Unnecessary multiple epidural steroid injections delay surgery for massive lumbar disc: Case discussion and review

Cervical epidural steroid injections: incidence and determinants of subsequent surgery

BACKGROUND CONTEXT

Cervical epidural steroid injections (CESIs) are sometimes used in the management of cervical radicular pain in order to delay or avoid surgery. However, the rate and determinants of surgery following CESIs remain uncertain.

PURPOSE

This study sought to determine: (1) the proportion of patients having surgery following CESI, and (2) the timing of and factors associated with subsequent surgery.

STUDY DESIGN

Retrospective analysis of a large, national administrative claims database.

PATIENT SAMPLE

The study included 192,777 CESI patients (age 50.9±11.3 years, 55.2% female) who underwent CESI for imaging-based diagnoses of cervical disc herniation or stenosis, a clinical diagnosis of radiculopathy, or a combination thereof.

OUTCOME MEASURES

The primary outcome was the time from index CESI to surgery.

METHODS

Inclusion criteria were CESI for cervical disc herniation, stenosis, or radiculopathy, age ≥18, and active enrollment for 1 year before CESI to screen for exclusions. Patients were followed until they underwent cervical surgery, or their enrollment lapsed. Rates of surgery were assessed with Kaplan-Meier survival curves and 99% confidence intervals. Factors associated with subsequent surgery were assessed with multivariable Cox proportional hazard models.

RESULTS

Within 6 months of CESI, 11.2% of patients underwent surgery, increasing to 14.5% by 1 year and 22.3% by 5 years. Male patients and those aged 35 to 54 had an increased likelihood of subsequent surgery. Patients with radiculopathy were less likely to undergo surgery following CESI than those with stenosis or herniation, while patients with multiple diagnoses were more likely. Patients with comorbidities including CHF, other cardiac comorbidities or chronic pain were less likely to undergo surgery, as were patients in the northeast US region. Some 33.5% of patients underwent >1 CESI, with 84.6% of these occurring within 1 year. Additional injections were associated with reduced rates of subsequent surgery.

CONCLUSIONS

Following CESI, over one in five patients underwent surgery within 5 years. Multiple patient-specific risk factors for subsequent surgery were identified, and patients undergoing repeated injections were at lower risk. Determining which patients may progress to surgery can be used to improve resource utilization and to inform shared decision-making.

Epidural Anesthesia With Low Concentration Ropivacaine and Sufentanil for Percutaneous Transforaminal Endoscopic Discectomy: A Randomized Controlled Trial

Introduction: Percutaneous transforaminal endoscopic discectomy is a simple and effective treatment for lumbar intervertebral disc herniation, and local anesthesia is often applied in this kind of surgery in many developing countries, including China. However, many patients still feel excruciating pain under this condition. Epidural anesthesia with low-concentration ropivacaine has no impact on muscle strength, and patients might follow the surgeon well during operation. We hypothesize that epidural anesthesia is feasible for percutaneous transforaminal endoscopic discectomy.

Methods: Two hundred patients with disc herniation who underwent percutaneous transforaminal endoscopic discectomy were randomized to receive either epidural anesthesia or local infiltration anesthesia. Primary outcome measures included the pain score, the cooperation degree, and patients' satisfaction. Mean arterial pressure and heart rate were also recorded.

Results: Compared with the local anesthesia group, visual analog scale scores, mean arterial pressure, and heart rate were significantly lower in the epidural anesthesia group (P < 0.05), and patients' satisfaction was higher. There were no significant differences in the total operation time or blood loss between two groups.

Conclusions: Epidural anesthesia with low-concentration ropivacaine and sufentanil is safe and effective for percutaneous transforaminal endoscopic discectomy.

Clinical Trial Registration:ClinicalTrials.gov, identifier: ChiCTR-IOR-17011768.

Unnecessary Cervical Epidural Injection in An Octogenarian

Background:

Epidural spine injections (ESI) have no documented long-term efficacy. Furthermore, cervical ESI uniquely risk intramedullary injections with resultant neurological deficits (e.g. monoplegia to quadriplegia), and intravascular vertebral injections (e.g. which potentially contribute to stroke, brain stem infarction).

Case Description:

A patient in his mid-eighties presented with 1 year’s duration of neck pain without any accompanying numbness, tingling or weakness in the upper or lower extremities. He had no radiculopathy, myelopathy, or neurological deficit. Two years earlier, the patient sustained a myocardial infarction (MI), requiring over 5 stents and a defibrillator. At the time of presentation, he was still on a baby ASA (81 mg/day), on anti-hypertensives, and cholesterol-lowering medications. His non-contrast cervical CT scan (patient had a pacemaker/defibrillator and could not have an MR) from the summer of 2018 showed no significant spinal cord or nerve root compression at any level. Nevertheless, he was subjected to two cervical epidural injections in the early fall; his baby ASA was stopped 5 days prior to each of these injections. Notably, this placed him at increased risk of MI and/or stroke. When he was seen by neurosurgery, without any neurological deficit or significant cervical radiographic findings, he was referred back to neurology for continued conservative management.

Conclusions:

Patients are increasingly subjected to epidural cervical spinal injections that have no documented long-term efficacy, and expose them to significant risks/complications. This 80+ year-old patient, without a neurological deficit or significant cervical CT-documented pathology, underwent 2 cervical ESI that unnecessarily exposed him to potential cardiac-stent related thrombosis (e.g. stopping ASA for 5 days-a bona-fide requirement for ESI to avoid acute epidural hematomas).

The impact of insurance coverage on access to orthopedic spine care

Background

Poor socioeconomic status is a significant barrier to health care in the United States. Policy changes have attempted to expand insurance coverage in hopes of improving access to care. These policies have prioritized primary care and preventative medicine. Access to specialty care, particularly orthopaedic care, has not received the same attention. This study examines access to orthopaedic spine surgery practices based on type of insurance coverage.

Methods

Five offices with board certified orthopaedic spine surgeons were randomly contacted from each state. A fictitious patient provided a scripted surgical indication for their appointment. They provided their insurance coverage as either Medicare, Medicaid or a private plan. Timing of the provided appointment was recorded. Any appointment was subsequently canceled so as not to interfere with the practice's scheduling.

Results

Two hundred and thirty-four orthopaedic spine surgery practices were contacted between January and June of 2016. Eighty-six percent of practices accepted a private plan without primary care provider (PCP) referral. Greater than 99% of practices accepted privately insured patients if a PCP referral were included. Those with Medicare were able to obtain an appointment from 81% of practices. No practices contacted in this study offered an appointment to the caller with Medicaid.

Conclusions

Policy changes have expanded insurance coverage in order to improve access to care for patients of low socioeconomic status. There was a significant barrier to accessing spine care for patients with Medicaid insurance. Access was greatest for those with private insurance followed by those with Medicare. This study demonstrates that there is a significant disparity in ability to access spine specialists despite having insurance coverage.