Geeta Nagpal

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.

A Prospective Randomized Comparative Trial of Targeted Steroid Injection Via Epidural Catheter Versus Standard C7-T1 Interlaminar Approach for the Treatment of Unilateral Cervical Radicular Pain.

Background and Objectives No study has compared cervical interlaminar epidural steroid injection (CIESI) with epidural catheter advancement to the side and level of pathology versus standard C7-T1 CIESI. This study investigated whether cervical radicular pain is more effectively treated by CIESI with a targeted epidural catheter versus a standard C7-T1 approach. Methods Prospective, randomized, single-blinded trial. Primary outcome: Numerical Rating Scale (NRS) pain at 1 month. Secondary outcomes: Oswestry Neck Disability Index (ONDI), Pain Disability Index (PDI), McGill Pain Questionnaire (MPQ), Patient Global Impression of Change (PGIC), daily morphine equivalents (DME), and Medication Quantification Scale (MQS) III scores. Results Seventy-six participants with a median age of 48 years (IQR, 40–56 years), 59% female, with C4 (n = 2), C5 (n = 27), or C6 (n = 47) radicular pain were enrolled. At 1 month in the catheter and no catheter groups, respectively: 26 (72%, 95% confidence interval [CI], 57%–87%) and 23 (60%; 95% CI, 45%–75%) participants reported 50% or greater NRS reduction; 24 (67%; 95% CI, 52%–84%) and 23 (58%; 95% CI, 42%–73%) participants reported 30% or greater ONDI reduction. There were no group differences in median NRS, ONDI, PDI, MPQ, PGIC, DME, or MQSIII scores (P > 0.05). Intergroup differences were not observed at any follow-up interval. Conclusions This trial showed no significant difference in clinical outcomes with CIESI using a targeted epidural catheter compared to a standard C7-T1 approach for the treatment of unilateral cervical radicular pain at the C5 or C6 level. Both techniques were associated with clinically meaningful improvement across outcome domains of pain, function, disability, and medication use. These effects persisted to 6-month follow-up. The study was registered at Clinical Trials.gov (NCT02095197).

Does cervical interlaminar epidural steroid injection with low-dose lidocaine cause objective upper extremity weakness? A preliminary study

Objective Low-dose local anesthetic is often used in cervical interlaminar epidural steroid injections (CIESI), yet its effect on upper extremity strength has not been studied. The presence of consequent weakness has potential implications for postprocedure safety. This study aimed to determine whether low-dose lidocaine in a C7-T1 CIESI causes objective weakness. Design Prospective case series. Setting Academic pain center. Subjects Adults, cervical radicular pain. Methods Participants underwent CIESI with 1 mL of 1% lidocaine (3 mL total injectate). Elbow flexion (EF), wrist extension (WE), elbow extension (EE), and handgrip strength were measured by dynamometry at baseline, 15 minutes, and 30 minutes postinjection. Changes in strength from baseline and the proportion of participants with a minimum perceptible change in EF, WE, EE, and handgrip strength (≥20%) and 95% confidence intervals (CIs) were calculated. Results Twenty-seven participants were included. At 15 and 30 minutes postinjection, there was no within-participant difference in EF, WE, EE, and handgrip strength from baseline overall. Nonetheless, five (19%, 95% CI = 4-33) of the participants demonstrated a 20% or greater strength decrease in at least one myotomal distribution. A 20% or greater decrease in strength was present in left EF 4% (95% CI = 0-11%), right EF 7% (95% CI = 0-17%), left WE 4% (95% CI = 0-11%), and right WE 7% (95% CI = 0-17%). Conclusions The present data suggest that CIESI with an injectate volume of 3 mL that includes 1 mL of 1% lidocaine may result in objective upper extremity weakness that is above the minimum threshold of perception in a subset of patients.

Poster 101: A Randomized Comparative Trial of Medial Branch Nerve Cooled Versus Traditional Radiofrequency Ablation for the Treatment of Zygaphophyseal Joint Pain; 6-Month Outcomes

Disclosures: Jennifer Bush: Research Grants Mission Connect grant Objective: To identify correlates of acute opioid use after human traumatic spinal cord injury (SCI) with quality of life outcomes at 1 year. Design: Retrospective chart review. T-tests and Rank-Sum test were used to detect differences between those that responded to the 1year survey (R) and non-responders (NR). Spearman correlation was performed on all variables in the R group. Significant correlates were used in the linear regression models. Setting: Level I trauma center and rehabilitation hospital. Participants: 180 consecutive admissions to the SCI Model Systems (SCIMS) database from 2008-2011. 90 had complete initial medication records, of which 51 answered the subjective pain question on the SCIMS 1 year post-injury survey. Interventions: Not applicable. Main Outcome Measures: Correlates to opioids administered within 4, 12, 24 hours, to 7 days post-injury, and correlates to pain scores at 1 year. Results: The R group (n1⁄451) was administered greater amounts of opioids from24hours to 1week (P<.05) compared toNR (n1⁄439). Therewere 8 variables correlated to opioid subtotals, of which the 24 hour subtotal was most frequently correlated. There were six correlates to pain at 1 year, of which four were opioid subtotals, the earliest being 24 hours (rs 1⁄40.409, P 1⁄4 .005). Linear regression was significant for increases in pain score by 0.007 (P 1⁄4 .01) and mobility score decreases by 0.04 (P 1⁄4 .043) for every 1 mg of morphine equivalents (ME) within 24 hours. For example, a decrease of 143 mgME in 24 hours could result in a decreased pain scoreby 1 point and increasedmobility score by5.72 points at 1 year. Conclusions: There is a positive correlation between acute SCI opioid dosage and chronic pain, and an inverse relationship with mobility at 1 year, supporting the animal evidence of Hook et al. Future prospective studies should be performed to examine the relationship of acute pain medications and long-term outcomes. Level of Evidence: Level IV

A Prospective Randomized Trial of Prognostic Genicular Nerve Blocks to Determine the Predictive Value for the Outcome of Cooled Radiofrequency Ablation for Chronic Knee Pain Due to Osteoarthritis

Background and Objectives Genicular nerve radiofrequency ablation is an effective treatment for patients with chronic pain due to knee osteoarthritis; however, little is known about factors that predict procedure success. The current study evaluated the utility of genicular nerve blocks to predict the outcome of genicular nerve cooled radiofrequency ablation (cRFA) in patients with osteoarthritis. Methods This randomized comparative trial included patients with chronic knee pain due to osteoarthritis. Participants were randomized to receive a genicular nerve block or no block prior to cRFA. Patients receiving a prognostic block that demonstrated ≥50% pain relief for six hours received cRFA. The primary outcome was the proportion of participants with ≥50% reduction in knee pain at six months. Results Twenty-nine participants (36 knees) had cRFA following a prognostic block, and 25 patients (35 knees) had cRFA without a block. Seventeen participants (58.6%) in the prognostic block group and 16 (64.0%) in the no block group had ≥50% pain relief at six months (P = 0.34). A 15-point decrease in the Western Ontario and McMaster Universities Osteoarthritis Index at six months was present in 17 of 29 (55.2%) in the prognostic block group and 15 of 25 (60%) in the no block group (P = 0.36). Conclusions This study demonstrated clinically meaningful improvements in pain and physical function up to six months following cRFA. A prognostic genicular nerve block using a local anesthetic volume of 1 mL at each injection site and a threshold of ≥ 50% pain relief for subsequent cRFA eligibility did not improve the rate of treatment success.

Epidural Abscess After Epidural Steroid Injection in a Patient on TNF-Alpha Inhibitors

Biologic response modifiers have revolutionized the treatment of a number of chronic inflammatory diseases, including rheumatoid arthritis, seronegative spondyloarthropathies, psoriasis, and inflammatory bowel disease. The tumor necrosis factor-alpha (TNF-alpha) inhibitors have a targeted strategy for the treatment of systemic inflammation and improve patient symptoms and function. However, TNF-alpha has demonstrated importance in the protection against several pathogens, leaving patients on this therapy more prone to infections.

Diskitis, Osteomyelitis, Spinal Epidural Abscess, Meningitis, and Endocarditis Following Sacroiliac Joint Injection for the Treatment of Low-Back Pain in a Patient on Therapy for Hepatitis C Virus

Objective Sacroiliac joint injections are frequently performed procedures in the management of acute and chronic low-back pain, including patients with various immunocompromised states. Infectious complications following these procedures along with other spinal injections are rarely reported, but the true incidence is unknown. The purpose of this report is to highlight the devastating neurologic sequela that can occur, and to discuss potential future management strategies. Case Report We present a patient who developed diskitis, osteomyelitis, spinal epidural abscess, meningitis, and endocarditis from Staphylococcus aureus, all of which developed shortly after a sacroiliac joint injection. The patient was on treatment for hepatitis C virus, and the resulting immunocompromised state likely contributed to the outcome. Conclusions Immunocompromised patients should be identified prior to treatment, and the small possibility of devastating complications should be thoughtfully weighed against the potential benefit of the procedure. Conservative management should be maximized initially, and if a procedure is done, strict asepsis must be maintained. Prophylaxis for S. aureus should be considered for immunocompromised patients undergoing interventional spine procedures.

Urine Drug Screens to Monitor Opioid Use for Managing Chronic Pain

A 53-year-old woman presented for a prescription refill of hydrocodone/acetaminophen 10 mg/325 mg. She had chronic low back pain and partial paralysis from a thoracic spinal cord infarction, secondary to aortic dissection from prior cocaine use. Taking 2 to 3 tablets of hydrocodone/acetaminophen daily improved her back pain from 5 to 2 on a 10-point scale. She reported no recent illicit substance or drug use and stated her last dose of hydrocodone was that day. The patient had not achieved pain control with prior nonopioid pharmacologic pain management, including duloxetine and gabapentin. Although past cocaine use was a risk factor for opioid misuse, a trial of hydrocodone was initiated, after discussion of risks and benefits, with a plan for careful monitoring. The state prescription drug monitoring program showed no other prescribers of controlled substances. A urine immunoassay drug screen was ordered to evaluate for medication misuse and illicit use (Table).

Interpretation of urine drug screens: Metabolites and impurities

A 50-year-old woman with chronic pain and recurrent infections from common variable immunodeficiency presented to a new primary care physician for management of her pain medications. Her pain was related to multiple vertebral fractures due to chronic steroid use for an inflammatory polyarthritis that was not responsive to hydroxychloriquine and methotrexate. Her pain medication regimen (methadone, 20 mg [3×/d]; immediaterelease morphine, 30 mg [5×/d]; gabapentin, 1200 mg [2×/d]; duloxetine, 60 mg/d; and celecoxib, 200 mg [2×/d]) helped her independently complete instrumental activities of daily living. She reported no adverse effects (eg, somnolence or constipation). A comprehensive urine drug screen using immunoassay and mass spectrometry was ordered (Table 1).