scholarly journals Interventional Techniques in Managing Persistent Pain After Vertebral Augmentation Procedures: A Retrospective Evaluation

2007 ◽  
Vol 5;10 (9;5) ◽  
pp. 673-676 ◽  
Author(s):  
Bassem Georgy
Keyword(s):  
Facet Joint ◽  
Persistent Pain ◽  
Cement Augmentation ◽  
Vertebral Compression Fractures ◽  
Nerve Blocks ◽  
Steroid Injections ◽  
Compression Fractures ◽  
Epidural Steroid Injections ◽  
Epidural Steroid ◽  
Joint Injections

Background: Based on systematic reviews, it appears that at least 10% of patients may continue to suffer with residual or persistent pain after successful vertebral or sacral augmentation procedures. Objective: To report and evaluate the incidence and prevalence of different spinal injections in patients who received vertebroplasty, kyphoplasty, and sacroplasty procedures for both benign and malignant compression fractures. Design: A retrospective case review. Methods: Retrospective review of all cases of vertebroplasty, sacroplasty, and kyphoplasty performed in a 12-month period in a single outpatient setting of interventional radiology was conducted. Results: In a 12-month period starting from October 2005 to September 2006, 144 patients underwent cement augmentation procedures. Of the 144, 34 patients required a spinal injection procedure for residual or persistent pain within a 1-year period after the augmentation procedure. Twenty-four patients required epidural steroid injections, 6 patients required intercostal nerve blocks, 5 patients required trigger point injections, 5 patients required sacroiliac joint injections, and 1 patient required facet joint injections. Nine patients who required lumbar epidural steroid injections and all patients who required intercostal nerve blocks and had underwent a thoracic cement augmentation procedure. Conclusion: A small proportion of patients undergoing percutaneous cement augmentation for vertebral compression fractures or sacral insufficiency fractures potentially require spinal injections to treat residual pain after the procedure. Key words: Kyphoplasty, vertebroplasty, sacroplasty, residual pain, vertebral compression fractures, epidural steroid injections, facet joint pain, sacroiliac joint injections, facet joint injections.

Antiplatelet and Anticoagulant Risk for Select Spine Interventions: A Retrospective Cohort

Pain Medicine ◽  
2020 ◽  
Vol 21 (5) ◽  
pp. 910-917
Author(s):  
Reza Ehsanian ◽  
Renee M Rosati ◽  
David J Kennedy ◽  
Byron J Schneider
Keyword(s):  
Epidural Hematoma ◽  
Facet Joint ◽  
Anticoagulant Effect ◽  
Bleeding Complications ◽  
Medial Branch ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Clinical Encounters ◽  
Epidural Steroid ◽  
Joint Injections

Abstract Objectives To identify significant bleeding complications following spinal interventions in patients taking medications with antiplatelet or anticoagulation effect. Design Retrospective chart review of a 12-month period. Setting Outpatient academic medical practice. Interventions Injections during outpatient interventional spine clinical encounters, including 14 cervical transforaminal epidural steroid injections, 26 cervical medial branch blocks, seven cervical radiofrequency neurotomies, three cervical facet joint injections, 88 lumbar transforaminal epidural steroid injections, 66 lumbosacral medial branch blocks, 18 lumbosacral radiofrequency neurotomies, 13 lumbar facet joint injections, one caudal epidural steroid injection, 11 sacral transforaminal epidural steroid injections, and 32 sacroiliac joint injections. Main Outcome Measure Epidural hematoma or other serious bleeding. Results In this cohort of 275 consecutive encounters with available records in which patients underwent a spinal injection while continuing medications with antiplatelet or anticoagulant effect, zero of the 275 clinical encounters (0%, 95% confidence interval = 0–1.4%) resulted in epidural hematoma or other serious bleeding. For antiplatelet medication, nonsteroidal anti-inflammatory drugs were continued in 102 procedures, aspirin in 142, clopidogrel in 21, and meloxicam and/or Celebrex in 81; for anticoagulation medication, warfarin was continued in four procedures, apixaban in six, dabigatran in one, and fondaparinux in two. Of note, one patient suffered a deep vein thrombosis, which was identified at two-week follow-up despite continuing aspirin therapy. Conclusions This cohort adds to the growing evidence that the risk of serious bleeding complications from select spine interventions while continuing medications with antiplatelet or anticoagulant effect appears low.

A Comparative Effectiveness Evaluation of Percutaneous Adhesiolysis and Epidural Steroid Injections in Managing Lumbar Post Surgery Syndrome: A Randomized, Equivalence Controlled Trial

2009 ◽  
Vol 6;12 (6;12) ◽  
pp. E355-E368
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Facet Joint ◽  
Low Back ◽  
Lumbar Surgery ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Post Surgery ◽  
Group I ◽  
Group Ii ◽  
Epidural Steroid ◽  
Caudal Epidural

Background: Speculated causes of post lumbar surgery syndrome include epidural fibrosis, acquired stenosis, and facet joint pain among other causes. Even though fluoroscopically directed caudal epidural injections and facet joint interventions are effective in some patients, others continue to suffer with chronic persistent pain. Percutaneous adhesiolysis with target delivery of medications has been demonstrated to be effective in these patients. However, the evidence for percutaneous adhesiolysis in managing post surgery syndrome has been questioned, coupled with a paucity of controlled trials. Study Design: A randomized, equivalence, controlled trial. Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objectives: To evaluate the effectiveness of percutaneous epidural adhesiolysis in patients with chronic low back and lower extremity pain in post surgery syndrome and compare with fluoroscopically directed caudal epidural steroid injections. Methods: Patients were randomly assigned to one of 2 groups: Group I (60 patients) receiving caudal epidural injections with catheterization up to S3 with local anesthetic, steroids, and 0.9% sodium chloride solution serving as the control group, and Group II (60 patients) receiving percutaneous adhesiolysis with targeted delivery of lidocaine, 10% hypertonic sodium chloride solution, and non-particulate Betamethasone serving as the intervention group. Randomization was performed by computer-generated random allocation sequence by simple randomization. Outcomes Assessment: Multiple outcome measures were utilized including the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3, 6, and 12 months post treatment. Significant pain relief was described as 50% or more, whereas significant improvement in the disability score was defined as a reduction of 40% or more. Results: Significant pain relief (≥ 50%) and functional status improvement was recorded in 73% of patients in Group II versus 12% in Group I (P < 0.001). The average procedures per year were 3.5 with an average total relief of 42 out of 52 weeks in Group II and 2.2 procedures with total relief per year of 13 weeks in Group I (P < 0.001). Limitations: The results of this study are limited by potentially inadequate double blinding, by the lack of a placebo group, and the preliminary report of one-year follow-up. Conclusions: Percutaneous adhesiolysis in chronic function-limiting, recalcitrant low back pain in post lumbar surgery syndrome demonstrated effectiveness in 73% of the patients. Key words: Post lumbar surgery syndrome, post lumbar laminectomy syndrome, chronic low back pain, epidural adhesions, epidural steroid injections, percutaneous adhesiolysis, epidural fibrosis, spinal stenosis, randomized trial, comparative effectiveness

scholarly journals Review of Occupational Medicine Practice Guidelines for Interventional Pain Management and Potential Implications

2008 ◽  
Vol 3;11 (5;3) ◽  
pp. 271-289
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Pain Management ◽  
Workers Compensation ◽  
Nerve Blocks ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Interventional Pain Management ◽  
Epidural Steroid ◽  
The Cost ◽  
Based Medicine

In the modern day environment, workers’ compensation costs continue to be a challenge, with a need to balance costs, benefits, and quality of medical care. The cost of workers’ compensation care affects all stakeholders including workers, employers, providers, regulators, legislators, and insurers. Consequently, a continued commitment to quality, accessibility to care, and cost containment will help ensure that workers are afforded accessible, high quality, and cost-effective care. In 2004, workers’ compensation programs in all 50 states, the District of Columbia, and federal programs in the United States combined received an income of $87.4 billion while paying out only $56 billion in medical and cash benefits with $31.4 billion or 37% in administrative expenses and profit. Occupational diseases represented only 8% of the workers’ compensation claims and 29% of the cost. The American College of Occupational and Environmental Medicine (ACOEM) has published several guidelines; though widely adopted by WCPs, these guidelines evaluate the practice of medicine of multiple specialties without adequate expertise and expert input from the concerned specialties, including interventional pain management. An assessment of the ACOEM guidelines utilizing Appraisal of Guidelines for Research and Evaluation (AGREE) criteria, the criteria developed by the American Medical Association (AMA), the Institute of Medicine (IOM), and other significantly accepted criteria, consistently showed very low scores (< 30%) in most aspects of the these guidelines. The ACOEM recommendations do not appear to have been based on a careful review of the literature, overall quality of evidence, standard of care, or expert consensus. Based on the evaluation utilizing appropriate and current evidence-based medicine (EBM) principles, the evidence ratings for diagnostic techniques of lumbar discography; cervical, thoracic, and lumbar facet joint nerve blocks and sacroiliac joint nerve blocks; therapeutic cervical and lumbar medial branch blocks and radiofrequency neurolysis; cervical interlaminar epidural steroid injections, caudal epidural steroid injections, and lumbar transforaminal epidural injections; caudal percutaneous adhesiolysis; abd spinal cord stimulation were found to be moderate with strong recommendation applying for most patients in most circumstances. The evidence ratings for intradiscal electrothermal therapy (IDET), an automated percutaneous disc decompression and also deserve further scrutiny and analysis. In conclusion, these ACOEM guidelines for interventional pain management have no applicability in modern patient care due to lack of expertise by the developing organization (ACOEM), lack of utilization of appropriate and current EBM principles, and lack of significant involvement of experts in these techniques resulting in a lack of clinical relevance. Thus, they may result in reduced medical quality of care; may severely hinder access to appropriate, medically needed and essential medical care; and finally, they may increase costs for injured workers, third party payors, and the government by transferring the injured worker into a non-productive disability system. Key words: Guidelines, ACOEM, ASIPP, interventional pain management, interventional techniques, evidence-based medicine, systematic reviews, guideline development, AHCPR, AHRQ, IOM, AMA, AGREE, workers’ compensation, chronic pain guidelines, low back pain guidelines

scholarly journals Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain

2007 ◽  
Vol 1;10 (1;1) ◽  
pp. 7-111
Author(s):  
ASIPP ASIPP
Keyword(s):  
Facet Joint ◽  
Spinal Pain ◽  
Evidence Based ◽  
Short Term ◽  
Steroid Injections ◽  
Interventional Techniques ◽  
Epidural Steroid Injections ◽  
Epidural Steroid ◽  
Chronic Spinal Pain

Background: The evidence-based practice guidelines for the management of chronic spinal pain with interventional techniques were developed to provide recommendations to clinicians in the United States. Objective: To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain, utilizing all types of evidence and to apply an evidence-based approach, with broad representation by specialists from academic and clinical practices. Design: Study design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions and statements about relationships between clinical interventions and outcomes. Methods: The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, and blinded peer review. Methodologic quality evaluation criteria utilized included the Agency for Healthcare Research and Quality (AHRQ) criteria, Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), to Level V (indeterminate). Results: Among the diagnostic interventions, the accuracy of facet joint nerve blocks is strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it is moderate in the diagnosis of thoracic facet joint pain. The evidence is strong for lumbar discography, whereas, the evidence is limited for cervical and thoracic discography. The evidence for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies is moderate. The evidence for diagnostic sacroiliac joint injections is limited. The evidence for therapeutic lumbar intraarticular facet injections is moderate for short-term and long-term improvement, whereas, it is limited for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks is moderate. The evidence for medial branch neurotomy is moderate. The evidence for caudal epidural steroid injections is strong for short-term relief and moderate for long-term relief in managing chronic low back and radicular pain, and limited in managing pain of postlumbar laminectomy syndrome. The evidence for interlaminar epidural steroid injections is strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence is moderate. The evidence for transforaminal epidural steroid injections is strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it is moderate for cervical nerve root pain and limited in managing pain secondary to lumbar post laminectomy syndrome and spinal stenosis. The evidence for percutaneous epidural adhesiolysis is strong. For spinal endoscopic adhesiolysis, the evidence is strong for short-term relief and moderate for long-term relief. For sacroiliac intraarticular injections, the evidence is limited. The evidence for radiofrequency neurotomy for sacroiliac joint pain is limited. The evidence for intradiscal electrothermal therapy is moderate in managing chronic discogenic low back pain, whereas for annuloplasty the evidence is limited. Among the various techniques utilized for percutaneous disc decompression, the evidence is moderate for short-term and limited for long-term relief for automated percutaneous lumbar discectomy, and percutaneous laser discectomy, whereas it is limited for nucleoplasty and for DeKompressor technology. For vertebral augmentation procedures, the evidence is moderate for both vertebroplasty and kyphoplasty. The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome is strong for shortterm relief and moderate for long-term relief. The evidence for implantable intrathecal infusion systems is strong for short-term relief and moderate for long-term relief. Conclusion: These guidelines include the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. These guidelines also do not represent a “standard of care.” Key words: Interventional techniques, chronic spinal pain, diagnostic blocks, therapeutic interventions, facet joint interventions, epidural injections, epidural adhesiolysis, discography, radiofrequency, disc decompression, vertebroplasty, kyphoplasty, spinal cord stimulation, intrathecal implantable systems

scholarly journals Iatrogenic neurological injury after radiofrequency ablation and epidural steroid injections: illustrative cases

2021 ◽  
Vol 1 (19) ◽  
Author(s):  
Lisa B. E. Shields ◽  
Vasudeva G. Iyer ◽  
Yi Ping Zhang ◽  
Christopher B. Shields
Keyword(s):  
Radiofrequency Ablation ◽  
Neck Pain ◽  
Facet Joint ◽  
Chronic Neck Pain ◽  
Neurological Injury ◽  
Left Shoulder ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Arm Pain ◽  
Epidural Steroid

BACKGROUND Neck pain is often chronic and disabling. Cervical facet joint injections and epidural steroid injections are frequently used to manage chronic neck pain and cervicogenic headaches. While minimal side effects are commonly associated with these treatments, severe complications are exceedingly rare. OBSERVATIONS The authors report 4 cases of iatrogenic neurological injury after radiofrequency ablation (RFA) and epidural steroid injections. One patient experienced left shoulder, scapular, and arm pain with left arm and hand weakness that developed immediately after RFA for chronic neck pain. Electromyography/nerve conduction velocity (EMG/NCV) studies confirmed denervation changes in the left C8–T1 distribution. Three patients complained of numbness and weakness of the hands immediately after an interlaminar cervical epidural block. One of these patients underwent EMG/NCV that confirmed denervation changes occurring in the left C8–T1 distribution. LESSONS Spine surgeons and pain management specialists should be aware of neurological injuries that may occur after cervical RFA and epidural steroid injections, especially after a multilevel cervical procedure and with severe cervical spinal stenosis. EMG/NCV studies plays an important role in detecting and localizing neurological injury and in differentiating from conditions that mimic cervical root injuries, including brachial plexus trauma due to positioning and Parsonage-Turner syndrome.

scholarly journals Diagnosis and Treatment of Sciatica in the Netherlands: A Survey among Neurologists and Anesthesiologists

2021 ◽  
pp. 1-11
Author(s):  
Bastiaan ter Meulen ◽  
Caroliene Overweg ◽  
Thomas Feenstra ◽  
Brigitte Brouwer ◽  
Michel Terheggen ◽  
...  
Keyword(s):  
Nerve Root ◽  
Pain Medication ◽  
Cross Sectional Survey ◽  
Nerve Blocks ◽  
Cross Sectional ◽  
Steroid Injections ◽  
Nerve Root Block ◽  
Epidural Steroid Injections ◽  
Epidural Steroid ◽  
Pulse Radiofrequency

<b><i>Background:</i></b> This study aimed to assess how Dutch neurologists and anesthesiologists diagnose and treat people with sciatica in secondary care and to evaluate their adherence to the newest guidelines. <b><i>Methods:</i></b> We conducted a cross-sectional survey. Respondents were asked about their current clinical practice related to sciatica. Three authors rated the respondents’ adherence to the guidelines on a three-point Likert scale. <b><i>Results:</i></b> Eighty neurologists and 44 anesthesiologists completed the questionnaire. Neurologists diagnose their sciatica patients primarily using a magnetic resonance imaging (89%). Selective diagnostic nerve blocks are considered useful by 81% of the neurologists. Neurologists primarily treat patients with pain medication, and 40% of them think epidural steroid injections are effective in 40–60% of injected patients. Twenty-nine percent of neurologists refer patients to a neurosurgeon after 4 months. Anesthesiologists consider a selective diagnostic nerve root block to have a higher diagnostic value than mapping. The most reported side effect of epidural injections is exacerbation of pain (82%). Pulse radiofrequency is applied in 9–11% of acute cases. The results also indicate that Dutch neurologists and anesthesiologists follow an evidence-based approach that is strictly or broadly in line with the guideline. <b><i>Conclusions:</i></b> Neurologists treat sciatica patients initially with pain medication and physiotherapy, followed by epidural steroid injections and referral for surgery. Anesthesiologists treat sciatica patients with one or more steroid injections or may perform a selective nerve root block. Imaging, selective nerve root blocks, medication, physiotherapy, and pulse radiofrequency are topics of further research.

Radiation Dose Exposure for Lumbar Transforaminal Epidural Steroid Injections and Facet Joint Blocks Under CT vs. Fluoroscopic Guidance

Pain Practice ◽  
2018 ◽  
Vol 18 (6) ◽  
pp. 798-804 ◽  
Author(s):  
Paolo Maino ◽  
Stefano Presilla ◽  
Paola A. Colli Franzone ◽  
Sander M.J. van Kuijk ◽  
Roberto S.G.M. Perez ◽  
...  
Keyword(s):  
Radiation Dose ◽  
Facet Joint ◽  
Fluoroscopic Guidance ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Radiation Dose Exposure ◽  
Epidural Steroid
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