Clark Smith

Interlaminar versus Transforaminal Epidural Steroid Injections for the Treatment of Symptomatic Lumbar Spinal Stenosis

BACKGROUND Lumbar spinal stenosis is a common condition that causes axial low back pain, radicular pain, and neurogenic claudication. Epidural steroid injections are commonly used for the treatment of radicular symptoms and neurogenic claudication associated with symptomatic lumbar spinal stenosis. No prior study has evaluated whether transforaminal or interlaminar epidural steroid injections produce better clinical outcomes. DESIGN Retrospective case control study. METHODS For each technique, 19 patients were retrospectively identified who received their first fluoroscopically guided epidural steroid injection for radicular and neurogenic claudication symptoms caused by lumbar spinal stenosis over a 12-month interval. All patients had corresponding MRI findings and had failed previous non-invasive therapies. Outcomes included the visual analog scale (VAS, 0-10 scale) immediately before the injection, immediately after the injection, and upon follow up at 4-6 weeks. Surgery rates and number of repeat injections over a 3 year period were also analyzed. The patient groups were matched for age and level of stenosis on MRI. RESULTS There was no statistically significant difference between the two groups in pre injection to follow up VAS scores (P=0.919). The difference between number of repeat injections between the interlaminar and transforaminal groups was not statistically significant (0.91-mean 2.47 and 2.58, respectively). Both the interlaminar and transforaminal groups experienced statistically significant improvement in VAS scores from before the injection to after the injection, and on follow up. Low numbers underwent surgery (11% in the interlaminar group vs 15% in the transforaminal group, not significant, P=0.63). CONCLUSIONS In the current study, neither transforaminal nor interlaminar steroid injections resulted in superior short term pain improvement or fewer long term surgical interventions or repeat injections when compared with each other.

Challenging Pain Syndromes Parsonage-Turner Syndrome

Parsonage-Turner syndrome (PTS) is a rare disorder typically characterized by an abrupt onset of upper extremity pain followed by progressive neurologic deficits, including weakness, atrophy, and occasionally sensory abnormalities. The exact cause and pathophysiology of PTS are complex and incompletely understood. Autoimmune, genetic, infectious, and mechanical processes have all been implicated. No specific treatments have been proven to reduce neurologic impairment or improve the prognosis of PTS. Most patients with PTS are treated with a multidisciplinary approach that includes both physical therapy and pharmacologic treatment, often with multiple agents. Further research is needed.

Epidural Steroid Injections are Safe and Effective: Multisociety Letter in Support of the Safety and Effectiveness of Epidural Steroid Injections

BACKGROUND In April 2014, the Food and Drug Administration (FDA) issued a Drug Safety Communication requesting that corticosteroid labeling include warnings that injection of corticosteroids into the epidural space of the spine may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death. RESULTS The International Spine Intervention Society spearheaded a collaboration of more than a dozen other medical societies in submitting the letter below to the FDA on November 7, 2014. We are publishing the letter to ensure that the readership of Pain Medicine is aware of the multisociety support for the safety and effectiveness of these procedures. A special note of thanks to all of the societies who signed on in support of the message.

Is There a Relationship Between Body Mass Index and Fluoroscopy Time During Sacroiliac Joint Injection? A Multicenter Cohort Study

OBJECTIVE To determine the relationship between BMI and fluoroscopy time during intra-articular sacroiliac joint (SIJ) injections performed for a pain indication. DESIGN Multicenter retrospective cohort study. SETTING Three academic, outpatient pain treatment centers. SUBJECTS Patients who underwent fluoroscopy guided SIJ injection with encounter data regarding fluoroscopy time during the procedure and body mass index (BMI). MAIN OUTCOME MEASURE Median and 25-75% Interquartile Range (IQR) fluoroscopy time. RESULTS 459 SIJ injections (350 patients) were included in this study. Patients had a median age of 57 (IQR 44, 70) years, and 72% were female. The median BMI in the normal weight, overweight, and obese groups were 23 (IQR 21, 24), 27 (IQR 26, 29), and 35 (IQR 32, 40), respectively. There was no significant difference in the median fluoroscopy time recorded between these BMI classes (p = 0.45). First-time SIJ injection (p = 0.53), bilateral injection (p = 0.30), trainee involvement (p = 0.47), and new trainee involvement (trainee participation during the first 2 months of the academic year) (p = 0.85) were not associated with increased fluoroscopy time for any of the three BMI categories. CONCLUSIONS Fluoroscopy time during sacroiliac joint injection is not increased in patients who are overweight or obese, regardless of whether a first-time sacroiliac joint injection was performed, bilateral injections were performed, a trainee was involved, or a new trainee was involved.

The Effectiveness and Risks of Non–Image-Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data

OBJECTIVE To determine the effectiveness and risks of non-image-guided lumbar interlaminar epidural steroid injections. DESIGN Systematic review. INTERVENTIONS Three reviewers with formal training and certification in evidence-based medicine searched the literature on non-image-guided lumbar interlaminar epidural steroid injections. A larger team of seven 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, and complications were noted, if reported. The evidence was appraised in accordance with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system of evaluating evidence. RESULTS The searches yielded 92 primary publications addressing non-image-guided lumbar interlaminar epidural steroid injections. The evidence supporting the effectiveness of these injections for pain relief and functional improvement in patients with lumbar radicular pain due to disc herniation or neurogenic claudication secondary to lumbar spinal stenosis is limited. This procedure may provide short-term benefit in the first 3-6 weeks. The small number of case reports on significant risks suggests these injections are relatively safe. In accordance with GRADE, the quality of evidence is very low. CONCLUSIONS In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, non-image-guided lumbar interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical practice, these procedures should be restricted to the rare settings where fluoroscopy is not available.

Bilateral stellate ganglion blockade for recalcitrant oral pain from Burning Mouth Syndrome: a case report.

Burning Mouth Syndrome (BMS) is a chronic painful disorder characterized by unremitting bilateral burning oral pain often associated with taste abnormalities and complaints of dry mouth. The diagnosis is made by history and symptom presentation in the absence of an identifiable cause or oral lesion. It is commonly seen in perimenopausal women but is also seen in men, and is considered a small-fiber neuropathy. Management can be challenging and few effective treatments are available. This article presents a case report of stellate ganglion blockade as a treatment for recalcitrant pain from BMS.

Anesthetic Test Dose and Seizure Risk with Cervical Transforaminal Epidural Steroid Injection

S neurological complications from cervical transforaminal injection of steroids (CTFIS) have been attributed to inadvertent injection of particulate steroids into a radicular artery or a vertebral artery [1-5]. The complications include spinal cord infarction, brainstem infarction, cerebral infarction, and death [3]. Two measures have been advocated to prevent these complications. One is to use a test-dose of local anesthetic, and the other is to use non-particulate steroids.

Particulate or Nonparticulate Steroids for Lumbar Transforaminal Injections

Fact: All particulate corticosteroid preparations have been implicated in rare cases of paraplegia, whereas no definitive evidence exists of paraplegia resulting from injection of nonparticulate steroids. Studies directly comparing the effectiveness of particulate and nonparticulate steroids largely show no differences between the two, with respect to relief of pain, restoration of function, or rate of spine surgery. There is no evidence-based rationale for the routine use of particulate steroids in lumbar transforaminal injections, given the increased risk of paraplegia.

Systemic Effects of Epidural Corticosteroid Injection

T and interlaminar epidural injections of corticosteroids are used to treat radicular pain. The presumed rationale is that the corticosteroid suppresses inflammation of the affected nerve root, which is responsible wholly or partly for the generation of pain. Once injected, the corticosteroid is absorbed through the epidural plexus of veins, and can exert systemic effects. The risk of side-effects is dependent on the dose used and the number of injections given over time. The nature of systemic effects depends on the systems affected and the duration of exposure to steroids.

Masks, Gowns, and Caps for Interventional Spine Pain Procedures

T Centers for Disease Control and Prevention (CDC) has investigated outbreaks of bacterial meningitis among patients undergoing various spine procedures. Some procedures that resulted in infection were performed by a healthcare provider who did not wear a face mask [1]. In several cases of meningitis, the strain of bacteria isolated from the cerebrospinal fluid of these patients was identical to the strain recovered from the oral flora of the healthcare provider who performed the procedure [2,3].