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Hong JY, Yeo C, Kim H, Lee J, Jeon WJ, Lee YJ, Ha IH. Repeated epidural delivery of Shinbaro2: effects on neural recovery, inflammation, and pain modulation in a rat model of lumbar spinal stenosis. Front Pharmacol 2024; 15:1324251. [PMID: 38828447 PMCID: PMC11140021 DOI: 10.3389/fphar.2024.1324251] [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] [Received: 10/23/2023] [Accepted: 04/30/2024] [Indexed: 06/05/2024] Open
Abstract
The choice of treatment for lumbar spinal stenosis (LSS) depends on symptom severity. When severe motor issues with urinary dysfunction are not present, conservative treatment is often considered to be the priority. One such conservative treatment is epidural injection, which is effective in alleviating inflammation and the pain caused by LSS-affected nerves. In this study, Shinbaro2 (Sh2), pharmacopuncture using natural herbal medicines for patients with disc diseases, is introduced as an epidural to treat LSS in a rat model. The treatment of primary sensory neurons from the rats' dorsal root ganglion (DRG) neurons with Sh2 at various concentrations (0.5, 1, and 2 mg/mL) was found to be safe and non-toxic. Furthermore, it remarkably stimulated axonal outgrowth even under H2O2-treated conditions, indicating its potential for stimulating nerve regeneration. When LSS rats received epidural injections of two different concentrations of Sh2 (1 and 2 mg/kg) once daily for 4 weeks, a significant reduction was seen in ED1+ macrophages surrounding the silicone block used for LSS induction. Moreover, epidural injection of Sh2 in the DRG led to a significant suppression of pain-related factors. Notably, Sh2 treatment resulted in improved locomotor recovery, as evaluated by the Basso, Beattie, and Bresnahan scale and the horizontal ladder test. Additionally, hind paw hypersensitivity, assessed using the Von Frey test, was reduced, and normal gait was restored. Our findings demonstrate that epidural Sh2 injection not only reduced inflammation but also improved locomotor function and pain in LSS model rats. Thus, Sh2 delivery via epidural injection has potential as an effective treatment option for LSS.
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Affiliation(s)
| | | | | | | | | | | | - In-Hyuk Ha
- Jaseng Spine and Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
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Rahimzadeh P, Imani F, Farahmand Rad R, Faiz SHR. Comparing the Efficacy of Transforaminal and Caudal Epidural Injections of Calcitonin in Treating Degenerative Spinal Canal Stenosis: A Double-Blind Randomized Clinical Trial. Anesth Pain Med 2024; 14:e142822. [PMID: 38725918 PMCID: PMC11078236 DOI: 10.5812/aapm-142822] [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] [Received: 11/07/2023] [Revised: 01/24/2024] [Accepted: 01/31/2024] [Indexed: 05/12/2024] Open
Abstract
Background Lumbar spinal stenosis (LSS) is the most common indication for lumbar surgery in elderly patients. Epidural injections of calcitonin are effective in managing LSS. Objectives This study aimed to compare the efficacy of transforaminal and caudal injections of calcitonin in patients with LSS. Methods In this double-blind randomized clinical trial, LSS patients were divided into two equal groups (N = 20). The first group received 50 IU (international units) of calcitonin via caudal epidural injection (CEI), and the second group received 50 IU of calcitonin via transforaminal epidural injection (TEI). The Visual Analogue Scale (VAS) and Oswestry Low Back Pain Disability Questionnaire (ODI) were used to assess the patient's pain and ability to stand, respectively. Visual Analogue Scale and ODI scores were recorded and analyzed. Results The results showed that caudal and TEIs of calcitonin significantly improved pain and ability to stand during follow-up compared to before intervention (P < 0.05). Additionally, CEI of calcitonin after 6 months significantly reduced pain in LSS patients compared to TEI of calcitonin (P < 0.05). However, no significant difference was observed between the two epidural injection techniques in improving the patient's ability to stand (P > 0.05). Conclusions The results of the study indicate that epidural injection of calcitonin in long-term follow-up (6 months) had a significant effect on improving pain intensity and mobility in patients with LSS, and its effect on pain in the TEI method was significantly greater than that in the CEI method.
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Affiliation(s)
- Poupak Rahimzadeh
- Department of Anesthesiology and Pain Medicine, Pain Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Farnad Imani
- Department of Anesthesiology and Pain Medicine, Pain Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Reza Farahmand Rad
- Department of Anesthesiology and Pain Medicine, Pain Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Hamid Reza Faiz
- Department of Anesthesiology and Pain Medicine, Minimally Invasive Surgery Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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Jang JN, Song Y, Kim JW, Kim YU. Comparison of ligamentum flavum thickness between central and lateral lesions in a patient with central lumbar spinal canal stenosis. Medicine (Baltimore) 2023; 102:e34873. [PMID: 37603515 PMCID: PMC10443754 DOI: 10.1097/md.0000000000034873] [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: 03/13/2023] [Accepted: 08/01/2023] [Indexed: 08/23/2023] Open
Abstract
Thickened ligamentum flavum has been considered as a major cause of central lumbar spinal canal stenosis (CLSCS). Previous studies have demonstrated that ligamentum flavum thickness (LFT) is correlated with aging, degenerative spinal stenosis, and disc degeneration. Thus, hypertrophy of the ligamentum flavum is a major cause of CLSCS, and measurement of LFT has been considered a morphologic parameter in the diagnosis of CLSCS. To our knowledge, comparison of LFT between central and lateral lesions has not been reported. In addition, no research has analyzed best clinical cutoff values of central ligament flavum thickness (CLFT) and lateral ligament flavum thickness (LLFT). This study aimed to compare CLFT with LLFT in patients with CLSCS and further compare the CLFT and LLFT findings between the 2 groups to analyze LFT variation. Both CLFT and LLFT samples were collected from 101 participants with CLSCS and from 103 participants in the control group who underwent lumbar magnetic resonance imaging without evidence of CLSCS. Axial T2-weighted lumbar magnetic resonance scans were acquired at the L4 to 5 facet joint level from each participant. Average CLFT value was 2.25 ± 0.51 mm in the control group and 4.02 ± 0.74 mm in the CLSCS group. Average LLFT value was 2.50 ± 0.51 mm in the control group and 3.38 ± 0.66 mm in the CLSCS group. CLSCS patients had significantly higher CLFT and LLFT (both P < .001). Regarding the validity of both CLFT and LLFT as predictors of CLSCS, a receiver operating characteristic estimation revealed that the most suitable cutoff value for CLFT was 3.10 mm, with sensitivity of 95.0%, specificity of 94.2%, and an area under the curve of 0.97. The best cut-off value of LLFT was 2.92 mm, with sensitivity of 78.2%, specificity of 77.7%, and area under the curve of 0.87. We have 4 important new findings: The mean CLFT is significantly lower than that of the mean LLFT in the normal control group; CLFT and LLFT are both significantly associated with CLSCS; Increase rate of CLFT is faster than that of LLFT in the CLSCS group; and CLFT is a more sensitive measurement parameter to predict CLSCS than LLFT.
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Affiliation(s)
- Jae Ni Jang
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International ST. Mary’s Hospital, Incheon, Republic of Korea
| | - Yumin Song
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International ST. Mary’s Hospital, Incheon, Republic of Korea
| | - Jae Won Kim
- Catholic Kwandong University of Korea College of Medicine, Gangneung, Republic of Korea
| | - Young Uk Kim
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University of Korea College of Medicine, International ST. Mary’s Hospital, Incheon, Republic of Korea
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Manakul P, Siribumrungwong K, Dhanachanvisith N. A Change in Global Sagittal Alignment after Transforaminal Epidural Steroid Injections in Lumbar Spinal Stenosis. J Clin Med 2023; 12:4727. [PMID: 37510841 PMCID: PMC10380783 DOI: 10.3390/jcm12144727] [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: 06/02/2023] [Revised: 07/12/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
Patients' functional adaptation to pain can affect global sagittal alignment. This study evaluated the short-term spinal sagittal alignment change after transforaminal epidural steroid injection (TFESI) in lumbar spinal stenosis patients. Patients with lumbar spinal stenosis who underwent TFESI were retrospectively examined. Clinical outcomes were assessed using the Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). Before and two weeks after the intervention, whole-spine lateral standing view radiographs were taken. Radiographic parameters including the Sagittal Vertical Axis (SVA), C2C7 Cobb, Thoracic Kyphosis (TK), Lumbar Lordosis (LL), Pelvic Incidence (PI), Pelvic Tilt (PT), Sacral Slope (SS), and Lumbopelvic Mismatch (PI-LL) were measured. Ninety-nine patients (mean age 64.3 ± 9.2 years) were included in this study. Both VAS and ODI outcomes were statistically improved after two weeks of intervention. Radiographic parameters showed that SVA, PT, and PI-LL mismatch were significantly decreased, while C2C7 Cobb, TK, SS, and LL were significantly increased after the intervention. SVA was improved by 29.81% (52.76 ± 52.22 mm to 37.03 ± 41.07 mm, p < 0.001). PT also decreased significantly from 28.71° ± 10.22° to 23.84° ± 9.96° (p < 0.001). Transforaminal epidural steroid injection (TFESI) significantly improves VAS, ODI, and global sagittal parameters in lumbar spinal stenosis patients.
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Affiliation(s)
- Park Manakul
- Department of Orthopedics, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand
| | - Koopong Siribumrungwong
- Chulabhorn International College of Medicine, Thammasat University, Pathum Thani 12120, Thailand
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Effect of repeated transforaminal epidural low-dose dexamethasone injections on glucose profiles of diabetic and non-diabetic patients with low back pain. J Anesth 2022; 37:261-267. [PMID: 36576588 DOI: 10.1007/s00540-022-03160-6] [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: 09/28/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE We aimed to investigate the effect of repeated transforaminal epidural low-dose dexamethasone injections on glucose profiles and pituitary-adrenal axis functions of diabetic and non-diabetic patients with low back pain. METHODS A total of 28 patients (ten diabetic [DM group] and 18 non-diabetic patients [non-DM group]) with low back pain were followed-up. Transforaminal epidural low-dose dexamethasone (1.65 mg) injections were repeated every 7-14 days for 8 weeks. Fasting blood sugar (FBS), hemoglobin A1c (HbA1c), morning plasma adrenocorticotropin (ACTH), and cortisol levels were measured at baseline and during the 8-week follow-up period. RESULTS There were no significant changes in FBS and HbA1c levels between baseline and 8-week follow-up period in both DM and non-DM groups (difference in FBS [95% confidence Interval, CI]: - 0.6 mg/dL [- 6.4, 5.1], p = 0.83 in the non-DM group, - 0.2 mg/dL [- 26.2, 25.8], p = 0.99 in the DM group; difference in HbA1c [95% CI] - 0.02% [- 0.1, 0.1], p = 0.69 in the non-DM group, 0.04% [- 0.3, 0.4], p = 0.79 in the DM group). There were no significant longitudinal changes in ACTH and cortisol levels (ACTH, p = 0.38 [baseline vs. 8 week], p = 0.58 [non-DM vs. DM]; cortisol, p = 0.52 [baseline vs. 8 week], p = 0.90 [non-DM vs. DM]). CONCLUSIONS Repeated transforaminal epidural low-dose dexamethasone injections provided no significant elevations in blood glucose or suppression of the pituitary-adrenal axis for two months from the first injection in both diabetic and non-diabetic patients. Our results indicate the intermediate-term safety of repeated transforaminal epidural low-dose dexamethasone injections with regard to the effect on glucose profile and pituitary-adrenal axis functions.
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Kim M, Cho S, Noh Y, Goh D, Son HJ, Huh J, Kang SS, Hwang B. Changes in pain scores and walking distance after epidural steroid injection in patients with lumbar central spinal stenosis. Medicine (Baltimore) 2022; 101:e29302. [PMID: 35713433 PMCID: PMC9276438 DOI: 10.1097/md.0000000000029302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 04/27/2022] [Indexed: 11/25/2022] Open
Abstract
Lumbar spinal stenosis is a common degenerative disorder that is characterized by pain and neurogenic claudication. Previous studies have evaluated the effects of an epidural steroid injection (ESI) on spinal stenosis, based on changes to the spinal canal diameter.This study aimed to examine the impact of the ESI on pain scores and walking distance in patients with lumbar central spinal stenosis, stratified based on disease severity, which was graded according to the degree of cauda equina separation.We reviewed the medical records of patients who received the ESI for lumbar spinal central canal stenosis. A total of 128 patients were divided into moderate and severe groups, based on the degree of cauda equina separation.Relative to baseline values, 2 weeks after the ESI, the moderate group showed a significant decrease in the numeric rating scale (NRS) scores and an increase in walking distance. Meanwhile, the severe group showed a significant decrease in the NRS scores and no significant change in walking distance. The moderate group had lower NRS scores and a longer walking distance than did the severe group 2 weeks after the ESI. The proportion of patients with improved levels of satisfaction was higher in the moderate group than in the severe group.Lumbar interlaminar ESI may reduce pain scores and increase walking distance in patients with moderate lumbar spinal central canal stenosis. Patients with moderate spinal stenosis achieved better outcomes than did patients with severe stenosis.
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Clinical and radiological outcomes following insertion of a novel removable percutaneous interspinous process spacer: an initial experience. Neuroradiology 2022; 64:1887-1895. [PMID: 35641830 DOI: 10.1007/s00234-022-02977-y] [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: 02/01/2022] [Accepted: 05/10/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate clinical and radiological outcomes of a series of patients treated with a removable percutaneous interspinous process spacer (IPS) (LobsterProject® Techlamed®) for symptomatic degenerative lumbar spinal stenosis (DLSS). METHODS All patients treated in two centres with this IPS during 2019 were retrospectively reviewed. Procedures were performed under deep sedation or general anaesthesia by two interventional radiologists. Patients were clinically evaluated before intervention and at 3-month follow-up with Visual Analog Scales for pain (VAS), Oswestry Disability Index (ODI) and radiologically with MRI or CT scans. Neural foramina were independently measured for each patient on pre- and post-procedural CT scans by two radiologists. RESULTS Fifty-nine patients were treated in the selected period of which fifty-eight had complete documentation (mean age 71.2 ± 9.2 years [55-92], 32 males, 26 females). Forty-eight interventions were performed under deep sedation and ten under general anaesthesia, without procedural complications. Clinical follow-up at 3 months showed a significant reduction of pain (VAS from 83 ± 9 to 29 ± 19, - 65%; p < 0.001) and an improvement in functional outcomes (ODI from 31 ± 12 to 13 ± 10%, - 58%; p < 0.001). There was one case of unsatisfactory positioning post procedure, two cases of posterior migration at 3-month follow-up and one case of spinous process fracture. Mean neural foramina area increased from 77 ± 23 to 95 ± 27 mm2 (+ 26%; p < 0.001) with very good inter-observer reliability (Cronbach's alpha = 0.899). CONCLUSION Percutaneous minimally invasive insertion of a removable IPS device demonstrates a favourable safety profile, good clinical outcomes at 3 months, and apparent anatomical increase in foraminal dimensions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05203666-Release Date: 21st January 2022, retrospectively registered.
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Pryzbylkowski P, Bux A, Chandwani K, Khemlani V, Puri S, Rosenberg J, Sukumaran H. Minimally invasive direct decompression for lumbar spinal stenosis: impact of multiple prior epidural steroid injections. Pain Manag 2021; 12:149-158. [PMID: 34344197 DOI: 10.2217/pmt-2021-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: A modified algorithm for the treatment of lumbar spinal stenosis with hypertrophic ligamentum flavum using minimally-invasive lumbar decompression (mild®)was assessed, with a focus on earlier intervention. Patients & methods: Records of 145 patients treated with mild after receiving 0-1 epidural steroid injections (ESIs) or 2+ ESIs were retrospectively reviewed. Pain assessments as measured by visual analog scale (VAS) scores were recorded at baseline and 1-week and 3-month follow-ups. Results: Improvements in VAS scores at follow-ups compared with baseline were significant in both groups. No statistically significant differences were found between the two groups. Conclusion: Multiple ESIs prior to mild showed no benefit. A modified algorithm to perform mild immediately upon diagnosis or after the failure of the first ESI is recommended.
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Affiliation(s)
- Peter Pryzbylkowski
- Relievus Pain Management, 3100 Hingston Ave. Suite 104, Egg Harbor Township, NJ 08234, USA
| | - Anjum Bux
- Ephraim McDowell Regional Medical Center, 230 West Main St., Danville, KY 40422, USA
| | - Kailash Chandwani
- UNC Health Southeastern, 4901 Dawn Dr. Suite 3300, Lumberton, NC 28358, USA
| | - Vishal Khemlani
- Columbia Pain Management, PC, 3601 Klindt Dr. Suite 200, The Dalles, OR 97058, USA
| | - Shawn Puri
- Relievus Pain Management, 9815 Roosevelt Blvd Suite J, Philadelphia, PA 19114, USA
| | - Jason Rosenberg
- SC Pain & Spine Specialists, 4731 Hwy 17 Bypass South, Murrells Inlet, SC 29576, USA
| | - Harry Sukumaran
- The Detroit Medical Center, 3990 John R, Box 162, Detroit, MI 48201, USA
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Awad M, Raouf MM, Mikhail HK, Megalla SA, Hamawy TY, Mohamed AH. Efficacy of transforaminal epidural magnesium administration when combined with a local anaesthetic and steroid in the management of lower limb radicular pain. Eur J Pain 2021; 25:1274-1282. [PMID: 33559245 DOI: 10.1002/ejp.1748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Lower limb radicular pain resulting from a herniated intervertebral disc is a cause of functional disability and could lead to increased consumption of opioids. We evaluated the efficacy of epidural magnesium combined with a local anaesthetic and steroid in the management of this pain. METHODS This was a prospective, case-control, randomized, double-blind study. Fifty patients each received 2 ml bupivacaine, 1 ml (40 mg) methylprednisolone and 1 ml saline (0.9%) (group C) or magnesium (200 mg) instead of saline (group M). The primary outcome measure was the improvement in the pain score (assessed using a visual analogue scale (VAS)), and the secondary outcome was the improvement in the functional ability (assessed using the Modified Oswestry Disability Questionnaire (MODQ)). The VAS and MODQ scores were assessed before and at 1 day, 1 week, 1 month and 3 months post-intervention. RESULTS The VAS and MODQ scores were significantly better in group M compared to those in group C at all times post-injection (p-value < 0.001). Comparisons within the same group showed that the VAS and MODQ scores were significantly better at all post-injection time points compared to the pre-injection scores in both group C and group M (p-values < 0.0001). CONCLUSIONS Adding magnesium to a local anaesthetic and steroid to be injected in the transforaminal epidural space could improve the pain and the quality of life in patients suffering from lower limb radicular pain due to lumbo-sacral disc herniation, and this improvement could last for up to 3 months. SIGNIFICANCE Magnesium is efficient when added to local anaesthetics and steroids for management of lower limb radicular pain.
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Affiliation(s)
- Mohammed Awad
- Anesthesia and Pain Management, Faculty of Medicine, Al-Fayoum Univeresity, Al-Fayoum, Egypt
| | - Mina M Raouf
- Faculty of medicine, ElMinia university, ElMinia, Egypt
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Srivastava MK, Gupta AK, Mishra SR, Kumar D, Ojha BK, Yadav G. Role of Epidural Steroid Injection in Lumbar Spinal Stenosis—A Randomized Controlled Trial. INDIAN JOURNAL OF NEUROSURGERY 2020. [DOI: 10.1055/s-0040-1719234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Abstract
Background Degenerative lumbar spinal stenosis (DLSS) is an important cause of pain and disability among the elderly and common indication for spinal surgery. However, due to age-related comorbidities, it becomes difficult for elderly patients of DLSS to immediately go for operative treatment. Caudal epidural steroid injection (CESI) can be an effective procedure for a selected group of patients who have chronic function-limiting lower back and lower extremity pain secondary to DLSS. The aim of this study was to compare the effects of CESI with physical therapy in patients afflicted with DLSS.
Materials and Methods It is a single center, open-label randomized controlled trial conducted in department of Physical Medicine and Rehabilitation at a tertiary care center of northern India from January 2016 to August 2017 among DLSS patients. Trial was registered under the clinical trial registry of India. Patients were randomized in two groups–32 in intervention group A (CESI with local anesthetic and physical therapy) and 32 in control group B (physical therapy alone). Outcome measures were numerical pain rating scale (NPRS), Oswestry disability index (ODI), and mean claudication distance (MCD) at 3, 6, 12, and 24 weeks.
Results NPRS and ODI showed significant improvement at 3, 6, 12, and 24 weeks (group A >> group B). Improvement in MCD was seen at each follow-up from baseline (group A >> group B).
Conclusion Caudal epidural steroid administration can ameliorate pain, disability and claudication distance in DLSS patients, which provides them a window period for further definitive management.
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Affiliation(s)
- Mohit Kishore Srivastava
- Department of Physical Medicine and Rehabilitation, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Anil Kumar Gupta
- Department of Physical Medicine and Rehabilitation, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Sudhir R. Mishra
- Department of Physical Medicine and Rehabilitation, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Dileep Kumar
- Department of Physical Medicine and Rehabilitation, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Bal Krishna Ojha
- Department of Neurosurgery, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Ganesh Yadav
- Department of Physical Medicine and Rehabilitation, King George’s Medical University, Lucknow, Uttar Pradesh, India
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Fornari M, Robertson SC, Pereira P, Zileli M, Anania CD, Ferreira A, Ferrari S, Gatti R, Costa F. Conservative Treatment and Percutaneous Pain Relief Techniques in Patients with Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations. World Neurosurg X 2020; 7:100079. [PMID: 32613192 PMCID: PMC7322792 DOI: 10.1016/j.wnsx.2020.100079] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/25/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Degenerative lumbar spinal stenosis (LSS) is a progressive disease with potentially dangerous consequences that affect quality of life. Despite the detailed literature, natural history is unpredictable. This uncertainty presents a challenge making the correct management decisions, especially in patients with mild to moderate symptoms, regarding conservative or surgical treatment. This article focused on conservative treatment for degenerative LSS. METHODS To standardize clinical practice worldwide as much as possible, the World Federation of Neurosurgical Societies Spine Committee held a consensus conference on conservative treatment for degenerative LSS. A team of experts in spinal disorders reviewed the literature on conservative treatment for degenerative LSS from 2008 to 2018 and drafted and voted on a number of statements. RESULTS During 2 consensus meetings, 14 statements were voted on. The Committee agreed on the use of physical therapy for up to 3 months in cases with no neurologic symptoms. Initial conservative treatment could be applied without major complications in these cases. In patients with moderate to severe symptoms or with acute radicular deficits, surgical treatment is indicated. The efficacy of epidural injections is still debated, as it shows only limited benefit in patients with degenerative LSS. CONCLUSIONS A conservative approach based on therapeutic exercise may be the first choice in patients with LSS except in the presence of significant neurologic deficits. Treatment with instrumental modalities or epidural injections is still debated. Further studies with standardization of outcome measures are needed to reach high-level evidence conclusions.
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Affiliation(s)
- Maurizio Fornari
- Neurosurgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Scott C. Robertson
- Neurosurgery Department, Laredo Medical Center, University of the Incarnate Word School of Osteopathic Medicine, Laredo, Texas, USA
| | - Paulo Pereira
- Department of Neurosurgery, University Hospital Center of São João and Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mehmet Zileli
- Department of Neurosurgery, Ege University Faculty of Medicine, Bornova, Izmir, Turkey
| | - Carla D. Anania
- Neurosurgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ana Ferreira
- Department of Neurosurgery, University Hospital Center of São João and Faculty of Medicine of the University of Porto, Porto, Portugal
| | | | | | - Francesco Costa
- Neurosurgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
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Diwan S, Sayed D, Deer TR, Salomons A, Liang K. An Algorithmic Approach to Treating Lumbar Spinal Stenosis: An Evidenced-Based Approach. PAIN MEDICINE 2020; 20:S23-S31. [PMID: 31808532 PMCID: PMC7101167 DOI: 10.1093/pm/pnz133] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Lumbar spinal stenosis (LSS) can lead to compression of the neural and vascular elements and is becoming more common due to degenerative changes that occur because of aging processes. Symptoms may manifest as pain and discomfort that radiates to the lower leg, thigh, and/or buttocks. The traditional treatment algorithm for LSS consists of conservative management (physical therapy, medication, education, exercise), often followed by epidural steroid injections (ESIs), and when nonsurgical treatment has failed, open decompression surgery with or without fusion is considered. In this review, the variables that should be considered during the management of patients with LSS are discussed, and the role of each treatment option to provide optimal care is evaluated. RESULTS This review leads to the creation of an evidence-based practical algorithm to aid clinicians in the management of patients with LSS. Special emphasis is directed at minimally invasive surgery, which should be taken into consideration when conservative management and ESI have failed.
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Affiliation(s)
- Sudhir Diwan
- Advanced Spine on Park Avenue, New York, NY 10022.,Albert Einstein College of Medicine, Pain Attending, Lenox Hill Hospital, New York, NY
| | - Dawood Sayed
- University of Kansas Medical Center, Kansas City, Kansas
| | - Timothy R Deer
- The Center for Pain Relief, Spine and Nerve Centers of the Virginias, Charleston, West Virginia, USA
| | | | - Kevin Liang
- Milestone Research Organization, San Diego, California, USA
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Cairns K, Deer T, Sayed D, van Noort K, Liang K. Cost-effectiveness and Safety of Interspinous Process Decompression (Superion). PAIN MEDICINE 2020; 20:S2-S8. [PMID: 31808529 PMCID: PMC6896024 DOI: 10.1093/pm/pnz245] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective There are several treatment options for patients suffering from lumbar spinal stenosis, including surgical and conservative care. Interspinous spacer decompression using the Superion device offers a less invasive procedure for patients who fail conservative treatment before traditional decompression surgery. This review assesses the current cost-effectiveness, safety, and performance of lumbar spinal stenosis treatment modalities compared with the Superion interspinous spacer procedure. Methods EMBASE and PubMed were searched to find studies reporting on the cost-effectiveness, safety, and performance of conservative treatment, including medicinal treatments, epidural injections, physical therapy, and alternative methods, as well as surgical treatment, including laminectomy, laminectomy with fusion, and interspinous spacer decompression. Results were supplemented with manual searches. Results Despite substantial costs, persistent conservative treatment (>12 weeks) of lumbar spinal stenosis showed only minimal improvement in pain and functionality. When conservative treatment fails, surgery is more effective than continuing conservative treatment. Lumbar laminectomy with fusion has considerably greater cost than laminectomy alone, as the length of hospital stay increases, the costs for implants are substantial, and complications increase. Although laminectomy and the Superion have comparable outcomes, the Superion implant is positioned percutaneously. This approach may minimize the direct and indirect costs of outpatient rehabilitation and absenteeism, respectively. Conclusions Superion interspinous lumbar decompression is a minimally invasive procedure for patients with lumbar spinal stenosis who have failed conservative treatment. Compared with extending conservative treatment or traditional spinal surgery, interspinous lumbar decompression reduces the direct and indirect costs associated with lumbar spinal stenosis.
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Affiliation(s)
- Kevin Cairns
- Florida Spine Specialists, Nova Southeastern University, Fort Lauderdale, Florida
| | - Tim Deer
- The Center for Pain Relief, Spine and Nerve Centers of The Virginias, Charleston, West Virginia
| | - Dawood Sayed
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Kevin Liang
- MileStone Research Organization, San Diego, California, USA
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Sabbaghan S, Mirzamohammadi E, Ameri Mahabadi M, Nikouei F, Rahbarian F, Ahmadichaboki S, Eftekhari S, Zamankhani M, Aghaie Aghdam A. Short-Term Efficacy of Epidural Injection of Triamcinolone Through Translaminar Approach for the Treatment of Lumbar Canal Stenosis. Anesth Pain Med 2020; 10:e99764. [PMID: 32337171 PMCID: PMC7158243 DOI: 10.5812/aapm.99764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/09/2020] [Accepted: 02/13/2020] [Indexed: 12/20/2022] Open
Abstract
Background Epidural steroid injection is a non-operative minimally invasive procedure for pain relief in spinal canal stenosis. However, there is no significant consensus regarding its efficacy. Objectives In this study, we aimed to evaluate the effectiveness of translaminar injection of triamcinolone in lumbar canal stenosis. Methods In a retrospective study, we included 111 patients with MRI-confirmed spinal canal stenosis who were irresponsive to 12 weeks of conservative treatment and underwent epidural injection of triamcinolone through the translaminar approach. Outcome measures were routinely checked before the intervention and four weeks after the intervention, which included the Visual Analog scale (VAS) for low back pain, VAS for lower-limb pain, and Oswestry Disability index (ODI). Results The study population included 32 (28.8%) males and 79 (71.2%) females with the mean age of 61 ± 13.4 years. The mean ODI, VAS for low back pain, and VAS for lower-limb pain significantly improved at the final evaluation session (P < 0.001, P = 0.001, and P < 0.001, respectively). The levels of improvement in ODI, VAS for low back pain, and VAS for lower-limb pain were considerably more in patients with single-level involvement (P < 0.001, P = 0.04, and P < 0.001, respectively). Improvement of lower-limb VAS was negatively correlated with age (r = -0.400, P < 0.001) and BMI (r = -0.525, P < 0.001). The ODI improvement was also negatively correlated with BMI (r = -0.569, P < 0.001). Conclusions Epidural injection of triamcinolone through the translaminar approach could be regarded as an efficacious method for the alleviation of pain and disability in patients with spinal canal stenosis.
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Affiliation(s)
- Saeed Sabbaghan
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Elham Mirzamohammadi
- Occupational Medicine, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Ameri Mahabadi
- Department of Forensic Medicine and Toxicology, Iran University of Medical Sciences, Tehran, Iran
| | - Farshad Nikouei
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Farhad Rahbarian
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Susan Ahmadichaboki
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Samira Eftekhari
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Zamankhani
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Amir Aghaie Aghdam
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran.
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15
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Merkow J, Varhabhatla N, Manchikanti L, Kaye AD, Urman RD, Yong RJ. Minimally Invasive Lumbar Decompression and Interspinous Process Device for the Management of Symptomatic Lumbar Spinal Stenosis: a Literature Review. Curr Pain Headache Rep 2020; 24:13. [PMID: 32072362 DOI: 10.1007/s11916-020-0845-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Symptomatic lumbar spinal stenosis (LSS) is a condition affecting a growing number of individuals resulting in significant disability and pain. Traditionally, treatment options have consisted of conservative measures such as physical therapy, medication management, epidural injections and percutaneous adhesiolysis, or surgery. There exists a treatment gap for patients failing conservative measures who are not candidates for surgery. Minimally invasive lumbar decompression (MILD®) and interspinous process device (IPD) with Superion® represent minimally invasive novel treatment options that may help fill this gap in management. We performed a literature review to separately evaluate these procedures and assess the effectiveness and safety. RECENT FINDINGS The available evidence for MILD and Superion has been continuously debated. Overall, it is considered that while the procedures are safe, there is only modest evidence for effectiveness. For both procedures, we have reviewed 13 studies. Based on the available evidence, MILD and Superion are safe and modestly effective minimally invasive procedures for patients with symptomatic LSS. It is our recommendation that these procedures may be incorporated as part of the continuum of treatment options for patients meeting clinical criteria.
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Affiliation(s)
- Justin Merkow
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Narayana Varhabhatla
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Alan D Kaye
- Department of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA.
| | - R Jason Yong
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA
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Usefulness of the Inferior Articular Process's Cross-Sectional Area as a Morphological Parameter for Predicting Central Lumbar Spinal Stenosis. J Clin Med 2020; 9:jcm9010214. [PMID: 31941110 PMCID: PMC7019757 DOI: 10.3390/jcm9010214] [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: 11/29/2019] [Revised: 12/27/2019] [Accepted: 01/08/2020] [Indexed: 11/23/2022] Open
Abstract
Hypertrophy of facet joints is associated with a high risk of central lumbar spinal stenosis (CLSS). However, no research has reported the effect of inferior articular process hypertrophy in CLSS. We hypothesize that the inferior articular process’s cross-sectional area (IAPCSA) is larger in patients with CLSS compared to those without CLSS. Data on IAPCSA were obtained from 116 patients with CLSS. A total of 102 control subjects underwent lumbar spine magnetic resonance imaging (LS-MRI) as part of a routine medical examination. Axial T1-weighted images were obtained from the two groups. Using an imaging analysis system, we investigated the cross-sectional area of the inferior articular process. The average IAPCSA was 70.97 ± 13.02 mm2 in control subjects and 88.77 ± 18.52 mm2 in patients with CLSS. CLSS subjects had significantly greater levels of IAPCSA (p < 0.001) than controls. A receiver operating characteristic (ROC) curve was plotted to determine the validity of IAPCSA as a predictor of CLSS. The most suitable cut-off point of IAPCSA for predicting CLSS was 75.88 mm2, with a sensitivity of 71.6%, a specificity of 68.6%, and an area under the curve (AUC) of 0.78 (95% CI: 0.72–0.84). Greater IAPCSA levels were associated with a higher incidence of CLSS. These results demonstrate that IAPCSA is a useful morphological predictor in the evaluation of CLSS.
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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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18
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Hashemi M, Dadkhah P, Taheri M, Ghasemi M, Hosseinpour A, Farjam M. Patient-Reported Outcomes and Satisfaction after Cervical Epidural Steroid Injection for Cervical Radiculopathy. Galen Med J 2019; 8:e1478. [PMID: 34466515 PMCID: PMC8343784 DOI: 10.31661/gmj.v8i0.1478] [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: 01/08/2019] [Revised: 02/10/2019] [Accepted: 03/15/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Cervical radiculopathy caused by disc herniation is a frequent public health issue with economical and socio-professional impacts. The objective of the present study is to evaluate the patient-reported outcomes and satisfaction from cervical epidural steroid injection during a 2-year follow-up. MATERIALS AND METHODS Results based on patients' reports from a previously performed intervention of cervical epidural steroid injection on patients with cervical radiculopathy due to cervical disc herniation are prospectively collected. Outcome measures are Neck Disability Index (NDI), numerical rating scale (NRS) for pain assessment, and 5-scale patient satisfaction questionnaire (PSQ) plus opioid medication for pain relief, additional injections, and progression to surgery. RESULTS Of total 37 cases, 34 were available for follow-up after 2-year postoperatively. The mean preoperative NDI was 21.17 and improved to 17.38, and the mean NRS was 7.7 and improved to 5.00; both were statistically significant. Mean patient satisfaction after 2 years was 3.17 out of 5. 11 cases needed additional injections, and 4 of patients proceeded to surgery. CONCLUSION We showed that transforaminal cervical epidural steroid injection for cervical radiculopathy is an effective non-surgical treatment option, providing significant pain relief and functional improvement during 2-years follow-up along with higher-than-average patient satisfaction in most of our patients.
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Affiliation(s)
- Masoud Hashemi
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Payman Dadkhah
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Taheri
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahshid Ghasemi
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Hosseinpour
- Non-Communicable Disease Research Center, Fasa University of Medical Sciences, Fasa, Fars, Iran
| | - Mojtaba Farjam
- Non-Communicable Disease Research Center, Fasa University of Medical Sciences, Fasa, Fars, Iran
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19
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Hashemi M, Dadkhah P, Taheri M, Ghasemi M, Hosseinpour A. Lumbar Transforaminal Epidural Steroid Injection in Patients with Lumbar Radicular Pain; Outcome Results of 2-Year Follow-Up. Bull Emerg Trauma 2019; 7:144-149. [PMID: 31198803 PMCID: PMC6555206 DOI: 10.29252/beat-070209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Objective To evaluate the effectiveness of transforaminal lumbar epidural steroid injections (TFESI) in patients with unilateral radiculopathy due to lumbar intervertebral disc protrusion regarding pain intensity, functional disability, current opioid intake and patients' satisfaction. Methods The study is conducted in a pain management center (Tehran, Iran), during 2018. Inclusion criteria were age ≥18 years, radiculopathy for more than 6 months due to imagine-proved lumbar intervertebral disc protrusion and no response to conservative treatments. Exclusion criteria were spinal canal stenosis, lumbar surgery, and inability to communicate in Persian language. During a phone call interview, cases were instructed to rate their pain intensity according to the visual analogue scale (VAS), functional ability, satisfaction according to the patient satisfaction score (PSQ) and report current opioid use and additional injection and/or surgery. Results Forty-three (89.5%) of the 48 subjects were reachable for study with mean age of 59.14 years and 16 subjects were men (37.2 %). Mean VAS after intervention was 4.67 and before the intervention was 6.91 (p=0.002). Mean functional disability before intervention was 47.23 and after intervention was 37 (p<0.001). Mean patient satisfaction score was 3.07 while 18 cases reported a PSQ level ≥4. 10 cases reported using opioid for analgesia, 23 cases reported receiving additional TFESIs and 11 reported having undergone lumbar surgery. Conclusion Lumbar Epidural steroid injection is an effective non-surgical treatment option with regard to pain relief and improvement in functional ability with an average patients' satisfaction during 2 years follow up although nearly 25% of patients may need additional injections and half of the patients may finally proceed to surgery.
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Affiliation(s)
- Masoud Hashemi
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Payman Dadkhah
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Taheri
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahshid Ghasemi
- Department of Anesthesiology, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Hosseinpour
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Non-communicable disease research center, Fasa University of Medical Sciences, Fasa, Iran
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20
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Smith GA, Pace J, Strohl M, Kaul A, Hayek S, Miller JP. Rare Neurosurgical Complications of Epidural Injections: An 8-Yr Single-Institution Experience. Oper Neurosurg (Hagerstown) 2019; 13:271-279. [PMID: 28927205 DOI: 10.1093/ons/opw014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 10/22/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Neurosurgical complications from epidural injections have rarely been reported. OBJECTIVE To define the spectrum of complications from these procedures in order to identify risk factors and strategies for prevention. METHODS A prospectively maintained database of 14 247 neurosurgical admissions over 8 yr was screened to identify patients who had suffered procedural complications associated with 1182 cervical and 4617 lumbar interlaminar epidural injection procedures performed at a single institution. Patients who developed new neurological symptoms or deficits were included. A retrospective analysis of demographic and procedural features was performed. RESULTS Thirteen patients experienced complications requiring neurosurgical treatment, accounting for an overall procedural complication rate of 0.22% (0.51% and 0.15% for cervical and lumbar injections, respectively), and representing 0.09% of all neurosurgical admissions over 8 yr. There were 3 categories: hemorrhage (n = 7), infection (n = 3), and inadvertent dural penetration (n = 3). There was significant association with anticoagulation use among patients with hemorrhagic vs nonhemorrhagic complications ( P < .01, Fisher's exact test). Six patients who developed epidural hematoma had been managed in accordance with current guidelines, either after prolonged cessation of anticoagulation (n = 3) or taking only aspirin (n = 3); all were decompressed promptly with good long-term outcome. All infections were associated with lumbar injection. Dural penetration resulted in diffuse pneumocephalus (n = 1), intramedullary air at the site of injection (n = 1), and acutely symptomatic colloid cyst (n = 1). CONCLUSION A majority of neurosurgical complications from epidural injections are hemorrhagic and associated with anticoagulation, although infection and inadvertent dural penetration also occur. Prompt treatment of compressive lesions is associated with good outcome.
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Affiliation(s)
- Gabriel A Smith
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Jonathan Pace
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Madeleine Strohl
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Anand Kaul
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Salim Hayek
- Division of Pain Medicine, Depart-ment of Anesthesiology, University Hospi-tals Case Medical Center, Cleveland, Ohio
| | - Jonathan P Miller
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
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21
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Przkora R, Kinsky MP, Fisher SR, Babl C, Heyde CE, Vasilopoulos T, Kaye AD, Volpi E. Functional Improvements Utilizing the Short Physical Performance Battery (SPPB) in the Elderly after Epidural Steroid Injections. Curr Pain Headache Rep 2019; 23:14. [PMID: 30796532 DOI: 10.1007/s11916-019-0748-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW The treatment of debilitating pain and loss of function secondary to lumbar stenosis is in high demand with the aging patient population. Options, including epidural steroid injections (ESIs) and medication therapy, are limited and it is unclear if they provide any functional improvements. In this prospective study, we evaluate functional outcomes in older adults with symptomatic lumbar stenosis treated with ESIs compared to those managed with medications by introducing the Short Physical Performance Battery (SPPB). Our study was IRB-approved and included 16 patients, 68 to 83 years old, with symptomatic back and radicular leg pain secondary to lumbar stenosis. Patients could elect to undergo a lumbar ESI (n = 11) or be treated via medication management (n = 5). Numeric pain score, SPPB score, and adverse events were measured and compared at baseline and a 1-month follow-up visit. RECENT FINDINGS Statistically significant improvements were observed from baseline compared to the 1-month follow-up for total SPPB score in the injection group. Similar improvements in the injection group were observed for pain scores and the SPPB subcomponents such as the 4-m walk test, chair stand time, and balance score. Comparatively, no statistically significant improvements were observed in the medication group. Lumbar ESIs improved objective physical capacity parameters and pain scores in elderly patients with symptomatic lumbar stenosis compared to medication management. In addition, the SPPB is an easy-to-use tool to measure changes in physical function in older adults and could easily be integrated into an outpatient pain clinic.
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Affiliation(s)
- Rene Przkora
- Department of Anesthesiology, University of Florida College of Medicine, SW Archer Road, PO Box 100254, Gainesville, FL, 32610, USA.
| | - Michael P Kinsky
- Departments of Anesthesiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Steve R Fisher
- Departments of Physical Therapy, University of Texas Medical Branch, Galveston, TX, USA
| | - Christopher Babl
- Department of Anesthesiology, University of Florida College of Medicine, SW Archer Road, PO Box 100254, Gainesville, FL, 32610, USA
| | - Christoph E Heyde
- Department of Orthopaedic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Terrie Vasilopoulos
- Department of Anesthesiology, University of Florida College of Medicine, SW Archer Road, PO Box 100254, Gainesville, FL, 32610, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Elena Volpi
- Internal Medicine-Geriatrics, University of Texas Medical Branch, Galveston, TX, 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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23
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Deer TR, Grider JS, Pope JE, Falowski S, Lamer TJ, Calodney A, Provenzano DA, Sayed D, Lee E, Wahezi SE, Kim C, Hunter C, Gupta M, Benyamin R, Chopko B, Demesmin D, Diwan S, Gharibo C, Kapural L, Kloth D, Klagges BD, Harned M, Simopoulos T, McJunkin T, Carlson JD, Rosenquist RW, Lubenow TR, Mekhail N. The MIST Guidelines: The Lumbar Spinal Stenosis Consensus Group Guidelines for Minimally Invasive Spine Treatment. Pain Pract 2018; 19:250-274. [PMID: 30369003 DOI: 10.1111/papr.12744] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 10/11/2018] [Accepted: 10/18/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lumbar spinal stenosis (LSS) can lead to compression of neural elements and manifest as low back and leg pain. LSS has traditionally been treated with a variety of conservative (pain medications, physical therapy, epidural spinal injections) and invasive (surgical decompression) options. Recently, several minimally invasive procedures have expanded the treatment options. METHODS The Lumbar Spinal Stenosis Consensus Group convened to evaluate the peer-reviewed literature as the basis for making minimally invasive spine treatment (MIST) recommendations. Eleven consensus points were clearly defined with evidence strength, recommendation grade, and consensus level using U.S. Preventive Services Task Force criteria. The Consensus Group also created a treatment algorithm. Literature searches yielded 9 studies (2 randomized controlled trials [RCTs]; 7 observational studies, 4 prospective and 3 retrospective) of minimally invasive spine treatments, and 1 RCT for spacers. RESULTS The LSS treatment choice is dependent on the degree of stenosis; spinal or anatomic level; architecture of the stenosis; severity of the symptoms; failed, past, less invasive treatments; previous fusions or other open surgical approaches; and patient comorbidities. There is Level I evidence for percutaneous image-guided lumbar decompression as superior to lumbar epidural steroid injection, and 1 RCT supported spacer use in a noninferiority study comparing 2 spacer products currently available. CONCLUSIONS MISTs should be used in a judicious and algorithmic fashion to treat LSS, based on the evidence of efficacy and safety in the peer-reviewed literature. The MIST Consensus Group recommend that these procedures be used in a multimodal fashion as part of an evidence-based decision algorithm.
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Affiliation(s)
- Timothy R Deer
- Center for Pain Relief, Charleston, West Virginia, U.S.A
| | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, Kentucky, U.S.A
| | - Jason E Pope
- Evolve Restorative Clinic, Santa Rosa, California, U.S.A
| | - Steven Falowski
- Functional Neurosurgery, St. Lukes University Health Network, Bethlehem, Pennsylvania, U.S.A
| | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | | | - David A Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania, U.S.A
| | - Dawood Sayed
- University of Kansas Medical Center, Kansas City, Kansas, U.S.A
| | - Eric Lee
- Summit Pain Alliance, Sonoma, California, U.S.A
| | - Sayed E Wahezi
- Montefiore Medical Center, SUNY-Buffalo, Buffalo, New York, U.S.A
| | - Chong Kim
- Center for Pain Relief, Charleston, West Virginia, U.S.A
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, New York, U.S.A
| | - Mayank Gupta
- Anesthesiology and Pain Medicine, HCA Midwest Health, Overland Park, Kansas, U.S.A
| | - Rasmin Benyamin
- Millennium Pain Center, Bloomington, Illinois, U.S.A.,College of Medicine, University of Illinois, Urbana-Champaign, Illinois, U.S.A
| | | | - Didier Demesmin
- Rutgers Robert Wood Johnson Medical School, Department of Pain Medicine, Saint Peter's University Hospital, New Brunswick, New Jersey, U.S.A
| | - Sudhir Diwan
- Manhattan Spine and Pain Medicine, Lenox Hill Hospital, New York, New York, U.S.A
| | - Christopher Gharibo
- Pain Medicine and Orthopedics, NYU Langone Hospitals Center, New York, New York, U.S.A
| | - Leo Kapural
- Carolina's Pain Institute at Brookstown, Wake Forest Baptist Health, Winston-Salem, North Carolina, U.S.A
| | - David Kloth
- Department of Anesthesiology, Danbury Hospital, Danbury, Connecticut, U.S.A
| | - Brian D Klagges
- Anesthesiology and Pain Medicine, Amoskeag Anesthesiology, Manchester, New Hampshire, U.S.A
| | - Michael Harned
- Department of Anesthesiology, University of Kentucky, Lexington, Kentucky, U.S.A
| | - Tom Simopoulos
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | | | | | | | | | - Nagy Mekhail
- Evidence-Based Pain Management Research and Education, Cleveland Clinic, Cleveland, Ohio, U.S.A
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Comparison of clinical efficacy of transforaminal and caudal epidural steroid injection in lumbar and lumbosacral disc herniation: A systematic review and meta-analysis. Spine J 2018; 18:2343-2353. [PMID: 30030083 DOI: 10.1016/j.spinee.2018.06.720] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 06/06/2018] [Accepted: 06/06/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND CONTEXT Epidural steroid injection has been used to treat back or radicular pain from lumbar and lumbosacral disc herniation (LDH). However, the superiority of transforaminal injection (TFESI) to caudal injection (CESI) remains controversial. PURPOSE This systematic review and meta-analysis aimed to investigate whether TFESI was more useful than CESI for achieving clinical outcomes in patients with LDH. STUDY DESIGN/SETTING A systematic review and/or is not appropriate. A systematic review and meta-analysis. Spine hospital and tertiary care hospital. PATIENT SAMPLE Articles were chosen that compared the clinical efficacy of TFESI and CESI for treatment of low back and radicular leg pain caused by LDH. OUTCOMES MEASURES Visual analogue scale, numeric rating scale, and Oswestry disability index. METHODS A literature search was performed using MEDLINE, EMBASE, Cochrane review, and KoreaMed databases for studies published until July 2017. After reviewing titles, abstracts, and full-texts of 6,711 studies after initial database search, six studies were included in a qualitative synthesis. Data including pain score, functional score, and follow-up period were extracted from four studies and were analyzed using a random effects model to obtain effect size and its statistical significance. Quality assessment and evidence level were established in accordance with the grading of recommendations assessment, development and evaluation methodology. RESULTS Among six studies, four articles supported the superiority of TFESI to CESI, one article showed no significant difference, and one article supported the superiority of CESI to TFESI. To obtain compatible or superior clinical results to TFESI, CESI might need to inject a larger amount of medication than was usually used. A meta-analysis showed short-term and long-term trends toward better clinical efficacy with TFESI than with CESI without statistical significance. The evidence level was low because of inconsistency and imprecision. CONCLUSIONS Comprehensive reviews of selected articles revealed better clinical benefits with TFESI than with CESI, possibly because TFESI had the ability to deliver medication directly into the target area. Because of a low level of evidence and no significant results on meta-analysis, TFESI could be weakly recommended over CESI.
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Abstract
Chronic low back pain (LBP) places a tremendous economic burden on society due to both direct and indirect costs. Health care costs for adults with chronic LBP have steadily increased over the past 20 years, coinciding with a large increase in the utilization of spinal injections, surgical interventions, opioid medications, and physical therapy. The treatment of LBP is best approached by a multimodal and even multidisciplinary approach with a combination of physical rehabilitation, pharmacologic management, psychological intervention, spinal injections, and surgical intervention with a goal of improving the functional status of the patient. In this review, we discuss the interventional management of LBP secondary to herniated nucleus pulposus, spinal stenosis, facet mediated pain, sacroiliitis, and discogenic pain.
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Manchikanti L, Manchikanti KN, Kaye AD, Kaye AM, Hirsch JA. Challenges and concerns of persistent opioid use in cancer patients. Expert Rev Anticancer Ther 2018; 18:705-718. [PMID: 29739242 DOI: 10.1080/14737140.2018.1474103] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION As a result of advancements in the diagnosis and treatment of cancer, two-thirds of individuals suffering with cancer survive more than 5 years after diagnosis, resulting in a large proportion of patients with chronic cancer pain alone or associated with chronic noncancer pain. There is a paucity of literature in reference to diagnosis and management of chronic cancer pain, specifically in relation to persistent opioid use, its effectiveness, and adverse consequences. Areas covered: This review covers the prevalence of chronic cancer pain and its association with multiple comorbidities, persistent opioid use and related consequences, and challenges in managing persistent chronic cancer pain patients. In addition, discussion includes therapeutic opioid use, effectiveness of opioid therapy, assessment of risk of persistent opioid use, and guidance for responsible, persistent opioid prescribing for chronic cancer pain patients. Expert commentary: Despite extensive availability of opioids and related common adverse consequences, including the potential for escalating use, abuse, and deaths, greater awareness is needed to counteract the present atmosphere and appropriately manage patients with chronic cancer pain. Chronic cancer pain is a complex biopsychosocial phenomenon with multiple comorbidities. Opioid therapy has become extremely complex with negative connotations related to escalating abuse and related deaths.
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Affiliation(s)
- Laxmaiah Manchikanti
- a Department of Anesthesiology and Perioperative Medicine , Pain Management Center of Paducah , Paducah , KY , USA.,b Anesthesiology and Perioperative Medicine , University of Louisville , Louisville , KY , USA.,c Department of Anesthesiology , School of Medicine, LSU Health Sciences Center , New Orleans , LA , USA
| | - Kavita N Manchikanti
- a Department of Anesthesiology and Perioperative Medicine , Pain Management Center of Paducah , Paducah , KY , USA
| | - Alan D Kaye
- c Department of Anesthesiology , School of Medicine, LSU Health Sciences Center , New Orleans , LA , USA.,d Department of Pharmacology , LSU Health Science Center , New Orleans , LA , USA
| | - Adam M Kaye
- e Thomas J. Long School of Pharmacy and Health Sciences , University of the Pacific , Stockton , CA , USA
| | - Joshua A Hirsch
- f Harvard Medical School , Massachusetts General Hospital , Boston , MA , USA
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Nascene DR, Ozutemiz C, Estby H, McKinney AM, Rykken JB. Transforaminal Lumbar Puncture: An Alternative Technique in Patients with Challenging Access. AJNR Am J Neuroradiol 2018; 39:986-991. [PMID: 29567652 DOI: 10.3174/ajnr.a5596] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 01/24/2018] [Indexed: 12/17/2022]
Abstract
Interlaminar lumbar puncture and cervical puncture may not be ideal in all circumstances. Recently, we have used a transforaminal approach in selected situations. Between May 2016 and December 2017, twenty-six transforaminal lumbar punctures were performed in 9 patients (25 CT-guided, 1 fluoroscopy-guided). Seven had spinal muscular atrophy and were referred for intrathecal nusinersen administration. In 2, CT myelography was performed via transforaminal lumbar puncture. The lumbar posterior elements were completely fused in 8, and there was an overlying abscess in 1. The L1-2 level was used in 2; the L2-3 level, in 10; the L3-4 level, in 12; and the L4-5 level, in 2 procedures. Post-lumbar puncture headache was observed on 4 occasions, which resolved without blood patching. One patient felt heat and pain at the injection site that resolved spontaneously within hours. One patient had radicular pain that resolved with conservative treatment. Transforaminal lumbar puncture may become an effective alternative to classic interlaminar lumbar puncture or cervical puncture.
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Affiliation(s)
- D R Nascene
- From the Department of Radiology (D.R.N., C.O., A.M.M., J.B.R.), Neuroradiology Section, University of Minnesota, Minneapolis, Minnesota
| | - C Ozutemiz
- From the Department of Radiology (D.R.N., C.O., A.M.M., J.B.R.), Neuroradiology Section, University of Minnesota, Minneapolis, Minnesota
| | - H Estby
- University of Minnesota Medical School (H.E.), Minneapolis, Minnesota
| | - A M McKinney
- From the Department of Radiology (D.R.N., C.O., A.M.M., J.B.R.), Neuroradiology Section, University of Minnesota, Minneapolis, Minnesota
| | - J B Rykken
- From the Department of Radiology (D.R.N., C.O., A.M.M., J.B.R.), Neuroradiology Section, University of Minnesota, Minneapolis, Minnesota
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Kwon JW, Kim SJ. The role of epidural contrast distribution in predicting the effectiveness of steroid and local anesthetic injection in patients with lumbar spinal stenosis. J Back Musculoskelet Rehabil 2018; 31:75-83. [PMID: 28759948 DOI: 10.3233/bmr-169674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN A prospective observational comparative study. BACKGROUND Because epidural corticosteroids are more effective for pain relief when delivered close to the site of pathology, lumbar spinal stenosis with multilevel stenotic areas can be treated more effectively when medications cover all of the stenotic areas. Distribution of medications to the pathologic sites is considered an important factor in the effectiveness of inter-laminar epidural injection. OBJECTIVE To determine whether spread of a lidocaine and triamcinolone mixture over the stenotic areas improves clinical symptom of spinal stenosis more effectively. METHODS Twenty-four patients with lumbar spinal stenosis were enrolled in this study. A lumbar inter-laminar epidural injection under fluoroscopic guidance was administered to each patient. A numeric rating scale (NRS), claudication distance, the Romberg test, and the Oswestry Disability Index (ODI) were checked pre-injection and at 2, 6, and 12 weeks after the epidural injection. Vertebrae that showed more than moderate stenosis were considered stenosis levels. Inter-laminar epidural injection was performed with radiopaque contrast and lidocaine mixed with triamcinolone acetate. When the contrast covered all of the stenosis levels, this was considered a sufficient distribution (SD) and when the contrast did not cover all stenosis levels, this was considered an insufficient distribution (ID). RESULTS At 2 weeks, percentages of NRS improvement were 71.4 (IQR, 20.2) in SD group and 50.0 (IQR, 31.4) in ID group (P= 0.02), changes in Romberg test time were 0.0 (IQR, 35.0) in SD group and -3.0 (IQR, 12.0) in ID group (P= 0.02), decreases in ODI were 9.6 (IQR, 11.2) in SD group and 0.0 (IQR, 7.8) in ID group (P= 0.02). However, these parameters were not significantly different at 6 weeks and 12 weeks. Claudication distance showed no significant group difference. CONCLUSION Coverage of the stenotic area by the lidocaine, triamcinolone, and contrast dye mixture during inter-laminar epidural injection was an important predictor of acute pain reduction.
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Affiliation(s)
- Jong Won Kwon
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Jun Kim
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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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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Pesteie M, Lessoway V, Abolmaesumi P, Rohling RN. Automatic Localization of the Needle Target for Ultrasound-Guided Epidural Injections. IEEE TRANSACTIONS ON MEDICAL IMAGING 2018; 37:81-92. [PMID: 28809679 DOI: 10.1109/tmi.2017.2739110] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Accurate identification of the needle target is crucial for effective epidural anesthesia. Currently, epidural needle placement is administered by a manual technique, relying on the sense of feel, which has a significant failure rate. Moreover, misleading the needle may lead to inadequate anesthesia, post dural puncture headaches, and other potential complications. Ultrasound offers guidance to the physician for identification of the needle target, but accurate interpretation and localization remain challenges. A hybrid machine learning system is proposed to automatically localize the needle target for epidural needle placement in ultrasound images of the spine. In particular, a deep network architecture along with a feature augmentation technique is proposed for automatic identification of the anatomical landmarks of the epidural space in ultrasound images. Experimental results of the target localization on planes of 3-D as well as 2-D images have been compared against an expert sonographer. When compared with the expert annotations, the average lateral and vertical errors on the planes of 3-D test data were 1 and 0.4 mm, respectively. On 2-D test data set, an average lateral error of 1.7 mm and vertical error of 0.8 mm were acquired.
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Lim YS, Mun JU, Seo MS, Sang BH, Bang YS, Kang KN, Koh JW, Kim YU. Dural sac area is a more sensitive parameter for evaluating lumbar spinal stenosis than spinal canal area: A retrospective study. Medicine (Baltimore) 2017; 96:e9087. [PMID: 29245329 PMCID: PMC5728944 DOI: 10.1097/md.0000000000009087] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Narrowing of the dural sac cross-sectional area (DSCSA) and spinal canal cross-sectional area (SCCSA) have been considered major causes of lumbar central canal spinal stenosis (LCCSS). DSCSA and SCCSA were previously correlated with subjective walking distance before claudication occurs, aging, and disc degeneration. DSCSA and SCCSA have been ideal morphological parameters for evaluating LCCSS. However, the comparative value of these parameters is unknown and no studies have evaluated the clinical optimal cut-off values of DSCSA and SCCSA. This study assessed which parameter is more sensitive.Both DSCSA and SCCSA samples were collected from 135 patients with LCCSS, and from 130 control subjects who underwent lumbar magnetic resonance imaging (MRI) as part of a medical examination. Axial T2-weighted MRI scans were acquired at the level of facet joint from each subject. DSCSA and SCCSA were measured at the L4-L5 intervertebral level on MRI using a picture archiving and communications system.The average DSCSA value was 151.67 ± 53.59 mm in the control group and 80.04 ± 35.36 mm in the LCCSS group. The corresponding average SCCSA values were 199.95 ± 60.96 and 119.17 ± 49.41 mm. LCCSS patients had significantly lower DSCSA and SCCSA (both P < .001). Regarding the validity of both DSCSA and SCCSA as predictors of LCCSS, Receiver operating characteristic curve analysis revealed an optimal cut-off value for DSCSA of 111.09 mm, with 80.0% sensitivity, 80.8% specificity, and an area under the curve (AUC) of 0.87 (95% confidence interval, 0.83-0.92). The best cut off-point of SCCSA was 147.12 mm, with 74.8% sensitivity, 78.5% specificity, and AUC of 0.85 (95% confidence interval, 0.81-0.89).DSCSA and SCCSA were both significantly associated with LCCSS, with DSCSA being a more sensitive measurement parameter. Thus, to evaluate LCCSS patients, pain specialists should more carefully investigate the DSCSA than SCCSA.
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Affiliation(s)
- Young Su Lim
- Department of Anesthesiology and Pain Medicine, Institute for Integrative Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary's Hospital, Incheon
| | - Jong-Uk Mun
- Department of Orthopaedic Surgery, Changwon Gyeongsang National University Hospital, Republic of Korea
| | - Mi Sook Seo
- Department of Anesthesiology and Pain Medicine, Institute for Integrative Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary's Hospital, Incheon
| | - Bo-Hyun Sang
- Department of Anesthesiology and Pain Medicine, Institute for Integrative Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary's Hospital, Incheon
| | - Yun-Sic Bang
- Department of Anesthesiology and Pain Medicine, Institute for Integrative Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary's Hospital, Incheon
| | - Keum Nae Kang
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul, Korea
| | - Jin Woo Koh
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul, Korea
| | - Young Uk Kim
- Department of Anesthesiology and Pain Medicine, Institute for Integrative Medicine, Catholic Kwandong University of Korea College of Medicine, International St. Mary's Hospital, Incheon
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Particulate versus non-particulate corticosteroids for transforaminal nerve root blocks: Comparison of outcomes in 494 patients with lumbar radiculopathy. Eur Radiol 2017; 28:946-952. [PMID: 28894933 DOI: 10.1007/s00330-017-5045-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 08/09/2017] [Accepted: 08/21/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE We set out to compare outcomes in CT-guided lumbar transforaminal nerve root block patients receiving either particulate or non-particulate corticosteroids. MATERIALS AND METHODS This was a retrospective comparative effectiveness outcomes study on two cohorts of lumbar radiculopathy patients. 321 received particulate and 173 non-particulate corticosteroids at CT-guided transforaminal lumbar nerve root injections. The particulate steroid was used from October 2009 until May 2014 and the non-particulate steroid was used from May 2014. Pain levels were collected at baseline using an 11-point numerical rating scale (NRS) and at 1 day, 1 week and 1 month. Overall 'improvement' was assessed using the Patients' Global Impression of Change (PGIC) at these same time points (primary outcome). The proportions of patients 'improved' were compared between the two groups using the Chi-square test. The NRS change scores were compared using the unpaired t-test. RESULTS A significantly higher proportion of patients treated with particulate steroids were improved at 1 week (43.2 % vs. 27.7 %, p = 0.001) and at 1 month (44.3 % vs. 33.1 %, p = 0.019). Patients receiving particulate steroids also had significantly higher NRS change scores at 1 week (p = 0.02) and 1 month (p = 0.007). CONCLUSION Particulate corticosteroids have significantly better outcomes than non-particulate corticosteroids. KEY POINTS • Better pain relief is achieved with particulate steroids. • Significantly more patients report overall 'improvement' with particulate steroids. • Significantly more patients report 'worsening' at 1 week with non-particulate steroids.
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Unterweger MT, Thomas D. Lumbar and cervical injection techniques. 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 2017; 26:418-419. [PMID: 28879374 DOI: 10.1007/s00586-017-5263-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Lee YJ, Shin JS, Lee J, Kim MR, Ahn YJ, Shin YS, Park KB, Shin BC, Lee MS, Kim JH, Cho JH, Ha IH. Survey of integrative lumbar spinal stenosis treatment in Korean medicine doctors: preliminary data for clinical practice guidelines. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2017; 17:425. [PMID: 28851418 PMCID: PMC5574237 DOI: 10.1186/s12906-017-1942-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 08/21/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Considering that large variations exist amongst practitioners in lumbar disorder management and the significant costs that lumbar disorders incur, determining clinical practice patterns to provide preliminary data for standardization should be given higher priority. Lumbar spinal stenosis (LSS) is commonly treated using integrative non-surgical methods by Korean medicine doctors (KMDs) in Korea, and this is the first study to assess current Korean medicine practice trends for LSS. METHODS A survey on KMD diagnosis, treatment, prognosis and decision-making in LSS treatment was developed in a 3-step procedure of preliminary drafting, revision based on extramural expert opinion, and final editing. The survey was conducted at the internal conference of a spine-specialty Korean medicine hospital on January 25th, 2015. RESULTS The response rate was high at 79.19% (n = 118/149). Participants replied that they treated 7.3 ± 6.8 LSS patients/day using a multimodal treatment method consisting of acupuncture, pharmacopuncture, herbal medicine, Chuna manipulation, and electroacupuncture. Acupuncture mainly used Ashi points and MSAT, and pharmacopuncture mainly Shinbaro solution. The most frequently prescribed herbal medicine was Chungpa-jun, and the most commonly applied Chuna techniques were sidelying lumbar extension dysfunction correction technique, and prone lumbosacral joint distraction method. Radiological findings were mainly referred to for diagnosis, and clinical symptoms, age, radiological findings, and medical history were regarded to be important for prognosis. Participants replied that 7.8 ± 3.3 weeks were required for 50% reduction in pain, and 16.1 ± 7.7 weeks for 80% reduction. CONCLUSIONS These results suggest that KMDs in Korea combine a conventional approach to LSS and a Korean medicine approach to low back pain for integration of empirical- and evidence-based diagnosis and treatment. The findings may contribute in bridging the divide between evidence and clinical practice guidelines for Korean medicine treatment of LSS and real-world clinical practice in future research.
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Fritz JM, Rundell SD, Dougherty P, Gentili A, Kochersberger G, Morone NE, Naga Raja S, Rodriguez E, Rossi MI, Shega J, Sowa G, Weiner DK. Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment. Part VI: Lumbar Spinal Stenosis. ACTA ACUST UNITED AC 2017; 17:501-10. [PMID: 26962233 DOI: 10.1093/pm/pnw011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE . To present the sixth in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. This article focuses on the evaluation and management of lumbar spinal stenosis (LSS), the most common condition for which older adults undergo spinal surgery. METHODS . The evaluation and treatment algorithm, a table articulating the rationale for the individual algorithm components, and stepped-care drug recommendations were developed using a modified Delphi approach. The Principal Investigator, a five-member content expert panel and a nine-member primary care panel were involved in the iterative development of these materials. The illustrative clinical case was taken from the clinical practice of a contributor's colleague (SR). RESULTS . We present an algorithm and supportive materials to help guide the care of older adults with LSS, a condition that occurs not uncommonly in those with CLBP. The case illustrates the importance of function-focused management and a rational approach to conservative care. CONCLUSIONS . Lumbar spinal stenosis exists not uncommonly in older adults with CLBP and management often can be accomplished without surgery. Treatment should address all conditions in addition to LSS contributing to pain and disability.
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Affiliation(s)
- Julie M Fritz
- *Department of Physical Therapy and College of Health, University of Utah, Salt Lake City, Utah
| | - Sean D Rundell
- Department of Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - Paul Dougherty
- Canandaigua VA Medical Center, Canandaigua, New York Department of Research, New York Chiropractic College, Seneca Falls, New York Division of Geriatrics, School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Angela Gentili
- Hunter Holmes McGuire VA Medical Center, Richmond, Virginia **Virginia Commonwealth University Health System, Richmond, Virginia
| | - Gary Kochersberger
- Canandaigua VA Medical Center, Canandaigua, New York Division of Geriatrics, School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Natalia E Morone
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Clinical and Translational Sciences Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and
| | - Srinivasa Naga Raja
- Department of Anesthesiology, Critical Care Medicines, and Division of Pain Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric Rodriguez
- Clinical and Translational Sciences Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and
| | - Michelle I Rossi
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania Clinical and Translational Sciences Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and
| | - Joseph Shega
- VITAS Healthcare, Miami, Florida; Departments of
| | - Gwendolyn Sowa
- Physical Medicine and Rehabilitation, Orthopedic Surgery, Bioengineering
| | - Debra K Weiner
- Geriatric Research Education and Clinical Center (GRECC), Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania Clinical and Translational Sciences Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and Clinical and Translational Sciences Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, and Psychiatry, and ****Anesthesiolgoy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Manchikanti L, Hirsch JA, Pampati V, Boswell MV. Utilization of Facet Joint and Sacroiliac Joint Interventions in Medicare Population from 2000 to 2014: Explosive Growth Continues! Curr Pain Headache Rep 2017; 20:58. [PMID: 27646014 DOI: 10.1007/s11916-016-0588-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Increasing utilization of interventional techniques in managing chronic spinal pain, specifically facet joint interventions and sacroiliac joint injections, is a major concern of healthcare policy makers. We analyzed the patterns of utilization of facet and sacroiliac joint interventions in managing chronic spinal pain. The results showed significant increase of facet joint interventions and sacroiliac joint injections from 2000 to 2014 in Medicare FFS service beneficiaries. Overall, the Medicare population increased 35 %, whereas facet joint and sacroiliac joint interventions increased 313.3 % per 100,000 Medicare population with an annual increase of 10.7 %. While the increases were uniform from 2000 to 2014, there were some decreases noted for facet joint interventions in 2007, 2010, and 2013, whereas for sacroiliac joint injections, the decreases were noted in 2007 and 2013. The increases were for cervical and thoracic facet neurolysis at 911.5 % compared to lumbosacral facet neurolysis of 567.8 %, 362.9 % of cervical and thoracic facet joint blocks, 316.9 % of sacroiliac joints injections, and finally 227.3 % of lumbosacral facet joint blocks.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, Kentucky, 42003, USA. .,Department of Anesthesiology and Perioperative Medicine, University of Louisville, 530 S Jackson Street, Room C2A01, Louisville, KY, 40202, USA.
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, 55 Blossom Street, Gray 241B, Boston, MA, 02114, USA
| | - Vidyasagar Pampati
- Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, Kentucky, 42003, USA
| | - Mark V Boswell
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, 530 S Jackson Street, Room C2A01, Louisville, KY, 40202, USA
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Benditz A, Loher M, Boluki D, Grifka J, Völlner F, Renkawitz T, Maderbacher G, Götz J. Positive medium-term influence of multimodal pain management on socioeconomic factors and health care utilization in patients with lumbar radiculopathy: a prospective study. J Pain Res 2017; 10:389-395. [PMID: 28243143 PMCID: PMC5319423 DOI: 10.2147/jpr.s128090] [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] [Indexed: 01/07/2023] Open
Abstract
Background Multimodal pain management (MPM) represents a central approach to avoiding surgery in patients with lumbar radiculopathy. Independent of the type of health system, cost effectiveness and socioeconomic factors are becoming increasingly important. This study investigated the medium-term influence of conservative MPM on health care utilization and socioeconomic factors. Methods This study compared subjective, objective, and socioeconomic factors of 60 patients after inpatient MPM because of lumbar radiculopathy, before and 1 year ± 2 weeks after treatment. Results Over the course of the 1-year follow-up, one-third of the patients had not required any conservative treatment in comparison to 100% of patients before MPM therapy. The number of patients requiring analgesics could be significantly reduced from 26 to 12, and the number of patients who did not require any analgesics had increased from 14 to 32. After 1 year, the number of patients who had to regularly contact a physician because of low back pain (once per month for 6 months) had been reduced from 58 to 27. Conclusion MPM is an effective approach to treating lumbar radiculopathy and reducing its negative influence on socioeconomic factors. Therapeutic benefits also include a decrease in health care utilization. Therefore, health care providers should place the mid-term success for patients and socioeconomic factors before the short-term costs of therapy.
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Affiliation(s)
- Achim Benditz
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Martin Loher
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Daniel Boluki
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Joachim Grifka
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Florian Völlner
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Tobias Renkawitz
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Günther Maderbacher
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
| | - Jürgen Götz
- Department of Orthopedics, University Medical Center Regensburg, Asklepios Klinikum Bad Abbach, Bad Abbach, Germany
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Sharma AK, Vorobeychik Y, Wasserman R, Jameson J, Moradian M, Duszynski B, Kennedy DJ. The Effectiveness and Risks of Fluoroscopically Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data. PAIN MEDICINE 2017; 18:239-251. [PMID: 28204730 DOI: 10.1093/pm/pnw131] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective To determine the effectiveness and risks of fluoroscopically guided lumbar interlaminar epidural steroid injections. Design Systematic review of the literature with comprehensive analysis of the published data. Interventions Three reviewers with formal training in evidence-based medicine searched the literature on fluoroscopically guided lumbar interlaminar epidural steroid injections. A larger team consisting of five reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented. Outcome Measures The primary outcome assessed was pain relief. Other outcomes such as functional improvement, reduction in surgery rate, decreased use of opioids/medications, and complications were noted, if reported. The evidence on each outcome was appraised in accordance with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system of evaluating evidence. Results The search yielded 71 primary publications addressing fluoroscopically guided lumbar interlaminar epidural steroid injections. There were no explanatory studies and all pragmatic studies identified were of low quality, yielding evidence comparable to observational studies. Conclusions The body of evidence regarding effectiveness of fluoroscopically guided interlaminar epidural steroid injection is of low quality according to GRADE. Studies suggest a lack of effectiveness of fluoroscopically guided lumbar interlaminar epidural steroid injections in treating primarily axial pain regardless of etiology. Most studies on radicular pain due to lumbar disc herniation and stenosis do, however, report statistically significant short-term improvement in pain.
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Affiliation(s)
- Anil K Sharma
- Spine and Pain Centers, Shrewsbury, New Jersey, NJ, USA
| | - Yakov Vorobeychik
- Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Ronald Wasserman
- Back and Pain Center, University of Michigan, Ann Arbor, Michigan, MI, USA
| | | | | | | | - David J Kennedy
- Department of Orthopedics, Stanford University, Redwood City, California, USA
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Degenerative Lumbar Spinal Stenosis. PAIN MEDICINE 2017. [DOI: 10.1007/978-3-319-43133-8_122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Manchikanti L, Pampati V, Hirsch JA. Retrospective cohort study of usage patterns of epidural injections for spinal pain in the US fee-for-service Medicare population from 2000 to 2014. BMJ Open 2016; 6:e013042. [PMID: 27965254 PMCID: PMC5168679 DOI: 10.1136/bmjopen-2016-013042] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 10/28/2016] [Accepted: 11/10/2016] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To assess the usage patterns of epidural injections for chronic spinal pain in the fee-for-service (FFS) Medicare population from 2000 to 2014 in the USA. DESIGN A retrospective cohort. METHODS The descriptive analysis of the administrative database from Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) master data from 2000 to 2014 was performed. The guidance from Strengthening the Reporting of Observational studies in Epidemiology (STROBE) was applied. Analysis included multiple variables based on the procedures, specialties and geography. RESULTS Overall epidural injections increased 99% per 100 000 Medicare beneficiaries with an annual increase of 5% from 2000 to 2014. Lumbar interlaminar and caudal epidural injections constituted 36.2% of all epidural injections, with an overall decrease of 2% and an annual decrease of 0.2% per 100 000 Medicare beneficiaries. However, lumbosacral transforaminal epidural injections increased 609% with an annual increase of 15% from 2000 to 2014 per 100 000 Medicare population. CONCLUSIONS Usage of epidural injections increased from 2000 to 2014, with a decline thereafter. However, an escalating growth has been seen for lumbosacral transforaminal epidural injections despite numerous reports of complications and regulations to curb the usage of transforaminal epidural injections.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, Kentucky, USA
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky, USA
| | | | - Joshua A Hirsch
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Oder B, Thurnher S. [Periradicular infiltration therapy : Clinical indications, technique and results]. Radiologe 2016; 55:833-9. [PMID: 26377920 DOI: 10.1007/s00117-015-0017-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Minimally invasive procedures have played an emerging role in pain management during recent years. OBJECTIVES Evaluation of the different types of periradicular infiltration as fundamental procedures in the progressive stepwise concept of pain management. Comparison of the different therapeutic substances. RESULTS In the mid-term and long-term periradicular infiltration is effective in 60-80 % of patients regarding analgesic and functional aspects. Compliance with the guidelines should help to minimize potentially fatal complications. CONCLUSION Periradicular infiltration is of significant importance concerning the treatment of spinal nerve root irritation. Periradicular infiltration is regarded as a safe procedure, especially when supported by computed tomography (CT) scans.
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Affiliation(s)
- B Oder
- Abteilung für Radiologie und Nuklearmedizin, Krankenhaus der Barmherzigen Brüder Wien, Johannes von Gott Platz 1, 1020, Wien, Österreich.
| | - S Thurnher
- Abteilung für Radiologie und Nuklearmedizin, Krankenhaus der Barmherzigen Brüder Wien, Johannes von Gott Platz 1, 1020, Wien, Österreich
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Introduction of a predictive model for epidural steroid injections leads to inappropriate and inaccurate conclusions. Spine J 2016; 16:905-6. [PMID: 27480023 DOI: 10.1016/j.spinee.2016.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 02/16/2016] [Indexed: 02/03/2023]
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Manchikanti L, Hirsch JA, Falco FJE, Boswell MV. Management of lumbar zygapophysial (facet) joint pain. World J Orthop 2016; 7:315-337. [PMID: 27190760 PMCID: PMC4865722 DOI: 10.5312/wjo.v7.i5.315] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 10/13/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the diagnostic validity and therapeutic value of lumbar facet joint interventions in managing chronic low back pain.
METHODS: The review process applied systematic evidence-based assessment methodology of controlled trials of diagnostic validity and randomized controlled trials of therapeutic efficacy. Inclusion criteria encompassed all facet joint interventions performed in a controlled fashion. The pain relief of greater than 50% was the outcome measure for diagnostic accuracy assessment of the controlled studies with ability to perform previously painful movements, whereas, for randomized controlled therapeutic efficacy studies, the primary outcome was significant pain relief and the secondary outcome was a positive change in functional status. For the inclusion of the diagnostic controlled studies, all studies must have utilized either placebo controlled facet joint blocks or comparative local anesthetic blocks. In assessing therapeutic interventions, short-term and long-term reliefs were defined as either up to 6 mo or greater than 6 mo of relief. The literature search was extensive utilizing various types of electronic search media including PubMed from 1966 onwards, Cochrane library, National Guideline Clearinghouse, clinicaltrials.gov, along with other sources including previous systematic reviews, non-indexed journals, and abstracts until March 2015. Each manuscript included in the assessment was assessed for methodologic quality or risk of bias assessment utilizing the Quality Appraisal of Reliability Studies checklist for diagnostic interventions, and Cochrane review criteria and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment tool for therapeutic interventions. Evidence based on the review of the systematic assessment of controlled studies was graded utilizing a modified schema of qualitative evidence with best evidence synthesis, variable from level I to level V.
RESULTS: Across all databases, 16 high quality diagnostic accuracy studies were identified. In addition, multiple studies assessed the influence of multiple factors on diagnostic validity. In contrast to diagnostic validity studies, therapeutic efficacy trials were limited to a total of 14 randomized controlled trials, assessing the efficacy of intraarticular injections, facet or zygapophysial joint nerve blocks, and radiofrequency neurotomy of the innervation of the facet joints. The evidence for the diagnostic validity of lumbar facet joint nerve blocks with at least 75% pain relief with ability to perform previously painful movements was level I, based on a range of level I to V derived from a best evidence synthesis. For therapeutic interventions, the evidence was variable from level II to III, with level II evidence for lumbar facet joint nerve blocks and radiofrequency neurotomy for long-term improvement (greater than 6 mo), and level III evidence for lumbosacral zygapophysial joint injections for short-term improvement only.
CONCLUSION: This review provides significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain.
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Liu J, Zhou H, Lu L, Li X, Jia J, Shi Z, Yao X, Wu Q, Feng S. The Effectiveness of Transforaminal Versus Caudal Routes for Epidural Steroid Injections in Managing Lumbosacral Radicular Pain: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2016; 95:e3373. [PMID: 27149443 PMCID: PMC4863760 DOI: 10.1097/md.0000000000003373] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Epidural steroid injection (ESI) is one of the most commonly used treatments for radiculopathy. Previous studies have described the effectiveness of ESI in the management of radiculopathy. However, controversy exists regarding the route that is most beneficial and effective with respect to the administration of epidural steroids, as both transforaminal (TF) and caudal (C) routes are commonly used.This analysis reviewed studies comparing the effectiveness of TF-ESIs with that of C-ESIs in the treatment of radiculopathy as a means of providing pain relief and improving functionality. This meta-analysis was performed to guide clinical decision-making.The study was a systematic review of comparative studies.A systematic literature search was performed using the PubMed, EMBASE, and Cochrane Library databases for trials written in English. The randomized trials and observational studies that met our inclusion criteria were subsequently included. Two reviewers, respectively, extracted data and estimated the risk of bias. All statistical analyses were performed using Review Manager 5.3.Six prospective and 2 retrospective studies involving 664 patients were included. Statistical analysis was performed utilizing only the 6 prospective studies. Although slight pain and functional improvements were noted in the TF-ESI groups compared with the C-ESI groups, these improvements were neither clinically nor statistically significant.The limitations of this meta-analysis resulted primarily from the weaknesses of the comparative studies and the relative paucity of patients included in each study.Both the TF and C approaches are effective in reducing pain and improving functional scores, and they demonstrated similar efficacies in the management of lumbosacral radicular pain.
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Affiliation(s)
- Jun Liu
- From the Department of Orthopedics (JL, HZ, LL, JJ, ZS, XY, QW, SF), Tianjin Medical University General Hospital, No. 154 Anshan Road; Key Laboratory of Immuno Microenvironment and Disease of the Educational Ministry of China (XL), Department of Immunology, Tianjin Medical University, No. 22 Qixiangtai Road, Heping District; and Department of Orthopedic Trauma (JJ), Tianjin Hospital, No. 406 Jiefangnan Road, Hexi District, Tianjin, PR China
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Manchikanti L, Hirsch JA. In Response to Risks and Pitfalls of Epidural Injections during Management of Lumbar Disc Herniation: Few Comments. Korean J Pain 2015; 28:219-20. [PMID: 26175884 PMCID: PMC4500788 DOI: 10.3344/kjp.2015.28.3.219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 04/03/2015] [Indexed: 12/04/2022] Open
Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, and University of Louisville, Louisville, KY, USA
| | - Joshua A Hirsch
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Manchikanti L, Hirsch JA. Comments on a systematic review and meta-analysis of steroids for epidural injections in spinal stenosis. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:2721-2. [PMID: 26056432 PMCID: PMC4445696 DOI: 10.2147/dddt.s86080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Center of Paducah, Paducah, KY, USA ; Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | - Joshua A Hirsch
- Interventional Care, Minimally Invasive Spine Surgery, Interventional Radiology, NeuroInterventional Services and Neuroendovascular Program, Massachusetts General Hospital, Boston, MA, USA ; Department of Radiology, Harvard Medical School, Boston, MA, USA
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