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Peene L, Cohen SP, Brouwer B, James R, Wolff A, Van Boxem K, Van Zundert J. 2. Cervical radicular pain. Pain Pract 2023; 23:800-817. [PMID: 37272250 DOI: 10.1111/papr.13252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Cervical radicular pain is pain perceived in the upper limb, caused by irritation or compression of a cervical spine nerve, the roots of the nerve, or both. METHODS The literature on the diagnosis and treatment of cervical radicular pain was retrieved and summarized. RESULTS The diagnosis is made by combining elements from the patient's history, physical examination, and supplementary tests. The Spurling and shoulder abduction tests are the two most common examinations used to identify cervical radicular pain. MRI without contrast, CT scanning, and in some cases plain radiography can all be appropriate imaging techniques for nontraumatic cervical radiculopathy. MRI is recommended prior to interventional treatments. Exercise with or without other treatments can be beneficial. There is scant evidence for the use of paracetamol, nonsteroidal anti-inflammatory drugs, and neuropathic pain medications such as gabapentin, pregabalin, tricyclic antidepressants, and anticonvulsants for the treatment of radicular pain. Acute and subacute cervical radicular pain may respond well to epidural corticosteroid administration, preferentially using an interlaminar approach. By contrast, for chronic cervical radicular pain, the efficacy of epidural corticosteroid administration is limited. In these patients, pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered. CONCLUSIONS There is currently no gold standard for the diagnosis of cervical radicular pain. There is scant evidence for the use of medication. Epidural corticosteroid injection and pulsed radiofrequency adjacent to the dorsal root ganglion may be considered. [Correction added on 12 June 2023, after first online publication: The preceding sentence was corrected.].
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Affiliation(s)
- Laurens Peene
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
| | - Steven P Cohen
- Pain Medicine Division, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, USA
| | - Brigitte Brouwer
- Department of Anesthesiology, Pain Medicine and Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rathmell James
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Leroy D. Vandam Professor of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Andre Wolff
- Department of Anesthesiology, UMCG Pain Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Koen Van Boxem
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
- Department of Anesthesiology, Pain Medicine and Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
- Department of Anesthesiology, Pain Medicine and Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
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Ma L, Wang Y, Yao M, Huang B, Deng J, Wen H. Evaluating the Extent of Ultrasound-Guided Cervical Selective Nerve Root Block in the Lower Cervical Spine: Evidence Based on Computed Tomography Images. J Pain Res 2023; 16:669-676. [PMID: 36908928 PMCID: PMC9999714 DOI: 10.2147/jpr.s399431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/23/2023] [Indexed: 03/08/2023] Open
Abstract
Objective To verify the injectate dispersal patterns (IDP) and therapeutic outcome of ultrasound-guided cervical selective nerve root block (UG-SCNRB) in treating cervical radiculopathy (CR). Methods Overall, 18 CR patients were recruited to undergo UG-SCNRB in the CT room. Following placement of the puncture needle tip between the target nerve root and posterior tubercle, 3 mL of the drug was administered per root (0.33% lidocaine 0.5 mL + Compound betamethasone injection 0.5mL + methylcobalamin injection 1mL + iohexol 1mL). Subsequently, the IDP was assessed on postintervention CT scan images. Results In all, 18 participants were analyzed. We injected 21 target cervical nerve roots, namely, 1 C4 nerve, 9 C5 nerves, and 11 C6 nerves. Among the IDPs on postintervention CT scan images, two IDPs were most prevalent, namely, the contrast spread into the extraforaminal spaces (Zone I, the interscalene) in 100% (21/21) of cases, and the foraminal space spread (Zone II) in 61.90% (13/21) of cases. The injectate spread into the epidural spaces (Zone III) in only 2 out of 21 cases (9.52%). The pain relief was significantly improved two hours after surgery, compared to the preoperative VAS pain scores (2 hours, 1.39±0.50 vs VAS at baseline, P<0.01). The VAS pain scores during follow-up were significantly lower than preoperation (1 weeks, 1.94±0.54 vs VAS at baseline; 2 weeks, 2.61±0.70, P<0.01 vs VAS at baseline; 4 weeks, 2.67±0.59, P<0.01 vs VAS at baseline). Conclusion We verified, via CT imaging, that the UG-SCNRB drug diffusion was within safe range (the injectate mainly spread to the extraforaminal spaces), and without any serious complications, such as, intravascular drug injection, extensive diffusion of the epidural space, and general spinal anesthesia.
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Affiliation(s)
- Ling Ma
- Department of Anesthesiology and Pain Research Center, The Affiliated Hospital of Jiaxing University, Jiaxing, People's Republic of China
| | - Yi Wang
- Department of Anesthesiology, First Affiliated Hospital of Wannan Medical College, Wuhu, People's Republic of China
| | - Ming Yao
- Department of Anesthesiology and Pain Research Center, The Affiliated Hospital of Jiaxing University, Jiaxing, People's Republic of China
| | - Bing Huang
- Department of Anesthesiology and Pain Research Center, The Affiliated Hospital of Jiaxing University, Jiaxing, People's Republic of China
| | - Jiajia Deng
- Department of Anesthesiology and Pain Research Center, The Affiliated Hospital of Jiaxing University, Jiaxing, People's Republic of China
| | - Huaichang Wen
- Department of Anesthesiology, First Affiliated Hospital of Wannan Medical College, Wuhu, People's Republic of China
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Cui X, Zhang D, Zhao Y, Song Y, He L, Zhang J. An open-label non-inferiority randomized trail comparing the effectiveness and safety of ultrasound-guided selective cervical nerve root block and fluoroscopy-guided cervical transforaminal epidural block for cervical radiculopathy. Ann Med 2022; 54:2681-2691. [PMID: 36164681 PMCID: PMC9553110 DOI: 10.1080/07853890.2022.2124445] [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] [Indexed: 11/01/2022] Open
Abstract
OBJECT To compare therapeutic efficacy and safety of ultrasound (US)-guided selective nerve root block (SNRB) and fluoroscopy (FL)-guided transforaminal epidural steroid injection (TFESI) for cervical spine radiculopathy (CSR). METHOD 156 patients with CSR randomly received US-guided SNRB verified by FL or FL-guided TFESI. We hypothesised that the accuracy rate of contrast dispersion into epidural or intervertebral foraminal space in the US group was not inferior to that in the FL group with a margin of clinical unimportance of -15%. Pain intensity assessed by Numeric Rating Scales (NRS) and functional disability estimated by neck disability index (NDI) were compared before treatment, at 1, 3 and 6 months after the intervention. Puncture time and complication frequencies were also reported. RESULTS 88.7% and 90.3% accuracy ratings were respectively achieved in the US and FL groups with a treatment difference of -1.6% (95%CI: -9.7%, 6.6%) revealing that the lower limit was above the non-inferiority margin. Both NRS and NDI scores illustrated improvements at 1, 3 and 6 months after intervention with no statistically significant differences between the two groups (all p > .05). Additionally, shorter administration duration was observed in the US group (p < .001). No severe complications were observed in both group. CONCLUSION Compared with the FL group, the US group provided a non-inferior accuracy rate of epidural/foraminal contrast pattern. For the treatment of CSR, the US technique provided similar pain relief and functional improvements while facilitating distinguishing critical vessels adjacent to the foramen and requiring a shorter procedure duration without exposure to radiation. Therefore, it was an attractive alternative to the conventional FL method.Key messagesWe conducted a prospective, open-label, randomised and non-inferiority clinical trial to estimate a hypothesis that the precisely accurate delivery through ultrasound (US)-guided cervical selective nerve root block (SNRB) was non-inferior to that using FL-guided transforaminal epidural steroid injection. Additionally, US-guided SNRB was as effective as FL-guided TFESI in the treatment effect on pain relief and function improvements. Notably, the US technique might be an alternative to the conventional FL method due to the ability to prevent inadvertent vascular puncture (VP) and intravascular injection (IVI) with a shorter administration time and absence of radiation exposure.
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Affiliation(s)
- Xiaohong Cui
- Department of Anesthesiology, Harbin Orthopedics Surgery Hospital, Harbin City, Heilongjiang Province, China
| | - Di Zhang
- Department of Anesthesiology, Harbin Orthopedics Surgery Hospital, Harbin City, Heilongjiang Province, China
| | - Yongming Zhao
- Department of Anesthesiology, Nanchong Central Hospital, Nanchong City, Sichuan Province, China
| | - Yongsheng Song
- Department of Anesthesiology, Harbin Orthopedics Surgery Hospital, Harbin City, Heilongjiang Province, China
| | - Liangliang He
- Department of Pain, Beijing Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Zhang
- Department of Anesthesiology, Cancer Hospital of Harbin Medical University, Harbin City, Heilongjiang Province, China
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Schuster NM, Ahadian FM, Zhao Z, Hooten WM, Miller DC, Hagedorn JM, Gulati A, Duszynski BS, McCormick ZL, Nagpal AS. Best practices for interventional pain procedures in the setting of an iodinated contrast media shortage: A multisociety practice advisory. INTERVENTIONAL PAIN MEDICINE 2022; 1:100122. [PMID: 39238514 PMCID: PMC11372943 DOI: 10.1016/j.inpm.2022.100122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 09/07/2024]
Abstract
Representatives from the Spine Intervention Society (SIS) and American Academy of Pain Medicine (AAPM) have developed the following best practice recommendations for the performance of interventional pain procedures in the setting of an iodinated contrast media shortage. The practice advisory has been endorsed by SIS, AAPM, American Academy of Physical Medicine and Rehabilitation (AAPMR), American Society of Neuroradiology (ASNR), American Society of Spine Radiology (ASSR), North American Neuromodulation Society (NANS), North American Spine Society (NASS), and Society of Interventional Radiology (SIR).
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Affiliation(s)
- Nathaniel M Schuster
- Center for Pain Medicine, Department of Anesthesiology, UC San Diego Health System, La Jolla, CA, USA
| | - Farshad M Ahadian
- Center for Pain Medicine, Department of Anesthesiology, UC San Diego Health System, La Jolla, CA, USA
| | - Zirong Zhao
- Neurology Service, Veterans Affairs Medical Center, Washington, DC, USA
| | - W Michael Hooten
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ameet S Nagpal
- Department of Orthopaedics & Physical Medicine, Medical University of South Carolina, Charleston, SC, USA
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William J, Roehmer C, Mansy L, Kennedy DJ. Epidural Steroid Injections. Phys Med Rehabil Clin N Am 2022; 33:215-231. [DOI: 10.1016/j.pmr.2022.01.009] [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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Kim BY, Concannon TA, Barboza LC, Khan TW. The Role of Diagnostic Injections in Spinal Disorders: A Narrative Review. Diagnostics (Basel) 2021; 11:diagnostics11122311. [PMID: 34943548 PMCID: PMC8700513 DOI: 10.3390/diagnostics11122311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 11/16/2022] Open
Abstract
Neck and back pain is increasingly prevalent, and has increased exponentially in recent years. As more resources are dedicated to the diagnosis of pain conditions, it is increasingly important that the diagnostic techniques used are as precise and accurate as possible. Traditional diagnostic methods rely heavily upon patient history and physical examination to determine the most appropriate treatments and/or imaging studies. Though traditional means of diagnosis remain a necessity, in many cases, correlation with positive or negative responses to injections may further enhance diagnostic specificity, and improve outcomes by preventing unnecessary treatments or surgeries. This narrative review aims to present the most recent literature describing the diagnostic validity of precision injections, as well as their impact on surgical planning and outcomes. Diagnostic injections are discussed in terms of facet arthropathy, lumbar radiculopathy, discogenic pain and discography, and sacroiliac joint dysfunction. There is a growing body of evidence supporting the use of diagnostic local anesthetic injections or nerve blocks to aid in diagnosis. Spinal injections add valuable objective information that can potentially improve diagnostic precision, guide treatment strategies, and aid in patient selection for invasive surgical interventions.
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Affiliation(s)
- Brian Y. Kim
- Correspondence: ; Tel.: +1-913-588-6670; Fax: +1-913-588-5311
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Manto KM, Govindappa PK, Parisi D, Karuman Z, Martinazzi B, Hegarty JP, Talukder MAH, Elfar JC. (4-Aminopyridine)-PLGA-PEG as a Novel Thermosensitive and Locally Injectable Treatment for Acute Peripheral Nerve Injury. ACS APPLIED BIO MATERIALS 2021; 4:4140-4151. [PMID: 34142019 PMCID: PMC8206837 DOI: 10.1021/acsabm.0c01566] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Traumatic peripheral nerve injury (TPNI) represents a major medical problem that results in loss of motor and sensory function, and in severe cases, limb paralysis and amputation. To date, there are no effective treatments beyond surgery in selective cases. In repurposing studies, we found that daily systemic administration of the FDA-approved drug 4-aminopyridine (4-AP) enhanced functional recovery after acute peripheral nerve injury. This study was aimed at constructing a novel local delivery system of 4-AP using thermogelling polymers. We optimized a thermosensitive (4-AP)-poly(lactide-co-glycolide)-b-poly(ethylene glycol)-b-poly(lactide-co-glycolide) (PLGA-PEG-PLGA) block copolymer formulation. (4-AP)-PLGA-PEG exhibited controlled release of 4-AP both in vitro and in vivo for approximately 3 weeks, with clinically relevant safe serum levels in animals. Rheological investigation showed that (4-AP)-PLGA-PEG underwent a solution to gel transition at 32 °C, a physiologically relevant temperature, allowing us to administer it to an injured limb while subsequently forming an in situ gel. A single local administration of (4-AP)-PLGA-PEG remarkably enhanced motor and sensory functional recovery on post-sciatic nerve crush injury days 1, 3, 7, 14, and 21. Moreover, immunohistochemical studies of injured nerves treated with (4-AP)-PLGA-PEG demonstrated an increased expression of neurofilament heavy chain (NF-H) and myelin protein zero (MPZ) proteins, two major markers of nerve regeneration. These findings demonstrate that (4-AP)-PLGA-PEG may be a promising long-acting local therapeutic agent in TPNI, for which no pharmacologic treatment exists.
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Affiliation(s)
- Kristen M Manto
- Department of Orthopaedics and Rehabilitation, Center for Orthopaedic Research and Translational Science, The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033, United States
| | - Prem Kumar Govindappa
- Department of Orthopaedics and Rehabilitation, Center for Orthopaedic Research and Translational Science, The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033, United States
| | - Daniele Parisi
- Department of Materials Science and Engineering, The Pennsylvania State University, University Park, Pennsylvania 16802, United States
| | - Zara Karuman
- Department of Orthopaedics and Rehabilitation, Center for Orthopaedic Research and Translational Science, The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033, United States
| | - Brandon Martinazzi
- Department of Orthopaedics and Rehabilitation, Center for Orthopaedic Research and Translational Science, The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033, United States
| | - John P Hegarty
- Department of Orthopaedics and Rehabilitation, Center for Orthopaedic Research and Translational Science, The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033, United States
| | - M A Hassan Talukder
- Department of Orthopaedics and Rehabilitation, Center for Orthopaedic Research and Translational Science, The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033, United States
| | - John C Elfar
- Department of Orthopaedics and Rehabilitation, Center for Orthopaedic Research and Translational Science, The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033, United States
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