Bruce Vrooman

Evidence-based knee injections for the management of arthritis.

OBJECTIVE Arthritis of the knee affects 46 million Americans. We aimed to determine the level of evidence of intraarticular knee injections in the management of arthritic knee pain. METHODS We systematically searched PUBMED/MEDLINE and the Cochrane databases for articles published on knee injections and evaluated their level of evidence and recommendations according to established criteria. RESULTS The evidence supports the use of intraarticular corticosteroid injections for rheumatoid arthritis (1A+ Level), osteoarthritis (1A+ Level), and juvenile idiopathic arthritis (2C+ Level). Pain relief and functional improvement are significant for months up to 1 year after the injection. Triamcinolone hexacetonide offers an advantage over triamcinolone acetonide and should be the intraarticular steroid of choice (2B+ Level). Intraarticular injection of hyaluronate may provide longer pain relief than steroid injection in osteoarthritis (2B+ Level). It can also be effective for rheumatoid arthritis knee pain (1A+ Level). However, it is only recommended for patients with significant surgical risk factors and for patients with mild radiographic disease in whom conservative treatment has failed (2B± Level). Botulinum toxin type A injection is effective in reducing arthritic knee pain (2B+ Level), and so is tropisetron (2B+ Level) and tanezumab (2B+ Level). The new agents, such as rAAV2-TNFR:Fc, SB-210396/CE 9.1, and various radioisotopes have provided various degrees of success, but their long-term safety and efficacy remains to be determined. CONCLUSIONS We conclude that strong evidence supports the use of intraarticular knee injection as a valuable intervention in the continuum of management of arthritis between conservative treatment and knee surgeries.

A Randomized, Placebo-Controlled Trial of Transdiscal Radiofrequency, Biacuplasty for Treatment of Discogenic Lower Back Pain

OBJECTIVE The aim was to compare the efficacy of intradiscal biacuplasty (IDB) with that of placebo treatment for discogenic low back pain. DESIGN This is a randomized, placebo-controlled trial. Subjects were randomized on a 1:1 basis to IDB and sham groups. Follow-ups were conducted at 1, 3, and 6 months. Subjects and coordinators were blinded to randomization until 6 months. Of the 1,894 subjects screened, 64 subjects were enrolled, and 59 were treated: 29 randomized to IDB and 30 to sham. All subjects had a history of chronic low back pain for longer than 6 months. INTERVENTIONS Two cooled radiofrequency (RF) electrodes placed in a bipolar manner in affected discs to lesion the nociceptive fibers of the annulus fibrosus. The sham procedure was identical to the active treatment except that probes were not directly inserted into the disc space, and RF energy was not actively delivered. RESULTS The principal outcome measures were physical function, pain, disability, and opioid usage. Patients in the IDB group exhibited statistically significant improvements in physical function (P = 0.029), pain (P = 0.006), and disability (P = 0.037) at 6-month follow-up as compared to patients who received sham treatment. Treatment patients reported a reduction of 16 mg daily intake of opioids at 6 months; however, the results were not statistically different from sham patients. CONCLUSIONS The results suggest that the clinical benefits observed in this study are the result of non-placebo treatment effects afforded by IDB. IDB should be recommended to select the patients with chronic discogenic low back pain. (Clinicaltrials.gov number, NCT00750191.).

Radiofrequency Intradiscal Biacuplasty for Treatment of Discogenic Lower Back Pain: A 12-Month Follow-Up

INTRODUCTION Discogenic low back pain (LBP) affects a considerable number of patients suffering from chronic LBP. Recently, a growing interest has emerged in minimally invasive treatment options for discogenic LBP. Intradiscal biacuplasty (IDB), which uses cooled radiofrequency technology to ablate nociceptors in the posterior aspect of the intervertebral disc, is one such option. We previously presented 6-month results of a randomized, double-blinded, sham-controlled study. Now, we present the unblinded, 12-month follow-up data for treatment patients and 6-month data for cross-over subjects from the original sham group. METHODS Physical function, pain relief, and disability were assessed using the Short Form-36, numerical rating scale, and Oswestry Disability Index, respectively. Subjects were unblinded at 6 months, and those initially randomized to sham procedure were given the option to cross over to IDB. RESULTS Twenty-two out of 27 subjects in the original active treatment group were followed until 12 months and had clinically significant improvements in physical function (Δ = 22) and pain (Δ = -2.9). Out of 30 subjects originally in the sham group, 24 chose to cross over, and 20 cross-over patients completed follow-up at 6 months. In cross-over patients, improvements in physical function and pain did not differ statistically from those of patients originally randomized to IDB treatment. No complications or adverse events related to the procedure were reported. CONCLUSIONS Clinically significant improvements after IDB initially reported at 6 months were maintained at 9 and 12 months. The cross-over subjects had similar improvement in all outcome measures at all observed time points.

Differential Epidural Block Predicts the Success of Visceral Block in Patients with Chronic Visceral Abdominal Pain

Abstract:  Background and Aims:  Differential thoracic epidural regional block, also known as a differential neural block (DNB), involves the placement of an epidural catheter placed in the thoracic epidural space to achieve appropriate anesthesia in a dermatomal distribution. This is a retrospective case series evaluating how well a DNB may predict success of subsequent visceral blockade in patients with chronic abdominal pain of visceral origin.

Lidocaine 5% Patch for Treatment of Acute Pain After Robotic Cardiac Surgery and Prevention of Persistent Incisional Pain: A Randomized, Placebo‐Controlled, Double‐Blind Trial

OBJECTIVES To test the hypotheses that lidocaine 5% patches decrease the severity of acute pain and incidence of persistent incisional pain after robotic cardiac valve surgery. DESIGN A randomized, placebo-controlled, double-blind trial. SETTING Tertiary care academic medical center. SUBJECTS Patients having robotic cardiac valve surgery. METHODS Patients having robotic cardiac valve surgery were randomly assigned to 5% lidocaine patches or identical-appearing placebo patches. Patches were applied around each incision 12 hours/day until pain resolved, or for 6 months. Supplemental opioid was provided by patient-controlled analgesia or orally. Pain was initially evaluated with a Visual Analog Scale, and subsequently by telephone with a Verbal Response Scale and the Pain Disability Index (our primary outcome) after 1 week, 1 month, 3 months, and 6 months. Global Perceived Effect, a measure of patient satisfaction, was simultaneously recorded. Repeated-measures analysis of variance and generalized estimating equations were our primary statistical tools. RESULTS Acute pain scores and opioid use were low, as was the incidence of persistent pain. Lidocaine 5% patches did not influence any measure of acute or persistent incisional pain. Estimated difference (95% CI) in mean Pain Disability Index for Lidocaine patch minus placebo was -2.5 (95% CI -7.1, 2.1), P = 0.28. CONCLUSIONS Lidocaine 5% patches did not reduce acute or persistent pain in patients having robotic thoracic surgery, though pain scores were low in both treatment groups. Clinicians should choose alternative analgesic approaches in these patients.

Glossopharyngeal neuralgia secondary to vascular compression in a patient with multiple sclerosis: a case report

IntroductionGlossopharyngeal neuralgia is an uncommon, painful syndrome, characterized by paroxysms of pain in the sensory distribution of the 9th cranial nerve. Idiopathic glossopharyngeal neuralgia may be due to compression of the glossopharyngeal nerve by adjacent vessels, while secondary glossopharyngeal neuralgia is associated with identifiable lesions affecting the glossopharyngeal nerve at different levels of its neuroanatomic pathway. Glossopharyngeal neuralgia is rare in the general population, but is more common in patients with multiple sclerosis.Case presentationA 56-year-old Caucasian woman with multiple sclerosis and migraine presented to our facility with intermittent lancinating pain to the right of her throat, tongue, and the floor of her mouth that had been occurring for the past year. The pain was intense, sharp, and stabbing, which lasted two to six seconds with radiation to the right ear. Initially, the attacks were infrequent, however, they had become more intense and frequent over time. Our patient reported weight loss, headache, painful swallowing, and the inability to maintain sleep due to painful attacks. A neurological examination revealed a right-handed woman with trigger points in the back of the tongue and throat on the right side. She also had dysphagia, hoarseness, and pain in the distribution of the right glossopharyngeal nerve. Mild right hemiparesis, hyperreflexia, dysmetria, and an ataxic gait were present. A magnetic resonance imaging scan of the brain was consistent with multiple sclerosis and magnetic resonance angiography demonstrated a loop of the posterior inferior cerebellar artery compressing the right glossopharyngeal nerve. She responded satisfactorily to carbamazepine. Microvascular decompression and Gamma Knife® radiosurgery were discussed in case of failure of the medical treatment; however, she declined these options.ConclusionsGlossopharyngeal neuralgia in multiple sclerosis may occur due to vascular compressive lesions and it should not be solely attributed to the underlying demyelinating process. Vascular compression of the glossopharyngeal nerve could independently cause glossopharyngeal neuralgia in patients with multiple sclerosis, and vascular imaging to exclude such a diagnosis is recommended.

Sympathetic Blocks for Chronic Abdominal Pain

The abdominal and pelvic organs contain at least five sympathetic structures that have been well described and are amenable to local anesthetic blockade as part of a multimodal analgesic strategy for malignant and non-malignant pain conditions. Patients suffering from abdominal pain that is entirely, or in part, mediated by transmission through the sympathetic nervous system may decrease both pain scores and reliance on analgesic medications, while improving function and quality of life following disruption of these fibers. We herein describe the anatomy pertinent to the pain physician, as well as indications, methodology, and complications associated with performing the splanchnic, celiac, superior hypogastric, inferior hypogastric, and ganglion impar blocks. A discussion of the advantages and pitfalls encountered with various technical approaches is presented alongside anatomic drawings and fluoroscopic images.