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Guntin J, Regalado L, Serhal A, Omar IM, Hsu WK, Garg A. Safety outcomes and improvement in pain scores after radiologist-performed fluoroscopy-guided interlaminar cervical epidural steroid injection. Skeletal Radiol 2024; 53:1145-1152. [PMID: 38110779 DOI: 10.1007/s00256-023-04548-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Image-guided spine injections are an important tool in the management of patients with a variety of spinal pathologies. Our practice offers radiologist-performed fluoroscopy-guided interlaminar cervical epidural steroid injection (ESI) routinely performed in the outpatient setting. The purpose of this study was to evaluate clinical outcomes and improvement in pain scores after radiologist-performed cervical ESI. METHODS An institutional database was used to retrospectively identify cervical injections performed between October 2016 and October 2022. All injections were performed at the C7-T1 level utilizing 1.0 mL of 10 mg/mL dexamethasone without epidural anesthetic. The Numerical Rating Scale (NRS) was used to assess pain improvement. Cervical MRI was reviewed to assess pre-injection cervical disease severity. Patient charts were reviewed for any post-injection complications. RESULTS A total of 251 cervical injections in 186 patients met our inclusion criteria with mean clinical follow up of 28.5 months (range 0.2 - 73.0 months). No patients experienced any major complications after injection. Post-injection pain scores were available for 218 of 251 injections (86.9%) with mean follow-up of 11.8 days (range 6 - 57 days). There was a significant improvement in pain scores from a mean pre-injection NRS score of 5.2/10 to 3.0/10 (p < .0001). 117 patients (53.7%) reported ≥ 50% improvement after injection. Patients who had prior injection were more likely to report ≥ 50% pain improvement after subsequent injection (p = .012). CONCLUSION Radiologist-performed fluoroscopy-guided interlaminar cervical ESI at the C7-T1 level is a safe and effective tool in the management of patients with cervical pathology.
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Affiliation(s)
- Jonathan Guntin
- Northwestern Memorial Hospital, Northwestern University, 676 N St Clair St, Suite 800, Chicago, IL, 60611, USA.
| | - Luis Regalado
- Northwestern Memorial Hospital, Northwestern University, 676 N St Clair St, Suite 800, Chicago, IL, 60611, USA
| | - Ali Serhal
- Northwestern Memorial Hospital, Northwestern University, 676 N St Clair St, Suite 800, Chicago, IL, 60611, USA
| | - Imran M Omar
- Northwestern Memorial Hospital, Northwestern University, 676 N St Clair St, Suite 800, Chicago, IL, 60611, USA
| | - Wellington K Hsu
- Northwestern Memorial Hospital, Northwestern University, 676 N St Clair St, Suite 800, Chicago, IL, 60611, USA
| | - Ankur Garg
- Northwestern Memorial Hospital, Northwestern University, 676 N St Clair St, Suite 800, Chicago, IL, 60611, USA
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Ter Meulen BC, Maas ET, van der Vegt R, Haumann J, Weinstein HC, Ostelo RWJG, van Dongen JM. Cost-effectiveness of Transforaminal epidural steroid injections for patients with ACUTE sciatica: a randomized controlled trial. BMC Musculoskelet Disord 2024; 25:247. [PMID: 38561748 PMCID: PMC10983727 DOI: 10.1186/s12891-024-07366-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 03/20/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Transforaminal epidural injections with steroids (TESI) are increasingly being used in patients sciatica. The STAR (steroids against radiculopathy)-trial aimed to evaluate the (cost-) effectiveness of TESI in patients with acute sciatica (< 8 weeks). This article contains the economic evaluation of the STAR-trial. METHODS Participants were randomized to one of three study arms: Usual Care (UC), that is oral pain medication with or without physiotherapy, n = 45); intervention group 1: UC and transforaminal epidural steroid injection (TESI) 1 ml of 0.5% Levobupivacaine and 1 ml of 40 mg/ml Methylprednisolone and intervention group 2: UC and transforaminal epidural injection (TEI) with 1 ml of 0,5% Levobupivacaine and 1 ml of 0.9% NaCl (n = 50). The primary effect measure was health-related quality of life. Secondary outcomes were pain, functioning, and recovery. Costs were measured from a societal perspective, meaning that all costs were included, irrespective of who paid or benefited. Missing data were imputed using multiple imputation, and bootstrapping was used to estimate statistical uncertainty. RESULTS None of the between-group differences in effects were statistically significant for any of the outcomes (QALY, back pain, leg pain, functioning, and global perceived effect) at the 26-weeks follow-up. The adjusted mean difference in total societal costs was €1718 (95% confidence interval [CI]: - 3020 to 6052) for comparison 1 (intervention group 1 versus usual care), €1640 (95%CI: - 3354 to 6106) for comparison 2 (intervention group 1 versus intervention group 2), and €770 (95%CI: - 3758 to 5702) for comparison 3 (intervention group 2 versus usual care). Except for the intervention costs, none of the aggregate and disaggregate cost differences were statistically significant. The maximum probability of all interventions being cost-effective compared to the control was low (< 0.7) for all effect measures. CONCLUSION These results suggest that adding TESI (or TEI) to usual care is not cost-effective compared to usual care in patients with acute sciatica (< 8 weeks) from a societal perspective in a Dutch healthcare setting. TRIAL REGISTRATION Dutch National trial register: NTR4457 (March, 6th, 2014).
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Affiliation(s)
- Bastiaan C Ter Meulen
- Department of Neurology at OLVG Teaching Hospital, Amsterdam, The Netherlands.
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands.
| | - Esther T Maas
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands
| | - Rien van der Vegt
- Department of Pain Medicine and Anesthesiology Zaans MC, Zaandam, The Netherlands
| | - Johan Haumann
- Department of Pain Medicine and Anesthesiology, OLVG, Amsterdam, The Netherlands
| | - Henry C Weinstein
- Department of Neurology at OLVG Teaching Hospital, Amsterdam, The Netherlands
| | - Raymond W J G Ostelo
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam and the Amsterdam Movement Sciences Research Institute, De Boelelaan 1085, 1081, HV, Amsterdam, The Netherlands
| | - Johanna M van Dongen
- Department of Epidemiology and Data Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam Movement Sciences Research Institute Musculoskeletal Health, De Boelelaan 1089a, 1081, HV, Amsterdam, The Netherlands
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Yan Z, Kenmegne GR, Wu L, Pu X, Dong C, Tan G, Wo H, Kang C. A comparison between transforaminal lumbar epidural injection performed under picture archiving and communication systems-based magnetic resonance imaging planning and injection under immediate X-ray guidance. Jt Dis Relat Surg 2024; 35:45-53. [PMID: 38108165 PMCID: PMC10746901 DOI: 10.52312/jdrs.2023.1260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/10/2023] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVES The study aimed to compare the treatment cost, operation time, clinical effect, and complications between punctures done under magnetic resonance imaging (MRI) planning based on picture archiving and communication systems (PACS) and punctures done under immediate X-ray fluoroscopy guidance in the treatment of lumbar disc herniation by transforaminal lumbar epidural injection. PATIENTS AND METHODS In this prospective study conducted between October 2016 and June 2021, 128 patients were randomly divided into Groups A and B by the random number table method. In Group A (n=66; 36 males, 30 females; mean age: 64.5±2.4 years, range, 50 to 72 years), puncture was performed by planning with PACS-based MRI; in Group B (n=62; 34 males, 28 females; mean age: 65.3±2.6 years; range, 48 to 73 years), puncture was performed under immediate X-ray guidance. The cost of treatment, duration of procedure, clinical outcome, and complications were compared between the two groups. RESULTS The difference in treatment cost in Groups A and B was statistically significant (p<0.001), with 755.67±29.45 yuan and 1.158.08±43.92 yuan, respectively. The mean treatment time was statistically significant (p<0.001) between the groups, with 21.16±1.91 min in Group A and 37.26±2 min in Group B. However, there was no significant difference between Group A and Group B in terms of improvement in pain scores and Oswestry disability index (both p>0.05). There was also no significant difference between Group A and Group B in terms of complication rates (both p>0.05). CONCLUSION Compared to immediate X-ray guided puncture, the puncture method using PACS for MRI planning shortened the transforaminal lumbar epidural injection procedure time and reduced the treatment costs without exposing the physician or patient to additional radiation, while there was no significant difference in the short-term clinical outcome or complication rate.
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Affiliation(s)
| | | | | | | | | | | | | | - Chengwei Kang
- Department of Orthopedic, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu 610041, Sichuan, China.
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Ter Meulen BC, van Dongen JM, Maas E, van de Vegt MH, Haumann J, Weinstein HC, Ostelo R. Effect of Transforaminal Epidural Corticosteroid Injections in Acute Sciatica: A Randomized Controlled Trial. Clin J Pain 2023; 39:654-662. [PMID: 37712323 DOI: 10.1097/ajp.0000000000001155] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 08/01/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE Transforaminal epidural steroid injections (TESIs) are widely administered for sciatica. The aim of this trial was to evaluate the effectiveness of TESIs in patients with acute sciatica (<8 wk). METHODS This study was conducted in 2 Dutch hospitals. Participants (n=141) were randomly assigned to (1) usual care and TESI of 1 ml of 40 mg/ml Methylprednisolone plus 1 ml of 0.5% Levobupivacaine (intervention 1); (2) usual care and transforaminal epidural injection with 1 ml of 0.5% Levobupivacaine and 1 ml NaCl 0.9% (intervention 2); (3) usual care consisting of oral pain medication with or without physiotherapy (control). Co-primary outcomes were back pain and leg pain intensity, physical functioning, and recovery measured during 6-month follow-up. RESULTS There were no statistically significant mean differences in co-primary outcomes between groups during follow-up, except for leg pain when comparing intervention group 1 with control (-0.96 95%CI:-1.83 to -0.09). For secondary outcomes, some statistical significant between-group differences were found for treatment satisfaction and surgery, but only when comparing intervention group 2 to control. Post hoc analyses showed a statistically significant difference in response [50% improvement of leg pain (yes/no)] between intervention 1 and the control group at 3 months and that both intervention groups used less opioids. DISCUSSION Except for a statistically significant effect of TESI on leg pain for patients with acute sciatica compared with usual care, there were no differences in co-primary outcomes. Nonetheless, transforaminal epidural injections seem to be associated with less opioid use, which warrants further exploration.
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Affiliation(s)
- Bastiaan C Ter Meulen
- Department of Neurology at OLVG Teaching Hospital
- Department of Epidemiology and Data Sciences, Amsterdam UMC
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
| | - Johanna M van Dongen
- Department of Epidemiology and Data Sciences, Amsterdam UMC
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
| | - Esther Maas
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
| | | | - Johan Haumann
- Department of Anesthesiology and Pain Medicine, OLVG, Amsterdam, The Netherlands
| | | | - Raymond Ostelo
- Department of Epidemiology and Data Sciences, Amsterdam UMC
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, and the Amsterdam Movement Sciences Research Institute, Amsterdam
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Delaney FT, MacMahon PJ. An update on epidural steroid injections: is there still a role for particulate corticosteroids? Skeletal Radiol 2023; 52:1863-1871. [PMID: 36171350 DOI: 10.1007/s00256-022-04186-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 02/02/2023]
Abstract
Epidural steroid injections (ESIs) play an important role in the multifaceted management of neck and back pain. Corticosteroid preparations used in ESIs may be considered "particulate" or "non-particulate" based on whether they form a crystalline suspension or a soluble clear solution, respectively. In the past two decades, there have been reports of rare but severe and permanent neurological complications as a result of ESI. These complications have principally occurred with particulate corticosteroid preparations when using a transforaminal injection technique at cervical or thoracic levels, and only rarely in the lumbosacral spine. As a result, some published clinical guidelines and recommendations have advised against the use of particulate corticosteroids for transforaminal ESI, and the FDA introduced a warning label for injectable corticosteroids regarding the risk of serious neurological adverse events. There is growing evidence that the efficacy of non-particulate corticosteroids for pain relief and functional improvement after ESI is non-inferior to particulate agents, and that non-particulate injections almost never result in permanent neurological injury. Despite this, particulate corticosteroids continue to be routinely used for transforaminal epidural injections. More consistent clinical guidelines and societal recommendations are required alongside increased awareness of the comparative efficacy of non-particulate agents among specialists who perform ESIs. The current role for particulate corticosteroids in ESIs should be limited to caudal and interlaminar approaches, or transforaminal injections in the lumbar spine only if initial non-particulate ESI resulted in a significant but short-lived improvement.
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Affiliation(s)
- Francis T Delaney
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - Peter J MacMahon
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
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Çetin E, Şah V, Zengin I, Arabacı Ö, Akyol ME, Yücel M. Comparative Effectiveness of Epidural Steroid İnjections in Patients With Disc Bulging and Disc Protrusion. Cureus 2023; 15:e45994. [PMID: 37900516 PMCID: PMC10601978 DOI: 10.7759/cureus.45994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2023] [Indexed: 10/31/2023] Open
Abstract
Purpose Discogenic low back pain is a widespread disorder in the world. Many methods have been developed and continue to be developed in the treatment of discogenic low back pain. We aimed to examine the effect of epidural steroid administration on disc bulging and disc protrusion in patients with discogenic low back pain. Design The clinical effects of interlaminar epidural steroids administered to 71 patients who were admitted to our clinic and whose treatment did not require surgery were radiologically divided into two groups disc bulging and disc protrusion. Patients were followed up for six months and clinical results were recorded. Methods The scores of the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were measured before the procedure, one week after the procedure, one month after the procedure, and six months after the procedure. The normal distribution of continuous variables was evaluated using the Kolmogorov-Smirnov test. Continuous variables were compared with the Mann-Whitney U test and categorical variables were compared using the Chi-square test or Fisher's exact test. Results There was no significant difference in demographic data in patients with disc bulging and disc protrusion. In the disc protrusion group, the VAS scores in the first week after, the first month after and the sixth month after the procedure showed a significant decrease compared to the pre-procedure. There was no significant difference between the disc bulging and protrusion groups in the first week of post-procedure VAS score reduction. In the Disc Bulging group, the ODI score one week after, one month after, and six months after the procedure showed a significant decrease compared to the pre-procedure. In the Disc Protrusion group, the ODI score one week after, one month after, and six months after the procedure showed a significant decrease compared to the pre-procedure. Conclusion There was strong evidence that lumbar interlaminar steroid injection is an effective treatment for disc bulging and discogenic pain due to protrusion. When the ODI and VAS scores of patients with both disc bulging and disc protrusion were evaluated, it was seen that they benefited from epidural steroid injection. In the disc protrusion group, except for the first week of injection, relief due to the use of epidural steroids was observed to be greater compared to disc bulging.
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Affiliation(s)
- Eyup Çetin
- Department of Neurosurgery, Haydarpaşa Numune Education and Research Hospital, Istanbul, TUR
| | - Volkan Şah
- Department of Sports Medicine, Van Yuzuncu Yıl University, Van, TUR
| | - Irfan Zengin
- Department of Neurosurgery, Faculty of Medicine, Yuzuncu Yil University, Van, TUR
| | - Özkan Arabacı
- Department of Neurosurgery, Van Yuzuncu Yıl University, Van, TUR
| | - Mehmet E Akyol
- Department of Neurosurgery, Faculty of Medicine, Yuzuncu Yil University, Van, TUR
| | - Murat Yücel
- Department of Neurosurgery, Yalova University, Yalova, TUR
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Alkosha HM. Interventional non-operative management of low back and neck pain. EGYPTIAN JOURNAL OF NEUROSURGERY 2023. [DOI: 10.1186/s41984-023-00189-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
Abstract
Background
Chronic neck and back pain are among the most commonly encountered health problems in neurosurgical practice. Many cases fail prolonged pharmacological and physical therapy and are not proper candidates for surgical interventions, or had refused proposed surgical treatment.
Objective
To provide an informative critical summary of the literature about the topic of interventional management of axial neck and low back pain and highlighting the new trends and pieces of evidence.
Methods
The English literature published over the last two decades was reviewed by the author for recent and relevant data about the principles of interventional management of chronic neck and low back pain. A PubMed search was performed through phrase searching and combined searching using Boolean operators. The articles thought to be most relevant to the study aim and the neurosurgeons’ practice were extracted.
Results
Neck and low back pain continue to be among the most common musculoskeletal health problems and the most common cause of disability worldwide. A detailed understanding of relevant spine anatomy is crucial for interventionists who should deal with the concept of “functional spine unit” with multiple potential pain generators. Chronic spinal pain is best managed through a dedicated multidisciplinary team in well-equipped healthcare facilities. An algorithmic approach for the diagnosis and management of spinal pain is the mainstay of providing the best patient care and should be based on the commonality and treatability of pain generators, values of patients and available resources.
Conclusion
Management of chronic neck and back pain can represent a clinical dilemma due to the multiplicity of pain generators that may coexist in the same individual resulting in a complex type and pattern of pain. Approach to these patients requires contributions from the members of a multidisciplinary team, implementing a standardized approach in a well-equipped healthcare facility.
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Kohan L, Pellis Z, Provenzano DA, Pearson ACS, Narouze S, Benzon HT. American Society of Regional Anesthesia and Pain Medicine contrast shortage position statement. Reg Anesth Pain Med 2022; 47:511-518. [DOI: 10.1136/rapm-2022-103830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 06/03/2022] [Indexed: 11/03/2022]
Abstract
The medical field has been experiencing numerous drug shortages in recent years. The most recent shortage to impact the field of interventional pain medicine is that of iodinated contrast medium. Pain physicians must adapt to these changes while maintaining quality of care. This position statement offers guidance on adapting to the shortage.
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Zhang F, Wang S, Li B, Tian W, Zhou Z, Liu S. Intradiscal injection for the management of low back pain. JOR Spine 2022; 5:e1186. [PMID: 35386759 PMCID: PMC8966879 DOI: 10.1002/jsp2.1186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 12/06/2021] [Accepted: 12/08/2021] [Indexed: 12/13/2022] Open
Abstract
Low back pain (LBP) is a common clinical problem and a major cause of physical disability, imposing a prominent socioeconomic burden. Intervertebral disc degeneration (IDD) has been considered the main cause of LBP. The current treatments have limited efficacy because they cannot address the underlying degeneration. With an increased understanding of the complex pathological mechanism of IDD, various medications and biological reagents have been used for intradiscal injection for the treatment of LBP. There is increasing clinical evidence showing the benefits of these therapies on symptomatic relief and their potential for disc repair and regeneration by targeting the disrupted pathways underlying the cause of the disease. A brief overview of the potential and limitations for these therapies are provided in this review, based on the recent and available data from clinical trials and systematic reviews. Finally, future perspectives are discussed.
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Affiliation(s)
- Fu Zhang
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopaedic Surgery The Seventh Affiliated Hospital of Sun Yat-sen University Shenzhen China
| | - Songjuan Wang
- Department of Medical Ultrasonic The Seventh Affiliated Hospital of Sun Yat-sen University Shenzhen China
| | - Baoliang Li
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopaedic Surgery The Seventh Affiliated Hospital of Sun Yat-sen University Shenzhen China
| | - Wei Tian
- Laboratory of Bone Tissue Engineering Beijing Laboratory of Biomedical Materials, Beijing Research Institute of Orthopaedics and Traumatology, Beijing JiShuiTan Hospital Beijing China
| | - Zhiyu Zhou
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopaedic Surgery The Seventh Affiliated Hospital of Sun Yat-sen University Shenzhen China.,Guangdong Provincial Key Laboratory of Orthopedics and Traumatology The First Affiliated Hospital of Sun Yat-sen University Guangzhou China
| | - Shaoyu Liu
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopaedic Surgery The Seventh Affiliated Hospital of Sun Yat-sen University Shenzhen China.,Guangdong Provincial Key Laboratory of Orthopedics and Traumatology The First Affiliated Hospital of Sun Yat-sen University Guangzhou China
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Krez A, Liu Y, Kanbour S, Clare S, Waldman S, Stein EM. The skeletal consequences of epidural steroid injections: a literature review. Osteoporos Int 2021; 32:2155-2162. [PMID: 34089066 DOI: 10.1007/s00198-021-05986-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 05/02/2021] [Indexed: 12/12/2022]
Abstract
UNLABELLED This literature review summarized studies that evaluated the effects of epidural steroid injections (ESIs) on skeletal health. While evidence is limited, studies suggest that ESIs may cause bone loss. Better understanding of these skeletal consequences will help foster strategies to prevent bone loss in the growing population of patients receiving ESIs. PURPOSE Approximately nine million epidural steroid injections (ESIs) are administered annually in the United States to treat radicular back pain. ESIs often provide pain relief and functional improvement. While the overall incidence of adverse events resulting from ESIs is low, their effects on the skeleton are poorly understood. This is an important consideration given the profound skeletal impact of other forms of glucocorticoids. METHODS Ovid MEDLINE and PubMed search results since 2010, including older, frequently referenced publications were reviewed. RESULTS Systemic absorption of glucocorticoids occurs after ESI, which can cause hyperglycemia and endogenous cortisol suppression. The majority of studies investigating the skeletal effects of ESIs are retrospective. Several have found a relationship between low areal bone mineral density (BMD) by dual-energy x-ray absorptiometry and ESI exposure, but this finding is not uniform. Recently a dose-response relationship between ESI exposure and low spine volumetric BMD by computed tomography has been reported. Few studies have investigated the relationship between ESI exposure and fracture risk. Results of these studies are conflicting, and most have not been adequately powered to detect fracture outcomes. CONCLUSIONS While evidence is limited, studies suggest that ESIs may cause bone loss, particularly those investigating volumetric BMD. Larger doses appear to confer greater risk. Further prospective studies are needed to investigate the relationship between ESI and fracture risk. Better understanding of the skeletal consequences of ESIs will help foster strategies to prevent bone loss in the growing population of patients receiving this treatment.
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Affiliation(s)
- A Krez
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Y Liu
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - S Kanbour
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - S Clare
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - S Waldman
- Department of Anesthesiology, Critical Care, & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - E M Stein
- Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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Deep Spinal Infection after Outpatient Epidural Injections for Pain: A Retrospective Sample Cohort Study Using a Claims Database in South Korea. Anesthesiology 2021; 134:925-936. [PMID: 33857291 DOI: 10.1097/aln.0000000000003770] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Deep spinal infection is a devastating complication after epidural injection. This study aimed to investigate the incidence of deep spinal infection primarily after outpatient single-shot epidural injection for pain. Secondarily, this study assessed the national trends of the procedure and risk factors for said infection. METHODS Using South Korea's National Health Insurance Service sample cohort database, the 10-yr national trend of single-shot epidural injections for pain and the incidence rate of deep spinal infection after the procedure with its risk factors were determined. New-onset deep spinal infections were defined as those occurring within 90 days of the most recent outpatient single-shot epidural injection for pain, needing hospitalization for at least 1 night, and receiving at least a 4-week course of antibiotics. RESULTS The number of outpatient single-shot epidural injections per 1,000 persons in pain practice doubled from 40.8 in 2006 to 84.4 in 2015 in South Korea. Among the 501,509 injections performed between 2007 and 2015, 52 cases of deep spinal infections were detected within 90 days postprocedurally (0.01% per injection). In multivariable analysis, age of 65 yr or more (odds ratio, 2.91; 95% CI, 1.62 to 5.5; P = 0.001), living in a rural area (odds ratio, 2.85; 95% CI, 1.57 to 5.0; P < 0.001), complicated diabetes (odds ratio, 3.18; 95% CI, 1.30 to 6.7; P = 0.005), multiple epidural injections (three times or more) within the previous 90 days (odds ratio, 2.34; 95% CI, 1.22 to 4.2; P = 0.007), and recent use of immunosuppressants (odds ratio, 2.90; 95% CI, 1.00 to 6.7; P = 0.025) were significant risk factors of the infection postprocedurally. CONCLUSIONS The incidence of deep spinal infection after outpatient single-shot epidural injections for pain is very rare within 90 days of the procedure (0.01%). The data identify high-risk patients and procedure characteristics that may inform healthcare provider decision-making. EDITOR’S PERSPECTIVE
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Benzon HT, Maus TP, Kang HR, Provenzano DA, Bhatia A, Diehn F, Nelson A, McCormick ZL, Liu BP, de Andres Ares J, Anitescu M, Blackham K, Bhaskar A, Brill S, Collins J, Gulve A, Hurley RW, Jeon YH, Moon JY, Rauck RL, Rodes M, Lee RK, Shah V, Shanthanna H, van Zundert J, Huntoon M, Rathmell JP, Borges MS, Cohen SP, Greenberger PA. The Use of Contrast Agents in Interventional Pain Procedures: A Multispecialty and Multisociety Practice Advisory on Nephrogenic Systemic Fibrosis, Gadolinium Deposition in the Brain, Encephalopathy After Unintentional Intrathecal Gadolinium Injection, and Hypersensitivity Reactions. Anesth Analg 2021; 133:535-552. [PMID: 33755647 DOI: 10.1213/ane.0000000000005443] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This Practice Advisory presents a comprehensive and evidence-based set of position statements and recommendations for the use of contrast media in interventional pain procedures. The advisory was established by an international panel of experts under the auspices of 11 multinational and multispecialty organizations based on a comprehensive review of the literature up to December 31, 2019. The advisory discusses the risks of using gadolinium-based contrast agents. These include nephrogenic systemic fibrosis, gadolinium brain deposition/retention, and encephalopathy and death after an unintentional intrathecal gadolinium injection. The advisory provides recommendations on the selection of a specific gadolinium-based contrast agent in patients with renal insufficiency, those who had multiple gadolinium-enhanced magnetic resonance imaging examinations, and in cases of paraspinal injections. Additionally, recommendations are made for patients who have a history of mild, moderate, or severe hypersensitivity reactions to contrast medium.
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Affiliation(s)
- Honorio T Benzon
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Timothy P Maus
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Hye-Ryun Kang
- Department of Medicine (Allergy and Immunology), Seoul National University, Seoul, South Korea
| | | | - Anuj Bhatia
- Department of Anesthesiology, University of Toronto, Toronto, Ontario, Canada
| | - Felix Diehn
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Ariana Nelson
- Department of Anesthesiology, University of California at Irvine, Irvine, California
| | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Benjamin P Liu
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Kristine Blackham
- Department of Radiology, University Hospital, Basel, Basel, Switzerland
| | - Arun Bhaskar
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Silviu Brill
- Institute of Pain Medicine, Tel Aviv Medical Centre, Tel Aviv, Israel
| | - Jeremy Collins
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Ashish Gulve
- Department of Pain Management, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Robert W Hurley
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Young Hoon Jeon
- Anesthesiology and Pain Medicine, School of Dentistry, Kyungpook National University, Daegu, South Korea
| | - Jee Youn Moon
- Department of Anesthesiology, Seoul National University, Seoul, South Korea
| | | | - Meghan Rodes
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ryan K Lee
- Department of Radiology, Sydney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Vinil Shah
- Department of Radiology, University of California at San Francisco, San Francisco, California
| | - Harsha Shanthanna
- Department of Anesthesiology, McMaster University, Hamilton, Ontario, Canada
| | - Jan van Zundert
- Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Marc Huntoon
- Department of Anesthesiology, Virginia Commonwealth University, Medical College of Virginia, Richmond, Virginia
| | - James P Rathmell
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mario Sanchez Borges
- Department of Allergy and Clinical Immunology, Centro Medico Docente La Trinidad, Caracas, Venezuela
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Pain Medicine Division, Department of Physical Medicine and Rehabilitation, and Department of Neurology, and Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Paul A Greenberger
- Department of Medicine, Division of Allergy and Immunology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Stueckle CA, Hackert B, Talarczyk S, Wawro M, Haage P, Weger U. The physician as a success determining factor in CT-guided pain therapy. BMC Med Imaging 2021; 21:11. [PMID: 33435895 PMCID: PMC7805076 DOI: 10.1186/s12880-020-00544-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 12/27/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Back pain is a common problem and a burden for the patient. MR-morphologically proven pain-causing changes of the spine is often successfully treated utilizing CT-guided pain therapy. The CT-guided execution enables a controlled and reproducible therapy. Nevertheless, treatment results can differ even with the same patient; the physician is a possible influencing factor of the outcome. Accordingly, the present study analyzes the different behaviors and forms of communication of the treating physicians during the course of the intervention as factors influencing the outcome of treatment. METHODS 67 patients suffering from specific back pain were included in this study. 5 treating physicians (2 female, 3 male) of different age (29-63 years), and experience and a total of 244 CT-guided treatments were included in this study. In every case a psychologist observed the treatment based on a standardized observation protocol. Observed were both the verbal and non-verbal interactions as well as the reaction of patient and physician. The success of the therapy was measured in the course of the treatment using the visual analogue pain scale. The technical comparability of the performed CT-guided periradicular therapy was ensured by the distribution of the drug mixture. RESULTS The outcome is significantly better if the patient considers the treating physician to be competent (correlation coefficient: 0.24, p < 0.006) and feels understood (correlation coefficient: 0.29, p < 0.001). In addition, the outcome is better when the physician believes that the treatment brings a positive reduction of pain, underlining his belief with positive statements of affirmation before the intervention thus creating a positive atmosphere [correlation coefficient: 0.24 (p < 0.009)]. In contrast, the outcome is worse if the patient complains about pain during the intervention [average pain reduction M = 0.9 (pain group) vs. M = 2.0 (no-pain group)]. CONCLUSION Our study shows that with comparable implementation of CT-guided periradicular therapy, the outcome of the patient with specific back pain can be significantly improved by certain behavioral patterns of the performing physician and this without side effects and without significant additional time expenditure. Our findings indicate that there is a non-negligible psychological factor linking confidence in therapy to actual therapy success. TRIAL REGISTRATION The study was designed as an observational study, therefore a trial registration was not necessary.
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Affiliation(s)
- Christoph A Stueckle
- Faculty of Health, Witten/Herdecke University, Witten, Germany.
- Department of Diagnostic and Interventional Radiology, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Wuppertal, Germany.
- MVZ Professor Uhlenbrock Und Partner GmbH, Dortmund, Germany.
| | - Benedikt Hackert
- Department of Psychology, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Sarah Talarczyk
- Faculty of Health, Witten/Herdecke University, Witten, Germany
- MVZ Professor Uhlenbrock Und Partner GmbH, Dortmund, Germany
| | - Martin Wawro
- Department of Psychology, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Patrick Haage
- Faculty of Health, Witten/Herdecke University, Witten, Germany
- Department of Diagnostic and Interventional Radiology, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Wuppertal, Germany
| | - Ulrich Weger
- Department of Psychology, Faculty of Health, Witten/Herdecke University, Witten, Germany
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14
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Raju R, Mehnert M, Stolzenberg D, Simon J, Conliffe T, Gehret J. Differential rates of intravascular uptake and pain perception during lumbosacral epidural injection among adults using a 22-gauge needle versus 25-gauge needle: a randomized clinical trial. BMC Anesthesiol 2020; 20:222. [PMID: 32883241 PMCID: PMC7469311 DOI: 10.1186/s12871-020-01137-0] [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: 05/15/2020] [Accepted: 08/24/2020] [Indexed: 11/10/2022] Open
Abstract
Background Inadvertent intravascular injection has been suggested as the most probable mechanism behind serious neurological complications during transforaminal epidural steroid injections. Authors believe a smaller gauge needle may lead to less intravascular uptake and less pain. Theoretically, there is less chance for a smaller gauge needle to encounter a blood vessel during an injection compared to a larger gauge needle. Studies have also shown smaller gauge needle to cause less pain. The aim of the study was to quantify the difference between a 22-gauge needle and 25-gauge needle during lumbosacral transforaminal epidural steroid injection in regards to intravascular uptake and pain perception. Methods This was a prospective single blind randomized clinical trial performed at outpatient spine practice locations of two academic institutions. One hundred sixty-two consecutive patients undergoing lumbosacral transforaminal epidural injections from February 2018 to June 2019 were recruited and randomized to each arm of the study – 84 patients were randomized to the 22-gauge needle arm and 78 patients to 25-gauge arm. Each transforaminal injection level was considered a separate incidence, hence total number of incidence was 249 (136 in 22-gauge arm and 113 in 25-gauge arm). The primary outcome measure was intravascular uptake during live fluoroscopy and/or blood aspiration. The secondary outcome measure was patient reported pain during the procedure on the numerical rating scale. Results Fisher exact test was used to detect differences between 2 groups in regards to intravascular uptake and paired t-tests were used to detect differences in pain scores. The incidence of intravascular uptake for a 22-gauge needle was 5.9% (95% confidence interval: 1.9 to 9.8%) and for a 25-gauge needle, 7.1% (95% confidence interval: 2.4 to 11.8%) [p = 0.701]. Average numerical rating scale scores during the initial needle entry for 22-gauge and 25-gauge needle was 3.46 (95% confidence interval: 2.94 to 3.98) and 3.13 (95% confidence interval: 2.57 to 3.69) respectively [p = 0.375]. Conclusions The study showed no statistically significant difference in intravascular uptake or pain perception between a 22-gauge needle and 25-gauge needle during lumbosacral transforaminal epidural steroid injections. Trial registration ClinicalTrials.gov NCT04350307. Registered 4/17/2020. (Retrospectively registered).
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Affiliation(s)
- Robin Raju
- Department of Orthopedics and Rehabilitation, Yale New Haven Hospital/Yale University, 1 Long Wharf Drive, New Haven, CT, 06511, USA.
| | - Michael Mehnert
- Department of Physical Medicine and Rehabilitation, Rothman Orthopaedic Institute/Thomas Jefferson University Hospital, 925 Chestnut Street, Philadelphia, PA, 19107, USA
| | - David Stolzenberg
- Department of Physical Medicine and Rehabilitation, Rothman Orthopaedic Institute/Thomas Jefferson University Hospital, 925 Chestnut Street, Philadelphia, PA, 19107, USA
| | - Jeremy Simon
- Department of Physical Medicine and Rehabilitation, Rothman Orthopaedic Institute/Thomas Jefferson University Hospital, 925 Chestnut Street, Philadelphia, PA, 19107, USA
| | - Theodore Conliffe
- Department of Physical Medicine and Rehabilitation, Rothman Orthopaedic Institute/Thomas Jefferson University Hospital, 925 Chestnut Street, Philadelphia, PA, 19107, USA
| | - Jeffrey Gehret
- Department of Physical Medicine and Rehabilitation, Rothman Orthopaedic Institute/Thomas Jefferson University Hospital, 925 Chestnut Street, Philadelphia, PA, 19107, USA
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15
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Shi W, Agbese E, Solaiman AZ, Leslie DL, Gater DR. Performance of Pain Interventionalists From Different Specialties in Treating Degenerative Disk Disease-Related Low Back Pain. Arch Rehabil Res Clin Transl 2020; 2:100060. [PMID: 33543087 PMCID: PMC7853372 DOI: 10.1016/j.arrct.2020.100060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To examine the utilization of current common treatments by providers from different specialties and the effect on delaying spinal surgery in patients with disk degenerative disease (DDD) related low back pain. DESIGN Retrospective observational study using data from the MarketScan Commercial Claims and Encounters database (2005-2013). SETTING Not applicable. PARTICIPANTS Patients (N=6229) newly diagnosed with DDD-related low back pain who received interventional treatments from only 1 provider specialty and continuously enrolled in the database for 3 years after diagnosis. MAIN OUTCOME MEASURES Measures of treatment utilization and cost were constructed for patients who received spinal surgery within 3 years after diagnosis. Cox proportional hazards models were used to examine time to surgery among provider specialties and generalized linear models were used to examine cost differences among provider specialties. RESULTS Of the 6229 patients, 427 (6.86%) underwent spinal surgery with unadjusted mean interventional treatment costs ranging from $555 to $851. Although the differences in mean costs across provider specialties were large, they were not statistically significant. Cox proportional hazards models showed that there was no significant difference between provider specialties in the time from DDD diagnosis to spinal surgery. However, patients diagnosed with DDD at a younger age and receiving physical therapy had significantly delayed time to surgery (hazard ratio, 0.66; 95% confidence interval [CI], 0.54-0.81 and hazard ratio, 0.77; 95% CI, 0.62-0.96, respectively). CONCLUSIONS Although there were no statistically significant differences among provider specialties for time to surgery and cost, patients receiving physical therapy had significantly delayed time to surgery.
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Affiliation(s)
- Weibin Shi
- Physical Medicine and Rehabilitation, Penn State Health Milton S Hershey Medical Center, Hershey, PA
- Pennsylvania State Hershey Rehabilitation Hospital, Hummelstown, PA
| | - Edeanya Agbese
- The Center for Applied Studies in Health Economics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA
| | | | - Douglas L. Leslie
- The Center for Applied Studies in Health Economics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA
| | - David R. Gater
- Physical Medicine and Rehabilitation, Miller School of Medicine, University of Miami, Miami, FL
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Tighe P, Modave F, Horodyski M, Marsik M, Lipori G, Fillingim R, Hu H, Hagen J. Geospatial Analyses of Pain Intensity and Opioid Unit Doses Prescribed on the Day of Discharge Following Orthopedic Surgery. PAIN MEDICINE 2020; 21:1644-1662. [PMID: 31800063 DOI: 10.1093/pm/pnz311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Inappropriate opioid prescribing after surgery contributes to opioid use disorder and risk of opioid overdose. In this cross-sectional analysis of orthopedic surgical patients, we examined the role of patient location on postoperative pain intensity and opioids prescribed on hospital discharge. METHODS We used geospatial analyses to characterize spatial patterns of mean pain intensity on the day of discharge (PiDoD) and opioid units prescribed on the day of discharge (OuPoD), as well as the effect of regional social deprivation on these outcomes. RESULTS At a 500-km radius from the surgery site, the Global Moran's I for PiDoD (2.71 × 10-3, variance = 1.67 × 10-6, P = 0.012) and OuPoD (2.19 × 10-3, SD = 1.87, variance = 1.66 × 10-6, P = 0.03) suggested significant spatial autocorrelation within each outcome. Local indicators of spatial autocorrelation, including local Moran's I, Local Indicator of Spatial Autocorrelation cluster maps, and Getis-Ord Gi* statistics, further demonstrated significant, specific regions of clustering both OuPoD and PiDoD. These spatial patterns were associated with spatial regions of area deprivation. CONCLUSIONS Our results suggest that the outcomes of pain intensity and opioid doses prescribed exhibit varying degrees of clustering of patient locations of residence, at both global and local levels. This indicates that a given patient's pain intensity on discharge is related to the pain intensity of nearby individuals. Similar interpretations exist for OuPoD, although the relative locations of hot spots of opioids dispensed in a geographic area appear to differ from those of hot spots of pain intensity on discharge.
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Affiliation(s)
| | | | - MaryBeth Horodyski
- Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, Florida
| | - Matthew Marsik
- Data Science and Planning, University of Florida Health, Gainesville, Florida
| | - G Lipori
- Data Science and Planning, University of Florida Health, Gainesville, Florida
| | - Roger Fillingim
- Pain Research & Intervention Center of Excellence, University of Florida, Gainesville, Florida
| | - Hui Hu
- Department of Epidemiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jennifer Hagen
- Orthopaedics and Rehabilitation, University of Florida College of Medicine, Gainesville, Florida
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Kang J, Park SS, Kim CH, Kim EC, Kim HC, Jeon H, Kim KH, Shin DA. Feasibility of Using the Epidural Space Detecting Device (EPI-Detection TM) for Interlaminar Cervical Epidural Injection. J Clin Med 2020; 9:jcm9082355. [PMID: 32717941 PMCID: PMC7463758 DOI: 10.3390/jcm9082355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 12/03/2022] Open
Abstract
Cervical epidural injection (CEI), which is widely used for the treatment of cervical radiculopathy, sometimes has been associated with post-operative complications. Recently, EPI-DetectionTM, which detects the negative pressure of the epidural space and notifies the proceduralist by flashing a light and producing a beeping sound, was introduced. We assumed that the newly developed device could be as safe and efficient as the conventional loss of resistance (LOR) method. Therefore, we aimed to evaluate the effectiveness of the EPI-DetectionTM and compare it to that of the conventional LOR method. We randomly assigned 57 patients to the LOR and EPI-Detection groups (29 and 28 patients, respectively). Subjects were treated with interlaminar CEI (ILCEI) using one of two methods. The measured parameters, i.e., operation time and radiation dose were lower in the EPI-DetectionTM group (4.6 ± 1.2 min vs. 6.9 ± 2.1 min; and 223.2 ± 206.7 mGy·cm2 vs. 380.3 ± 340.9 mGy·cm2, respectively; all p < 0.05) than in the LOR group. There were no complications noted in either group. Both the EPI-DetectionTM and LOR methods were safe and effective in detecting the epidural space, but the former was superior to the latter in terms of operation time and radiation exposure. The EPI-DetectionTM may help perform ILCEI safely.
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Affiliation(s)
- Jiin Kang
- Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (J.K.); (S.S.P.); (C.H.K.); (E.C.K.); (H.C.K.); (H.J.)
- Department of Neurosurgery, Yongin Severance Hospital, Yonsei University College of Medicine, 363, Dongbaekjukjeon-daero, Giheung-gu, Yongin-si, Gyeonggi-do 16995, Korea
| | - Sam Sun Park
- Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (J.K.); (S.S.P.); (C.H.K.); (E.C.K.); (H.C.K.); (H.J.)
| | - Chul Hwan Kim
- Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (J.K.); (S.S.P.); (C.H.K.); (E.C.K.); (H.C.K.); (H.J.)
| | - Eui Chul Kim
- Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (J.K.); (S.S.P.); (C.H.K.); (E.C.K.); (H.C.K.); (H.J.)
| | - Hyung Cheol Kim
- Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (J.K.); (S.S.P.); (C.H.K.); (E.C.K.); (H.C.K.); (H.J.)
| | - Hyungseok Jeon
- Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (J.K.); (S.S.P.); (C.H.K.); (E.C.K.); (H.C.K.); (H.J.)
| | - Kyung Hyun Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Spine and Spinal Cord Institute, Yonsei University College of Medicine, 211, Eonju-ro, Gangnam-gu, Seoul 06273, Korea
- Correspondence: (K.H.K.); (D.A.S.); Tel.: +82-2-2228-2150 (D.A.S.)
| | - Dong Ah Shin
- Department of Neurosurgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (J.K.); (S.S.P.); (C.H.K.); (E.C.K.); (H.C.K.); (H.J.)
- Correspondence: (K.H.K.); (D.A.S.); Tel.: +82-2-2228-2150 (D.A.S.)
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18
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Bolash RB, Foorsov V. Spinal Injection Techniques, 2nd ed. Anesth Analg 2020. [DOI: 10.1213/ane.0000000000004798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Cho SI, Shin S, Jung H, Moon JY, Lee HJ. Analysis of judicial precedent cases regarding epidural injection in chronic pain management in Republic of Korea. Reg Anesth Pain Med 2020; 45:337-343. [PMID: 32114483 DOI: 10.1136/rapm-2019-101169] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/06/2020] [Accepted: 02/10/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although there is a low incidence of complications associated with epidural injections, pain physicians should still remain vigilant for potentially serious adverse outcomes. This study aimed to identify and describe the major complications of epidural injections. METHODS This retrospective, observational, medicolegal study analyzed closed cases of precedents involving complications of epidural injections from January 1997 to August 2019 using the database of the Supreme Court of Korea's judgement system. Clinical characteristics and judgement statuses were analyzed. RESULTS Of the 73 potential cases assessed for eligibility, a total of 49 malpractice cases were included in the final analysis. Thirty-three claims resulted in payments to the plaintiffs, with a median payment of US$103 828 (IQR: US$45 291-US$265 341). The most common complication was infection (n=13, 26.5%), followed by worsening pain (n=8, 16.3%). Physician malpractice before, during, and after the procedure was claimed by plaintiffs in 18 (36.7%), 44 (89.8%), and 31 (63.3%) cases, respectively. Of these cases, 6 (33.3%), 19 (43.2%), and 15 (48.4%), respectively, were adjudicated in favor of the plaintiffs by the courts. In cases involving postprocedural physician errors, the majority (13/15) of the plaintiff verdicts were related to delayed management. Violation of the physician's duty of informed consent was claimed by plaintiffs in 31 (63.3%) cases, and 14 (45.2%) of these cases were judged medical malpractice. CONCLUSIONS Our data will allow pain physicians to become acquainted with the major epidural injection-associated complications that underlie malpractice cases.
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Affiliation(s)
- Soo Ick Cho
- Department of Dermatology, Seoul National University Hospital, Seoul, South Korea
| | - SuHwan Shin
- Department of Medical Law and Ethics, Graduate School, Yonsei University, Seoul, South Korea.,Blue Urology Clinic, Seoul, South Korea
| | - Haesun Jung
- Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jee Youn Moon
- Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea.,Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Ho-Jin Lee
- Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea .,Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
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20
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Neurological Complication Rates of Epidural Injections and Selective Nerve Blocks: A Comparison of Steroid Use Patterns. Clin J Pain 2020; 36:449-457. [PMID: 32068540 DOI: 10.1097/ajp.0000000000000816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Epidural injections and selective nerve blocks are widely used for pain relief, but steroid usage is controversial due to safety concerns. We carried out this retrospective cohort study to estimate the incidence rates of neurological complications associated with epidural and selective nerve blocks, in relation to steroid use patterns. MATERIALS AND METHODS Using a national insurance claims database, we identified patients who received at least one epidural injection or nerve block from 2009 to 2013. We estimated incidence rates and hazard ratios in propensity score-matched cohorts stratified by steroids, using the Charlson comorbidity index, age, sex, anesthetics, and antithrombotics as variables. We included cases attending hospital within 24 hours after injection and treated for neurological complications. RESULTS Incidence rates of neurological complications per 100,000 person-days for injections with and without steroids were 1.48 (95% confidence interval [CI]: 1.25-1.65) and 0.86 (95% CI: 0.66-1.30), respectively; rates for particulate steroid injections and nonparticulate steroid injections were 1.73 (95% CI: 1.41-1.95) and 0.90 (95% CI: 0.43-1.47), respectively. The adjusted hazard ratio (aHR) of neurological complications for injections with versus without steroids was 1.71 (95% CI: 0.96-2.49). The aHR of particulate versus nonparticulate steroid injections was 4.98 (95% CI: 1.01-262.35), at the cervicothoracic level. The aHR of neurological complications for nonparticulate steroids compared with nonsteroidal injections was 0.97 (95% CI: 0.46-3.01). DISCUSSION At the cervicothoracic level, the incidence rate of neurological complications with particulate steroid injections was higher than that with nonparticulate steroid injections. Injections with nonparticulate steroids and without steroids were equally safe.
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21
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Pearson ACS, Dexter F, Epstein RH. Heterogeneity Among Hospitals in the Percentages of All Lumbosacral Epidural Steroid Injections Where the Patient Had Received 4 or More in the Previous Year. Anesth Analg 2020; 129:493-499. [PMID: 31166229 DOI: 10.1213/ane.0000000000004253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current guidelines for the administration of therapeutic epidural injections suggest that these be limited to a maximum of 4 per year. We sought to gain an understanding of the proportion of lumbosacral epidural injections administered to patients who had received ≥4 such injections during the preceding 364 days, and whether these proportions varied among hospitals. METHODS This observational cohort study included data from all facilities owned by the 121 nonfederal hospitals in the State of Iowa, July 2012 through September 2017. One end point was the percentage of all lumbar or sacral transforaminal or interlaminar epidural injections where the patient had received ≥4 such injections during the preceding 364 days. Comparisons also were made among hospitals' percentages of injections that were the fifth or greater (ie, patient had already received ≥4 during preceding 364 days) using Bonferroni-adjusted conservative 95% confidence intervals. RESULTS There were 48,270 unique patients who underwent at least 1 lumbosacral epidural steroid injection. The patients received care at 112 hospitals' facilities. Most patients received no additional steroid injections within 364 subsequent calendar days after the first steroid injection (54.1%). There were ≥5 steroid injections for 1.27% of patients (ie, the injection was the fifth or greater). Among the 39 hospitals in Iowa that performed overall at least 1 steroid injection every 4 days, there were 6 hospitals at which the percentages of injections that were the fifth or greater significantly exceeded the overall prevalence of 1.91% (range: 3.0%-6.4%). There were 14 of the 39 hospitals with prevalences significantly less. CONCLUSIONS Although most patients received only 1 lumbosacral steroid injection within 1 year, 1.27% of patients received 5 or more, and 1.91% of injections were the fifth or greater. Several hospitals had significantly greater than the overall average percent of steroid injections which were fifth or more. This heterogeneity warrants study of whether annual steroid injections per patient should be a clinical quality measure for the care received by patients with lower back pain or whether payment should be greater when injections are in accordance with guidelines.
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Affiliation(s)
- Amy C S Pearson
- From the Department of Anesthesia, University of Iowa, Iowa City, Iowa
| | - Franklin Dexter
- Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa
| | - Richard H Epstein
- Department of Anesthesiology, Pain Management and Perioperative Medicine, University of Miami, Miami, Florida
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Comparing the short-term cost-effectiveness of epidural steroid injections and medical management alone for discogenic lumbar radiculopathy. Clin Neurol Neurosurg 2020; 191:105675. [PMID: 31954364 DOI: 10.1016/j.clineuro.2020.105675] [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: 04/14/2019] [Revised: 10/19/2019] [Accepted: 01/11/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Epidural steroid injections (ESIs) are a commonly used treatment strategy for low back pain and lumbar radiculopathy. However, their cost-effectiveness and ability to mediate long-term quality of life (QOL) improvements is debated. We sought to analyze the cost-effectiveness of lumbar epidural steroid injections (ESIs) compared to medical management alone for patients with lumbar radiculopathy and low back pain. PATIENTS AND METHODS QOL outcomes were prospectively collected at 3- and 6-months following initial consultation. Metrics included the EuroQol-5 Dimensions (EQ-5D) questionnaire, the Pain Disability Questionnaire (PDQ), the Patient Health Questionnaire (PHQ-9) and the Visual Analogue Scale (VAS). Cost estimations were based on Medicare national payment amounts, median income, and missed workdays. A cost-utility analysis was performed based upon cost estimations and a cost-effectiveness threshold of $100,000/Quality-adjusted life year (QALY). RESULTS One hundred forty-one patients met our inclusion/exclusion criteria; 89 received ESI and 52 were treated with medical management alone. Both cohorts showed improved EQ-5D scores at 3 months but were similar to one another: ESI (ΔEQ-5D = 0.06; p = 0.03) and medical-alone (ΔEQ-5D = 0.07; p = 0.03). No significant difference was seen between groups for total costs ($2,190 vs. $1,772; p = 0.18) or cost-utility ratios ($38,710/QALY vs. $27,313/QALY; p = 0.73). At both the 3-month and 6-month endpoints, absolute differences in cost-utility was driven by overall costs as opposed to QALY gains. Medical management alone was more cost effective at both points owing to lower expenditures, however these differences were not significant. No benefits were seen in either group on the EQ-5D or any of the patient reported outcomes at the 6-month time point. CONCLUSION ESIs were not cost-effective at either the 3-month or 6-month follow-up period. At 3 months, ESIs provide similar improvements in QOL outcomes relative to medical management and at similar costs. At 6 months, neither ESIs nor conservative management provide significant improvements in QOL outcomes.
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Johnson SM, Hutchins T, Peckham M, Anzai Y, Ryals E, Davidson HC, Shah L. Effects of implementing evidence-based appropriateness guidelines for epidural steroid injection in chronic low back pain: the EAGER (Esi Appropriateness GuidElines pRotocol) study. BMJ Open Qual 2020; 8:e000772. [PMID: 31909212 PMCID: PMC6937044 DOI: 10.1136/bmjoq-2019-000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/19/2019] [Accepted: 11/28/2019] [Indexed: 11/18/2022] Open
Abstract
Objective Chronic low back pain is very common and often treated with epidural steroid injections (ESIs). As ESI referrals had been rapidly increasing at our Veterans’ Administration hospital, we were concerned that they were supplanting more comprehensive care. The objective was to determine how referral patterns and multidisciplinary care might change with the implementation of evidence-based guidelines. Methods In this retrospective observational study, multidisciplinary evidence-based guidelines were implemented in 2014 (EAGER: Esi Appropriateness GuidElines pRotocol) as part of the ordering process for an ESI. Time series analysis was performed to assess the primary outcome of subspecialty referral pattern, that is, the number of patients receiving referrals to ancillary services which might serve to provide a more comprehensive approach to their back pain. Secondary outcomes included patient-level changes (ie, body mass index, number of injections, opioid use), which were compared before and after protocol implementation. Results Comparing preimplementation and postimplementation protocol periods, referrals to physical medicine/rehabilitation increased 11.7% (p=0.003) per year and integrative health increased 2.1% (p<0.001) per year among the 2294 individual patients who received ESI through the neurointerventional radiology service. Of 100 randomly selected patients for patient-level analysis, the median body mass index decreased from 31.57 to 30.22 (p=<0.001) and the mean number of injections decreased from 1.76 to 0.73 (p<0.001). The percentage of patients using oral opioid analgesics decreased from 72% to 49% (p=<0.001). Conclusion Implementation of evidence-based guidelines for ESI referral helps guide patients into a more comprehensive care pathway for chronic low back pain and is correlated with patient-level changes such as decreased body mass index and decreased opioid usage.
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Affiliation(s)
- Scott M Johnson
- Radiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Troy Hutchins
- Radiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Miriam Peckham
- Radiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Yoshimi Anzai
- Radiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Elizabeth Ryals
- Radiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - H Christian Davidson
- Radiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA.,Radiology, George E Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Lubdha Shah
- Radiology, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
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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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Cherkin DC, Deyo RA, Goldberg H. Time to Align Coverage with Evidence for Treatment of Back Pain. J Gen Intern Med 2019; 34:1910-1912. [PMID: 31243710 PMCID: PMC6712111 DOI: 10.1007/s11606-019-05099-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/06/2019] [Accepted: 05/06/2019] [Indexed: 12/28/2022]
Abstract
Despite improved knowledge about the benefits and harms of treatments for chronic back pain in the past several decades, there is a large and consequential mismatch between treatments found safe and effective and those routinely covered by health insurance. As a result, care for back pain has, if anything, deteriorated in recent decades-expenses are higher, harms are greater, and use of ineffective treatments is more common. Deficiencies in health care delivery processes and payment models are centrally involved in the failure to improve care for back pain. A key step for accelerating progress is changing insurance coverage policies to facilitate use of the safest and most helpful approaches while discouraging riskier and less effective treatments. Relatively simple changes in reimbursement policies may minimize harm and improve quality of life for many patients with chronic back and similar pain syndromes. Such changes might also reduce health care expenditures because the costs of treatments currently covered by insurance and their associated harms may well outweigh the costs of the relatively safe and effective treatments recommended by current guidelines but poorly covered by insurance. There is no justification for continuing the status quo-patients and clinicians deserve better.
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Affiliation(s)
- Daniel C Cherkin
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.
| | - Richard A Deyo
- Department of Family Medicine and Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Harley Goldberg
- Spine Care Program, and Complementary and Alternative Medicine Program, Northern California Kaiser Permanente, Oakland, CA, USA.,Family Medicine, Boston University School of Medicine, Boston, MA, USA
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Utilization Patterns of Facet Joint Interventions in Managing Spinal Pain: a Retrospective Cohort Study in the US Fee-for-Service Medicare Population. Curr Pain Headache Rep 2019; 23:73. [DOI: 10.1007/s11916-019-0816-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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27
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Walsh ME, Boland F, O’Byrne JM, Fahey T. Geographical variation in musculoskeletal surgical care in public hospitals in Ireland: a repeated cross-sectional study. BMJ Open 2019; 9:e028037. [PMID: 31142532 PMCID: PMC6549729 DOI: 10.1136/bmjopen-2018-028037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To examine the extent of geographical variation across musculoskeletal surgical procedures and associated factors in Ireland. DESIGN Repeated cross-sectional study. SETTING 36 public hospitals in Ireland. PARTICIPANTS Adult admissions for hip fracture, hip and knee replacement, knee arthroscopy and lumbar spine interventions over 5 years (2012-2016). PRIMARY OUTCOME MEASURE Standardised discharge rate (SDR). ANALYSIS Age and sex SDRs were calculated for 21 geographical areas. Extremal quotients, coefficients of variation and systematic components of variance were calculated. Linear regression analyses were conducted exploring the relationship between SDRs and year, unemployment, % urban population, number of referral hospitals, % on waiting lists>6 months and % with private health insurance for each procedure. RESULTS Across 36 public hospitals, n=102 756 admissions were included. Hip fracture repair showed very low variation. Elective hip and knee procedures showed high variation in particular years, while variation for lumbar interventions was very high. Knee arthroscopy rates decreased over time. Higher unemployment was associated with knee and hip replacement rates and urban areas had lower hip replacement rates. Spinal procedure rates were associated with a lower number of referral hospitals in a region and spinal injection rates were associated with shorter waiting lists. A higher proportion of patients having private health insurance was associated with higher rates of hip and knee replacement and lumbar spinal procedures. CONCLUSIONS Variation and factors associated with SDRs for publicly funded hip and knee procedures are consistent with similar international research in this field. Further research should explore reasons for high rates of spinal injections and the impact of private practice on musculoskeletal procedure variation.
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Affiliation(s)
- Mary E Walsh
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John M O’Byrne
- Professorial Unit, RCSI at Cappagh National Orthopaedic Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
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Engle AM, Chen Y, Marascalchi B, Wilkinson I, Abrams WB, He C, Yao AL, Adekoya P, Cohen ZO, Cohen SP. Lumbosacral Radiculopathy: Inciting Events and Their Association with Epidural Steroid Injection Outcomes. PAIN MEDICINE 2019; 20:2360-2370. [DOI: 10.1093/pm/pnz097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Abstract
Objective
Low back pain is the leading cause of worldwide disability, with lumbosacral radiculopathy accounting for over one-third of these cases. There are limited data on the relationship between etiologies and lumbosacral radiculopathy, and it is unknown whether specific causes predict treatment outcomes.
Design, Setting, and Subjects
This study explores patient-reported etiologies for lumbosacral radiculopathy in a chronic pain clinic between January 2007 and December 2015 and examines whether these causes affected epidural steroid injection outcomes.
Methods
We reviewed the medical records of 1,242 patients with lumbosacral radiculopathy who received epidural steroid injections. The recording of an inciting event was done contemporaneously based on note templates. A positive outcome following an epidural steroid injection was defined as ≥30% pain relief sustained for six or more weeks without additional intervention. Factors associated with epidural steroid injection outcome were analyzed by multivariable logistic regression.
Results
Fifty point seven percent reported an inciting event, and 59.9% of patients experienced a positive epidural steroid injection outcome. The most commonly reported causes were falls (13.1%), motor vehicle collisions (10.7%), and lifting (7.8%). Individuals with a herniated disc (56.3%) were more likely to report a precipitating cause than those with stenosis (44.7%) or degenerative discs (47.8%, P = 0.012). An inciting event did not predict treatment outcome. Factors associated with negative treatment outcome included opioid consumption (odds ratio [OR] = 0.61, 95% confidence interval [CI] = 0.39–0.95, P = 0.027), secondary gain (OR = 0.69, 95% CI = 0.50–0.96, P = 0.030), and baseline pain score (OR = 0.90, 95% CI = 0.84–0.97, P = 0.006). The number of levels injected was associated with a positive outcome (OR = 2.72, 95% CI = 1.28–6.47, P = 0.008).
Conclusions
Reported inciting events are common in patients with lumbosacral radiculopathy but are not associated with outcome following epidural steroid injection, and their occurrence is not always consistent with the purported mechanism of injury.
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Affiliation(s)
| | - Yian Chen
- Departments of Anesthesiology and Critical Care Medicine
| | | | - Indy Wilkinson
- Departments of Anesthesiology and Critical Care Medicine
| | - Winfred B Abrams
- Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Cathy He
- Departments of Anesthesiology and Critical Care Medicine
- Department of Anesthesiology and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ada Lyn Yao
- Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
- Division of Pain Medicine, Stanford University, Palo Alto, California
| | - Peju Adekoya
- Departments of Anesthesiology and Critical Care Medicine
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Steven Paul Cohen
- Departments of Anesthesiology and Critical Care Medicine
- Departments of Neurology and Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland
- Departments of Anesthesiology and Physical Medicine & Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Neurointerventional Radiology for the Aspiring Radiology Resident: Current State of the Field and Future Directions. AJR Am J Roentgenol 2019; 212:899-904. [PMID: 30699013 DOI: 10.2214/ajr.18.20336] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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30
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Altafulla J, Yilmaz E, Lachkar S, Iwanaga J, Peacock J, Litvack Z, Tubbs RS. Neck movement during cervical transforaminal epidural injections and the position of the vertebral artery: an anatomical study. Acta Radiol Open 2019; 8:2058460119834688. [PMID: 30886742 PMCID: PMC6415478 DOI: 10.1177/2058460119834688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/09/2019] [Indexed: 11/15/2022] Open
Abstract
BackgroundCervical transforaminal epidural steroid injections (CTFESIs) are sometimes performed in patients with cervical radiculopathy secondary to nerve-root compression. Neck movements for patient positioning may include rotation, flexion, and extension. As physicians performing such procedures do not move the neck for fear of injuring the vertebral artery, we performed fluoroscopy and cadaveric dissection to analyze any movement of the vertebral artery during head movement and its relation to the foramina in the setting of CTFESI.PurposeTo determine cervical rotational positioning for optimized vertebral artery location in the setting of cervical transforaminal epidural steroid injections.Material and MethodsFour sides from two Caucasian whole cadavers (all fresh-frozen) were used. Using a guide wire and digital subtraction fluoroscopy, we evaluated the vertebral artery mimicking a CTFESI, then we removed the transverse processes and evaluated the vertebral artery by direct observation.ResultsAfter performing such maneuvers, no displacement of the vertebral artery was seen throughout its course from the C6 to the C2 intervertebral foramina. To our knowledge, this is the first anatomical observation of its kind that evaluates the position of the vertebral artery inside the foramina during movement of the neck.ConclusionSpecial caution should be given to the medial border of the intervertebral foramina when adjusting the target site and needle penetration for the injection. This is especially true for C6-C4 levels, whereas for the remaining upper vertebrae, the attention should be focused on the anterior aspect of the foramen. Since our study was centered on the vertebral artery, we do not discard the need for contrast injection and real-time digital subtraction fluoroscopy while performing the transforaminal epidural injection in order to prevent other vascular injuries.
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Affiliation(s)
- Juan Altafulla
- Seattle Science Foundation, Seattle, WA, USA
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- Juan Altafulla, Seattle Science Foundation, 550 17th Avenue, Seattle, WA 98122, USA.
| | - Emre Yilmaz
- Seattle Science Foundation, Seattle, WA, USA
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | | | - Joe Iwanaga
- Seattle Science Foundation, Seattle, WA, USA
| | - Jacob Peacock
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - Zachary Litvack
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - R Shane Tubbs
- Seattle Science Foundation, Seattle, WA, USA
- Department of Anatomical Sciences, St. George’s University, St. George’s, Grenada
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Doshi TL, Cohen SP. Cracks in the Case against Epidural Steroids: Examining the Evidence for Vertebral Fracture Risk. PAIN MEDICINE 2019; 19:417-418. [PMID: 29145651 DOI: 10.1093/pm/pnx290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Tina L Doshi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.,Department of Anesthesiology, Pain Management Center, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Comparative Analysis of Utilization of Epidural Procedures in Managing Chronic Pain in the Medicare Population: Pre and Post Affordable Care Act. Spine (Phila Pa 1976) 2019; 44:220-232. [PMID: 30005043 DOI: 10.1097/brs.0000000000002785] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study of utilization patterns of epidural injections. OBJECTIVE The aim of this study was to assess patterns of utilization and variables of in chronic spinal pain in the fee-for-service (FFS) Medicare population, with a comparative analysis of pre- and post-Affordable Care Act (ACA) data from 2000 to 2009 and 2009 to 2016. SUMMARY OF BACKGROUND DATA Over the years, utilization of interventional pain management techniques, specifically epidural injections have increased creating concern over costs and public health policy. METHODS The master data from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2016 was utilized to assess utilization patterns. The descriptive analysis of the database analysis was performed using guidance from the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Multiple variables were analyzed based on the procedures, specialties, and geography. RESULTS Caudal and lumbar interlaminar epidural injections decreased 25% from 2009 to 2016 with an annual decrease of 4% in contrast to lumbosacral transforaminal epidural injection episodes, increasing at an annual rate of 0.3%. In contrast, lumbar interlaminar epidural injections increased 2.4% annually, while transforaminal episodes increased 23% from 2000 to 2009. The ratio of interlaminar epidural injections to transforaminal epidural injection episodes has changed from 7 in 2000 to 1 in 2016, whereas ratio of services changed from 5 to 0.7. From 2009 to 2016, cervical/thoracic interlaminar epidural injections episodes increased at an annual rate of 0.5%, with a decrease of 2.3% for transforaminal epidural injections. CONCLUSION Comparative analysis of the utilization of epidural injections from 2000 to 2009 and 2009 to 2016 showed vast differences with overall significant decreases in utilization, specifically for lumbar interlaminar and caudal epidural injections, with a continued, though greatly slowed increase of lumbosacral transforaminal epidural injections. LEVEL OF EVIDENCE 3.
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Sun X, Liu S, Liu C, Xu J, Sun J, Pan Y. An inadvertent subarachnoid injection reversed by cerebrospinal fluid lavage for the treatment of chronic low back pain: A case report. Medicine (Baltimore) 2019; 98:e14406. [PMID: 30732190 PMCID: PMC6380745 DOI: 10.1097/md.0000000000014406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE We present a case of high spinal anesthesia after inadvertent injection of local anesthetics and corticosteroids into the subarachnoid space during attempted epidural injection. Cerebrospinal fluid (CSF) lavage is a suitable method for treatment. PATIENT CONCERNS A 45-year-old woman presented with posterior thigh, leg, and ankle pain for >6 months and was treated with epidural injection. Five minutes after the third time of epidural injection, the patient complained loss of sensation and muscle strength in the lower extremities and abdominal area. DIAGNOSES A high spinal anesthesia was confirmed by the patient loss of sensation and muscle strength in the lower extremities and abdominal area. INTERVENTIONS CSF lavage was performed for treatment. OUTCOMES After CSF lavage, the patient gradually returns to normal sensory and motor functions of lower limbs. On the fourth day, the patient sensed her physical function restoring gradually and was discharged uneventfully. At 4-month follow-up, the patient could have normal activities without obvious subsequent complications and any pain. LESSONS We conclude that CSF lavage could be a helpful maneuver to clear lidocaine and betamethasone and avoid potential nerve damage caused by an unintentional intrathecal injection during an epidural injection for the treatment of chronic low back pain.
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Affiliation(s)
- Xiaodi Sun
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Shijiang Liu
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Cunming Liu
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Jijun Xu
- Department of Pain Management, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jie Sun
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Yinbing Pan
- Department of Anesthesiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
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Manchikanti L, Malla Y, Cash KA, Pampati V, Hirsch JA. Comparison of effectiveness for fluoroscopic cervical interlaminar epidural injections with or without steroid in cervical post-surgery syndrome. Korean J Pain 2018; 31:277-288. [PMID: 30310553 PMCID: PMC6177539 DOI: 10.3344/kjp.2018.31.4.277] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 09/16/2018] [Indexed: 12/12/2022] Open
Abstract
Background Neck and back pain are leading sources of disability placing substantial burden on health care systems. Surgical interventions in managing chronic neck pain secondary to various disorders continue to increase. Even though surgical interventions are effective, a significant proportion of patients continue to have symptomatology and develop cervical post-surgery syndrome. This study was performed to know the effectiveness of cervical interlaminar epidural injections with or without steroids. Methods The effectiveness of fluoroscopic cervical interlaminar epidural injections in post-surgery syndrome was evaluated in a randomized, active controlled trial. The study population included 116 patients assigned to 2 groups. Group 1 received cervical interlaminar epidural injections with local anesthetic alone and Group 2 received injection with local anesthetic and steroids. The main outcomes were defined as significant improvement (greater than 50%) of pain relief using the numeric rating scale and/or functional status improvement using the Neck Disability Index (NDI). Results Both groups had similar results with significant improvement (≥ 50% pain relief and functional status improvement) in 69% of the patients in Group I, whereas, in Group II, 71% of the patients showed significant improvement at the end of 2 years. During a 2-year period, the average number of procedures was 5 to 6, with an average of approximately 12 weeks of significant improvement per procedure. Conclusions Fluoroscopic cervical interlaminar epidural injections administered in cervical post-surgery syndrome using local anesthetic, regardless of the use of steroids, may be effective in approximately 70% of the patients at 2-year follow-up.
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Affiliation(s)
| | - Yogesh Malla
- Pain Management Center of Paducah, Paducah, Kentucky, USA
| | - Kimberly A Cash
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Vidyasagar Pampati
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Pain States, the Opioid Epidemic, and the Role of Radiologists. Curr Pain Headache Rep 2018; 22:20. [DOI: 10.1007/s11916-018-0672-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Cotten A, Drapé JL, Sans N, Feydy A, Bartoli JM, Meder JF. Société d'imagerie musculosquelettique (SIMS), Fédération de radiologie interventionnelle (FRI), and Société française de radiologie (SFR) recommendations for epidural and transforaminal corticosteroid injections. Diagn Interv Imaging 2018; 99:219-224. [PMID: 29454550 DOI: 10.1016/j.diii.2018.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 01/24/2018] [Indexed: 12/14/2022]
Affiliation(s)
- A Cotten
- Centre de consultation et d'imagerie de l'appareil locomoteur, CHRU de Lille, rue du professeur Emile-Laine, 59037 Lille cedex, France.
| | - J-L Drapé
- AP-HP, site Cochin, 27, rue du Faubourg St-Jacques, 75679 Paris, France.
| | - N Sans
- CHU Purpan, hôpital Pierre-Paul-Riquet, TSA 40031, 31059 Toulouse cedex 9, France.
| | - A Feydy
- AP-HP, site Cochin, 27, rue du Faubourg St-Jacques, 75679 Paris, France.
| | - J-M Bartoli
- Université d'Aix-Marseille, rue Saint-Pierre, 13385 Marseille cedex 05, France.
| | - J-F Meder
- Université Paris V, 1, rue Cabanis, 75674 Paris cedex 14, France.
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House LM, Barrette K, Mattie R, McCormick ZL. Cervical Epidural Steroid Injection. Phys Med Rehabil Clin N Am 2018; 29:1-17. [DOI: 10.1016/j.pmr.2017.08.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Ong KL, Beall DP, Frohbergh M, Lau E, Hirsch JA. Were VCF patients at higher risk of mortality following the 2009 publication of the vertebroplasty "sham" trials? Osteoporos Int 2018; 29:375-383. [PMID: 29063215 PMCID: PMC6394540 DOI: 10.1007/s00198-017-4281-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 10/17/2017] [Indexed: 12/24/2022]
Abstract
UNLABELLED The 5-year period following 2009 saw a steep reduction in vertebral augmentation volume and was associated with elevated mortality risk in vertebral compression fracture (VCF) patients. The risk of mortality following a VCF diagnosis was 85.1% at 10 years and was found to be lower for balloon kyphoplasty (BKP) and vertebroplasty (VP) patients. INTRODUCTION BKP and VP are associated with lower mortality risks than non-surgical management (NSM) of VCF. VP versus sham trials published in 2009 sparked controversy over its effectiveness, leading to diminished referral volumes. We hypothesized that lower BKP/VP utilization would lead to a greater mortality risk for VCF patients. METHODS BKP/VP utilization was evaluated for VCF patients in the 100% US Medicare data set (2005-2014). Survival and morbidity were analyzed by the Kaplan-Meier method and compared between NSM, BKP, and VP using Cox regression with adjustment by propensity score and various factors. RESULTS The cohort included 261,756 BKP (12.6%) and 117,232 VP (5.6%) patients, comprising 20% of the VCF patient population in 2005, peaking at 24% in 2007-2008, and declining to 14% in 2014. The propensity-adjusted mortality risk for VCF patients was 4% (95% CI, 3-4%; p < 0.001) greater in 2010-2014 versus 2005-2009. The 10-year risk of mortality for the overall cohort was 85.1%. BKP and VP cohorts had a 19% (95% CI, 19-19%; p < 0.001) and 7% (95% CI, 7-8%; p < 0.001) lower propensity-adjusted 10-year mortality risk than the NSM cohort, respectively. The BKP cohort had a 13% (95% CI, 12-13%; p < 0.001) lower propensity-adjusted 10-year mortality risk than the VP cohort. CONCLUSIONS Changes in treatment patterns following the 2009 VP publications led to fewer augmentation procedures. In turn, the 5-year period following 2009 was associated with elevated mortality risk in VCF patients. This provides insight into the implications of treatment pattern changes and associated mortality risks.
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Affiliation(s)
- K L Ong
- Exponent, Inc., 3440 Market St, Suite 600, Philadelphia, PA, USA.
| | | | - M Frohbergh
- Exponent, Inc., 3440 Market St, Suite 600, Philadelphia, PA, USA
| | - E Lau
- Exponent, Inc., Menlo Park, CA, USA
| | - J A Hirsch
- Massachusetts General Hospital, Boston, MA, USA
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Manchikanti L, Pampati V, Kaye AD, Hirsch JA. Therapeutic lumbar facet joint nerve blocks in the treatment of chronic low back pain: cost utility analysis based on a randomized controlled trial. Korean J Pain 2018; 31:27-38. [PMID: 29372023 PMCID: PMC5780212 DOI: 10.3344/kjp.2018.31.1.27] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 10/03/2017] [Accepted: 10/12/2017] [Indexed: 12/29/2022] Open
Abstract
Background Related to escalating health care costs and the questionable effectiveness of multiple interventions including lumbar facet joint interventions, cost effectiveness or cost utility analysis has become the cornerstone of evidence-based medicine influencing coverage decisions. Methods Cost utility of therapeutic lumbar facet joint nerve blocks in managing chronic low back pain was performed utilizing data from a randomized, double-blind, controlled trial with a 2-year follow-up, with direct payment data from 2016. Based on the data from surgical interventions, utilizing the lowest proportion of direct procedural costs of 60%, total cost utility per quality adjusted life year (QALY) was determined by multiplying the derived direct cost at 1.67. Results Patients in this trial on average received 5.6 ± 2.6 procedures over a period of 2 years, with average relief over a period of 2 years of 82.8 ± 29.6 weeks with 19 ± 18.77 weeks of improvement per procedure. Procedural cost for one-year improvement in quality of life showed USD $2,654.08. Estimated total costs, including indirect costs and drugs with multiplication of direct costs at 1.67, showed a cost of USD $4,432 per QALY. Conclusions The analysis of therapeutic lumbar facet joint nerve blocks in the treatment of chronic low back pain shows clinical effectiveness and cost utility at USD $2,654.08 for the direct costs of the procedures, and USD $4,432 for the estimated overall cost per one year of QALY, in chronic persistent low back pain non-responsive to conservative management.
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Affiliation(s)
| | | | - Alan D Kaye
- LSU Health Science Center, New Orleans, LA, USA
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Braun E, Sack AM, Sayed D, Manion S, Hamm B, Brimacombe M, Tollette M, Khan TW, Orr W, Nicol A. Reducing Radiation Exposure in Lumbar Transforaminal Epidural Steroid Injections with Pulsed Fluoroscopy: A Randomized, Double-blind, Controlled Clinical Trial. Pain Physician 2018; 21:53-60. [PMID: 29357331 PMCID: PMC6413313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Fluoroscopy-guided lumbar transforaminal epidural steroid injections (L-TFESI) result in radiation exposure that carries risks to patients, physicians, and procedural staff. OBJECTIVE We aim to evaluate the feasibility of using pulsed fluoroscopy to safely reduce radiation exposure during L-TFESI. STUDY DESIGN This is a prospective, double-blind, randomized controlled trial. SETTING This study took place in a single-center, academic, outpatient interventional pain management clinic. METHODS Patients undergoing L-TFESI were randomly assigned to either continuous mode fluoroscopy (high-dose), pulsed fluoroscopy with 8 pulses per second (medium-dose), or pulsed fluoroscopy with one pulse per second (low-dose). Data on radiation doses and other clinical and demographic factors were also collected. RESULTS In total, 231 cases were analyzed in the high-dose group (n = 81), medium-dose group (n = 72), and low-dose group (n = 78). Mean radiation effective dose (µSv) was 121 in the high-dose group, 57.9 in the medium-dose group, and 34.8 in the low-dose group (P < 0.001). The incidence of inadequate image quality in the pulsed groups was 6% (9/150). The body mass index (BMI, mean ± SD) was significantly higher in patients with inadequate image quality (37.3 ± 7.2) than with adequate quality (30.5 ± 7.2, P = 0.005). LIMITATIONS Radiation doses were measured using the meter on C-arm fluoroscopes rather than by direct measurement. CONCLUSIONS The use of pulsed fluoroscopy during L-TFESI resulted in radiation dose reduction of up to 72.1% without causing any significant adverse events. Pulsed fluoroscopy should be considered as an initial fluoroscopic setting for L-TFESI to reduce radiation exposure. KEY WORDS Radiation, epidural, fluoroscopy, injection, exposure, pulse.
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Affiliation(s)
- Edward Braun
- University of Kansas Medical Center, Kansas City, KS
| | - Andrew M Sack
- University of Kansas Medical Center, Kansas City, KS
| | - Dawood Sayed
- University of Kansas Medical Center, Kansas City, KS
| | - Smith Manion
- University of Kansas Medical Center, Kansas City, KS
| | - Brian Hamm
- University of Kansas Medical Center, Kansas City, KS
| | | | | | - Talal W Khan
- University of Kansas Medical Center, Kansas City, KS
| | - Walter Orr
- University of Kansas Medical Center, Kansas City, KS
| | - Andrea Nicol
- University of Kansas Medical Center, Kansas City, KS
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Shao ZX, He W, He SQ, Lin SL, Huang ZY, Tang HC, Ni WF, Wang XY, Wu AM. A 3D navigation template for guiding a unilateral lumbar pedicle screw with contralateral translaminar facet screw fixation: a study protocol for multicentre randomised controlled trials. BMJ Open 2017; 7:e016328. [PMID: 28733301 PMCID: PMC5642762 DOI: 10.1136/bmjopen-2017-016328] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION The incidence of lumbar disc degeneration disease has increased in recent years. Lumbar interbody fusion using two unilateral pedicle screws and a translaminar facet screw fixation has advantages of minimal invasiveness and lower costs compared with the traditional methods. Moreover, a method guided by a three-dimensional (3D) navigation template may help us improve the surgical accuracy and the success rate. This is the first randomised study using a 3D navigation template to guide a unilateral lumbar pedicle screw with contralateral translaminar facet screw fixation. METHODS AND ANALYSIS Patients who meet the criteria of the surgery will be randomly divided into experimental groups and control groups by a computer-generated randomisation schedule. We will preoperatively design an individual 3D navigation template using CATIA software and MeditoolCreate. The following primary outcomes will be collected: screw angles compared with the optimal screw trajectories in 3D digital images, length of the wound incision, operative time, intraoperative blood loss and complications. The following secondary outcomes will be collected: visual analogue scale (VAS) for back pain, VAS for leg pain and the Oswestry Disability Index. These parameters will be evaluated on day 1 and then 3, 6, 12 and 24 months postoperatively. ETHICS AND DISSEMINATION The study has been reviewed and approved by the institutional ethics review board of the Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University. The results will be presented at scientific communities and peer-reviewed journals. TRIAL REGISTRATION NUMBER ChiCTR-IDR-17010466.
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Affiliation(s)
- Zhen-Xuan Shao
- Department of Spine Surgery, Orthopaedic Hospital, The Second Affiliated Hospital and Yuying Children’s Hospital of the Wenzhou Medical University, The Second Medical School of the Wenzhou Medical University, Zhejiang Spine Center, Wenzhou, China
| | - Wei He
- Department of Orthopaedics, People’s Hospital of Shaoxing, Zhejiang University Shaoxing Hospital, Shaoxing, China
| | - Shao-Qi He
- Department of Orthopaedics, People’s Hospital of Ruian, The Third Affiliated Hospital of Wenzhou Medical University, Ruian, China
| | - Sheng-Lei Lin
- Department of Orthopaedics, Wenzhou Center Hospital, Dingli Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhe-Yu Huang
- Department of Orthopaedics, Ningbo No. 6 Hospital, Ningbo, Zhejiang, China
| | - Hong-Chao Tang
- Department of Orthopaedics, Jiaxing Hospital of Zhejiang General Corps of Armed Police Forces, Jiaxing, China
| | - Wen-Fei Ni
- Department of Spine Surgery, Orthopaedic Hospital, The Second Affiliated Hospital and Yuying Children’s Hospital of the Wenzhou Medical University, The Second Medical School of the Wenzhou Medical University, Zhejiang Spine Center, Wenzhou, China
| | - Xiang-Yang Wang
- Department of Spine Surgery, Orthopaedic Hospital, The Second Affiliated Hospital and Yuying Children’s Hospital of the Wenzhou Medical University, The Second Medical School of the Wenzhou Medical University, Zhejiang Spine Center, Wenzhou, China
| | - Ai-Min Wu
- Department of Spine Surgery, Orthopaedic Hospital, The Second Affiliated Hospital and Yuying Children’s Hospital of the Wenzhou Medical University, The Second Medical School of the Wenzhou Medical University, Zhejiang Spine Center, Wenzhou, China
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Ter Meulen BC, Maas ET, Vyas A, van der Vegt M, de Priester K, de Boer MR, van Tulder MW, Weinstein HC, Ostelo RWJG. Treatment of acute sciatica with transforaminal epidural corticosteroids and local anesthetic: design of a randomized controlled trial. BMC Musculoskelet Disord 2017; 18:215. [PMID: 28545491 PMCID: PMC5445356 DOI: 10.1186/s12891-017-1571-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 05/11/2017] [Indexed: 12/28/2022] Open
Abstract
Background Transforaminal epidural injections with steroids (TESI) are used increasingly for patients with sciatica. However there is much debate about their safety and effectiveness. It is important to identify patients that benefit most from TESI and only few trials have yet evaluated the effects in patients with acute sciatica. Methods We describe a prospective, randomized controlled trial (RCT), with the aim to evaluate the hypothesis that TESI plus Levobupivacaine (TESI-plus) added to oral pain medication is more effective compared to pain medication alone or compared to transforaminal injection with a local anesthetic of short duration among patients with acute sciatica. We will recruit a total of 264 patients with sciatica (<8 weeks) caused by a herniated disc, from two clinical sites. Participants are randomly assigned one of three study groups: 1) oral pain medication (control group), 2) oral pain medication and TESI-plus (intervention group one), 3) oral pain medication and transforaminal epidural injection (TEI) with Levobupivaine and saline solution (intervention group two). Primary outcomes are functional status (Roland-Morris Disability Questionnaire), pain intensity for both leg and back, (100 mm visual analogous scale (VAS)), and global perceived recovery (GPR, reported on a 7-point Likert scale, dichotomized into ‘recovered’ and ‘not recovered’). The secondary outcomes are health-related quality of life (EQ5D-5 L) and patient satisfaction (7-point Likert scale). We will also collect information on healthcare utilization and costs, to perform an economic evaluation. All outcomes are measured at three and six weeks, three and six months after randomization. We defined a minimal clinically relevant difference between groups as a difference between both intervention groups and the control group of 20 points for pain (100-point VAS), four points for functional status (24-point RDQ) and a 20% difference on dichotomized GPR (recovered versus not recovered). Discussion A clinically relevant outcome in favor of TESI-plus implies that future patients with acute sciatica should be recommended TESI-plus within the first few weeks rather than being treated with pain medication alone in order to relieve pain and improve their functioning. In case of a negative result (no relevant differences in outcome between the three study arms), pain medication will remain the mainstay of treatment in the acute stages of sciatica. Trial registration Dutch National trial register: NTR4457 (March, 6th, 2014)
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Affiliation(s)
- Bastiaan C Ter Meulen
- Department of Neurology, Zaans Medisch Centrum, Zaandam and Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
| | - Esther T Maas
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Amrita Vyas
- Department of Neurology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | - Koo de Priester
- Department of Radiology Zaans Medisch Centrum, Zaandam, The Netherlands
| | - Michiel R de Boer
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands.,Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Henry C Weinstein
- Department of Neurology, Zaans Medisch Centrum, Zaandam and Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Raymond W J G Ostelo
- Department of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands.,Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
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Epstein NE. Neurological complications of lumbar and cervical dural punctures with a focus on epidural injections. Surg Neurol Int 2017; 8:60. [PMID: 28540126 PMCID: PMC5421209 DOI: 10.4103/sni.sni_38_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 01/26/2017] [Indexed: 11/21/2022] Open
Abstract
Background: Various types of lumbar dural punctures may contribute to neurological injury. The etiologies of dural injury include; inadvertent dural punctures due to epidurals placed for labor anesthesia, epidural steroid injections (ESI/transforaminal TESI; approximately 9 million ESI performed in the US per year), deliberate placement of intradural pain devices, and spontaneous cerebrospinal fluid (CSF) fistulas. Resulting neurological complications may include; spinal headaches/intracranial hypotension, subdural hematomas, and 6th nerve cranial palsies. Furthermore, uniquely in the cervical spine, inadvertent cervical dural punctures attributed to cervcial ESI (CESI) may lead to intramedullary spinal cord injuries (e.g. resulting in monoparesis to quadriplegia) or spinal cord strokes due to intravascular/vertebral artery injections. Methods/Results: In 8 studies, inadvertent lumbar dural punctures contributed to intracranial hypotension, subdural hematomas, and double vision/6th cranial nerve palsies. In 5 of the 6 studies, inadvertent dural punctures occurring during CESI were responsible for intramedullary spinal cord injuries, or direct intravascular/vertebral injections resulting in monoplegia/quadriplegia. Conclusions: Inadvertent lumbar dural punctures led to multiple neurological complications including intracranial hypotension, subdural hematomas, and double vision/6th cranial nerve palsies. Uniquely, inadvertent cervical dural punctures solely due to CESI directly resulted in intramedullary spinal cord injuries or cord stroked and monoplegia/quadriplegia attributed to intravascular/vertebral artery injections. The potential neurological risks/complications/adverse events attributed to lumbar and cervical ESI must be taken into account before spine surgeons and others order these procedures.
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Affiliation(s)
- Nancy E Epstein
- Department of Neuroscience, Winthrop Neuroscience, Winthrop University Hospital, Mineola, New York, USA
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Manchikanti L, Pampati V, Kaye AD, Hirsch JA. Cost Utility Analysis of Cervical Therapeutic Medial Branch Blocks in Managing Chronic Neck Pain. Int J Med Sci 2017; 14:1307-1316. [PMID: 29200944 PMCID: PMC5707747 DOI: 10.7150/ijms.20755] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 07/06/2017] [Indexed: 02/06/2023] Open
Abstract
Background: Controlled diagnostic studies have established the prevalence of cervical facet joint pain to range from 36% to 67% based on the criterion standard of ≥ 80% pain relief. Treatment of cervical facet joint pain has been described with Level II evidence of effectiveness for therapeutic facet joint nerve blocks and radiofrequency neurotomy and with no significant evidence for intraarticular injections. However, there have not been any cost effectiveness or cost utility analysis studies performed in managing chronic neck pain with or without headaches with cervical facet joint interventions. Study Design: Cost utility analysis based on the results of a double-blind, randomized, controlled trial of cervical therapeutic medial branch blocks in managing chronic neck pain. Objectives: To assess cost utility of therapeutic cervical medial branch blocks in managing chronic neck pain. Methods: A randomized trial was conducted in a specialty referral private practice interventional pain management center in the United States. This trial assessed the clinical effectiveness of therapeutic cervical medial branch blocks with or without steroids for an established diagnosis of cervical facet joint pain by means of controlled diagnostic blocks. Cost utility analysis was performed with direct payment data for the procedures for a total of 120 patients over a period of 2 years from this trial based on reimbursement rates of 2016. The payment data provided direct procedural costs without inclusion of drug treatments. An additional 40% was added to procedural costs with multiplication of a factor of 1.67 to provide estimated total costs including direct and indirect costs, based on highly regarded surgical literature. Outcome measures included significant improvement defined as at least a 50% improvement with reduction in pain and disability status with a combined 50% or more reduction in pain in Neck Disability Index (NDI) scores. Results: The results showed direct procedural costs per one-year improvement in quality adjusted life year (QALY) of United States Dollar (USD) of $2,552, and overall costs of USD $4,261. Overall, each patient on average received 5.7 ± 2.2 procedures over a period of 2 years. Average significant improvement per procedure was 15.6 ± 12.3 weeks and average significant improvement in 2 years per patient was 86.0 ± 24.6 weeks. Limitations: The limitations of this cost utility analysis are that data are based on a single center evaluation. Only costs of therapeutic interventional procedures and physician visits were included, with extrapolation of indirect costs. Conclusion: The cost utility analysis of therapeutic cervical medial branch blocks in the treatment of chronic neck pain non-responsive to conservative management demonstrated clinical effectiveness and cost utility at USD $4,261 per one year of QALY.
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Affiliation(s)
| | | | | | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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