
- Adena Spine Center, Adena Health System, Chillicothe, OH, USA,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Michael Verdolin
- Anesthesiology and Pain Medicine, Pain Consultants of San Diego, San Diego, CA, USA
| | - Shashank Vodapally
- Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA
| | - Alexios Carayannopoulos
- Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Newport Hospital, Lifespan Physician Group, Providence, RI, USA,Comprehensive Spine Center at Rhode Island Hospital, Newport Hospital, Providence, RI, USA,Neurosurgery, Brown University, Providence, RI, USA
| | - Sameer Jain
- Interventional Pain Management, Pain Treatment Centers of America, Little Rock, AR, USA
| | - Nomen Azeem
- Department of Neurology, University of South Florida, Tampa, FL, USA,Florida Spine & Pain Specialists, Riverview, FL, USA
| | - Reda Tolba
- Pain Management, Cleveland Clinic, Abu Dhabi, United Arab Emirates,Anesthesiology, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - George C Chang Chien
- Pain Management, Ventura County Medical Center, Ventura, CA, USA,Center for Regenerative Medicine, University Southern California, Los Angeles, CA, USA
| | | | | | | | - Krishnan Chakravarthy
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA,Va San Diego Healthcare, San Diego, CA, USA
| | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA,Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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Ratnasamy PP, Gouzoulis MJ, Kammien AJ, Holder EK, Grauer JN. Changes in the Utilization of Lumbosacral Epidural Injections Between 2010 and 2019. Spine (Phila Pa 1976) 2022; 47:1669-1674. [PMID: 36281568 PMCID: PMC9643603 DOI: 10.1097/brs.0000000000004467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022]
Abstract
STUDY DESIGN A descriptive epidemiologic study. OBJECTIVE To analyze trends and patient characteristics for lumbosacral transforaminal and interlaminar/caudal epidural injection utilization over time. BACKGROUND Lumbosacral transforaminal and interlaminar/caudal epidural injections are considered for varying lumbar pathologies. Reported studies, physician practices, insurance authorization, and other factors may influence utilization patterns over time. METHODS Patients undergoing lumbosacral transforaminal and interlaminar/caudal epidural injections between 2010 and 2019 were identified in the M91Ortho PearlDiver database based on Current Procedural Terminology coding. Patient age, sex, Elixhauser Comorbidity Index (ECI), insurance plan (commercial, Medicaid, Medicare), and region of the country where the procedure was performed (Midwest, Northeast, South, West) were assessed and tracked over the years studied based on prevalence per 100,000 covered lives. RESULTS Lumbosacral transforaminal and interlaminar/caudal epidural injections were identified for 426,039 and 501,228 patients, respectively. The number of injections performed per year decreased over the years studied: for transforaminal injections from 160.81 to 76.36 per 100,000 patients and for interlaminar/caudal injections from 200.53 to 77.56 per 100,000 patients. The decrease in overall injections was greatest for those with Commercial and Medicare coverage (53.40% and 66.50%, respectively), with a smaller drop amongst those with Medicaid coverage (32.39%).Over the years, the average patient undergoing injection was older and there was a relative shift toward transforaminal injections ( P <0.05 for both). In terms of specialty of those performing the injections, they were mostly performed by Anesthesiology specialists (who performed less transforaminal than interlaminar/caudal injections). CONCLUSION Lumbosacral transforaminal and interlaminar/caudal spinal epidural injections were shown to decrease by 52.37% per 100,000 patients from 2010 to 2019. Changing demographics of those undergoing such injections and practice patterns are important to consider in the picture of overall spine service utilization. Variations in injection utilization trends by patient insurance raise questions regarding disparities in care.
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Affiliation(s)
- Philip P Ratnasamy
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT
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9
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Arora P, Kanthed P, Vyas N, Dey S. Minimally invasive pain and spine interventions for low backache. INDIAN JOURNAL OF PAIN 2022. [DOI: 10.4103/ijpn.ijpn_122_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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10
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Dalrymple AN, Ting JE, Bose R, Trevathan JK, Nieuwoudt S, Lempka SF, Franke M, Ludwig KA, Shoffstall AJ, Fisher LE, Weber DJ. Stimulation of the dorsal root ganglion using an Injectrode ®. J Neural Eng 2021; 18. [PMID: 34650008 DOI: 10.1088/1741-2552/ac2ffb] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/14/2021] [Indexed: 01/15/2023]
Abstract
Objective. The goal of this work was to compare afferent fiber recruitment by dorsal root ganglion (DRG) stimulation using an injectable polymer electrode (Injectrode®) and a more traditional cylindrical metal electrode.Approach. We exposed the L6 and L7 DRG in four cats via a partial laminectomy or burr hole. We stimulated the DRG using an Injectrode or a stainless steel (SS) electrode using biphasic pulses at three different pulse widths (80, 150, 300μs) and pulse amplitudes spanning the range used for clinical DRG stimulation. We recorded antidromic evoked compound action potentials (ECAPs) in the sciatic, tibial, and common peroneal nerves using nerve cuffs. We calculated the conduction velocity of the ECAPs and determined the charge-thresholds and recruitment rates for ECAPs from Aα, Aβ, and Aδfibers. We also performed electrochemical impedance spectroscopy measurements for both electrode types.Main results. The ECAP thresholds for the Injectrode did not differ from the SS electrode across all primary afferents (Aα, Aβ, Aδ) and pulse widths; charge-thresholds increased with wider pulse widths. Thresholds for generating ECAPs from Aβfibers were 100.0 ± 32.3 nC using the SS electrode, and 90.9 ± 42.9 nC using the Injectrode. The ECAP thresholds from the Injectrode were consistent over several hours of stimulation. The rate of recruitment was similar between the Injectrodes and SS electrode and decreased with wider pulse widths.Significance. The Injectrode can effectively excite primary afferents when used for DRG stimulation within the range of parameters used for clinical DRG stimulation. The Injectrode can be implanted through minimally invasive techniques while achieving similar neural activation to conventional electrodes, making it an excellent candidate for future DRG stimulation and neuroprosthetic applications.
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Affiliation(s)
- Ashley N Dalrymple
- Department of Mechanical Engineering, Carnegie Mellon University, 5000 Forbes Ave, Wean 1323, Pittsburgh, PA 15217, United States of America.,Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15217, United States of America
| | - Jordyn E Ting
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15217, United States of America.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States of America.,Center for Neural Basis of Cognition, Pittsburgh, PA, 15217, United States of America
| | - Rohit Bose
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15217, United States of America.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States of America.,Center for Neural Basis of Cognition, Pittsburgh, PA, 15217, United States of America
| | - James K Trevathan
- Departments of Biomedical Engineering and Neurological Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | | | - Scott F Lempka
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States of America
| | | | - Kip A Ludwig
- Departments of Biomedical Engineering and Neurological Surgery, University of Wisconsin-Madison, Madison, WI, United States of America.,Neuronoff Inc., Cleveland, OH, United States of America.,Wisconsin Institute for Translational Neuroengineering (WITNe), Madison, WI, United States of America
| | - Andrew J Shoffstall
- Neuronoff Inc., Cleveland, OH, United States of America.,Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, United States of America
| | - Lee E Fisher
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15217, United States of America.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States of America.,Center for Neural Basis of Cognition, Pittsburgh, PA, 15217, United States of America.,Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Douglas J Weber
- Department of Mechanical Engineering, Carnegie Mellon University, 5000 Forbes Ave, Wean 1323, Pittsburgh, PA 15217, United States of America.,Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15217, United States of America.,Center for Neural Basis of Cognition, Pittsburgh, PA, 15217, United States of America.,Neuroscience Institute, Carnegie Mellon University, 5000 Forbes Ave, Wean 1323, Pittsburgh, PA 15217, United States of America
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11
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Lam M, J Burke C, R Walter W. Correlation of 18F-FDG PET/CT uptake with severity of MRI findings and epidural steroid injection sites in patients with symptomatic degenerative disease of the lumbar spine: a retrospective study. ACTA ACUST UNITED AC 2021; 27:580-586. [PMID: 34313246 DOI: 10.5152/dir.2021.20438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to retrospectively correlate 18F-fluorodeoxyglucose (18F-FDG) metabolic activity with lumbar spine magnetic resonance imaging (MRI) findings and epidural steroid injection sites in patients with symptomatic degenerative disease of the lumbar spine. METHODS A database search was conducted for patients receiving epidural injections <12 months after a positron emission tomography/computed tomography (PET/CT). Maximum standard uptake values (SUVmax) were measured at the facet joints, neural foramina, and spinal canal. Severity of facet arthrosis, disc degeneration, neuroforaminal, and canal stenosis was determined on MRI using previously described grading scales. Spearman rank coefficient assessed association between PET/CT FDG uptake and severity of MRI findings. The SUVmax was also compared with injection sites. RESULTS Twenty-five patients were included, comprising MRI (n=19) and injection (n=22 patients; 18 interlaminar, 8 transforaminal) groups. Injections were performed an average of 2.6 months after PET/CT. The greatest SUVmax occurred at the L5-S1 spinal canal (mean SUVmax = 2.25). A statistically significant, positive correlation between uptake and grade of spinal canal stenosis was seen only at L4-L5 (r=0.60, p = 0.007). No other significant association was found with spinal canal or neuroforaminal stenosis, or grade of facet joint or disc degeneration. All patients reported symptomatic improvement after injections with mean pain score improvement of 4.4 on a 10-point scale (SD, 2.9). There was moderate agreement between sites of epidural injection and highest SUVmax (κ= 0.591, p < 0.001). CONCLUSION 18F-FDG metabolic activity on PET/CT corresponds with MRI findings about the lumbar spinal column, but there is no significant correlation between severity of MRI findings and radiotracer uptake. Given the moderate agreement between metabolic activity and levels of symptomatic spinal stenosis, further studies are warranted to fully evaluate the diagnostic potential of FDG PET/CT as a surrogate for guiding epidural injections.
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Affiliation(s)
- Michelle Lam
- NYU Langone Health, New York University School of Medicine, New York, USA
| | - Christopher J Burke
- Department of Radiology, NYU Langone Health, Musculoskeletal Division Langone Orthopedic Hospital, New York, USA
| | - William R Walter
- Department of Radiology, NYU Langone Health, Musculoskeletal Division Langone Orthopedic Hospital, New York, USA
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12
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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: 413] [Impact Index Per Article: 137.7] [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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13
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Common Clinical Practice for Low Back Pain Treatment: A Modified Delphi Study. Pain Ther 2021; 10:589-604. [PMID: 33713307 PMCID: PMC8119580 DOI: 10.1007/s40122-021-00249-w] [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: 11/11/2020] [Accepted: 02/16/2021] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Low back pain (LBP) is a common reason for adults to seek medical care and is associated with important functional limitation and patient burden. Yet, heterogeneity in the causes and presentation of LBP and a lack of standardization in its management impede effective prevention and treatment. METHODS We conducted a modified Delphi study to generate consensus statements for the diagnosis, management, and prognosis of LBP. A panel of five experts proposed 19 statements that were subsequently evaluated by physicians who treat LBP in their everyday clinical practice. Physicians were asked to validate statements in the form of a web survey assessing level of agreement on a five-point Likert-like scale. RESULTS Consensus (≥ 70% agreement) was obtained for all 19 statements. Strength of agreement and physician comments highlighted the importance of pain management, but also strategies to ameliorate functional limitation and prevent future LBP episodes. Respondents favored multidisciplinary approaches and multimodal management for LBP, although there was some ambiguity as to how multidisciplinary strategies could be feasibly incorporated into daily practice. Finally, the results indicated some conflict regarding the use of imaging for the diagnosis of LBP and how to classify LBP for targeted treatment. CONCLUSION The results of this study provide a summary of favored clinical practice for the management of chronic LBP. While the consensus statements were generally agreeable to survey respondents, some areas of ambiguity, including how to increase the feasibility of multidisciplinary strategies, when and how to use diagnostic imaging in LBP, and LBP classification, necessitate clarification in future studies and guidelines.
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14
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El-Tallawy SN, Nalamasu R, Salem GI, LeQuang JAK, Pergolizzi JV, Christo PJ. Management of Musculoskeletal Pain: An Update with Emphasis on Chronic Musculoskeletal Pain. Pain Ther 2021; 10:181-209. [PMID: 33575952 PMCID: PMC8119532 DOI: 10.1007/s40122-021-00235-2] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 01/09/2021] [Indexed: 12/28/2022] Open
Abstract
Musculoskeletal pain is a challenging condition for both patients and physicians. Many adults have experienced one or more episodes of musculoskeletal pain at some time of their lives, regardless of age, gender, or economic status. It affects approximately 47% of the general population. Of those, about 39–45% have long-lasting problems that require medical consultation. Inadequately managed musculoskeletal pain can adversely affect quality of life and impose significant socioeconomic problems. This manuscript presents a comprehensive review of the management of chronic musculoskeletal pain. It briefly explores the background, classifications, patient assessments, and different tools for management according to the recently available evidence. Multimodal analgesia and multidisciplinary approaches are fundamental elements of effective management of musculoskeletal pain. Both pharmacological, non-pharmacological, as well as interventional pain therapy are important to enhance patient’s recovery, well-being, and improve quality of life. Accordingly, recent guidelines recommend the implementation of preventative strategies and physical tools first to minimize the use of medications. In patients who have had an inadequate response to pharmacotherapy, the proper use of interventional pain therapy and the other alternative techniques are vital for safe and effective management of chronic pain patients.
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Affiliation(s)
- Salah N El-Tallawy
- Anesthesia and Pain Management Department, King Khalid University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia. .,Faculty of Medicine, Minia University and NCI, Cairo University, Cairo, Egypt.
| | - Rohit Nalamasu
- Department of Physical Medicine and Rehabilitation, University of Nebraska Medical Center, Omaha, NE, USA
| | - Gehan I Salem
- Rheumatology, Rehabilitation and Physical Medicine Department, Assiut University Hospital, Assiut, Egypt.,Rehabilitation Medicine Department, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | | | | | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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15
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Kim J, Park HJ, Sim WS, Lee S, Kim K, Kim WJ, Lee JY. Predictive Value of the Phase Angle for Analgesic Efficacy in Lumbosacral Transforaminal Block. J Clin Med 2021; 10:jcm10020240. [PMID: 33445595 PMCID: PMC7827249 DOI: 10.3390/jcm10020240] [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: 12/03/2020] [Revised: 12/19/2020] [Accepted: 01/08/2021] [Indexed: 12/11/2022] Open
Abstract
The mechanism of low back and leg pain involves mixed neuropathic and nociceptive components. Spinal neuropathic pain is related to increased levels of inflammatory cytokines and disrupted and increased permeability of the blood-spinal cord barrier, originally composed of tight junctions of capillary endothelial cells surrounded by lamina. The phase angle (PA) estimates cell membrane integrity using bioelectrical impedance analysis. We evaluated the predictive value of the PA for analgesic efficacy in lumbosacral transforaminal block. We retrospectively collected data from 120 patients receiving transforaminal blocks for lumbosacral radicular pain and assessed the PA before and 5 min following the block. Responders (group R) and non-responders (group N) were defined by ≥50% and <50% pain reduction, respectively, on a numerical rating scale, 30 min following the block; clinical data and the PA were compared. Among the 109 included patients, 50 (45.9%) and 59 (54.1%) had ≥50% and <50% pain reduction, respectively. In group N, the PA change ratio showed 88.1% specificity, 32.0% sensitivity, and 62.4% accuracy; a ratio of <0.087 at 5 min following the block predicted non-response. A PA change ratio of <0.087 at 5 min following lumbar transforaminal blocks predicted non-responders with high specificity.
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Affiliation(s)
- Jeayoun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul 06351, Korea; (J.K.); (W.S.S.); (S.L.); (K.K.); (W.J.K.)
| | - Hue Jung Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Woo Seog Sim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul 06351, Korea; (J.K.); (W.S.S.); (S.L.); (K.K.); (W.J.K.)
| | - Seungwon Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul 06351, Korea; (J.K.); (W.S.S.); (S.L.); (K.K.); (W.J.K.)
| | - Keoungah Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul 06351, Korea; (J.K.); (W.S.S.); (S.L.); (K.K.); (W.J.K.)
| | - Woo Jin Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul 06351, Korea; (J.K.); (W.S.S.); (S.L.); (K.K.); (W.J.K.)
| | - Jin Young Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul 06351, Korea; (J.K.); (W.S.S.); (S.L.); (K.K.); (W.J.K.)
- Correspondence: ; Tel.: +82-2-3410-1929; Fax: +82-2-3410-6626
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16
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Chen P, Tran K, Korah T. Mania Induced by Epidural Steroid Injection in an Elderly Female With No Psychiatric History. Cureus 2021; 13:e12594. [PMID: 33457147 PMCID: PMC7797411 DOI: 10.7759/cureus.12594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The psychiatric risks of epidural steroid injections for chronic pain in a geriatric patient with no prior psychiatric history are presented here. A 76-year old Caucasian female presented to the emergency department with her family for an inability to sleep, confusion, and behavioral outbursts. The mood instability and psychosis were reported as having started a week after her third epidural steroid injection for low-back pain associated with a prior fall. After 12 days of mixed treatment outcomes and increasing paranoia without any localized neurological findings, the patient was transferred to the geriatric psychiatry unit. Upon admission to the inpatient unit, she was loud, grandiose, verbally aggressive, unable to sleep, hyper-religious, paranoid, and identified her husband and daughter as demons. The patient was started on risperidone and valproic acid for the management of psychosis and manic symptoms. Hyper-religiosity and paranoia greatly improved within a week, though the patient remained very talkative and tangential, with a disorganized thought process. Valproic acid was titrated to 500 mg twice a day, yielding a level of 56.2 ug/ml, accompanied by improvement to mild talkativeness and circumstantiality. She was able to interact appropriately, with minimal lorazepam requirement, and discharged with a linear thought process and absence of psychosis. On outpatient follow up, there were minimal residual mania and no recurrence of psychosis, allowing her to be weaned off valproic acid and to discontinue risperidone. Two months later, symptoms resolved completely. The persistence of this patient’s psychosis for nearly one month, and mania for about three months, underscores the importance of careful risk-benefit analysis before initiating epidural steroids. This is particularly important in elderly patients who may be more susceptible to psychiatric adverse effects that can outlast any analgesic benefits.
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Affiliation(s)
- Pauline Chen
- Psychiatry, University of Florida, Gainesville, USA
| | - Kelvin Tran
- Psychiatry, University of Florida, Gainesville, USA
| | - Tessy Korah
- Psychiatry, University of Florida, Gainsville, USA
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17
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Shrestha P, Subba L, Agrawal P, Lohani S. Outcome of transforaminal epidural steroid injection for lumbar radiculopathy: initial three-year experience at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences, Nepal. Chin Neurosurg J 2020; 6:6. [PMID: 32922935 PMCID: PMC7398303 DOI: 10.1186/s41016-020-0184-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/06/2020] [Indexed: 11/23/2022] Open
Abstract
Background The prevalence of low back pain with radiculopathy in general population varies from 9.9% to 25%, which can be due to bony narrowing of the lateral recess or due to prolapsed intervertebral disc. Transforaminal epidural injection of a mixture of long-acting anaesthetic (bupivacaine) and particulate steroids (depomedrol) has been a treatment modality in patients not responding to initial physiotherapy and neuropathic pain medications. Methods To analyze the effectiveness of transforaminal epidural steroid injection (TFESI) in the treatment of low back pain with radiculopathy, a retrospective case series evaluating the records of patients that received TFESI (1 mL 0.5% bupivacaine +1 ml/40 mg depomedrol) under C-arm guidance from January 2015 to December 2018 (3 years) at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences (UDM-NINAS), their lumbo-sacral MRI and the pre-procedure, 1-week and 3-month numeric pain rating scale, were analyzed. Successful treatment (reduction of pain scale by more than 50% of baseline at 3 months) in the patients with bony recess stenosis and those with prolapsed intervertebral disc was compared. Results Out of 67 patients that received TFESI, 35 (52.23%) could be followed up. The mean age was 55.8 ± 14.39 years and 51.3% were females. 68.57% had L5 and 20% had S1 radiculopathy. Bony recess stenosis was seen in the aged 40% and PIVD was the cause of radiculopathy in 60%. The median duration of radicular pain prior to intervention was 3 months. TFESI was effective as the mean numeric pain scale before injection was 8.97 ± 1.32 which reduced to 3.91 ± 3.23 (paired t test p value < 0.001) at 1 week post injection and 3.23 ± 3.34 (paired t test p value < 0.001) at 3 months post injection. Twenty-six of the 35 patients (75.29%) had more than 50% pain relief compared to baseline at 3 months and were satisfied. Nine patients continued to have pain; however, only one required a surgical intervention. The effectiveness of TFESI was not significantly different in different ages (Fisher’s exact test p value 0.182) and in different anatomic levels (Fisher’s exact test p value 0.241). Six out of eight patients with bony recess stenosis benefited as compared to 14 out of 19 patients with PIVD, though it was not statistically significant (Fischer’s exact test p value 0.688). There were no adverse events recorded. Conclusion TFESI is a safe and efficacious treatment modality in patients with radicular low back pain especially in aged patients in whom surgery under general anaesthesia is not free from risk.
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Affiliation(s)
- Pratyush Shrestha
- Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences (UDM-NINAS), Bansbari, Kathmandu, Nepal
| | - Lojima Subba
- Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences (UDM-NINAS), Bansbari, Kathmandu, Nepal
| | - Prity Agrawal
- Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences (UDM-NINAS), Bansbari, Kathmandu, Nepal
| | - Subash Lohani
- Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences (UDM-NINAS), Bansbari, Kathmandu, Nepal
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18
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Li P, Hou X, Gao L, Zheng X. Infection Risk of Lumbar Epidural Injection in the Operating Theatre Prior to Lumbar Fusion Surgery. J Pain Res 2020; 13:2181-2186. [PMID: 32922068 PMCID: PMC7457848 DOI: 10.2147/jpr.s261922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/07/2020] [Indexed: 12/17/2022] Open
Abstract
Purpose To determine the association between preoperative lumbar epidural injections (LEIs) in the operating theater (OR) and the occurrence of surgical site infection (SSI) after posterior lumbar instrumented fusion surgery. Methods This study was performed from January 2015 to September 2019. We enrolled 2312 patients who underwent lumbar surgery without LEIs (control group) and 469 patients who underwent lumbar surgery after LEIs in the OR. We further separated the patients by the time interval between the LEIs and surgery: 1) for the 0–1 M group, lumbar surgery was performed within 1 month after the LEIs, and 2) for the >1 M group, it was performed more than 1 month after the LEIs. Results The postoperative infection rate in the 0–1 M group was considerably higher than that in the control group (p = 0.0101). We further subdivided the 0–1 M and >1 M groups into four subgroups: a) the 0–1 MNS group included patients in the 0–1 M group who did not receive steroids; b) the 0–1 MS group who received steroids; c) the >1 MNS group included patients in the >1 M group who did not receive steroids; d) the >1 MS group who received steroids. The postoperative infection rate in the 0–1 MS subgroup was considerably higher than that in the control group (p = 0.0018). However, the infection rate was lower in the >1 MS subgroup (p = 0.1650). There were no statistically significant differences in the postoperative infection rate between the control group and the two non-steroid groups (0–1 MNS group, p = 0.4961; 1 MNS group, p = 0.7381). Conclusion The administration of LEIs without steroids in the OR before lumbar instrumented fusion does not significantly increase patients’ risk of postoperative infection. We recommend avoiding steroid injections administered within 1 month before lumbar instrumented fusion.
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Affiliation(s)
- Peng Li
- Department of Orthopedics, The Second Affiliated Hospital of Luohe Medical College, Luohe, Henan 462300, People's Republic of China
| | - Xiuwei Hou
- Department of Orthopedics, The Second Affiliated Hospital of Luohe Medical College, Luohe, Henan 462300, People's Republic of China
| | - Lifeng Gao
- Department of Orthopedics, The Second Affiliated Hospital of Luohe Medical College, Luohe, Henan 462300, People's Republic of China
| | - Xiaochen Zheng
- Department of Orthopedics, The Second Affiliated Hospital of Luohe Medical College, Luohe, Henan 462300, People's Republic of China
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19
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Scipione R, Alfieri G, De Maio A, Panella E, Napoli S, Bianchi L, Pandaloro N, Bazzocchi A, Facchini G, Albisinni U, Spinnato P, Catalano C, Napoli A. STUDY PROTOCOL - pulsed radiofrequency in addition to transforaminal epidural steroid injection in patients with acute and subacute sciatica due to lumbosacral disc herniation: rationale and design of a phase III, multicenter, randomized, controlled trial. Expert Rev Med Devices 2020; 17:945-949. [PMID: 32880493 DOI: 10.1080/17434440.2020.1815529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Lumbosacral disc herniation (LDH) represents the most common cause of sciatica. Currently, there is limited evidence about minimally invasive interventional therapies for the treatment of this condition. This paper presents the protocol for a multicenter, prospective, randomized, controlled, phase III trial evaluating if PRF in addition to TFESI leads to better outcomes in patients with sciatica due to LDH, compared to TFESI alone, during the first year after treatment (Pulsed Radiofrequency in Addition to TFESI for Sciatica [PRATS]). Eligible patients are between 18 and 75 years of age, suffer from sciatica of less than 12-week duration with pain intensity >4 on the Visual Analogue Scale (VAS) and have unilateral LDH compatible with symptoms at MRI. The Medical Ethics Committee of participating hospitals approved the study protocol. Patients will be randomized to receive either combined treatment (PRF and TFESI) or TFESI alone. The primary outcome will be the assessment of pain intensity with VAS at different timepoints from week-1 to 52 after treatment; secondary outcomes will include Roland Disability Questionnaire for sciatica and Oswestry Disability Index, evaluated at 4, 12 and 52 weeks. The follow-up will last 52 weeks for each patient. Statistical analysis will be performed on a per-protocol basis.
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Affiliation(s)
- Roberto Scipione
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I - Sapienza University of Rome , Rome, Italy
| | - Giulia Alfieri
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I - Sapienza University of Rome , Rome, Italy
| | - Alessandro De Maio
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I - Sapienza University of Rome , Rome, Italy
| | | | - Simone Napoli
- Spine Unit, Centro SaNa Servizi Sanitari , Aprilia, Italy
| | - Luca Bianchi
- Spine Unit, Centro SaNa Servizi Sanitari , Aprilia, Italy
| | | | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli , Bologna, Italy
| | - Giancarlo Facchini
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli , Bologna, Italy
| | - Ugo Albisinni
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli , Bologna, Italy
| | - Paolo Spinnato
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli , Bologna, Italy
| | - Carlo Catalano
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I - Sapienza University of Rome , Rome, Italy
| | - Alessandro Napoli
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I - Sapienza University of Rome , Rome, Italy.,Spine Unit, Centro SaNa Servizi Sanitari , Aprilia, Italy
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20
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Shi W, Agbese E, Solaiman AZ, Leslie DL, Gater DR. Performance of Pain Interventionalists From Different Specialties in Treating Degenerative Disk Disease-Related Low Back Pain. Arch Rehabil Res Clin Transl 2020; 2:100060. [PMID: 33543087 PMCID: PMC7853372 DOI: 10.1016/j.arrct.2020.100060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To examine the utilization of current common treatments by providers from different specialties and the effect on delaying spinal surgery in patients with disk degenerative disease (DDD) related low back pain. DESIGN Retrospective observational study using data from the MarketScan Commercial Claims and Encounters database (2005-2013). SETTING Not applicable. PARTICIPANTS Patients (N=6229) newly diagnosed with DDD-related low back pain who received interventional treatments from only 1 provider specialty and continuously enrolled in the database for 3 years after diagnosis. MAIN OUTCOME MEASURES Measures of treatment utilization and cost were constructed for patients who received spinal surgery within 3 years after diagnosis. Cox proportional hazards models were used to examine time to surgery among provider specialties and generalized linear models were used to examine cost differences among provider specialties. RESULTS Of the 6229 patients, 427 (6.86%) underwent spinal surgery with unadjusted mean interventional treatment costs ranging from $555 to $851. Although the differences in mean costs across provider specialties were large, they were not statistically significant. Cox proportional hazards models showed that there was no significant difference between provider specialties in the time from DDD diagnosis to spinal surgery. However, patients diagnosed with DDD at a younger age and receiving physical therapy had significantly delayed time to surgery (hazard ratio, 0.66; 95% confidence interval [CI], 0.54-0.81 and hazard ratio, 0.77; 95% CI, 0.62-0.96, respectively). CONCLUSIONS Although there were no statistically significant differences among provider specialties for time to surgery and cost, patients receiving physical therapy had significantly delayed time to surgery.
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Affiliation(s)
- Weibin Shi
- Physical Medicine and Rehabilitation, Penn State Health Milton S Hershey Medical Center, Hershey, PA
- Pennsylvania State Hershey Rehabilitation Hospital, Hummelstown, PA
| | - Edeanya Agbese
- The Center for Applied Studies in Health Economics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA
| | | | - Douglas L. Leslie
- The Center for Applied Studies in Health Economics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA
| | - David R. Gater
- Physical Medicine and Rehabilitation, Miller School of Medicine, University of Miami, Miami, FL
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Shamov T, Al-Hashel JY, Rоusseff RT. Fluoroscopic Epidural Steroid Injection: Pain Relief in Discogenic Sciatica Versus Lumbar Spinal Stenosis. A Study on Middle Eastern Patients. ACTA MEDICA (HRADEC KRÁLOVÉ) 2020; 63:73-78. [PMID: 32771072 DOI: 10.14712/18059694.2020.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To compare the effect of epidural steroid injections (ESI) in patients with discogenic sciatica (Sci) versus patients with lumbar canal stenosis (LSS), not controlled by conservative treatment. MATERIALS AND METHODS In our study, 80 patients with Sci and 66 with LSS were included. A single ESI (10 mg dexamethasone in 3 cc 0.25% bupivacaine) was applied under fluoroscopic control: one level above the highest stenotic level, in the posterior epidural space, via interlaminar approach in LSS and at the prolapse level, in the anterior epidural space, via transforaminal route in Sci. Pain intensity was assessed by VAS at baseline and on days 1, 15 and 30 after intervention. RESULTS The procedure was successful in 78 Sci and 63 LSS patients. Patients with Sci responded significantly better. At one month, pain reduction over 50% was achieved in 63% (52.3-73.7% at p = 0.95) of Sci but only in 35% (23.2-46.8%) of LSS (p = 0.03). Return to pre-intervention level happened in 47% (34.7-59.3%) of LSS versus 14% (6.3-21.7%) of Sci patients (p = 0.01). In 5 patients the procedure failed, without resulting morbidity. CONCLUSION ESI are more effective in patients with Sci than in single level LSS. In multiple level LSS, results are disappointing.
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Affiliation(s)
- Todor Shamov
- Armed Forces Hospital "Jaber Al-Ahmad Al-Sabah", Subhan, 46012, Kuwait.,Department of Neurosurgery, Military Medical Academy, St Georgi Sofijski Str 3, 1606, Sofia, Bulgaria
| | - Jasem Y Al-Hashel
- Department of Neurology, Ibn-Sina Hospital, Sabah Health Area, Safat 13115, Kuwait
| | - Rossen T Rоusseff
- Department of Neurology, Ibn-Sina Hospital, Sabah Health Area, Safat 13115, Kuwait.
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Gerling MC, Bortz C, Pierce KE, Lurie JD, Zhao W, Passias PG. Epidural Steroid Injections for Management of Degenerative Spondylolisthesis: Little Effect on Clinical Outcomes in Operatively and Nonoperatively Treated Patients. J Bone Joint Surg Am 2020; 102:1297-1304. [PMID: 32769595 PMCID: PMC7508264 DOI: 10.2106/jbjs.19.00596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although epidural steroid injection (ESI) may provide pain relief for patients with degenerative spondylolisthesis in treatment regimens of up to 4 months, it remains unclear whether ESI affects crossover from nonoperative to operative management. METHODS This retrospective cohort study analyzed 2 groups of surgical candidates with degenerative spondylolisthesis: those who received ESI within 3 months after enrollment (ESI group) and those who did not (no-ESI group). Annual outcomes following enrollment were assessed within operative and nonoperative groups (patients who initially chose or were assigned to surgery or nonoperative treatment) by using longitudinal mixed-effect models with a random subject intercept term accounting for correlations between repeated measurements. Treatment comparisons were performed at follow-up intervals. Area-under-the-curve analysis for all time points assessed the global significance of treatment. RESULTS The study included 192 patients in the no-ESI group and 74 in the ESI group. The no-ESI group had greater baseline Short Form-36 (SF-36) Bodily Pain scores (median, 35 versus 32) and self-reported preference for surgery (38% versus 11%). There were no differences in surgical rates within 4 years after enrollment between the no-ESI and ESI groups (61% versus 62%). The surgical ESI and no-ESI groups also showed no differences in changes in patient-reported outcomes at any follow-up interval or in the 4-year average. Compared with the nonoperative ESI group, the nonoperative no-ESI group showed greater improvements in SF-36 scores for Bodily Pain (p = 0.004) and Physical Function (p = 0.005) at 4 years, Bodily Pain at 1 year (p = 0.002) and 3 years (p = 0.005), and Physical Function at 1 year (p = 0.030) and 2 years (p = 0.002). Of the patients who were initially treated nonsurgically, those who received ESI and those who did not receive ESI did not differ with regard to surgical crossover rates. The rates of crossover to nonoperative treatment by patients who initially chose or were assigned to surgery also did not differ between the ESI and no-ESI groups. CONCLUSIONS There was no relationship between ESI and improved clinical outcomes over a 4-year study period for patients who chose or were assigned to receive surgery for degenerative spondylolisthesis. In the nonsurgical group, ESI was associated with inferior pain reduction through 3 years, although this was confounded by greater baseline pain. ESI showed little relationship with surgical crossover. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michael C. Gerling
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Cole Bortz
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | | | - Jon D. Lurie
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Wenyan Zhao
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Peter G. Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
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Bise S, Dallaudiere B, Pesquer L, Pedram M, Meyer P, Antoun MB, Hocquelet A, Silvestre A. Comparison of interlaminar CT-guided epidural platelet-rich plasma versus steroid injection in patients with lumbar radicular pain. Eur Radiol 2020; 30:3152-3160. [DOI: 10.1007/s00330-020-06733-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 01/27/2020] [Accepted: 02/07/2020] [Indexed: 12/24/2022]
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Xu Z, Lin G, Zhang H, Xu S, Zhang M. Three-dimensional architecture of the neurovascular and adipose zones of the upper and lower lumbar intervertebral foramina: an epoxy sheet plastination study. J Neurosurg Spine 2020; 32:722-732. [PMID: 31923892 DOI: 10.3171/2019.10.spine191164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 10/28/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Kambin's triangle and the safe triangle are common posterolateral approaches for lumbar transforaminal endoscopic surgery and epidural injection. To date, no consensus has been reached on the optimal transforaminal approach, in particular its underlying anatomical mechanism. The aim of this study was to investigate the 3D architecture of the neurovascular and adipose zones in the upper and lower lumbar intervertebral foramina (IVFs). METHODS Using the epoxy sheet plastination technology, 22 cadaveric lumbar spines (12 female and 10 male, age range 46-89 years) were prepared as a series of transverse (11 sets), sagittal (8 sets), and coronal (3 sets) slices with a thickness of 0.25 mm (6 sets) or 2.5 mm (16 sets). The high-resolution images of the slices were scanned and analyzed. The height, area, and volume of 30 IVFs from T12-L1 to L4-5 were estimated and compared. This study was performed in accord with the authors' institutional ethical guidelines and approved by the institutional ethics committees. RESULTS The findings were as follows. 1) The 3D boundaries of the lumbar IVF and its subdivisions were precisely defined. 2) The 3D configuration of the neurovascular and adipose zones was different between the upper and lower lumbar IVFs; zoning in the upper lumbar IVFs was much more complex than that in the lower lumbar IVFs. 3) In general, the infraneural adipose zone gradually tapered and rotated from the inferoposterolateral aspect to the superoanteromedial aspect. 4) The average height, area, and volume of the IVF gradually increased from the upper to the lower lumbar spine. Within a lumbar IVF, the volumes below and above the inferior border of the dorsal root ganglia were similar. CONCLUSIONS This study highlights differences of fine 3D architecture of neurovascular and adipose tissues between the upper and lower lumbar IVFs, with related effects on the transforaminal approaches. The findings may contribute to optimization of the surgical approaches to and through the IVF at different lumbar spinal levels and also may help to shorten the learning curve for the transforminal techniques.
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Affiliation(s)
- Zhaoyang Xu
- 1Department of Anatomy, Anhui Medical University, Hefei, China
- 2Department of Anatomy, University of Otago; and
| | - Guoxiong Lin
- 1Department of Anatomy, Anhui Medical University, Hefei, China
| | - Han Zhang
- 3School of Medicine, University of Otago, Dunedin, New Zealand
| | - Shengchun Xu
- 1Department of Anatomy, Anhui Medical University, Hefei, China
| | - Ming Zhang
- 2Department of Anatomy, University of Otago; and
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Aoun SG, Peinado Reyes V, El Ahmadieh TY, Davies M, Patel AR, Ban VS, Plitt A, El Tecle NE, Moreno JR, Raisanen J, Bagley CA. Stem cell injections for axial back pain: a systematic review of associated risks and complications with a case illustration of diffuse hyperplastic gliosis resulting in cauda equina syndrome. J Neurosurg Spine 2019; 31:906-913. [PMID: 31491761 DOI: 10.3171/2019.6.spine19594] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 06/17/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Axial low-back pain is a disease of epidemic proportions that exerts a heavy global toll on the active workforce and results in more than half a trillion dollars in annual costs. Stem cell injections are being increasingly advertised as a restorative solution for various degenerative diseases and are becoming more affordable and attainable by the public. There have been multiple reports in the media of these injections being easily available abroad outside of clinical trials, but scientific evidence supporting them remains scarce. The authors present a case of a serious complication after a stem cell injection for back pain and provide a systematic review of the literature of the efficacy of this treatment as well as the associated risks and complications. METHODS A systematic review of the literature was performed using the PubMed, Google Scholar, and Scopus online electronic databases to identify articles reporting stem cell injections for axial back pain in accordance with the PRISMA guidelines. The primary focus was on outcomes and complications. A case of glial hyperplasia of the roots of the cauda equina directly related to stem cell injections performed abroad is also reported. RESULTS The authors identified 14 publications (including a total of 147 patients) that met the search criteria. Three of the articles presented data for the same patient population with different durations of follow-up and were thus analyzed as a single study, reducing the total number of studies to 12. In these 12 studies, follow-up periods ranged from 6 months to 6 years, with 50% having a follow-up period of 1 year or less. Most studies reported favorable outcomes, although 36% used subjective measures. There was a tendency for pain relief to wane after 6 months to 2 years, with patients seeking a surgical solution. Only 1 study was a randomized controlled trial (RCT). CONCLUSIONS There are still insufficient data to support stem cell injections for back pain. Additional RCTs with long-term follow-up are necessary before statements can be made regarding the efficacy and safety.
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Affiliation(s)
| | | | | | | | | | | | | | - Najib E El Tecle
- 2Department of Neurological Surgery, Saint Louis University Hospital, St. Louis, Missouri
| | | | - Jack Raisanen
- 3Pathology, University of Texas Southwestern Medical Center, Dallas, Texas; and
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Does facet tropism negatively affect the response to transforaminal epidural steroid injections? A prospective clinical study. Skeletal Radiol 2019; 48:1051-1058. [PMID: 30603772 DOI: 10.1007/s00256-018-3129-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/25/2018] [Accepted: 12/03/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the impact of the presence of facet tropism on the results of transforaminal epidural steroid injection for unilateral radicular pain induced by lumbar disc herniation. MATERIALS AND METHODS We included 112 patients diagnosed with unilateral, single-level lumbar disc herniation-induced radicular pain. Injection was planned at relevant levels. The patients were assessed using the Numerical Rating Scale, the Modified Oswestry Disability Index, and the Beck Depression Inventory before the injection and at hour 1, week 3, and month 3 after the injection. Presence of facet tropism was assessed by measuring the facet angles in the L3-4, L4-5, and L5-S1 segments of lumbar MRI T2 sequence axial section. RESULTS A significant decrease in the Numerical Rating Scale and an increase in the Modified Oswestry Disability Index scores were detected at all follow-ups in groups comprising 39 patients with and 61 without facet tropism (p < 0.05). On comparison, improvement in clinical parameters at week 3 and month 3 in the group without facet tropism was greater (p < 0.05). As treatment success is considered to be a ≥ 50% reduction in the Numerical Rating Scale scores, 55.2% of the patients attained treatment success at month 3. Further, although the treatment success rate in the group with facet tropism was 34.2%, it was 69% in that without facet tropism (p < 0.05). CONCLUSION Facet tropism correlates with less success of transforaminal epidural steroid injection; therefore, facet tropism may be a worthwhile measurement in a discussion with patients of the benefits of the procedure.
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Shin WS, Ahn DK, Kim MJ, Cho KJ, Go YR. Influence of Epidural Steroid Injection on Adrenal Function. Clin Orthop Surg 2019; 11:183-186. [PMID: 31156770 PMCID: PMC6526135 DOI: 10.4055/cios.2019.11.2.183] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 01/28/2019] [Indexed: 11/06/2022] Open
Abstract
Background Spinal diseases are self-limited or non-progressive in many cases. Epidural steroid injection (ESI) is a common nonsurgical treatment option for spinal pain. Despite concerns about complications of repeated steroid injection, few studies reported on the adrenal function of spine disease patients undergoing surgery after ESI. We investigated the influence of preoperative multiple ESIs on adrenal function in spine surgery patients. Methods This was a retrospective study with prospective data collection. Those who underwent elective spinal operations and had a history of multiple ESIs from January to June 2017 were selected as a study group. Those who underwent knee arthroplasty and did not have a history of ESI and any kind of steroid injection in other areas during 6 months before surgery were selected as a control group. Demographic data were compared to assess homogeneity between groups. We assessed the preoperative serum cortisol level (SCL) to compare the basal adrenal function between groups. Also, we assessed the elevation of SCL postoperatively to evaluate the adrenal response to the surgical stress in each group. For subgroup analysis, we divided all patients into normal (7-28 µg/dL) and subnormal groups according to SCL and analyzed risk factors of adrenal suppression with multivariate logistic regression test. Results There were 53 patients in the study group and 130 in the control group. Age and sex were homogeneous between groups. There was significant intergroup difference in preoperative SCL (10.4 ± 4.8 µg/dL in the study group vs. 12.0 ± 4.2 µg/dL in the control group; p = 0.026).The postoperative day one SCL was 11.6 ± 5.0 µg/dL in the study group without significant increase from the preoperative level (p = 0.117), whereas the increase was significant in the control group with a postoperative level of 14.4 ± 4.4 µg/dL (p < 0.001). Among all patients, the SCL was subnormal in 18 patients and within the normal range in 165. Spine surgery was the independent risk factor irrespective of age and sex (odds ratio, 3.472; p = 0.015). Conclusions Our results suggest that concern should be raised about the influence of preoperative multiple ESIs on adrenal suppression in spine surgery patients.
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Affiliation(s)
- Won Shik Shin
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Dong Ki Ahn
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Myung Jin Kim
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Kyung Jun Cho
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
| | - Young Rok Go
- Department of Orthopedics, Seoul Sacred Heart General Hospital, Seoul, Korea
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Correlation of Perfusion Index Change and Analgesic Efficacy in Transforaminal Block for Lumbosacral Radicular Pain. J Clin Med 2019; 8:jcm8010051. [PMID: 30621004 PMCID: PMC6352091 DOI: 10.3390/jcm8010051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/01/2019] [Accepted: 01/03/2019] [Indexed: 12/25/2022] Open
Abstract
Transforaminal epidural injection is used to treat radicular pain. However, there is no objective method of assessing pain relief following transforaminal injection. Perfusion index is a metric for monitoring peripheral perfusion status. This study evaluates the correlation between perfusion index change and analgesic efficacy in transforaminal blocks for lumbosacral radicular pain. We retrospectively analyzed data of 100 patients receiving transforaminal block for lumbosacral radicular pain. We assessed perfusion index before treatment and at 5, 15, and 30 min following the block. We defined responders (group R) and non-responders (group N) as those with ≥50% and <50% pain reduction, respectively, 30 min following block. Clinical data and perfusion index of the groups were analyzed. Ninety-two patients were examined, of whom 57 (61.9%) and 35 (38.0%) patients reported ≥50% and <50% pain reduction, respectively. Group R had a significantly higher perfusion index change ratio 5 min following the block (p = 0.029). A perfusion index change ratio of ≥0.27 was observed in group R (sensitivity, 75.4%; specificity, 51.4%; AUC (area under the curve), 0.636; p = 0.032). A perfusion index change ratio of ≥0.27 at 5 min after block is associated with, but does not predict improvement in, pain levels following lumbosacral transforaminal block.
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Comparison of clinical efficacy of transforaminal and caudal epidural steroid injection in lumbar and lumbosacral disc herniation: A systematic review and meta-analysis. Spine J 2018; 18:2343-2353. [PMID: 30030083 DOI: 10.1016/j.spinee.2018.06.720] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 06/06/2018] [Accepted: 06/06/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT Epidural steroid injection has been used to treat back or radicular pain from lumbar and lumbosacral disc herniation (LDH). However, the superiority of transforaminal injection (TFESI) to caudal injection (CESI) remains controversial. PURPOSE This systematic review and meta-analysis aimed to investigate whether TFESI was more useful than CESI for achieving clinical outcomes in patients with LDH. STUDY DESIGN/SETTING A systematic review and/or is not appropriate. A systematic review and meta-analysis. Spine hospital and tertiary care hospital. PATIENT SAMPLE Articles were chosen that compared the clinical efficacy of TFESI and CESI for treatment of low back and radicular leg pain caused by LDH. OUTCOMES MEASURES Visual analogue scale, numeric rating scale, and Oswestry disability index. METHODS A literature search was performed using MEDLINE, EMBASE, Cochrane review, and KoreaMed databases for studies published until July 2017. After reviewing titles, abstracts, and full-texts of 6,711 studies after initial database search, six studies were included in a qualitative synthesis. Data including pain score, functional score, and follow-up period were extracted from four studies and were analyzed using a random effects model to obtain effect size and its statistical significance. Quality assessment and evidence level were established in accordance with the grading of recommendations assessment, development and evaluation methodology. RESULTS Among six studies, four articles supported the superiority of TFESI to CESI, one article showed no significant difference, and one article supported the superiority of CESI to TFESI. To obtain compatible or superior clinical results to TFESI, CESI might need to inject a larger amount of medication than was usually used. A meta-analysis showed short-term and long-term trends toward better clinical efficacy with TFESI than with CESI without statistical significance. The evidence level was low because of inconsistency and imprecision. CONCLUSIONS Comprehensive reviews of selected articles revealed better clinical benefits with TFESI than with CESI, possibly because TFESI had the ability to deliver medication directly into the target area. Because of a low level of evidence and no significant results on meta-analysis, TFESI could be weakly recommended over CESI.
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Gungor S, Ozcan A. Management of lumbar radiculopathy due to disc herniation with interlaminar epidural steroid injection in the presence of multilevel Tarlov cysts in the neural foramina: A case report. Medicine (Baltimore) 2018; 97:e12389. [PMID: 30213006 PMCID: PMC6155954 DOI: 10.1097/md.0000000000012389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Perineural cysts, commonly referred to as Tarlov cysts, are cerebrospinal fluid-filled dilations between the perineurium and endoneurium typically arising at the junction of posterior and dorsal root ganglia in the neural foramina. This anatomical location is in close proximity to usual needle trajectory during performing transforaminal epidural injection, and therefore presents a potential risk of dural puncture and associated complications. PATIENT CONCERNS Severe lower extremity pain interfering with activities of daily living. DIAGNOSES Lumbar radiculopathy secondary to left-sided L4-5 disc herniation in the presence of multilevel Tarlov cysts in the neural foramina. INTERVENTIONS Posterior interlaminar epidural steroid injection technique was preferred, as opposed to transforaminal approach, to avoid potential risk of dural puncture and associated complications in the presence of multilevel Tarlov cysts in the neural foramina. OUTCOMES The patient responded favorably to epidural steroid injection via interlaminar approach with complete resolution of pain, symptoms, and signs. There were no complications. The patient was able to tolerate physical therapy, wean pain medications, and achieve normal activities of daily living without any significant limitations. LESSONS In patients presenting with an MRI report of "Tarlov cysts", meticulous evaluation of diagnostic images should be an essential first step before considering invasive spinal procedures. Should there be any presence of Tarlov cyst in close proximity to planned needle trajectory, we recommend appropriate modification of spinal intervention to avoid potential complications.
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Affiliation(s)
- Semih Gungor
- Division of Pain Medicine, Department of Anesthesiology, Hospital for Special Surgery—Weill Cornell Medicine
| | - Asli Ozcan
- Touro College of Osteopathic Medicine, New York
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Ding Y, Li H, Zhu Y, Yao P, Zhao G. Transforaminal epidural steroid injection combined with pulsed radio frequency on spinal nerve root for the treatment of lumbar disc herniation. J Pain Res 2018; 11:1531-1539. [PMID: 30147357 PMCID: PMC6097521 DOI: 10.2147/jpr.s174318] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Lumbar disc herniation (LDH) is a common disease in clinical practice. The symptoms recur and are aggravated by time; severe pain and long-term movement disorder cause physiological and psychological problems that affect the quality of life of patients. Therefore, relieving the pain symptoms and promoting functional recovery are the primary goals that have gained increased attention. Objective To assess the efficacy of CT-guided transforaminal epidural steroid injection (TFESI) combined with pulsed radio frequency (PRF) on spinal nerve root for the treatment of LDH. Study design Retrospective comparative study. Setting Shengjing Hospital of China Medical University. Methods A total of 135 patients with LDH were selected from the Department of Pain Management in the Shengjing Hospital of China Medical University between January 2014 and December 2016. All patients were divided into three groups according to the order of entry (n=45): TFESI (group A); PRF on spinal nerve root (group B); and TFESI combined with PRF on spinal nerve root (group C). The visual analog scale (VAS), Oswestry disability index (ODI), and global perceived effect (GPE) before treatment and at different time points after treatment were observed, and patients' satisfaction was assessed. Results At every point of observation, the VAS and ODI decreased significantly as compared to that before treatment in all groups (P<0.05). The VAS and ODI in group A at 3 and 6 months after treatment were significantly higher than that in the other two groups (P<0.05). At day 1, day 14, and 1 month after treatment, the VAS and ODI in group C were significantly lower than that in group B (P<0.05). The GPE in group C was high in the early days, while that at day 14 and 1 month after treatment was significantly higher than that in the other two groups (P<0.05); no significant difference was observed in GPE at 3 and 6 months after treatment between groups B and C (P>0.05). Conclusion TFESI combined with PRF for the treatment of LDH could effectively and rapidly relieve lumbago and radicular pain and achieve long-term remission. Although the method is widely applicable, the precise selection of patients is imperative.
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Affiliation(s)
- Yuanyuan Ding
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang, China
| | - Hongxi Li
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yongqiang Zhu
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang, China
| | - Peng Yao
- Department of Pain Management, Shengjing Hospital of China Medical University, Shenyang, China
| | - Guangyi Zhao
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China,
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Comparison of Treatment Outcomes Following Either Prefrontal Cortical-only or Dual-site Repetitive Transcranial Magnetic Stimulation in Chronic Tinnitus Patients: A Double-blind Randomized Study. Otol Neurotol 2017; 40:e1024-e1029. [PMID: 28068305 DOI: 10.1097/mao.0000000000001266] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES We evaluated treatment outcomes following single-site repetitive transcranial magnetic stimulation (rTMS) in the dorsolateral prefrontal cortex (DLPFC) and dual-site rTMS in the auditory cortex (AC) and DLPFC (AC + FC). STUDY DESIGN AND PATIENTS This prospective randomized double-blind trial initially included 19 patients with chronic tinnitus and 17 of these patients received rTMS on the left AC and left DLPFC or only the left DLPFC. The subjects were randomly allocated to either the dual-site rTMS (AC + FC) protocol (Group 1, n = 9) or the singlesite rTMS (DLPFC) protocol (Group 2, n = 8). Group 1 received daily treatments with 2,000 pulses applied to the AC and 1,000 pulses applied to the DLPFC for 4 days (total of 12,000 pulses) and Group 2 received daily treatments with 3,000 pulses applied the DLPFC for 4 days (total of 12,000 pulses). MAIN OUTCOME MEASURES The severity of tinnitus was assessed before rTMS treatment using the Tinnitus Handicap Inventory (THI) and the self-rated Visual Analog Scale. These measures were used to determine the awareness, loudness, annoyance, and effects of tinnitus on daily life at 1, 2, 4, and 12 weeks after treatment. RESULTS The improvement in THI score was significantly better in Group 1 than in Group 2, even after controlling for the between-group differences in pretreatment THI score. In terms of psychological factors, Group 1 exhibited significant improvements in scores on the State-Trait Anxiety Inventory (STAI) for both state anxiety (STAI-X1) and trait anxiety (STAI-X2) at 12 weeks posttreatment and scores on the Pittsburgh Sleep Quality Index at 4 weeks posttreatment. Group 2 showed an improvement in only the STAI-X2 score at 12 weeks posttreatment. CONCLUSIONS The rTMS protocol effectively suppressed tinnitus in the dual-site rTMS (AC+FC) group but not in the single-site rTMS (DLPFC) group. Although recent evidence has shown that non-auditory cortices in the tinnitus network play an important role in the generation of tinnitus, our findings indicate that rTMS on non-auditory cortical sites alone may not be sufficient for treatment. Thus, dual-site rTMS in the AC and DLPFC may be preferable for controlling this condition.
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