David R. Walega

Comparison of the particle sizes of different steroids and the effect of dilution: a review of the relative neurotoxicities of the steroids.

Background:Central nervous system injuries after transforaminal epidural steroid injections have been ascribed to occlusion of the blood vessels supplying the spinal cord and brain by the particulate steroid. Methods:The authors compared the sizes of the particles of the steroids methylprednisolone acetate, triamcinolone acetonide, dexamethasone sodium phosphate, betamethasone sodium phosphate/betamethasone acetate (both Celestone Soluspan®; Schering-Plough, Kenilworth, NJ, the commercial betamethasone; and betamethasone repository, a betamethasone preparation that can be ordered from a compounding company), and betamethasone sodium phosphate. Both undiluted and diluted samples were examined. The samples were examined with a laser scanning confocal microscope, and images were analyzed and measured. The particles were categorized (or tabulated) into groups: 0-20, 21-50, 51-1000, and greater than 1000 &mgr;. Chi-square analyses, with Bonferroni correction, were used to compare the proportion of particles among the undiluted and diluted drug formulations. Results:Dexamethasone and betamethasone sodium phosphate were pure liquid. The proportion of larger particles was significantly greater in the methylprednisolone and the compounded betamethasone preparations compared with the commercial betamethasone. There was no statistical difference between the commercial betamethasone and triamcinolone, although betamethasone had a smaller percentage of the larger particles. Increased dilution of the compounded betamethasone with lidocaine decreased the percentage of the larger particles, whereas increased dilution of methylprednisolone 80 mg/ml with saline increased the proportion of larger particles. Conclusion:Commercial betamethasone is the recommended preparation if a nonsoluble steroid is preferred. Dexamethasone is a nonparticulate steroid, but its routine use awaits further studies on its safety and efficacy.

Diagnostic criteria and treatment of discogenic pain: a systematic review of recent clinical literature.

BACKGROUND CONTEXT Pain innate to intervertebral disc, often referred to as discogenic pain, is suspected by some authors to be the major source of chronic low back and neck pain. Current management of suspected discogenic pain lacks standardized diagnosis, treatment, and terminology. PURPOSE In an attempt to determine whether patterns existed that may facilitate standardization of care, we sought to analyze the terminologies used and the various modes of diagnosis and treatment of suspected discogenic pain. STUDY DESIGN A systematic review of the recent literature. METHODS A Medline search was performed using the terms degenerative disc disease, discogenic pain, internal disc disruption while using the limits of human studies, English language, and clinical trials, for the last 10 years. The search led to a total of 149 distinct citations, of which 53 articles, where the intervertebral disc itself was considered the principal source of patients pain and was the main target of the treatment, were retained for further analysis. RESULTS The results of this review confirm and help quantify the significant differences that existed in the terminology and all the areas of diagnosis and treatment of presumed discogenic pain. CONCLUSIONS Our findings show that suspected discogenic pain, despite its extensive affirmation in the literature and enormous resources regularly devoted to it, currently lacks clear diagnostic criteria and uniform treatment or terminology.

Effects of stellate ganglion block on vasomotor symptoms: findings from a randomized controlled clinical trial in postmenopausal women.

ObjectiveUncontrolled intervention studies, including studies involving breast cancer survivors, have demonstrated improvements in vasomotor symptoms (VMS) after stellate ganglion blockade (SGB) with a local anesthetic. This study presents the first randomized sham-controlled trial of SGB for the treatment of VMS. MethodsParticipants included 40 postmenopausal women, aged 30 to 70 years, with moderate to severe VMS. The study was a randomized sham-controlled trial comparing the effects of SGB versus sham injection on the frequencies of total and moderate to severe VMS, as measured by daily diaries. Image-guided SGB was performed with 5 mL of 0.5% bupivacaine. Sham injection of saline was performed in subcutaneous tissues in the neck. VMS were recorded at baseline and for 6 months thereafter. Objective VMS were recorded using ambulatory sternal skin conductance monitoring during a 24-hour period at baseline and on 3-month follow-up. ResultsThere were no significant group differences in overall VMS frequency, but the frequency of moderate to very severe VMS was reduced more in the active group compared with the sham treatment group (event rate ratio, 0.50; 95% CI, 0.35-0.71; P < 0.001). The frequency of objective VMS was also reduced to a greater degree in the SGB group than in the sham group (event rate ratio, 0.71; 95% CI, 0.64-0.99; P < 0.05). There were no study-related serious adverse events. ConclusionsSGB may provide effective treatment of VMS in women who seek nonhormonal treatments because of safety concerns and personal preference. The finding that SGB significantly reduces objectively measured VMS provides further evidence of efficacy. A larger trial is warranted to confirm these findings.

Third-Degree Burn from Cooled Radiofrequency Ablation of Medial Branch Nerves for Treatment of Thoracic Facet Syndrome

Radiofrequency ablation of medial branch nerves is considered a safe and effective treatment for chronic facet joint pain in the cervical, thoracic, and lumbosacral spine. Cooled radiofrequency ablation (C‐RFA) is gaining popularity over conventional thermal radiofrequency ablation (RFA) in pain management. However, complications of C‐RFA have not been reported in the literature. We present a first report of third‐degree skin burn resulting from C‐RFA electrode use for the treatment of facet syndrome.

Long-Term Function, Pain and Medication Use Outcomes of Radiofrequency Ablation for Lumbar Facet Syndrome

Objective Radiofrequency ablation (RFA) of the medial branch nerves for facet-mediated low back pain demonstrates clinical benefit for 6–12 months and possibly up to 2 years. This study investigated function, pain, and medication use outcomes of RFA for lumbar facet syndrome in a cohort with long-term follow-up. Methods Individuals evaluated in a tertiary academic pain practice between January, 2007–December, 2013, 18–60 years of age, with a clinical and radiologic diagnosis of lumbar facet syndrome, who underwent ≥1set of diagnostic medial branch blocks with resultant >75% pain relief and subsequent RFA were included. Outcomes measured were the proportion of individuals who reported ≥50% improvement in function, ≥50% improvement in pain; change in median NRS pain score, daily morphine equivalent consumption (DME), Medication Quantification Scale III (MSQ III) score and procedure complications. Results Sixty-two consecutive individuals with a median age and 25%–75% interquartile range (IQR) of 34 years (35, 52) met inclusion criteria. Seven individuals were lost to follow-up. Duration of pain was <2 years in 42%, 2–5 years in 40%, >5 years in 18% of individuals. Median duration of follow-up was 39 months (16, 60). Function and pain improved by ≥50% in 58% (CI 45%, 71%) and 53% (CI 40%, 66%) of individuals, respectively. The median reduction in MQS III score was 3.4 points (0, 8.8). No complications occurred in this cohort. Conclusions This study demonstrates a durable treatment effect of RFA for lumbar facet syndrome at long-term follow-up, as measured by improvement in function, pain, and analgesic use.

The Incidence and Severity of Physical Pain Symptoms in Marfan Syndrome: A Survey of 993 Patients.

Objective:To characterize the incidence, severity, quality, and treatment of pain in a large cohort of Marfan patients. Materials and Methods:A web-based survey was distributed to all individuals on the Marfan Foundation listserv. Respondents who endorsed a diagnosis of Marfan syndrome were queried as to the presence, frequency, severity, location, and quality of their pain and were asked to describe the specific treatments used to manage pain. The primary outcome was the presence of pain symptoms in respondents during the 7-day period preceding completion of the survey. Results:Of the 993 patients with a verified diagnosis of Marfan syndrome, 67% (95% confidence interval, 64%-69%) reported pain in the preceding 7 days. Median (interquartile range) “average daily pain” was 4 (3 to 5) on the numeric rating scale; “worst pain” was 7 (5 to 8). “Worst pain experienced” was ≥4 in 93% of respondents. Analgesic use to control pain related to Marfan syndrome was reported in 56% of respondents with 55% reporting <50% pain relief with this modality. Few patients underwent interventional procedures for pain control, despite intractable back and joint pain being common. A majority (52%) of respondents rated “chronic pain care” from their physicians as either “poor” or “fair.” Discussion:Our findings suggest that pain symptoms in Marfan patients are underestimated and likely undertreated. We propose a need for improved patient and medical provider awareness of pain management options in this population, including the development of effective algorithms to treat pain in Marfan patients.

Bilateral cervicothoracic transforaminal blood patches for persistent headache from spontaneous intracranial hypotension: A case report and review

ObjectivesSpontaneous intracranial hypotension (SIH) is an uncommon cause of headache that can be challenging to treat and can have serious clinical consequences. When symptoms persist despite conservative treatment, an interlaminar epidural blood patch is often performed, but may not be effective. MethodsCase report and review of the literature. Results and DiscussionIn this clinical report, we describe a case of spontaneous intracranial hypotension caused by a ventral dural tear at the cervicothoracic junction. Our patient suffered from recalcitrant postural headaches despite undergoing conventional interlaminar epidural blood patches. Bilateral transforaminal epidural blood patches were performed in order to deliver blood to the ventral epidural space at the site of the tear identified on magnetic resonance imaging. The transforaminal technique may be useful in patients who have failed conventional treatment, though a high degree of interventional experience and vigilance is required to safely perform this procedure.

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.

Spinal Cord Stimulator Implant Infection Rates and Risk Factors: A Multicenter Retrospective Study.

Spinal cord stimulation is an evidence‐based treatment for a number of chronic pain conditions. While this therapy offers improvement in pain and function it is not without potential complications. These complications include device failure, migration, loss of therapeutic paresthesia, and infection. This article looked to establish a modern infection rate for spinal cord stimulators, assess the impact of known risk factors for surgical site infections and to determine the impact of certain preventative measures on the rate of infection.

Evaluation of anxiety in procedure-naive patients during cervical and lumbar epidural steroid injection procedures

Background and Objectives The lack of studies that identify patient and procedural risk factors for increased levels of anxiety during spine injections represents a major barrier to the development of safe tailored sedation practices. We measured and compared anxiety in procedure-naive patients undergoing a cervical or lumbar interlaminar epidural steroid injection to identify predictors of patient movement and vasovagal responses in the periprocedural period. Methods This prospective observational cohort study was conducted with injection-naive patients presenting for a routine cervical or lumbar epidural steroid injection. The primary outcome measure was the Spielberger State Trait Anxiety Inventory (STAI) score. Participants also reported anxiety using the Numeric Rating Scale in the periprocedural period. The Wilcoxon rank sum test was used to compare STAI scores; Numeric Rating Scale values were compared using Friedman test. Post hoc tests were corrected for 12 comparisons using the Bonferroni method. Results We found no group differences in age, gender, marital status, Visual Analog Scale pain score, duration of pain symptoms, or utilization of health care resources for pain symptom management. The mean STAI score was 43 ± 8 in the cervical group (n = 140) and 44 ± 9 in the lumbar group (n = 140) (P = 0.35), a low level of anxiety. There were no between-group differences in anxiety at any point during the periprocedural period. A vasovagal response was identified in 10% of the cervical group and in 3% of the lumbar group (P = 0.04). Conclusions No group differences in anxiety were seen between cervical and lumbar groups. Anxiety levels were not associated with patient movement or vasovagal symptoms. Our results suggest that the practice of routine prevention or treatment of injection-related anxiety in the procedure-naive general population with a duration of pain less than 6 months and without a history of an anxiety disorder should be reevaluated.