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Brown A, Parmar J, Ganji-Angirekula S, Robinson CL, Al-Jumah R, Gill J, Hasoon J. Practice Patterns of Physicians who Perform Caudal Epidural Steroid Injections. Orthop Rev (Pavia) 2024; 16:123283. [PMID: 39286465 PMCID: PMC11405026 DOI: 10.52965/001c.123283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Accepted: 08/08/2024] [Indexed: 09/19/2024] Open
Abstract
Introduction Caudal epidural steroid injections (ESIs) are commonly employed in the management of low back pain and radiculopathy. Despite their widespread use, practice patterns among physicians performing caudal ESIs can vary significantly. This study aims to identify variability in injection techniques utilized by physicians during caudal ESIs, focusing on steroid use, needle selection, and catheter use. This study also looks at major permanent neurological injuries related to caudal ESIs. Methods A survey was distributed to a cohort of physicians who regularly perform ESIs. The survey comprised questions regarding the type of needle primarily used, steroid selection, the use of catheters, and major neurological injuries from caudal ESIs. The respondents included a diverse group of pain management physicians from various specialties and practice settings. Results The results revealed a predominant preference for the use of particulate steroids (72.41%) when performing caudal ESIs. Additionally, physicians primarily prefer to use spinal needles (72.41%) compared to other needle types. A majority of physicians (65.12%) reported that they never use a catheter when performing caudal ESIs to access higher pathology. Finally, all physician responders (100%) reported that they have never caused a permanent neurological injury when performing a caudal ESI. Conclusion This survey provides initial data among physicians who perform caudal ESIs. Our results demonstrate the majority of physicians favor using particulate steroids and a spinal needle, with fewer opting to use a catheter during these procedures. There were no reported major permanent neurological injuries, demonstrating that caudal ESIs are a safe interventional option for managing lumbosacral pain complaints.
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Affiliation(s)
- Ashlyn Brown
- H. Ben Taub Department of Physical Medicine and Rehabilitation Baylor College of Medicine
| | - Jason Parmar
- H. Ben Taub Department of Physical Medicine and Rehabilitation Baylor College of Medicine
| | - Suma Ganji-Angirekula
- Department of Emergency Medicine The University of Texas Health Science Center at Houston
| | - Christopher L Robinson
- Department of Anesthesiology, Perioperative, and Pain Medicine Harvard Medical School, Brigham and Women's Hospital
| | - Rana Al-Jumah
- Department of Anesthesiology and Pain Medicine University of Washington
| | - Jatinder Gill
- Department of Anesthesiology, Critical Care, and Pain Medicine Harvard Medical School, Beth Israel Deaconess Medical Center
| | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine The University of Texas Health Science Center at Houston
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Yang H, Wang H, Lu J, Hu L. A novel simplified sonographic approach with fluoroscopy-controlled L5 transforaminal epidural injections in patients with high iliac crest: a retrospective study. JA Clin Rep 2024; 10:43. [PMID: 39030365 PMCID: PMC11264496 DOI: 10.1186/s40981-024-00725-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 05/27/2024] [Accepted: 06/07/2024] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND To explore a novel ultrasound (US) modality for lumbar transforaminal epidural injections (TFEIs) in patients with low back pain (LBP) and L5 radicular pain combined with high iliac crest (HIC). METHODS One-hundred and forty-one patients were retrospectively stratified into two groups based on the treatment they received: novel group, receiving US-guided and fluoroscopy (FL)-controlled TFEIs using a sagittal oblique approach between the superior articular process of L5 and S1, and control group, receiving US-guided TFEIs with conventional transverse approach combined with FL confirmation. Accuracy of contrast dispersing into lumbar epidural space was set as the primary endpoint. Radiation dosages, procedure time, numeric rating scale (NRS) scores, Modified Oswestry Disability Questionnaire (MODQ) scores, adverse events, and rescue analgesic requirement were also recorded. The generalized liner mixed model (GLMMs) was employed to compare the repeatedly measured variables between groups, taking individual confounding factors as covariance. RESULTS The accuracy of TFEIs was 92.8% and 65.2% in novel and control group, with a significant difference of 26.7% (95% CI: 15.4%, 39.8%) between two modalities (p < 0.001). Significant pain relief was observed in novel group as opposed to control group after one injection. Procedure time in novel group (8.4 ± 1.6 min) was shorter than control group (15.8 ± 3.5 min) (p < 0.001) with less radiation dosage (3047 ± 5670 vs. 8808 ± 1039 μGy/m2, p < 0.001). Significantly, lower incidence of L5 paresthesia occurred in novel group. Statistical differences of NRS scores between the novel and control group were reached at 1 week after procedure (1 (IQR: - 1-3) vs. 3 (IQR: - 1-7), p = 0.006), while not reached at both 1- (1 (IQR: 0-2) vs. 1 (IQR: - 1-3), p = 0.086) or 3-month follow-up (0 (IQR: - 1-1) vs. 1 (IQR: 0-2), p = 0.094). Both groups showed similar functional improvement (F = 0.103, p = 0.749) during follow-up. CONCLUSIONS The novel sonographic technique provided superior accuracy needle placement and better pain-relieving effect through one injection as compared to the routine transverse approach. Consequently, in situations where the HIC imposed limitations for TFEIs performance on L5, the novel technique should be recommended to consider increasing accurate puncture, minimizing radiation exposure, consuming procedure time, and reducing the risk of neuraxial injury.
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Affiliation(s)
- Haichang Yang
- Department of Pain Management, The Second Hospital of Tangshan, no. 21 Jianshe North Road, Lubei District, Tangshan City, 063015, Hebei Province, China
| | - Hongyan Wang
- Department of Pain Management, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Jie Lu
- Department of Pain Management, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Ling Hu
- Department of Pain Management, Beijing Nuclear Industry Hospital, No. 2 Nan Fourth Lane, Sanlihe Street, Xicheng District, Beijing, 100045, China.
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Manchikanti L, Pampati V, Knezevic NN, Kaye AD, Abdi S, Sanapati MR, Abd-Elsayed A, Kosanovic R, Soin A, Beall DP, Shah S, Hirsch JA. The Influence of COVID-19 on Utilization of Epidural Procedures in Managing Chronic Spinal Pain in the Medicare Population. Spine (Phila Pa 1976) 2023; 48:950-961. [PMID: 36728775 DOI: 10.1097/brs.0000000000004574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/19/2022] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN A retrospective cohort study of utilization patterns and variables of epidural injections in the fee-for-service (FFS) Medicare population. OBJECTIVES To update the utilization of epidural injections in managing chronic pain in the FFS Medicare population, from 2000 to 2020, and assess the impact of COVID-19. SUMMARY OF BACKGROUND DATA The analysis of the utilization of interventional techniques also showed an annual decrease of 2.5% per 100,000 FFS Medicare enrollees from 2009 to 2018, contrasting to an annual increase of 7.3% from 2000 to 2009. The impact of the COVID-19 pandemic has not been assessed. METHODS This analysis was performed by utilizing master data from the Centers for Medicare and Medicaid Services, physician/supplier procedure summary from 2000 to 2020. The analysis was performed by the assessment of utilization patterns using guidance from Strengthening the Reporting of Observational Studies in Epidemiology. RESULTS Epidural procedures declined at a rate of 19% per 100,000 Medicare enrollees in the FFS Medicare population in the United States from 2019 to 2020, with an annual decline of 3% from 2010 to 2019. From 2000 to 2010, there was an annual increase of 8.3%. This analysis showed a decline in all categories of epidural procedures from 2019 to 2020. The major impact of COVID-19, with closures taking effect from April 1, 2020, through December 31, 2020, will be steeper and rather dramatic compared with April 1 to December 31, 2019. However, monthly data from the Centers for Medicare and Medicaid Services is not available as of now. Overall declines from 2010 to 2019 showed a decrease for cervical and thoracic transforaminal injections with an annual decrease of 5.6%, followed by lumbar interlaminar and caudal epidural injections of 4.9%, followed by 1.8% for lumbar/sacral transforaminal epidurals, and 0.9% for cervical and thoracic interlaminar epidurals. CONCLUSION Declining utilization of epidural injections in all categories was exacerbated to a decrease of 19% from 2019 to 2020, related, in part, to the COVID-19 pandemic. This followed declining patterns of epidural procedures of 3% overall annually from 2010 to 2019.
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Affiliation(s)
| | | | - Nebojsa Nick Knezevic
- Advocate Illinois Masonic Medical Center and College of Medicine, University of Illinois, Chicago, IL
| | - Alan D Kaye
- LSU Health Sciences Center, Shreveport, Ochsner Shreveport Hospital and Interventional Pain Clinic Feist-Wieller Cancer Center, Shreveport, LA
| | - Salahadin Abdi
- University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | - Alaa Abd-Elsayed
- UW Health Pain Services and University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Amol Soin
- Ohio Pain Clinic, Centerville, OH, Wright State University, Dayton, OH
| | | | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Clinical Observation of Patients Undergoing Glioma Surgery under Propofol and Sevoflurane Anesthesia: A Retrospective Study. JOURNAL OF ONCOLOGY 2022; 2022:4516537. [PMID: 35720226 PMCID: PMC9200574 DOI: 10.1155/2022/4516537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/27/2022] [Accepted: 05/04/2022] [Indexed: 11/22/2022]
Abstract
Objective To observe the effects of propofol and sevoflurane anesthesia on patients undergoing glioma surgery. Methods 192 patients with gliomas treated in our hospital from January 2016 to January 2021 were selected. All patients were randomly divided into observation group and control group. The observation group was given sevoflurane and the control group was given propofol. The clinical effects of the two groups were observed. Results Comparison of clinical indexes related to intraoperative conditions between the two groups revealed that the time of anesthesia and extubation after operation in the observation group were shorter than those in the control group, and the difference was statistically significant (P < 0.05). The amount of intraoperative bleeding in the observation group was less than that in the control group, and the difference was statistically significant (P < 0.05). There was no significant difference in intracranial operation time, operation time, fluid volume, and urine volume between the two groups (P < 05). Comparing the recovery time of anesthesia between the two groups, the recovery time of orientation and the time of eye-opening in the observation group were significantly shorter than those in the control group (P < 0.05). Comparing the consciousness and cognitive function of the two groups, the OAAS score of the observation group after extubation, before leaving the operating room and 1 hour after extubation, was significantly higher than that of the control group (P < 0.05), and the MMSE score l h after extubation was significantly higher than that of the control group (P < 0.05). Comparing the incidence of postoperative complications between the two groups, the number of cases of restlessness, urinary infection, deep vein thrombosis, and hypertension in the observation group was lower than that in the control group, with statistical significance (P < 0.05). Conclusion The anesthesia time and extubation time of the sevoflurane anesthesia group were shorter than that of the propofol anesthesia group, and the orientation recovery time and eye-opening time were shortened. The OAAS score of the sevoflurane anesthesia group was higher than that of the propofol anesthesia group after extubation, before extubation, and 1 hour after extubation. The probability of postoperative complications in the sevoflurane anesthesia group was lower than that in the propofol anesthesia group. Sevoflurane anesthesia may be more suitable for surgical induction of glioma patients than propofol anesthesia.
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Holder EK, Raju R, Dundas MA, Husu EN, McCormick ZL. Is there an association between lumbosacral epidural lipomatosis and lumbosacral epidural steroid injections? A comprehensive narrative literature review. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2022; 9:100101. [PMID: 35243452 PMCID: PMC8857075 DOI: 10.1016/j.xnsj.2022.100101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 11/29/2022]
Abstract
Background Exogenous systemic steroid exposure is a well-established risk factor for spinal epidural lipomatosis (SEL), however the association between lumbosacral epidural steroid injections (LESIs) and lumbosacral epidural lipomatosis (LEL) is generally regarded as poorly understood. Our objective was to investigate the rationale and the evidence implicating LESI(s) as a potential cause of LEL as well as the evidence related to use of LESI(s) as a potential pain relieving treatment option for radicular pain in the setting of LEL. Methods PubMed, Embase, Google Scholar, OVID were searched from inception until April 2021. Three investigators identified literature that provided original descriptive patient clinical data attributing the development/progression of LEL to LESI(s) or described the use of LESI(s) as a pain relieving modality for radicular pain in the setting of LEL. Results Fourteen publications were included for review. Overall, the current level of evidence is of low-quality. There are significant methodological gaps on this subject matter and many studies do not account for confounding variables independently associated with LEL. Conclusions This review has identified substantial limitations in the literature regarding that which is truly known regarding LESI(s) and LEL, as well as conservative management overall. To provide a well-rounded perspective, we synthesized literature as it pertains to: 1) current knowledge regarding SEL, notable associations and potential implications for corticosteroid exposure; 2) corticosteroid exposure and lipoatrophy; 3) current management recommendations for SEL and 4) areas for future focus. Although LESI(s) have been associated with LEL in the literature, presently due to a lack of rigorous, high-quality studies, the presence or absence of an independent causal relationship between LESI(s) and LEL cannot be stated with confidence.
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Affiliation(s)
- Eric K. Holder
- Yale University School of Medicine, Department of Orthopaedics and Rehabilitation: Section of Physiatry, New Haven, CT 06510, USA
- Corresponding author at: Yale University School of Medicine, Department of Orthopaedics and Rehabilitation, P.O Box 208071, USA.
| | - Robin Raju
- Yale University School of Medicine, Department of Orthopaedics and Rehabilitation: Section of Physiatry, New Haven, CT 06510, USA
| | - Mark A. Dundas
- Yale University School of Medicine, Department of Orthopaedics and Rehabilitation: Section of Physiatry, New Haven, CT 06510, USA
| | - Emanuel N. Husu
- Baylor College of Medicine, H. Ben Taub Department of Physical Medicine and Rehabilitation, Houston, TX, USA
- Rosalind Franklin University of Medicine and Science, Chicago Medical School, Department of Clinical Sciences, North Chicago, IL, USA
| | - Zachary L. McCormick
- University of Utah School of Medicine, Department of Physical Medicine and Rehabilitation, Salt Lake City, UT, USA
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Song JH, Lee WY, Cho KR, Nam SH, Park KD, Park Y. Fluoroscopy-Guided Transforaminal versus Caudal Epidural Steroid Injection for Chronic Pain After Spinal Surgery: A Retrospective Mid-Term Comparative Study. J Pain Res 2021; 14:2129-2138. [PMID: 34285573 PMCID: PMC8286249 DOI: 10.2147/jpr.s314044] [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: 04/19/2021] [Accepted: 06/30/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction This study is to compare advantages, safety and mid-term effects of fluoroscopy (FL)-guided transforaminal (TF) to caudal (CA) epidural steroid injection (ESI) for chronic pain after spinal surgery (CPSS) by assessing pain relief and improvement of functionality. Methods Patients with radicular pain in CPSS who received FL-guided CA (n = 21) or TF (n = 28) ESI were included in this retrospective study. Complication frequencies, adverse events, treatment effects, and functional improvements for each procedure were compared at 1, 3, and 6 months following the last injection. Results Both the Oswestry Disability Index (ODI) and verbal numeric pain scale scores (VNS) demonstrated improvement in both groups at all 1, 3, and 6 months following the last injection, without meaningful difference between groups (p < 0.05). Moreover, no meaningful difference was present between groups in terms of treatment success rate at every time point. The amount of time used for the injection procedure was shorter in CA group than in TF group (410.32 ± 25.73 seconds vs 640.65 ± 18.03 seconds, p < 0.05). Within 2 weeks of the injection treatment, the patient satisfactory scores were evaluated, with excellent being rated 85.7% (n = 18) among CA-ESI patients and 55.7% (n = 16) among TF-ESI patients (p < 0.05). Logistic regression analysis revealed that variables such as method of injection (CA or TF approach), sex, use of analgesics, pain duration, number of injections, and age were not significant variables for successful treatment results. There were no adverse complications after the procedure in both groups. Conclusion The outcomes of FL-guided CA-ESI and TF-ESI for CPSS are similar in terms of pain reduction and functional improvements. CA-ESI is associated with lesser procedure time. In addition, compared with the TF-ESI, the patient experiences less discomfort during the injection, and the satisfaction with the injection treatment is confirmed to be better. Accordingly, both methods are effective; however, in the CA approach, patient satisfaction is higher and the procedure time is shorter.
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Affiliation(s)
- Jun Hyeong Song
- Department of Physical Medicine & Rehabilitation, Sanggye Paik Hospital, Inje UniversityCollege of Medicine, Seoul, Republic of Korea
| | - Woo Yong Lee
- Department of Anesthesiology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, South Korea
| | - Kyoung Rai Cho
- Department of Otorhinolaryngology Head and Neck Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Sang Hyun Nam
- Department of Plastic and Reconstructive Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Ki Deok Park
- Department of Rehabilitation Medicine, Gachon University, Gil Medical Center, Incheon, South Korea
| | - Yongbum Park
- Department of Physical Medicine & Rehabilitation, Sanggye Paik Hospital, Inje UniversityCollege of Medicine, Seoul, Republic of Korea
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Ertilav E, Akyol A, Aydin ON. Posterior Reversible Encephalopathy Syndrome after caudal epidural steroid ınjection: A case report. Pain Pract 2021; 21:974-977. [PMID: 34233073 DOI: 10.1111/papr.13057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Caudal epidural injections are easy, effective, and safe methods and are good options for patients with low back pain and radicular lower extremity pain. Although various complications related to the technique of the procedure or the drugs used in the procedure have been described, Posterior Reversible Encephalopathy Syndrome (PRES) has not yet been defined for this intervention. CASE In this case report, we describe a case of PRES, which we supported with MRI findings in our patient who developed convulsions, changes in consciousness, and vision loss after being administered with caudal epidural steroid, and whose imaging findings regressed with the regression of clinical symptoms during the treatment process. CONCLUSION Although PRES is rarely reported, it should be kept in mind that it is a complication that can develop after caudal epidural steroid injection.
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Affiliation(s)
- Esra Ertilav
- Algology-Neurology Department, Mehmet Akif Ersoy State Hospital, Canakkale, Turkey
| | - Ali Akyol
- Algology-Neurology Department, Adnan Menderes University Medical Faculty, Aydın, Turkey
| | - Osman Nuri Aydin
- Algology-Anesthesiology Department, Adnan Menderes University Medical Faculty, Aydın, Turkey
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Comparison Between a Single Subpedicular Transforaminal Epidural Steroid Injection and Lateral Recess Steroid Injection in Reducing Paracentral Disc Herniation-Related Chronic Neuropathic Leg Pain: A Retrospective Study. World Neurosurg 2021; 149:e392-e399. [PMID: 33578022 DOI: 10.1016/j.wneu.2021.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND This retrospective study compares the results of 2 different techniques of transforaminal epidural steroid injection (TFESI)-subpedicular (SP-TFESI) and lateral recess epidural steroid injection (LRSI) in relieving chronic lumbar radicular pain. METHODS Records of 97 patients who had undergone injection for unilateral lumbar radicular pain and had a paracentral disc were analyzed. Numerical rating scale (NRS) and Oswestry Disability Index (ODI) scores were measured at baseline and at 2, 4, 12, and 24 weeks thereafter. RESULTS At 24 weeks, the NRS was significantly lower than the baseline in both groups; NRS in the LRSI group was significantly lower than NRS in the SP-TFESI group at 12 and 24 weeks (P = 0.02 each). ODI score was also significantly lower in the LRSI group through the 12-week time point (P = 0.003 at 2 weeks; P = 0.009 at 4 weeks; P = 0.02 at 12 weeks). At the end of 24 weeks, a significantly greater number of patients in the LRSI group achieved minimal clinically important difference for NRS and ODI (P = 0.008 and 0.016, respectively). CONCLUSIONS At the end of 24 weeks, LRSI appears to be a superior technique in relieving unilateral lumbar radicular pain due to a paracentral disc.
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Manchikanti L, Singh V, Kaye AD, Hirsch JA. Lessons for Better Pain Management in the Future: Learning from the Past. Pain Ther 2020; 9:373-391. [PMID: 32410070 PMCID: PMC7648810 DOI: 10.1007/s40122-020-00170-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Indexed: 12/24/2022] Open
Abstract
The treatment of noncancer pain in the United States and globally is met with significant challenges, resulting in profound physical, emotional, and societal costs. Based on this need, numerous modalities have been proposed to manage chronic pain, including opioid and nonopioid interventions as well as surgical approaches. Thus, the future of pain management continues to be mired in evolving concepts and constant debates. Consequently, it is crucial to understand the past as we move towards the future. The evolution of lessons for better pain management at present and for the future starting from the 1990s to the present date are reviewed and emphasized with a focus on learning from the past for the future. This review summarizes the evolution of multiple modalities of treatments, including multidisciplinary programs, multimodal therapy, interventional techniques, opioid therapy, other conservative modalities, and surgical interventions. This review emphasizes the individual, patient-centered development of an effective pain treatment plan after proper evaluation to establish a diagnosis. It includes measurable outcomes that focus on improvements in the quality of life and activities of daily living, as well as improvement in pain and function and, most importantly, return to productive citizenship. It is crucial that the knowledge of best practices be advanced, along with emphasis on lessons learned in the past to provide best practices for better pain management.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY, USA.
- University of Louisville, Louisville, KY, USA.
- Department of Anesthesiology, School of Medicine, LSU Health Sciences Center, New Orleans, LA, USA.
| | - Vanila Singh
- Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Alan D Kaye
- Department of Anesthesiology, School of Medicine, LSU Health Sciences Center, New Orleans, LA, USA
- Department of Anesthesiology, LSU School of Medicine, Shreveport, LA, USA
- Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA, USA
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
- Department of Radiology, Harvard Medical School, Boston, MA, USA
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Oh DCS, Rispoli L, Ghosh P, Gulati A. Epidural Steroid Injections for the Management of Spinal Malignancy-Related Pain: A Pragmatic Review and Retrospective Study. Pain Pract 2020; 21:285-298. [PMID: 33025670 DOI: 10.1111/papr.12957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/29/2020] [Accepted: 09/25/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Spinal malignancy-related pain results from tumor, fracture, instability, inflammation, and/or nerve root/spinal cord compression. Systemic corticosteroids are commonly used but have many undesirable adverse effects that impact quality of life and continuation of cancer treatments. Epidural steroid injections (ESIs) may be a viable alternative pain treatment. OBJECTIVES This study starts with a pragmatic review on the efficacy of ESIs to treat spinal malignancy-related pain. Given the limited evidence, we supplement the study with a single-center, retrospective review. METHODS A pragmatic review using PRISMA guidelines was conducted in MEDLINE, EMBASE, SCOPUS, and Cochrane Review. Then, a retrospective chart review was performed. RESULTS A pragmatic review yielded 10 patients who underwent ESI for spinal malignancy-related pain. Three patients had "excellent" relief (≥ 50% relief), who all received thoracic injections. This amounted to level IV evidence and an inconclusive recommendation (Grade C) as per Wright's criteria. In our retrospective review, all thoracic cases achieved at least "moderate" pain improvement (30% to 49% relief). 55.6% had "excellent" relief. Lumbosacral injections resulted in 86.0% with at least "moderate" relief and 69.8% with "excellent" relief. Caudal injections were less likely to benefit than lumbosacral injections (P = 0.02). The transforaminal approach resulted in the best relief. There were no adverse events. CONCLUSIONS There is inconclusive evidence to use ESIs to treat spinal malignancy-related pain in the current literature. Our retrospective review provides level III evidence for our conclusion that ESIs are safe and efficacious to treat spinal malignancy-related pain. Thoracic/lumbosacral injections led to significantly better pain relief compared with caudal injections.
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Affiliation(s)
- Daniel Chun-Suk Oh
- Department of Rehabilitation and Regenerative Medicine, NewYork-Presbyterian Hospital - University Hospital of Columbia and Cornell, New York, New York, U.S.A
| | - Leia Rispoli
- Department of Anesthesiology and Pain Medicine, Weill Cornell Medicine, New York, New York, U.S.A
| | - Priyanka Ghosh
- Department of Anesthesiology and Pain Medicine, Weill Cornell Medicine, New York, New York, U.S.A
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, U.S.A
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Munjupong S, Kumnerddee W. Effect of supraneural transforaminal epidural steroid injection combined with caudal epidural steroid injection with catheter in chronic radicular pain management: Double blinded randomized controlled trial. F1000Res 2020; 9:634. [PMID: 32695314 PMCID: PMC7344176 DOI: 10.12688/f1000research.23188.2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2020] [Indexed: 11/20/2022] Open
Abstract
Background: Epidural steroid injection (ESI) has been used in managing chronic radicular pain. Regarding various techniques of ESI, the synergistic effect of caudal ESI (CESI) on transforaminal ESI (TFESI) in chronic lumbosacral radicular pain in prospective randomized controlled trial has not been determined.
Methods: A total of 54 eligible patients with lumbosacral radicular pain were randomly allocated to undergo TFESI plus CESI (TC group) or TFESI alone (T group). The effective response to treatment was predefined by at least a 30% reduced verbal numerical rating scale (VNRS) from baseline between group comparison and the functional outcomes as measured by improved Oswestry Disability Index by least 15 points from baseline. All participants were evaluated using a single blinded outcome assessor before the procedure and at 1, 3 and 6 months after the procedure. P <0.05 was considered as statistically significant.
Results: Average VNRS reduced significantly from baseline after receiving procedure at 1, 3 and 6 months in both groups (P-value <0.05). The TC group exhibited more effective and showed significant pain relief compared with the T group at 3 months (P=0.01). However, no statistical difference was observed between sub group analysis in pain relief and insignificant difference between group comparisons of functional outcomes. Conclusions: A treatment combining TFESI and CESI showed significant pain relief over TFESI alone at 3 months. No effect was found concerning functional evaluation. Registration: Thai Clinical Trials Registry ID TCTR20171101002 01/11/2017F
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Affiliation(s)
- Sithapan Munjupong
- Department of Anaesthesiology, Phramongkutklao Hospital and College of Medicine, Bangkok, Bangkok, 10400, Thailand
| | - Wipoo Kumnerddee
- Department of Rehabilitation Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Bangkok, 10400, Thailand
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Moore D, Galvin D, Conroy MJ, Das B, Dunne M, Lysaght J, McCrory C. Characterisation of the effects of pulsed radio frequency treatment of the dorsal root ganglion on cerebrospinal fluid cellular and peptide constituents in patients with chronic radicular pain: A randomised, triple-blinded, controlled trial. J Neuroimmunol 2020; 343:577219. [PMID: 32224326 DOI: 10.1016/j.jneuroim.2020.577219] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 02/29/2020] [Accepted: 03/18/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Chronic radicular neuropathic pain is a major clinical problem with a life time prevalence of more than 50%. Pulsed radiofrequency (PRF) treatment is a recognised therapy. However, the pathophysiology of chronic neuropathic pain (CNP) and the mechanism of action of PRF remains ill-defined. Improving our knowledge of the mechanisms of CNP and PRF action will enhance our ability to treat patients with this common debilitating problem more effectively. This study aims to characterise the CSF cellular and peptide constituents in patients with CNP and the effect of pulsed radiofrequency (PRF) on these constituents and reported pain. MATERIALS AND METHODS Prospective randomised tripled-blinded control trial of patients receiving PRF treatment versus sham for radicular pain. All patients received local anaesthetic to the appropriate dermatome to confirm diagnosis. Clinical assessment using standard clinical assessment tools and examination of CSF using flow cytometry and ELISA for cellular and peptide constituents was carried out before and 3 months after treatment. RESULTS Ten patients were randomised to PRF (n = 5) or Sham (n = 5) treatment. PRF resulted in a significant reduction in pain score (NRS) at 3 months (6.8 to 2.6, p < .05). PRF reduced the TNF-α concentration and CD3+ count in CSF. CD4/CD8 ratio of patients with CNP was lower than historical controls (1.4 versus 3.0-4.2). The majority of CD3+ cells in the CNP patients were activated effector memory cells (80%) versus the surveillance central memory cells (85%) seen in healthy controls. CONCLUSIONS PRF is superior to local anaesthetic administration for the management of radicular pain and is associated with CSF constituent modulation in vivo. Patients with CNP have lymphocyte characteristics which suggest immune activation.
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Affiliation(s)
- David Moore
- Department of Pain Medicine, St James's Hospital, Dublin 8, Ireland
| | - Deborah Galvin
- Department of Pain Medicine, St James's Hospital, Dublin 8, Ireland.
| | - Melissa J Conroy
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
| | - Basabjit Das
- Department of Pain Medicine, St James's Hospital, Dublin 8, Ireland
| | - Margaret Dunne
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
| | - Joanne Lysaght
- Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
| | - Connail McCrory
- Department of Pain Medicine, St James's Hospital, Dublin 8, Ireland; Department of Surgery, Trinity Translational Medicine Institute, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
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13
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Lee JH, Choi KH, Kang S, Kim DH, Kim DH, Kim BR, Kim W, Kim JH, Do KH, Do JG, Ryu JS, Min K, Bahk SG, Park YH, Bang HJ, Shin KH, Yang S, Yang HS, Yoo SD, Yoo JS, Yoon KJ, Yoon SJ, Lee GJ, Lee SY, Lee SC, Lee SY, Lee IS, Lee JS, Lee CH, Lim JY, Han JY, Han SH, Sung DH, Cho KH, Kim SY, Kim HJ, Ju W. Nonsurgical treatments for patients with radicular pain from lumbosacral disc herniation. Spine J 2019; 19:1478-1489. [PMID: 31201860 DOI: 10.1016/j.spinee.2019.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/02/2019] [Accepted: 06/04/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbosacral disc herniation (LDH) is one of the most frequent musculoskeletal diseases causative of sick leave in the workplace and morbidity in daily activities. Nonsurgical managements are considered as first line treatment before surgical treatment. PURPOSE This clinical practice guideline (CPG) is intended to provide physicians who treat patients diagnosed with LDH with a guideline supported by scientific evidence to assist in decision-making for appropriate and reasonable treatments. STUDY DESIGN/SETTING A systematic review. PATIENT SAMPLE Studies of human subjects written in Korean or English that met the following criteria were selected: patients aged ≥18 years, clinical presentation of low back and radicular leg pain, diagnosis of LDH on radiological evaluation including computed tomography or magnetic resonance imaging. OUTCOMES MEASURES Pain and functional evaluation scales such as visual analogue scale, numeric rating scale, and Oswestry disability index METHODS: The MEDLINE (PubMed), EMBASE, Cochrane Review, and KoreaMed databases were searched for articles regarding non-surgical treatments for LDH published up to July 2017. Of the studies fulfilling these criteria, those investigating clinical results after non-surgical treatment including physical and behavioral therapy, medication, and interventional treatment in terms of pain control and functional improvements were chosen for this study. RESULTS Nonsurgical treatments were determined to be clinically effective with regards to pain reduction and functional improvement in patients with LDH. Nevertheless, the evidence level was generally not evaluated as high degree, which might be attributed to the paucity of well-designed randomized controlled trials. Exercise and traction were strongly recommended despite moderate level of evidence. Epidural injection was strongly recommended with high degree of evidence and transforaminal approach was more strongly recommended than caudal approach. CONCLUSIONS This CPG provides new and updated evidence-based recommendations for treatment of the patients with LDH, which suggested that, despite an absence of high degrees of evidence level, non-surgical treatments were clinically effective.
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Affiliation(s)
- Jung Hwan Lee
- Namdarun Rehabilitation Clinic, Yongin-si, Gyeongg-do, South korea
| | - Kyoung Hyo Choi
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
| | - Seok Kang
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, South Korea
| | - Dong Hwan Kim
- Department of Physical and Rehabilitation Medicine, College of Medicine, Kyung Hee University Hospital, South Korea
| | - Du Hwan Kim
- Department of Physical and Rehabilitation Medicine, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, South Korea
| | - Bo Ryun Kim
- Department of Rehabilitation Medicine, School of Medicine, Jeju National University, Jeju, South Korea
| | - Won Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jung Hwan Kim
- Rehabilitation Hospital and Research Institute, National Rehabilitation Center, Seoul, South Korea
| | - Kyung Hee Do
- Department of Physical Medicine and Rehabilitation, Veterans Health Service Medical Center, Seoul, South Korea
| | - Jong Geol Do
- Department of Physical and Rehabilitation Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ju Seok Ryu
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundnang Hospital, Seoul, South Korea
| | - Kyunghoon Min
- Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Sung Gin Bahk
- Department of Physical Medicine & Rehabilitation, Seocho Se Barun Hospital, Seoul, South Korea
| | - Yun Hee Park
- Department of Physical Medicine and Rehabilitation, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Heui Je Bang
- Department of Rehabilitation Medicine, College of Medicine, Chungbuk National University, Cheongju, South Korea
| | - Kyoung-Ho Shin
- Heal & Tun Rehabilitation Medicine Clinic, Seongnam-si, Gyeonggi-do, South Korea
| | - Seoyon Yang
- Department of Physical and Rehabilitation Medicine, Seoul Hyundai Hospital, Seoul, South Korea
| | - Hee Seung Yang
- Department of Physical and Rehabilitation Medicine, Veterans medical center, Seoul, South Korea
| | - Seung Don Yoo
- Department of Physical and Rehabilitation Medicine, Kyung Hee university, College of Medicine, Seoul, South Korea
| | - Ji Sung Yoo
- Department of Rehabilitation Medicine, Research Institute and Hospital, National Cancer Center, South Korea
| | - Kyung Jae Yoon
- Department of Physical and Rehabilitation Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Se Jin Yoon
- Department of Physical and Rehabilitation Medicine, Danam Rehabilitation Hospital, South Korea
| | - Goo Joo Lee
- Department of Rehabilitation Medicine, Chungbuk National University Hospital, Cheongju, South Korea
| | - Sang Yoon Lee
- Department of Rehabilitation Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Sang Chul Lee
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Yeol Lee
- Department of Physical Medicine and Rehabilitation, College of Medicine, Soonchunhyang University Hospital, Seoul, South Korea
| | - In-Sik Lee
- Department of Rehabilitation Medicine, Konkuk University School of Medicine and Konkuk University Medical Center, Seoul, South Korea
| | - Jung-Soo Lee
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chang-Hyung Lee
- Department of Physical and Rehabilitation Medicine, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Busan, South Korea
| | - Jae-Young Lim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jae-Young Han
- Department of Physical and Rehabilitation Medicine, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Seung Hoon Han
- Department of Rehabilitation Medicine, Hanyang University Guri Hospital, Seoul, South Korea
| | - Duk Hyun Sung
- Department of Physical Medicine and Rehabilitation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kang Hee Cho
- Department of Physical and Rehabilitation Medicine, Chungnam National University, Daejeon, South Korea
| | - Soo Young Kim
- Department of Family Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, Institute for Evidence-based Medicine, Cochrane Korea, College of Medicine, Korea University, Seoul, South Korea
| | - Woong Ju
- Department of Obstetrics and Gynecology, Ewha Womans University, Seoul, South Korea
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14
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Lee JJ, Nguyen ET, Harrison JR, Gribbin CK, Hurwitz NR, Cheng J, Boachie-Adjei K, Bogner EA, Moley PJ, Wyss JF, Lutz GE. Fluoroscopically guided caudal epidural steroid injections for axial low back pain associated with central disc protrusions: a prospective outcome study. INTERNATIONAL ORTHOPAEDICS 2019; 43:1883-1889. [PMID: 31168645 DOI: 10.1007/s00264-019-04350-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/21/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE To determine if axial low back pain (LBP) associated with central disc protrusions can be improved by caudal epidural steroid injections (ESIs). METHODS Adults with chronic (> 3 months) moderate-to-severe axial LBP with L4-5 and/or L5-S1 central disc protrusions were enrolled in this prospective study. Participants underwent caudal ESIs under standard-of-care practice. The numerical rating scale (NRS) pain score, modified North American Spine Society satisfaction, and Roland Morris Disability Questionnaire (RMDQ) were collected at one week, one month, three months, six months, and one year post-injection. Pre-injection magnetic resonance images were assessed by a musculoskeletal radiologist. RESULTS Sixty-eight participants (42 males, 26 females) were analyzed. There were statistically significant improvements in all outcome measures at all follow-up time points, with the exception of NRS best pain at six months. Clinically significant improvements in outcomes were observed at various time points: at three months and one year for current pain; at one week, one month, three months, six months, and one year for worst pain; and at one month and one year for RMDQ. The proportion of satisfied participants ranged from 57 to 69% throughout the study. No adverse events were observed. CONCLUSIONS This study demonstrated significant improvements in pain and function following caudal ESIs in a cohort of axial LBP with associated central disc protrusions. Further studies, including the use of randomized controlled trials, are needed to determine the ideal subset of candidates for this treatment and to explore additional applications that caudal ESIs may have for chronic LBP.
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Affiliation(s)
- James J Lee
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA
| | - Elizabeth T Nguyen
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA
| | - Julian R Harrison
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA
| | - Caitlin K Gribbin
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA
| | - Nicole R Hurwitz
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA
| | - Jennifer Cheng
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA
| | | | - Eric A Bogner
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA
| | - Peter J Moley
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA
| | - James F Wyss
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA
| | - Gregory E Lutz
- Department of Physiatry, Hospital for Special Surgery, New York, NY, USA.
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15
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Fan G, Liu H, Wu Z, Li Y, Feng C, Wang D, Luo J, Wells WM, He S. Deep Learning-Based Automatic Segmentation of Lumbosacral Nerves on CT for Spinal Intervention: A Translational Study. AJNR Am J Neuroradiol 2019; 40:1074-1081. [PMID: 31147353 DOI: 10.3174/ajnr.a6070] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/16/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE 3D reconstruction of a targeted area ("safe" triangle and Kambin triangle) may benefit the viability assessment of transforaminal epidural steroid injection, especially at the L5/S1 level. However, manual segmentation of lumbosacral nerves for 3D reconstruction is time-consuming. The aim of this study was to investigate the feasibility of deep learning-based segmentation of lumbosacral nerves on CT and the reconstruction of the safe triangle and Kambin triangle. MATERIALS AND METHODS A total of 50 cases of spinal CT were manually labeled for lumbosacral nerves and bones using Slicer 4.8. The ratio of training/validation/testing was 32:8:10. A 3D U-Net was adopted to build the model SPINECT for automatic segmentations of lumbosacral structures. The Dice score, pixel accuracy, and Intersection over Union were computed to assess the segmentation performance of SPINECT. The areas of Kambin and safe triangles were measured to validate the 3D reconstruction. RESULTS The results revealed successful segmentation of lumbosacral bone and nerve on CT. The average pixel accuracy for bone was 0.940, and for nerve, 0.918. The average Intersection over Union for bone was 0.897 and for nerve, 0.827. The Dice score for bone was 0.945, and for nerve, it was 0.905. There were no significant differences in the quantified Kambin triangle or safe triangle between manually segmented images and automatically segmented images (P > .05). CONCLUSIONS Deep learning-based automatic segmentation of lumbosacral structures (nerves and bone) on routine CT is feasible, and SPINECT-based 3D reconstruction of safe and Kambin triangles is also validated.
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Affiliation(s)
- G Fan
- From the Orthopedic Department, Shanghai Tenth People's Hospital (G.F., C.F., D.W., S.H.), Tongji University School of Medicine, Shanghai, China .,Department of Spine Surgery (G.F.), Third Affiliated Hospital of Sun Yatsen University, Guangzhou, China.,Surgical Planning Lab (G.F., J.L., W.M.W.), Radiology Department, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - H Liu
- Spinal Pain Research Institute of Tongji University (H.L., C.F., D.W., S.H.), Shanghai, China
| | - Z Wu
- School of Data and Computer Science (Z.W.), Sun Yat-sen University, Guangzhou, China
| | - Y Li
- Shanghai Jiao Tong University School of Medicine (Y.L.), Shanghai, China
| | - C Feng
- From the Orthopedic Department, Shanghai Tenth People's Hospital (G.F., C.F., D.W., S.H.), Tongji University School of Medicine, Shanghai, China.,Spinal Pain Research Institute of Tongji University (H.L., C.F., D.W., S.H.), Shanghai, China
| | - D Wang
- From the Orthopedic Department, Shanghai Tenth People's Hospital (G.F., C.F., D.W., S.H.), Tongji University School of Medicine, Shanghai, China.,Spinal Pain Research Institute of Tongji University (H.L., C.F., D.W., S.H.), Shanghai, China
| | - J Luo
- Surgical Planning Lab (G.F., J.L., W.M.W.), Radiology Department, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Graduate School of Frontier Sciences (J.L.), University of Tokyo, Tokyo, Japan
| | - W M Wells
- Surgical Planning Lab (G.F., J.L., W.M.W.), Radiology Department, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - S He
- From the Orthopedic Department, Shanghai Tenth People's Hospital (G.F., C.F., D.W., S.H.), Tongji University School of Medicine, Shanghai, China .,Spinal Pain Research Institute of Tongji University (H.L., C.F., D.W., S.H.), Shanghai, China
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16
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Celik M, Tulgar S, Ahiskalioglu A, Alper F. Is high volume lumbar erector spinae plane block an alternative to transforaminal epidural injection? Evaluation with MRI. Reg Anesth Pain Med 2019; 44:rapm-2019-100514. [PMID: 30992410 DOI: 10.1136/rapm-2019-100514] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Mine Celik
- Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey
| | - Serkan Tulgar
- Anesthesiology and Reanimation, Maltepe Universitiy School of Medicine, Istanbul, Turkey
| | - Ali Ahiskalioglu
- Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey
| | - Fatih Alper
- Radiology, Ataturk University School of Medicine, Erzurum, Turkey
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