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Cohen SP, Ross J. Lumbar transforaminal epidural steroid injections with particulate vs. nonparticulate steroid: an evidence-informed review on shifting gear to a personalized medicine paradigm. Curr Opin Anaesthesiol 2024:00001503-990000000-00205. [PMID: 39011664 DOI: 10.1097/aco.0000000000001402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
PURPOSE OF REVIEW To provide an evidence-informed review weighing the pros and cons of particulate vs. nonparticulate steroids for lumbar transforaminal epidural steroid injections (TFESI). RECENT FINDINGS The relative use of nonparticulate vs. particulate steroids for lumbar TFESI has risen recently in light of catastrophic consequences reported for the latter during cervical TFESI. Among various causes of spinal cord infarct, an exceedingly rare event in the lower lumbar spine, embolization of particulate steroid is among the least likely. Case reports have documented cases of spinal cord infarct during lower lumbar TFESI with both particulate and nonparticulate steroids, with database reviews finding no difference in complication rates. There is some evidence for superiority of particulate over nonparticulate steroids in well-designed studies, which could lead to increase steroid exposure (i.e. more injections) and treatment failure resulting in surgical and/or opioid management when nonparticulate steroids are utilized. SUMMARY Similar to a paradigm shift in medicine, a personalized approach based on a shared decision model and the consequences of treatment failure, should be utilized in deciding which steroid to utilize. Alternatives to ESI include high-volume injections with nonsteroid solutions, and the use of hypertonic saline, which possesses anti-inflammatory properties and has been shown to be superior to isotonic saline in preliminary clinical studies.
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Affiliation(s)
- Steven P Cohen
- Departments of Anesthesiology, Neurology, Physical Medicine & Rehabilitation, Psychiatry and Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jason Ross
- Departments of Anesthesiology and Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Coker C, Park J, Jacobson RD. Neurologic Approach to Radiculopathy, Back Pain, and Neck Pain. Prim Care 2024; 51:345-358. [PMID: 38692779 DOI: 10.1016/j.pop.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Back pain and neck pain are common in clinical practice, but significant challenges and pitfalls exist in their diagnosis, treatment, and management. From the neurologic standpoint, cervical radiculopathy and lumbosacral radiculopathy are characterized by neck pain or back pain accompanied by sensory and motor symptoms in an arm or leg. The basic neurologic examination is vital, but testing like electromyography and MRI is often needed especially in cases that fail conservative management. Oral medications, injection-based therapies, physical therapy, and surgical evaluation all have a place in the comprehensive neurologic management of back and neck pain and associated radiculopathy.
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Affiliation(s)
- Canaan Coker
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison Street, Suite 1118, Chicago, IL 60612, USA
| | - Jade Park
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison Street, Suite 1118, Chicago, IL 60612, USA
| | - Ryan D Jacobson
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison Street, Suite 1118, Chicago, IL 60612, USA.
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Gandhi G, Ethiraj P, Ramachandraiah MK, Kumaar A. Functional Outcomes of Fluoroscopy-Guided Intra-articular Steroids in Lumbar Facet Arthropathy: A Retrospective Comparative Study of Dexamethasone Versus Triamcinolone Acetonide. Cureus 2024; 16:e61551. [PMID: 38962603 PMCID: PMC11220230 DOI: 10.7759/cureus.61551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2024] [Indexed: 07/05/2024] Open
Abstract
Introduction Mechanical low back pain frequently originates from the lumbar facet joint (LFJ). Axial low back discomfort can result from osteoarthritis in the LFJ. Depending on the severity of LFJ degeneration, the effect of intra-articular (IA) LFJ corticosteroid injection may vary. For LFJ discomfort, IA block with steroids and local anaesthetics has also been utilised, with varying degrees of success. The main objective of this study was to assess the efficacy of IA steroid injections dexamethasone vs. triamcinolone acetonide for the treatment of LFJ syndrome and to compare functional outcome in terms of Visual Analog Scale (VAS) score, Modified Oswestry Disability Index (MODI) score, and short-form McGill Pain Questionnaire between the two groups. Methodology Dexamethasone 8 mg or triamcinolone acetonide 40 mg was given intra-articularly to 27 patients comprising group A and 33 patients comprising group B, respectively (total 60 patients). Before intervention and at one, three, and six months, observation was conducted using the VAS score, short-form McGill pain questionnaire, and MODI score. Results There was a significant difference between both the groups after the procedure with pain alleviation and functional improvement, more in the group that received triamcinolone acetonide. A significant difference was observed in all three parameters that assessed pain with differences more pronounced at six months. Conclusion Pain reduction and clinical outcomes were better among the group that received triamcinolone acetonide. Injection of a steroid alone is associated with its own side effects. When a lumbar transforaminal epidural injection is used to treat radiculopathy in the lumbar area, particulate medication (triamcinolone) is more effective than non-particulate medication (dexamethasone) with no known drug-related complications.
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Affiliation(s)
- Gowtham Gandhi
- Department of Orthopaedics, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Prabhu Ethiraj
- Department of Orthopaedics, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Manoj K Ramachandraiah
- Department of Orthopaedics, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
| | - Arun Kumaar
- Department of Orthopaedics, Sri Devaraj Urs Medical College, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, IND
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Grifka J, Götz J, Fenk-Mayer A, Benditz A. [Injection treatment for cervical and lumbar syndromes: principles, indications and general performance]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:1017-1024. [PMID: 38015212 DOI: 10.1007/s00132-023-04449-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 11/29/2023]
Abstract
An intensive conservative treatment that exhausts all treatment options should fundamentally be carried out before every surgical intervention in the region of the spinal column. The therapeutic measures are determined by the extent of the cervical or lumbar syndrome. As a rule, in cases of local complaints symptomatic measures with physiotherapy or digital healthcare applications are indicated. In cases of referred cervical and lumbar syndromes targeted injections can be employed. Before targeted injection treatment a detailed orthopedic clarification with respect to the intensity of local, radicular or pseudoradicular complaints must be carried out. When carrying out minimally invasive injection treatment specific prerequisites with respect to spatial, personnel and technical conditions must be fulfilled. The indications and contraindications must be strictly controlled.
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Affiliation(s)
- J Grifka
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach GmbH, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - J Götz
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach GmbH, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - A Fenk-Mayer
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach GmbH, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - A Benditz
- Klinikum Fichtelgebirge Marktredwitz, Schillerhain 1-8, 95615, Marktredwitz, Deutschland
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Lee GY, Lee JW, Lee E, Yeom JS, Kim KJ, Shin HI, Kang HS. Evaluation of the efficacy and safety of epidural steroid injection using a nonparticulate steroid, dexamethasone or betamethasone: a double-blind, randomized, crossover, clinical trial. Korean J Pain 2022; 35:336-344. [PMID: 35768989 PMCID: PMC9251387 DOI: 10.3344/kjp.2022.35.3.336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 11/28/2022] Open
Abstract
Background The U.S. Food and Drug Administration has prohibited epidural steroid injection (ESI) with particulate steroids. Thus, this study aimed to compare the efficacy and safety of ESI with two nonparticulate steroids, dexamethasone and betamethasone. Methods The eligible patients (n = 600) who received ESI (0 week) with dexamethasone (ESI-dexa) or betamethasone (ESI-beta) had follow-up visits at 2, 4, and 8 weeks with a phone interview at 12 weeks. The primary endpoint was the proportion of effective responders without pain or who were much improved at 2 weeks. The secondary endpoints were the proportion of crossover injections at 2 weeks; changes in the visual analog scale (VAS) and disability index scores at 2, 4, and 8 weeks; the number of additional ESIs in 12 weeks; the number of participants having spinal surgery, as well as the incidence of adverse events over the 12 weeks. Results The proportion of effective responders at 2 weeks was not different between ESI-beta (72/216, 33.3%) and ESI-dexa (63/200, 31.5%; P = 0.670). Adverse events were more common with ESI-dexa (40/200, 20.0%) than with ESI-beta (24/216, 11.1%; P = 0.012). VAS scores decreased more with ESI-beta than with ESI-dexa at 2 weeks (difference, 0.35; P = 0.023) and 4 weeks (difference, 0.42; P = 0.011). The disability score improved significantly more with ESI-beta compared with ESI-dexa at 2 weeks (difference, 3.37; P = 0.009), 4 weeks (difference, 4.01; P = 0.002), and 8 weeks (difference, 3.54; P = 0.007). Conclusions Betamethasone would be more appropriate for ESI.
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Affiliation(s)
- Guen Young Lee
- Department of Radiology, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea
| | - Joon Woo Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Eugene Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jin S Yeom
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyung-Ik Shin
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Heung Sik Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
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Lee SY, Kim IY, Jeong KW, Ryu T, Kwak SK, Jung JY. Comparison between the coronal diameters of the cervical spinal canal and spinal cord measured using computed tomography and magnetic resonance imaging in Korean patients. Korean J Anesthesiol 2022; 75:323-330. [PMID: 35272447 PMCID: PMC9346277 DOI: 10.4097/kja.22006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Cervical epidural block could cause spinal cord injury if the epidural needle is over-inserted and punctures the spinal cord. However, if the proportion of the spinal cord in the epidural space can be determined under C-arm fluoroscopy, a safe entry point for the epidural needle can be established. Methods We retrospectively evaluated the imaging data of 100 patients (50 men and 50 women) who underwent both cervical computed tomography (CT) and cervical magnetic resonance imaging (MRI) at our hospital. We measured the diameters of the spinal canal and spinal cord from the 3rd cervical vertebra to the 1st thoracic vertebra (T1) at each level by using the patients' cervical CT and MR images. The spinal cord and spinal canal diameters were measured in the transverse plane of cervical MR and CT images, respectively. Results The spinal cord to spinal canal diameter ratio was the highest at the 4th and 5th cervical vertebrae (0.64 ± 0.07) and the lowest at T1 (0.55 ± 0.06, 99% confidence interval : 0.535 - 0.565). Conclusions Our findings suggest that the cord to canal transverse diameter ratio could be used as a reference to reduce direct spinal cord injuries during cervical epidural block under C-arm fluoroscopy. In the C-arm fluoroscopic image, if an imaginary line connecting the left and right innermost lines of the pedicles of T1 is drawn and if the needle is inserted into the outer one-fifth of the left and right sides, the risk of puncturing the spinal cord would be relatively reduced.
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Affiliation(s)
- So Young Lee
- Department Anesthesiology and Pain Medicine, School of Medicine Daegu Catholic University, Daegu, Korea
| | - In Young Kim
- Department Anesthesiology and Pain Medicine, School of Medicine Daegu Catholic University, Daegu, Korea
| | - Kyung Wook Jeong
- Department Anesthesiology and Pain Medicine, School of Medicine Daegu Catholic University, Daegu, Korea
| | - Taeha Ryu
- Department Anesthesiology and Pain Medicine, School of Medicine Daegu Catholic University, Daegu, Korea
| | - Sang Kyu Kwak
- Department of Medical Statistics, School of Medicine Daegu Catholic University, Daegu, Korea
| | - Jin Yong Jung
- Department Anesthesiology and Pain Medicine, School of Medicine Daegu Catholic University, Daegu, Korea
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Park CH, Lee SH. Effect of lumbar epidural steroid injection on neuropathic pain: a prospective observational study. AIMS Neurosci 2022; 9:24-30. [PMID: 35434275 PMCID: PMC8941192 DOI: 10.3934/neuroscience.2022003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/20/2021] [Accepted: 01/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background Low back pain (LBP) is caused by disc herniation, spinal stenosis, facet syndrome or etc. This LBP could be either nociceptive or neuropathic pain (NP). In addition, these neuropathic pain is a major contributor to chronic low back pain. It is already known that lumbar epidural steroid injection (ESI) is effective for low back pain, but no study has assessed both nociceptive and neuropathic pain separately. This study investigated whether neuropathic or nociceptive pain was better improved after an epidural steroid injection. Methods This was a prospective study. Patients were classified according to the pre-procedure painDETECT questionnaire (PD-Q) score. If the PD-Q score was ≤12, it was considered as nociceptive pain, and it the PD-Q was ≥19, it was considered NP. The patients were given a transforaminal (TF) or interlaminar (IL) epidural steroid injection (ESI). The PD-Q was filled out by each patient prior to the ESI (baseline), and again at 4 weeks after the ESI. Outcomes was assessed using a numerical rating scale (NRS) score, short form McGill Pain Questionnaire (MPQ), and revised Oswestry Back Disability Index (ODI) at 1 month later. Results A total of 114 patients were enrolled and of these, 54 patients with a PD-Q score of ≤12 were classified into the nociceptive pain, and 60 patients with a PD-Q score ≥19 were classified into the neuropathic pain group. At 1 month after treatment, both groups had significantly lower than improved their mean NRS score. Not withstanding these improvements and difference between NRS, the differences in MPQ and ODI after treatment between the groups (nociceptive vs. neuropathic) not significant. After the procedure (TF-ESI or IL-ESI), the patients in group 1 (PD-Q score ≤12, n = 54) had no change in their PD-Q score. Among the patients in group 2 (pre-treatment PD-Q score ≥19, n = 41), 13 patients moved to a PD-Q score <12 and 15 patients had a PD-Q score of 13–18. Conclusion For the short-term relief of neuropathic pain, ESI was effective for both nociceptive and neuropathic pain, therefore ESI could be treat the try neuropathic pain component in patients with low back pain.
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Affiliation(s)
- Chan Hong Park
- Department of Anesthesiology and Pain Medicine, Daegu Wooridul Spine Hospital of Daegu, Daegu, South Korea
- * Correspondence: ; Tel: 82532123179; Fax: 82532123049
| | - Sang Ho Lee
- Department of Neurosurgery, Chungdam Wooridul Spine Hospital, Seoul, South Korea
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Kang S, Jeong HM, Kim BS, Yoon JS. Risk Analysis of Needle Injury to the Long Thoracic Nerve during Ultrasound-Guided C7 Selective Nerve Root Block. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:635. [PMID: 34205371 PMCID: PMC8235341 DOI: 10.3390/medicina57060635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/17/2021] [Accepted: 06/17/2021] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Ultrasound (US)-guided cervical selective nerve root block (SNRB) is a widely used treatment for upper limb radicular pain. The long thoracic nerve (LTN) passes through the middle scalene muscle (MSM) at the C7 level. The needle trajectory of US-guided C7 SNRB pierces the MSM, therefore indicating a high probability of injury to the LTN. We aimed to identify the LTN and to investigate the risk of needle injury to the nerve during US-guided C7 SNRB. Materials and Methods: This retrospective observational study included 30 patients who underwent US-guided SNRB at the C7 level in a university hospital. We measured the maximal cross-sectional diameter (MCSD) of the LTN and cross-sectional area (CSA) of the C7 nerve root and assessed the injury risk of LTN during US-guided C7 SNRB by simulating the trajectory of the needle in the ultrasound image. Results: The LTN was detectable in all the cases, located inside and outside the MSM in 19 (63.3%) and 11 (36.7%) of cases, respectively. The LTN's mean MCSD was 2.10 mm (SD 0.13), and the C7 root's CSA was 10.78 mm2 (SD 1.05). The LTN location was within the simulated risk zone in 86.7% (26/30) of cases. Conclusion: Our findings suggest a high potential for LTN injury during US-guided C7 SNRB. The clear visualization of LTNs in the US images implies that US guidance may help avoid nerve damage and make the procedure safer. When performing US-guided C7 SNRB, physicians should take into consideration the location of the LTN.
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Affiliation(s)
- Seok Kang
- Department of Rehabilitation Medicine, Korea University Guro Hospital, Seoul 08308, Korea; (S.K.); (H.-M.J.)
| | - Ha-Mok Jeong
- Department of Rehabilitation Medicine, Korea University Guro Hospital, Seoul 08308, Korea; (S.K.); (H.-M.J.)
| | - Beom-Suk Kim
- Uijeongbu Eulji Medical Center, Department of Rehabilitation Medicine, Uijeongbu 11759, Korea;
| | - Joon-Shik Yoon
- Department of Rehabilitation Medicine, Korea University Guro Hospital, Seoul 08308, Korea; (S.K.); (H.-M.J.)
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Conger A, Kendall RW, Sperry BP, Petersen R, Salazar F, Cunningham S, Henrie AM, Bisson EF, Teramoto M, McCormick ZL. One-year results from a randomized comparative trial of targeted steroid injection via epidural catheter versus standard transforaminal epidural injection for the treatment of unilateral cervical radicular pain. Reg Anesth Pain Med 2021; 46:813-819. [PMID: 33990435 DOI: 10.1136/rapm-2021-102514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The objective of this study was to evaluate the long-term effectiveness of catheter-directed cervical interlaminar epidural steroid injection with triamcinolone compared with cervical transforaminal steroid injection with dexamethasone for the treatment of refractory unilateral radicular pain. DESIGN Prospective, randomized, comparative trial. METHODS The primary outcome was the proportion of participants with ≥50% Numeric Rating Scale 'dominant pain' (the greater of arm vs neck) reduction from baseline. Secondary outcomes included ≥30% Neck Disability Index reduction and Patient Global Impression of Change response indicating 'much improved' or 'very much improved'. RESULTS Data from 117 participants (55.6% women; 52.3±12.5 years of age; body mass index, 28.2±6.5 kg/m2) were analyzed. The proportion of participants who experienced ≥50% pain reduction at 1 month, 3 months, and 6 months has been previously reported. At 1 year, 61.2% (95% CI, 46.9% to 73.9%) of the catheter group compared with 51.9% (95% CI, 38.4% to 65.2%) of the transforaminal group reported ≥50% 'dominant' pain reduction (p=0.35). The proportion of participants who experienced ≥30% improvement in Neck Disability Index score was 60.4% (95% CI, 45.9% to 73.3%) and 47.1% (95% CI, 33.7% to 60.8%) in the catheter and transforaminal groups (p=0.18). Patient Global Impression of Change improvement was similar in both groups: 60.5% (95% CI, 44.2% to 74.8%) and 57.5% (95% CI, 41.7% to 71.9%) of the catheter and transforaminal groups reported being 'much improved' or 'very much improved', respectively (p=0.79). CONCLUSION Both cervical catheter-directed interlaminar epidural injection and cervical transforaminal steroid injection were effective in reducing pain and disability in the majority of participants with refractory unilateral cervical radiculopathy for up to 1 year.
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Affiliation(s)
- Aaron Conger
- Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Richard W Kendall
- Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Beau P Sperry
- Los Angeles David Geffen School of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Fabio Salazar
- Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Shellie Cunningham
- Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - A Michael Henrie
- Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Erica F Bisson
- Department of Neurosurgery, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Masaru Teramoto
- Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
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McCormick ZL, Conger A, Sperry BP, Teramoto M, Petersen R, Salazar F, Cunningham S, Michael Henrie A, Bisson E, Kendall R. A Randomized Comparative Trial of Targeted Steroid Injection via Epidural Catheter vs Standard Transforaminal Epidural Injection for the Treatment of Unilateral Cervical Radicular Pain: Six-Month Results. PAIN MEDICINE 2020; 21:2077-2089. [DOI: 10.1093/pm/pnaa242] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Abstract
Objectives
Compare the effectiveness of catheter-directed cervical interlaminar epidural steroid injection (C-CIESI) with triamcinolone to cervical transforaminal steroid injection (CTFESI) with dexamethasone for the treatment of refractory unilateral radicular pain.
Design
Prospective, randomized, comparative trial.
Methods
Primary outcome: proportion of participants with ≥50% numeric rating scale pain score reduction from baseline “dominant pain” (the greater of arm vs neck) at one month postinjection. Secondary outcomes: ≥30% Neck Disability Index (NDI-5) reduction and Patient Global Impression of Change (PGIC) response indicating “much improved” or “very much improved.”
Results
One hundred twenty participants (55.6% females, 52.3 ± 12.5 years of age, BMI 28.2 ± 6.5 kg/m2), were enrolled. The proportions of participants who experienced ≥50% pain reduction at one, three, and six months were 68.5% (95% CI = 54.9–79.5%), 59.3% (95% CI = 45.7–71.6%), and 60.8% (95% CI = 46.7–73.2%), respectively, in the C-CIESI group compared with 49.1% (95% CI = 36.4–62.0%), 46.4% (95% CI = 33.8–59.6%), and 51.9% (95% CI = 38.4–65.2%), respectively, in the CTFESI group. The between-group difference at one month was significant (P = 0.038). The proportions of participants who experienced a ≥30% NDI-5 score improvement were 64.0% (95% CI = 49.8–76.1%) and 54.9% (95% CI = 41.1–68.0%) in the C-CIESI and CTFESI groups (P = 0.352). Participants reported similar PGIC improvement in both groups: At six months, 53.2% (95% CI 38.9–67.1%) and 54.5% (95% CI = 39.7–68.7%) of the C-CIESI and CTFESI groups reported being “much improved” or “very much improved,” respectively (P = 0.897).
Conclusions
Both C-CIESI with triamcinolone and CTFESI with dexamethasone are effective in reducing pain and disability associated with refractory unilateral cervical radiculopathy in a substantial proportion of participants for at least six months.
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Affiliation(s)
- Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Aaron Conger
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Beau P Sperry
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Masaru Teramoto
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | | | - Fabio Salazar
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Shellie Cunningham
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - A Michael Henrie
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Erica Bisson
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Richard Kendall
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
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Faber F, Benditz A, Boluki D, Grifka J. [Application of image-guided injection for cervical and lumbar syndromes]. Z Rheumatol 2020; 79:367-378. [PMID: 32333102 DOI: 10.1007/s00393-020-00776-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The X‑ray image-guided injection methods are an important tool for the treatment of cervical and lumbar pain syndromes. For the application of these methods it is necessary to have a differentiated consideration of cervical and lumbar pain syndromes. This leads to a decoding of complaints to assignable pain generators, which enables a targeted injection method. Depending on the origin of pain, injections are placed at the nerve root or the joints. Thus, the vicious cycle of pain can be stopped. A correct technical procedure is of enormous importance. Particular attention must be paid to the pharmacological effects and special complications. A monitoring and precautionary measures are mandatory.
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Affiliation(s)
- F Faber
- Orthopädische Universitätsklinik Regensburg, Asklepios Klinikum Bad Abbach, Kaiser Karl V. Allee 3, 93077, Bad Abbach, Deutschland.
| | - A Benditz
- Orthopädische Klinik, Universität Regensburg, Bad Abbach, Deutschland
| | - D Boluki
- Orthopädische Klinik, Universität Regensburg, Bad Abbach, Deutschland
| | - J Grifka
- Orthopädische Klinik, Universität Regensburg, Bad Abbach, Deutschland
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The safety and efficiency of performing cervical transforaminal epidural steroid injections under fluoroscopic control on an ambulatory/outpatient basis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 29:994-1000. [PMID: 31535205 DOI: 10.1007/s00586-019-06147-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/20/2019] [Accepted: 09/10/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE Cervical transforaminal epidural steroid injections (CTFESIs) have become an increasingly utilised means of treating radicular pain over recent decades, although a number of reports have brought their safety into question. Much of this has been attributed to the use of particulate steroids and the theoretical risk of embolic complications with inadvertent intra-arterial injection. This study documents the complications encountered at our centre when performing CTFESI over a more than 10-year study period with predominant use of particulate steroid. Our procedural technique is also described. This study aims to highlight the importance of operator technique first and foremost and how, with safe and reproducible technique that confidently avoids intra-arterial injection, CTFESI can be performed safely irrespective of the choice of steroid. METHODS All patients undergoing CTFESI between January 2008 and August 2018 at our centre were prospectively recruited to the study, documenting total number of injections/procedures per patient, presence of/description of complications and severity and type of steroid administered. RESULTS Five hundred and twenty-seven patients underwent 1047 procedures (1753 individual cervical levels injected) over the study period: 1011 procedures performed with particulate steroid (triamcinolone acetonide) and 36 performed with non-particulate (dexamethasone). Only six complications were encountered, all spontaneously self-resolving without intervention and considered minor (grade 1). CONCLUSIONS With fastidious safe technique, CTFESI can be safe, efficacious and cost-effectively administered on an outpatient basis. Predominant use of particulate steroids did not lead to any significant complications. These slides can be retrieved under Electronic Supplementary Material.
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Conger A, Cushman DM, Speckman RA, Burnham T, Teramoto M, McCormick ZL. The Effectiveness of Fluoroscopically Guided Cervical Transforaminal Epidural Steroid Injection for the Treatment of Radicular Pain; a Systematic Review and Meta-analysis. PAIN MEDICINE 2019; 21:41-54. [DOI: 10.1093/pm/pnz127] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Abstract
Objective
Determine the effectiveness of fluoroscopically guided cervical transforaminal epidural steroid injection (CTFESI) for the treatment of radicular pain.
Design
Systematic review and meta-analysis.
Subjects
Persons aged ≥18 years with cervical radicular pain due to disc herniation or degenerative spondylosis.
Comparison
Sham, placebo procedure, or active standard of care treatment, excluding alternative versions of epidural steroid injection.
Outcomes
The primary outcome measure was patient-reported improvement in pain of at least 50% from baseline, assessed four or more weeks after the treatment intervention. Secondary outcomes included validated functional assessment tools and avoidance of spinal surgery.
Methods
Randomized or nonrandomized comparative studies and nonrandomized studies without internal control were included. Three reviewers independently assessed publications in the Medline, PubMed, and Cochrane databases up to July 2018. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system was used to evaluate risk of bias and overall quality of evidence. A meta-analysis was conducted for comparative measures of effect and for within-group response rates if applicable.
Results
There were no studies with an internal comparison group (control group) meeting the review’s definition of comparison group. Therefore, comparative measures of effect were not calculated. In cohort studies, pooled response rates were 48% (95% confidence interval [CI] = 34–61%) at one month and 55% (95% CI = 45–64%) at three months.
Conclusions
Approximately 50% of patients experience ≥50% pain reduction at short- and intermediate-term follow-up after CTFESI. However, the literature is very low quality according the GRADE criteria, primarily due to a lack of studies with placebo/sham or active standard of care control comparison groups.
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Affiliation(s)
- Aaron Conger
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Daniel M Cushman
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Rebecca A Speckman
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
- Department of Veterans Affairs, Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Taylor Burnham
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Masaru Teramoto
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
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Tagowski M, Lewandowski Z, Hodler J, Spiegel T, Goerres GW. Pain reduction after lumbar epidural injections using particulate versus non-particulate steroids: intensity of the baseline pain matters. Eur Radiol 2019; 29:3379-3389. [DOI: 10.1007/s00330-019-06108-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/06/2019] [Accepted: 02/12/2019] [Indexed: 12/13/2022]
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Ozsoy-Unubol T, Ercalik T, Gunduz OH. Comparison of Epidural Steroid Injection Efficiency with Two Different Doses in Radiculopathies Associated with Lumbar Disc Herniation. World Neurosurg 2018; 124:S1878-8750(18)32879-1. [PMID: 30590213 DOI: 10.1016/j.wneu.2018.12.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/11/2018] [Accepted: 12/13/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Transforaminal epidural steroid injections (TFESIs) have been increasingly used in the treatment of lumbar radicular pain resistant to conservative modalities. Although different steroids can be used at different doses, the minimally effective steroid dose should be used to reduce side effects. The present retrospective study examined and compared the efficacy of 40 mg and 80 mg of methylprednisolone in TFESIs. METHODS We included 67 patients who had undergone unilateral L5-S1 TFESIs under fluoroscopic guidance in the present study. Assessments were conducted at baseline and at 1 hour, 3 weeks, and 3 months after the TFESIs. The Short-Form 36-item Health Survey, Numeric Rating Scale, Oswestry Disability Index, and Istanbul Low Back Pain Disability Index were used as outcome measures. RESULTS The present study evaluated 33 patients who had undergone TFESIs with 40 mg of methylprednisolone and 34 patients who had undergone TFESIs with 80 mg of methylprednisolone. Although no statistically significant differences were found between the 2 groups' outcome measures, both groups showed significant improvements in pain, disability, and quality of life at 3 weeks and 3 months after treatment. CONCLUSIONS TFESIs with 40 mg and 80 mg are effective for the treatment of pain that results from lumbar disc herniation. They also positively affect patients' disability and quality of life. However, neither steroid dose was more efficient than the other dose. Therefore, we believe the smaller dose should be preferred to reduce the potential side effects of steroids.
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Affiliation(s)
- Tugba Ozsoy-Unubol
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey.
| | - Tulay Ercalik
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey; Department of Physical Medicine and Rehabilitation, Section of Pain Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Osman Hakan Gunduz
- Department of Physical Medicine and Rehabilitation, Marmara University School of Medicine, Istanbul, Turkey; Department of Physical Medicine and Rehabilitation, Section of Pain Medicine, Marmara University School of Medicine, Istanbul, Turkey
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16
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Chutatape A, Menon M, Fook-Chong SMC, George JM. Metabolic and endocrinal effects of epidural glucocorticoid injections. Singapore Med J 2018; 60:140-144. [PMID: 30402653 DOI: 10.11622/smedj.2018140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Epidural steroid injections are an integral part of nonsurgical management of radicular pain from lumbar spine disorders. We studied the effect of dexamethasone 8 mg epidural injections on the hypothalamic-pituitary-adrenal axis and serum glucose control of Asian patients. METHODS 18 patients were recruited: six diabetics and 12 non-diabetics. Each patient received a total of dexamethasone 8 mg mixed with a local anaesthetic solution of lignocaine or bupivacaine, delivered into the epidural space. Levels of plasma cortisol, adrenocorticotropic hormone (ACTH), serum glucose after an overnight fast and two-hour postprandial glucose, as well as weight, body mass index, blood pressure and heart rate were measured within one week prior to the procedure (baseline) and at one, seven and 21 days after the procedure. RESULTS Median fasting blood glucose levels were significantly higher on post-procedure Day 1 than at baseline. However, there was no significant change in median two-hour postprandial blood glucose from baseline levels. At seven and 21 days, there was no significant difference in fasting or two-hour postprandial glucose levels. Both ACTH and serum cortisol were significantly reduced on Day 1 compared to baseline in all patients. There was no significant difference in ACTH and serum cortisol levels from baseline at Days 7 and 21. CONCLUSION Our study shows that epidural steroid injections with dexamethasone have a real, albeit limited, side effect on glucose and cortisol homeostasis in an Asian population presenting with lower back pain or sciatica.
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Affiliation(s)
| | - Mahesh Menon
- Department of Pain Medicine and Palliative Care Services, Kokilaben Dhirubhai Ambani Hospital, Mumbai, India
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Kesikburun S, Aras B, Kelle B, Yavuz F, Yaşar E, Taşkaynatan MA. The effectiveness of cervical transforaminal epidural steroid injection for the treatment of neck pain due to cervical disc herniation: long-term results. Pain Manag 2018; 8:321-326. [PMID: 30278822 DOI: 10.2217/pmt-2018-0002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To investigate the long-term effect of fluoroscopy guided cervical transforaminal epidural steroid injection on neck pain radiating to the arm due to cervical disc herniation. MATERIALS & METHODS 64 patients (26 women [40.6%], 38 men [59.4%]; mean age, 44.9 ± 12.1 years) who had received fluoroscopy guided cervical transforaminal epidural steroid injection for neck pain due to cervical disc herniation at least 1 year before were included in the study. The effectiveness of transforaminal epidural steroid injection was assessed using data obtained by medical records and a standardized telephone questionnaire. Multiple linear regression analysis was applied to evaluate the factors affecting the pain reduction after injection and the duration of treatment effect. RESULTS The mean duration of neck pain symptom was 23.3 ± 23.9 months. Most of the patients received a single injection (50 patients, 78.1%). The mean time since injection at the time of interview was 21.4 ± 9.4 months. There was a significant reduction in mean pain visual analog scale (VAS [10 cm]) score, from 8.6 ± 1.4 at baseline to 3.2 ± 2.5 at check visit two weeks after injection (p < 0.001). 52 patients (81.2%) reported pain relief of more than 50%. The mean duration of treatment effect was 13.3 ± 9.44 months. Greater pain on the VAS was found to predict strongly the higher pain reduction and longer treatment effect (p = 0.042 and 0.011, respectively). CONCLUSION The results suggested that cervical transforaminal epidural steroid injections might be an effective treatment for neck back pain radiating to the arm due to cervical disc herniation.
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Affiliation(s)
- Serdar Kesikburun
- Department of Physical Medicine & Rehabilitation, Gulhane School of Medicine, University of Health Science, Ankara 06100, Turkey
| | - Berke Aras
- Kastamonu Rehabilitation Centre, Kastamonu 37100, Turkey
| | - Bayram Kelle
- Çukurova University, Physical Therapy & Rehabilitation Department, Adana 01100, Turkey
| | - Ferdi Yavuz
- Fizyocare Physical Therapy & Rehabilitation Centre, Ankara 01110, Turkey
| | - Evren Yaşar
- Department of Physical Medicine & Rehabilitation, Gulhane School of Medicine, University of Health Science, Ankara 06100, Turkey
| | - Mehmet A Taşkaynatan
- Department of Physical Medicine & Rehabilitation, Gulhane School of Medicine, University of Health Science, Ankara 06100, Turkey
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Van Boxem K, Rijsdijk M, Hans G, de Jong J, Kallewaard JW, Vissers K, van Kleef M, Rathmell JP, Van Zundert J. Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group. Pain Pract 2018; 19:61-92. [PMID: 29756333 PMCID: PMC7379698 DOI: 10.1111/papr.12709] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/03/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Epidural corticosteroid injections are used frequently worldwide in the treatment of radicular pain. Concerns have arisen involving rare major neurologic injuries after this treatment. Recommendations to prevent these complications have been published, but local implementation is not always feasible due to local circumstances, necessitating local recommendations based on literature review. METHODS A work group of 4 stakeholder pain societies in Belgium, The Netherlands, and Luxembourg (Benelux) has reviewed the literature involving neurological complications after epidural corticosteroid injections and possible safety measures to prevent these major neurologic injuries. RESULTS Twenty-six considerations and recommendations were selected by the work group. These involve the use of imaging, injection equipment particulate and nonparticulate corticosteroids, epidural approach, and maximal volume to be injected. CONCLUSION Raising awareness about possible neurological complications and adoption of safety measures recommended by the work group aim at reducing the risks for these devastating events.
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Affiliation(s)
- Koen Van Boxem
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
| | - Mienke Rijsdijk
- Pain Clinic, Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Guy Hans
- Multidisciplinary Pain Center, Antwerp University Hospital, Edegem, Belgium.,Laboratory for Pain Research, University of Antwerp, Wilrijk, Belgium
| | - Jasper de Jong
- Department of Pain Management, Westfriesgasthuis, Hoorn, The Netherlands
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Management, Rijnstate Ziekenhuis, Arnhem, The Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands
| | - James P Rathmell
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, U.S.A.,Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A
| | - Jan Van Zundert
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium.,Department of Anesthesiology and Pain Management, University Medical Centre Maastricht, Maastricht, The Netherlands
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19
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Brunner M, Schwarz T, Zeman F, König M, Grifka J, Benditz A. Efficiency and predictive parameters of outcome of a multimodal pain management concept with spinal injections in patients with low back pain: a retrospective study of 445 patients. Arch Orthop Trauma Surg 2018; 138:901-909. [PMID: 29511801 DOI: 10.1007/s00402-018-2916-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Indexed: 12/26/2022]
Abstract
Low back pain is one of the most common diseases of modern civilization. Multimodal pain management (MPM) represents a central approach to avoiding surgery. Short-term results are published rarely and often incomparable because of different treatment concepts. This study compared the subjective and objective parameters as well as the anamnestic and clinical parameters of 445 patients with low back pain before and after inpatient MPM to investigate the influence of this type of therapy on short-term outcome. The majority of patients were very satisfied (39%) or satisfied (58%) with the treatment outcome. The median pain reduction for back pain was 3.0 (IQR 2.88) (numeric rating scale, NRS), thus 66% and 2.75 (IQR 3.38, 62%) for leg pain. The main pain reduction occurred within the first 10 days of treatment and was clinically significant from day 5 onwards. The outcome for patients with hospitalization of more than 10 days was significantly worse. The parameters female sex, BMI of > 30, local pain, and pain duration of 3-24 months had a significantly better outcome. In contrast, age, treatment cause, depression, anxiety, and other diseases had no statistically significant influence on outcome. MPM therapy for more than 5 days seems to be an efficient short-term approach to treating low back pain. Knowledge of some of the outcome predictors helps to early identify patients who require more intensive individual care. In the case of no clear indication for surgery, MPM can be an appropriate treatment option.
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Affiliation(s)
- Melanie Brunner
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Germany
| | - Timo Schwarz
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Germany
| | - Florian Zeman
- Centre for Clinical Studies, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Matthias König
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Germany
| | - Joachim Grifka
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Germany
| | - Achim Benditz
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl-V-Allee 3, 93077, Bad Abbach, Germany.
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21
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Kamawal Y, Raab P, Rudert M, Konrads C. [Targeted injections can relieve pain]. MMW Fortschr Med 2017; 159:58-62. [PMID: 29124580 DOI: 10.1007/s15006-017-0280-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Yama Kamawal
- Orthopädische Universitätsklinik König-Ludwig-Haus, Brettreichstr. 11, D-97074, Würzburg, Deutschland.
| | - Peter Raab
- Orthopädische Universitätsklinik König-Ludwig-Haus, Brettreichstr. 11, D-97074, Würzburg, Deutschland
| | - Maximilian Rudert
- Orthopädische Universitätsklinik König-Ludwig-Haus, Brettreichstr. 11, D-97074, Würzburg, Deutschland
| | - Christian Konrads
- Orthopädische Universitätsklinik König-Ludwig-Haus, Brettreichstr. 11, D-97074, Würzburg, Deutschland
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Effectiveness of a multimodal pain management concept for patients with cervical radiculopathy with focus on cervical epidural injections. Sci Rep 2017; 7:7866. [PMID: 28801567 PMCID: PMC5554143 DOI: 10.1038/s41598-017-08350-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/06/2017] [Indexed: 12/31/2022] Open
Abstract
Cervical radiculopathy has become an increasing problem worldwide. Conservative treatment options have been recommended in many reviews on cervical radiculopathy, ranging from different types of physiotherapy to waiting for remission by natural history. No multimodal pain management concept (MPM) on an inpatient basis has been evaluated. This study aimed at showing the positive short-term effects of an inpatient multimodal pain management concept with focus on cervical translaminar epidural steroid injection for patients with cervical radiculopathy. 54 patients who had undergone inpatient MPM for 10 days were evaluated before and after 10-days treatment. The NRS (0-10) value for arm pain could be reduced from 6.0 (IQR 5.7-6.8) to 2.25 (IQR 2.0-3.1) and from 5.9 (IQR 4.8-6.0) to 2.0 (IQR 1.7-2.6) for neck pain. Neck pain was reduced by 57.4% and arm pain by 62.5%. 2 days after epidural steroid injection, pain was reduced by 40.1% in the neck and by 43.4% in the arms. MPM seems to be an efficient short-term approach to treating cervical radiculopathy. Cervical translaminar epidural steroid injection is an important part of this concept. In the absence of a clear indication for surgery, MPM represents a treatment option.
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Joswig H, Neff A, Ruppert C, Hildebrandt G, Stienen MN. The value of short-term pain relief in predicting the 1-month outcome of 'indirect' cervical epidural steroid injections. Acta Neurochir (Wien) 2017; 159:291-300. [PMID: 27796650 DOI: 10.1007/s00701-016-2997-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/13/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Clinical management after epidural steroid injections (ESI) of patients with radiculopathy secondary to a cervical disc herniation (CDH) is uncertain. This study aims to determine whether short-term arm pain alleviation following computed tomography-guided 'indirect' cervical ESI can predict the 1-month outcome. METHODS We conducted a prospective observation of 45 consecutive patients at a tertiary radiological department. Study components were visual analog scale arm and neck pain at baseline, 15, 30, and 45 min, 1, 2, and 4 h, on days 1-14, 1 month, and at 1 year. Health-related quality of life and functional impairment were assessed using the short form-12 and Neck Pain and Disability Scale. Patients who reported ≥80 % persisting arm pain, as well as patients who underwent a second injection or an operation within 1 month were defined as 'non-responders'. Logistic regression was used to analyze the effect size of the relationship between >50 % pain relief at any given study visit and responder status. RESULTS Patients experiencing a >50 % pain reduction 4 h after the injection were four times as likely to be responders as those experiencing ≤50 % pain reduction (OR 4.04, 95 % CI 1.10-14.87). The effect was strongest on days 5-6 (OR 18.37, 95 % CI 3.39-99.64) and remained significant until day 14. CONCLUSIONS The results of this study can guide physicians in managing patients with CDH: a ≤50 % arm pain relief within 1 week after an 'indirect' cervical ESI predicts an unfavorable 1-month outcome and suggests that other treatment options may be considered at an earlier point in time.
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Affiliation(s)
- Holger Joswig
- Department of Neurosurgery, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007, St. Gallen, Switzerland.
| | - Armin Neff
- Department of Radiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | | | - Gerhard Hildebrandt
- Department of Neurosurgery, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007, St. Gallen, Switzerland
| | - Martin Nikolaus Stienen
- Department of Neurosurgery and Faculty of Medicine, University Hospital of Geneva, Geneva, Switzerland
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Grifka J, Benditz A, Boluki D. [Injection therapy for cervical and lumbar syndromes]. DER ORTHOPADE 2017; 46:195-214. [PMID: 28108775 DOI: 10.1007/s00132-016-3382-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In cervical and lumbar pain syndromes special injections are key for effective pain therapy. Depending on the origin of pain injections are placed at the nerve root or the joints. Thus, the vicious cycle can be stopped. A correct technical procedure is of enormous importance. Because pharmacological effects and special complications are possible, monitoring and precautions are mandatory.
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Affiliation(s)
- J Grifka
- Orthopädische Klinik, Universität Regensburg, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Deutschland.
| | - A Benditz
- Orthopädische Klinik, Universität Regensburg, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - D Boluki
- Orthopädische Klinik, Universität Regensburg, Kaiser-Karl-V.-Allee 3, 93077, Bad Abbach, Deutschland
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Systematic Review of the Efficacy of Particulate Versus Nonparticulate Corticosteroids in Epidural Injections. PM R 2016; 9:502-512. [DOI: 10.1016/j.pmrj.2016.11.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 11/13/2016] [Accepted: 11/16/2016] [Indexed: 12/15/2022]
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Bensler S, Sutter R, Pfirrmann CWA, Peterson CK. Is there a difference in treatment outcomes between epidural injections with particulate versus non-particulate steroids? Eur Radiol 2016; 27:1505-1511. [PMID: 27436028 DOI: 10.1007/s00330-016-4498-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 05/28/2016] [Accepted: 06/30/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To compare the outcomes of patients after interlaminar computed tomography (CT)-guided epidural injections of the lumbar spine with particulate vs. non-particulate steroids. METHODS 531 consecutive patients were treated with CT-guided lumbar interlaminar epidural injections with steroids and local anaesthetics. 411 patients received a particulate steroid and 120 patients received a non-particulate steroid. Pain levels were assessed using the 11-point numerical rating scale (NRS) and overall reported 'improvement' was assessed using the Patients Global Impression of Change (PGIC) at 1 day, 1 week and 1 month post-injection. Descriptive and inferential statistics were applied. RESULTS Patients receiving particulate steroids had statistically significantly higher NRS change scores (p = 0.0001 at 1 week; p = 0.0001 at 1 month). A significantly higher proportion of patients receiving particulate steroids reported relevant improvement (PGIC) at both 1 week and 1 month post injection (p = 0.0001) and they were significantly less likely to report worsening at 1 week (p = 0.0001) and 1 month (p = 0.017). CONCLUSION Patients treated with particulate steroids had significantly greater pain relief and were much more likely to report clinically relevant overall 'improvement' at 1 week and 1 month compared to the patients treated with non-particulate steroids. KEY POINTS • CT-guided epidural injections of the lumbar spine with particulate vs. non-particulate steroids. • Good outcomes with particulate steroids. • Less pain relief in patients with non-particulate steroids. • Less improvement in patients with non-particulate steroids.
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Affiliation(s)
- Susanne Bensler
- Department of Radiology, Orthopedic University Hospital Balgrist, Forchstrasse 340, 8008, Zurich, Switzerland. .,Faculty of Medicine, University of Zurich, Pestalozzistrasse 3, 8091, Zurich, Switzerland.
| | - Reto Sutter
- Department of Radiology, Orthopedic University Hospital Balgrist, Forchstrasse 340, 8008, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Pestalozzistrasse 3, 8091, Zurich, Switzerland
| | - Christian W A Pfirrmann
- Department of Radiology, Orthopedic University Hospital Balgrist, Forchstrasse 340, 8008, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Pestalozzistrasse 3, 8091, Zurich, Switzerland
| | - Cynthia K Peterson
- Department of Radiology, Orthopedic University Hospital Balgrist, Forchstrasse 340, 8008, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Pestalozzistrasse 3, 8091, Zurich, Switzerland
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Biltaji E, Tak C, Ma J, Ruiz-Negron N, Bellows BK. Using Electronic Medical Records to Assess the Effectiveness of Pharmacotherapy in Pain: A Review of Recent Observational Studies. J Pain Palliat Care Pharmacother 2016; 30:210-7. [PMID: 27261324 DOI: 10.1080/15360288.2016.1184215] [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: 10/21/2022]
Abstract
Pain disorders affect a large number of individuals throughout the world and are costly. Although randomized clinical trials assess the efficacy (i.e., how well treatments work in controlled settings) of pain pharmacotherapy, clinical trials do not assess effectiveness (i.e., how well treatments work in real-world settings). The number of observational studies that use real-world data to assess the effectiveness of medications is increasing rapidly in many disease areas. It is important for clinicians to understand how real-world data may be used to assess the effectiveness of medications. This paper aims to review the current body of literature assessing the effectiveness of pain pharmacotherapy using medical records. To do this, a literature search was conducted to identify papers published between January 2013 and September 2015 that examined the effectiveness of pain pharmacotherapy using electronic medical records. The search found only three papers meeting these criteria, which were described, reviewed, and critiqued in this paper. Electronic medical records are an underutilized source of data to assess pain outcomes in real-world settings. Although there are many methodological challenges in using these data, there is also great opportunity to impact clinical practice and explore the real-world effectiveness of pharmacotherapy used in pain management.
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Feeley IH, Healy EF, Noel J, Kiely PJ, Murphy TM. Particulate and non-particulate steroids in spinal epidurals: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:336-344. [DOI: 10.1007/s00586-016-4437-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 12/01/2015] [Accepted: 01/31/2016] [Indexed: 12/01/2022]
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Comparative effectiveness of lumbar epidural steroid injections using particulate vs. non-particulate steroid: an intra-individual comparative study. Skeletal Radiol 2016; 45:169-76. [PMID: 26537154 DOI: 10.1007/s00256-015-2277-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 10/21/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To perform an intra-individual comparison for the effectiveness of lumbar epidural steroid injection (ESI) between injections using particulate (triamcinolone) and non-particulate (dexamethasone) steroid. MATERIALS AND METHODS This study included 162 patients(M:F = 60:102, mean age 66.3 years) who underwent lumbar ESI using dexamethasone(ESI_DEXA) from April 2013 to May 2013 and who had previously underwent lumbar ESI using triamcinolone(ESI_TRIAM) within 1 year. Degree of relative satisfaction, injection-free interval and injection frequency were determined. Subgroup analyses were also done according to the diagnosis, approach-methods, patients' ages and sex. RESULTS Eighty-seven of 139 patients (62.6 %) responded that the effect of ESI_TRIAM was better than that of ESI_DEXA (p = 0.004). In the four subgroups-patients with herniated intervertebral disc (HIVD), who underwent transforaminal ESI, were under age 70 and were male patients-the proportion of patients who preferred ESI_TRIAM was significantly greater than the proportion patients who preferred ESI_DEXA in terms of relative satisfaction (p < 0.05). The injection-free interval of ESI_TRIAM was significantly longer than that of ESI_DEXA (p = 0.01). In the subgroup analyses, the patient groups HIVD, who underwent transforaminal ESI, under age 70 and female patients with longer injection-free interval of ESI_TRIAM than ESI_DEXA were statistically significant (p < 0.05). Other factors were not significant. CONCLUSION The relative satisfaction with ESI_TRIAM was significantly better than that with ESI_DEXA in the same patient, and the injection-free interval after ESI_TRIAM was significantly longer than that after ESI_DEXA.
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Comparison of Pain Score Reduction Using Triamcinolone vs. Betamethasone in Transforaminal Epidural Steroid Injections for Lumbosacral Radicular Pain. Am J Phys Med Rehabil 2015; 94:1058-64. [DOI: 10.1097/phm.0000000000000296] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ideal Cervical Epidural Injection Route: Interlaminar or Transforaminal. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2015. [DOI: 10.1007/s40141-015-0084-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Schneider B, Varghis N, Kennedy DJ. Ideal Corticosteroid Choice for Epidural Steroid Injections: A Review of Safety and Efficacy. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2015. [DOI: 10.1007/s40141-015-0086-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Particulate versus non-particulate steroids for lumbar transforaminal or interlaminar epidural steroid injections: an update. Skeletal Radiol 2015; 44:149-55. [PMID: 25394547 DOI: 10.1007/s00256-014-2048-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 10/24/2014] [Accepted: 10/28/2014] [Indexed: 02/02/2023]
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Kennedy DJ, Plastaras C, Casey E, Visco CJ, Rittenberg JD, Conrad B, Sigler J, Dreyfuss P. Comparative Effectiveness of Lumbar Transforaminal Epidural Steroid Injections with Particulate Versus Nonparticulate Corticosteroids for Lumbar Radicular Pain due to Intervertebral Disc Herniation: A Prospective, Randomized, Double-Blind Trial. PAIN MEDICINE 2014; 15:548-55. [DOI: 10.1111/pme.12325] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Engel A, King W, MacVicar J. The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data. PAIN MEDICINE 2013; 15:386-402. [PMID: 24308846 DOI: 10.1111/pme.12304] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine the effectiveness and risks of fluoroscopically guided cervical transforaminal injection of corticosteroids in the treatment of radicular pain. DESIGN Systematic review of the literature with comprehensive analysis of the published data. INTERVENTIONS Three reviewers with formal training in evidence-based medicine searched the literature on fluoroscopically guided cervical transforaminal injection of steroids (CTFIS). Each reviewer independently assessed the methodology of studies found and appraised the quality of the evidence presented. OUTCOME MEASURES The primary outcome assessed was relief of radicular pain. Other outcomes such as reduction in surgery rate and complications were noted if reported. The evidence on each outcome was appraised in accordance with the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system of evaluating evidence. RESULTS The searches yielded 16 primary publications on effectiveness. Available evidence, derived mainly from observational studies, suggests that approximately 50% of patients experience 50% relief of radicular pain for at least 4 weeks after CTFIS, and the intervention may have surgery-sparing effects. The literature also contains 21 articles with primary reports of serious complications, including 13 deaths and many catastrophic neurological injuries. The evidence of pain-relieving effects, of surgery-sparing effects, and of risks of CTFIS were all rated as of very low quality according to the GRADE system. CONCLUSIONS In patients with cervical radicular pain, fluoroscopically guided CTFIS may be effective in easing pain and reducing need for surgery. However, the evidence of effectiveness is of very low quality, and the benefits of the procedure are compromised by the risks of serious complications.
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Affiliation(s)
- Andrew Engel
- Continental Anesthesia, Oak Brook, Illinois, USA
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The impact of type 2 diabetes on numeric pain score reduction following cervical transforaminal epidural steroid injections. Skeletal Radiol 2013; 42:1543-7. [PMID: 23955580 DOI: 10.1007/s00256-013-1702-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 06/29/2013] [Accepted: 07/25/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study aimed to determine whether the presence of type 2 diabetes impairs the therapeutic response to transforaminal cervical epidural steroid injections (TF-CESI) in the treatment of pain due to cervical radiculopathy. DESIGN This is a retrospective cohort study of patients with cervical radiculopathy who underwent TF-CESI performed by a single physician. SETTING Single community-based multidisciplinary pain clinic and ambulatory surgery center. INTERVENTIONS Patients underwent from one to three TF-CESI with dexamethasone or triamcinolone. MAIN OUTCOME MEASURES Change in self-reported numerical pain score. RESULTS Out of 387 charts reviewed, complete data were available for 329 subjects who underwent TF-CESI from February 2006 through January 2010. The injections consisted of either 40 mg triamcinolone or 15 mg dexamethasone. Of the 329 total subjects, 35 had type 2 diabetes and 294 did not. The diabetic group had a mean age of 58.1 years with standard deviation (SD) of 11.2, mean body mass index (BMI) of 33.1 (SD 7.1), mean pre-procedure pain score of 6.7 (SD 2.2) and mean reduction in pain score of 2.5 (SD 2.4). The non-diabetic group had a mean age of 52.8 (SD 12.4), mean BMI of 28.2 (SD 5.4), mean pre-procedure pain score of 6.7 (SD 1.8), and mean reduction in pain score of 2.4 (SD 2.2). A two-sample t test with equivalent variance showed no statistically significant difference in the mean reduction in pain score between the diabetic and non-diabetic groups. The patients in the diabetic group were typically older and had higher BMIs. CONCLUSIONS The efficacy of TF-CESI for treating cervical radicular pain in this set of 329 patients was independent of the presence of type 2 diabetes.
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