Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation of the Musculocutaneous Nerve for Refractory Antecubital ElbowPain-Brief Technical Report and Illustrative Case Report

Chronic pain following distal biceps rupture (DBR) is often nonspecific in that it may arise due to the injury, subsequent surgical repair, or a combination of factors, making the painful symptoms challenging to treat. Peripheral nerve injury in the setting of DBR most commonly affects the musculocutaneous nerve or one of its terminal branches and may lead to chronic neuropathic pain involving the elbow and lateral/radial aspect of the forearm. In this brief technical report, we describe an ultrasound-guided (USG) technique for percutaneous implantation of a peripheral nerve stimulator (PNS) targeting the musculocutaneous nerve, along with an illustrative case report of successful treatment of chronic refractory pain following DBR utilizing this technique. Six months postimplantation, the patient reported a greater than 60% baseline pain intensity reduction, and no complications were noted.

Combination Intrathecal Drug Therapy Strategies for Pain Management

BACKGROUND

Numerous combination intrathecal drug therapy (CIDT) strategies exist and are utilized for varying pain syndromes, typically when monotherapy dose escalation or medication alternation is deemed untenable or unfeasible. Unfortunately, the supportive evidence basis for the use of these strategies and specific drug combinations is generally lacking and unclear, with many medications being used for off-label indications.

OBJECTIVE

In this manuscript, we provide a robust exploration and analysis of the literature to provide an evidence-based narrative for the use of CIDT strategies in regard to clinical indications, pharmacologic parameters, specific drug combinations, safety profiles, and future directions.

STUDY DESIGN

Narrative review.

METHODS

This was an evidence based narrative performed after extensive review of the literature.

RESULTS

Variances in intrathecal pharmacokinetics and pharmacodynamics are utilized advantageously with CIDT strategies to achieve improved analgesic benefit; however, appropriate use may be limited by increased or compounded risk of adverse effects. The supportive evidence for CIDT use for chronic pain conditions is largely lacking and limited to small, uncontrolled, observational studies, with many having various confounding factors, including a lack of standardized dosing. The most evidenced CIDT strategies include polyanalgesia with morphine-ziconotide, opioid-clonidine, and morphine-bupivacaine. Notably, in addition to pain relief, morphine-bupivacaine has been shown to decrease early opioid escalation requirements.

LIMITATIONS

The supportive evidence for CIDT use for chronic pain conditions is largely lacking and limited to small, uncontrolled, observational studies, with many having various confounding factors including a lack of standardized dosing.

CONCLUSIONS

CIDT strategies and polyanalgesia combinations can be effective for treating various patient populations with chronic pain. The appropriate use of these strategies may be limited by increased or compounded risk of adverse effects, both of which are highly patient and scenario dependent. Therefore, practitioners should maintain a particularly low threshold of suspicion for adverse effects in patients with CIDT such that safety profiles associated with this therapy can be favorably maintained.

Trends in steroid agent and diluent choices for epidural steroid injections: a survey of Spine Intervention Society physicians

BACKGROUND

Epidural steroid injections (ESIs) are a frequently used treatment for refractory radicular spinal pain. ESIs, particularly transforaminal epidural steroid injections (TFESI), may provide pain relief and delay the need for surgery. Corticosteroid agent and diluent choices are known to impact the safety of ESIs. In particular, the risk of embolization with particulate corticosteroids has led to recommendations for non-particulate steroid use by the Multisociety Pain Workgroup. Additionally, there is in vitro evidence that ropivacaine can crystalize in the presence of dexamethasone, potentially creating a particulate-like injectate. Despite widespread use and known risk mitigation strategies, current practice trends related to steroid and diluent choices are unknown.

OBJECTIVE

Identify the use of particulate versus non-particulate corticosteroids for epidural steroid injections in the cervical and lumbar spine, as well as local anesthetics commonly used as diluents during these procedures.

METHODS

Cross-sectional survey study of 314 physician members of the Spine Interventional Society.

RESULTS

41% and 9% of providers reported using particulate corticosteroids during lumbar TFESIs and cervical TFESI, respectively. Four per cent of providers reported the use of ropivacaine in cervical TFESIs. Forty-four per cent of respondents reported using anesthetic in cervical interlaminar ESIs. 21% of providers report using high volumes (> 4.5 mL) during cervical interlaminar ESIs.

CONCLUSION

Current trends, as assessed by this survey study, indicate substantial variability in steroid and diluent choice for ESIs. Patterns were identified that may impact patient safety including the continued use of particulate corticosteroids for TFESIs and the use of ropivacaine during TFESIs by a subset of respondents.