Mark C. Bicket

Epidural Steroids: A Comprehensive, Evidence-based Review

Abstract Epidural steroid injections (ESIs) are the most widely utilized pain management procedure in the world, their use supported by more than 45 placebo-controlled studies and dozens of systematic reviews. Despite the extensive literature on the subject, there continues to be considerable controversy surrounding their safety and efficacy. The results of clinical trials and review articles are heavily influenced by specialty, with those done by interventional pain physicians more likely to yield positive findings. Overall, more than half of controlled studies have demonstrated positive findings, suggesting a modest effect size lasting less than 3 months in well-selected individuals. Transforaminal injections are more likely to yield positive results than interlaminar or caudal injections, and subgroup analyses indicate a slightly greater likelihood for a positive response for lumbar herniated disk, compared with spinal stenosis or axial spinal pain. Other factors that may increase the likelihood of a positive outcome in clinical trials include the use of a nonepidural (eg, intramuscular) control group, higher volumes in the treatment group, and the use of depo-steroid. Serious complications are rare following ESIs, provided proper precautions are taken. Although there are no clinical trials comparing different numbers of injections, guidelines suggest that the number of injections should be tailored to individual response, rather than a set series. Most subgroup analyses of controlled studies show no difference in surgical rates between ESI and control patients; however, randomized studies conducted by spine surgeons, in surgically amenable patients with standardized operative criteria, indicate that in some patients the strategic use of ESI may prevent surgery.

Epidural injections for spinal pain: a systematic review and meta-analysis evaluating the "control" injections in randomized controlled trials.

Background:Epidural steroid injection is the most frequently performed pain procedure. This study of epidural steroid “control” injections aimed to determine whether epidural nonsteroid injections constitute a treatment or true placebo in comparison with nonepidural injections for back and neck pain treatment. Methods:This systematic review with direct and indirect meta-analyses used PubMed and EMBASE searches from inception through October 2012 without language restrictions. Study selection included randomized controlled trials with a treatment group receiving epidural injections of corticosteroids or another analgesic and study control groups receiving either an epidural injection devoid of treatment drug or a nonepidural injection. Two reviewers independently extracted data including short-term (up to 12 weeks) pain scores and pain outcomes. All reviewers evaluated studies for eligibility and quality. Results:A total of 3,641 patients from 43 studies were included in this systematic review and meta-analysis. Indirect comparisons suggested epidural nonsteroid were more likely than nonepidural injections to achieve positive outcomes (risk ratio, 2.17; 95% CI, 1.87–2.53) and provide greater pain score reduction (mean difference, −0.15; 95% CI, −0.55 to 0.25). In the very limited direct comparisons, no significant differences were noted between epidural nonsteroid and nonepidural injections for either outcome (risk ratio [95% CI], 1.05 [0.88–1.25]; mean difference [95% CI], 0.22 [−0.50 to 0.94]). Conclusion:Epidural nonsteroid injections may provide improved benefit compared with nonepidural injections on some measures, though few, low-quality studies directly compared controlled treatments, and only short-term outcomes (⩽12 weeks) were examined.

The physical environment influences neuropsychiatric symptoms and other outcomes in assisted living residents

Although the number of elderly residents living in assisted living (AL) facilities is rising, few studies have examined the AL physical environment and its impact on resident well‐being. We sought to quantify the relationship of AL physical environment with resident outcomes including neuropsychiatric symptoms (NPS), quality of life (QOL), and fall risk, and to compare the effects for demented and non‐demented residents.

Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study

Abstract Objective To quantify the effects of varying opioid prescribing patterns after surgery on dependence, overdose, or abuse in an opioid naive population. Design Retrospective cohort study. Setting Surgical claims from a linked medical and pharmacy administrative database of 37 651 619 commercially insured patients between 2008 and 2016. Participants 1 015 116 opioid naive patients undergoing surgery. Main outcome measures Use of oral opioids after discharge as defined by refills and total dosage and duration of use. The primary outcome was a composite of misuse identified by a diagnostic code for opioid dependence, abuse, or overdose. Results 568 612 (56.0%) patients received postoperative opioids, and a code for abuse was identified for 5906 patients (0.6%, 183 per 100 000 person years). Total duration of opioid use was the strongest predictor of misuse, with each refill and additional week of opioid use associated with an adjusted increase in the rate of misuse of 44.0% (95% confidence interval 40.8% to 47.2%, P<0.001), and 19.9% increase in hazard (18.5% to 21.4%, P<0.001), respectively. Conclusions Each refill and week of opioid prescription is associated with a large increase in opioid misuse among opioid naive patients. The data from this study suggest that duration of the prescription rather than dosage is more strongly associated with ultimate misuse in the early postsurgical period. The analysis quantifies the association of prescribing choices on opioid misuse and identifies levers for possible impact.

Prescription Drug Coverage for Treatment of Low Back Pain Among US Medicaid, Medicare Advantage, and Commercial Insurers

Key Points Question Among US insurers, what are the coverage policies for pharmacologic treatments for low back pain? Findings In this cross-sectional study of 62 products used to treat low back pain examined across 50 Medicaid, Medicare Advantage, and commercial insurance plans, utilization management strategies were common for nonopioids and opioids alike. Key informant interviews with plan executives underscored the frequent absence of comprehensive strategies to improve chronic pain treatment and to better integrate pharmacologic and nonpharmacologic opioid alternatives. Meaning Our findings underscore important opportunities among insurers to redesign coverage policies to improve pain management and reduce opioid-related injuries and deaths.

The role of perioperative chewing gum on gastric fluid volume and gastric pH: a meta-analysis.

STUDY OBJECTIVE To determine if preoperative gum chewing affects gastric pH and gastric fluid volume. DESIGN Systematic review and meta-analysis. METHODS Data sources included Cochrane, PubMed, and EMBASE databases from inception to June 2012 and reference lists of known relevant articles without language restriction. Randomized controlled trials in which a treatment group that chewed gum was compared to a control group that fasted were included. Relevant data, including main outcomes of gastric fluid volume and gastric pH, were extracted. RESULTS Four studies involving 287 patients were included. The presence of chewing gum was associated with small but statically significant increases in gastric fluid volume (mean difference = 0.21 mL/kg; 95% confidence interval, 0.02-0.39; P = .03) but not in gastric pH (mean difference = 0.11 mL/kg; 95% confidence interval, -0.14 to 0.36; P = .38). Gastric fluid volume and gastric pH remained unchanged in subgroup analysis by either sugar or sugarless gum type. CONCLUSIONS Chewing gum in the perioperative period causes small but statically significant increases in gastric fluid volume and no change in gastric pH. The increase in gastric fluid most likely is of no clinical significance in terms of aspiration risk for the patient. Elective surgery should not necessarily be canceled or delayed in healthy patients who accidentally chew gum preoperatively.

Demographics and living arrangements of the minority elderly in the United States

Using data from the U.S. Census Bureau, this study assesses the demographics and living arrangements of the minority elderly population of the United States. Rapid growth in both the number and the proportion of all elderly minority populations are expected. By 2050, one-third of the elderly population will be other than a non-Hispanic White. While existing literature primarily focuses on the demographics and living arrangements of the White elderly population, this study attempts to show the diversity and differences in economic and cultural patterns among the minority elderly population and the implications of such diversity on the living arrangements of the elderly. The data show variations in elderly living arrangements in minority population groups by gender, and across and within the groups themselves. Such differences in living arrangements have important policy implications on both macro and micro level.

The Development and Validation of a Quality Assessment and Rating of Technique for Injections of the Spine (AQUARIUS).

Background and Objectives Systematic reviews evaluate the utility of procedural interventions of the spine, including epidural steroid injections (ESIs). However, existing quality assessment tools either fail to account for proper technical quality and patient selection or are not validated. We developed and validated a simple scale for ESIs to provide a quality assessment and rating of technique for injections of the spine (AQUARIUS). Methods Seven experts generated items iteratively based on prior ESI technique studies and professional judgment. Following testing for face and content validity, a 17-item instrument was used by 8 raters from 2 different backgrounds to assess 12 randomized controlled trials, selected from 3 different categories. Using frequency of assessment, a 12-item instrument was also generated. Both instruments underwent reliability (intraclass correlation coefficient), validity (ability to distinguish “low,” “random,” and “high” study categories), and diagnostic accuracy (receiver operating characteristics) testing. Results Both 17- and 12-item instruments were scored consistently by raters regardless of background, with overall intraclass correlation coefficients of 0.72 (95% confidence interval [CI], 0.53–0.89) and 0.71 (95% CI, 0.51–0.89), respectively. Both instruments discriminated between clinical trials from all 3 categories. Diagnostic accuracy was similar for the 2 instruments, with areas under receiver operating characteristic curves of 0.89 (95% CI, 0.82–0.96) and 0.90 (95% CI, 0.82–0.97), respectively. Conclusions The instrument in both 17- and 12-item formats demonstrates good reliability and diagnostic accuracy in rating ESI studies. As a complement to other tools that assess bias, the instrument may improve the ability to evaluate evidence for systematic reviews and improve clinical trial design.

Neuropathic Pain Medication Use Does Not Alter Outcomes of Spinal Cord Stimulation for Lower Extremity Pain

Spinal cord stimulation (SCS) for the treatment of lower extremity pain is believed to the result of increased activity in the descending inhibitory and decreased activity in the ascending excitatory tracts. Evidence suggests that the analgesia afforded by SCS may be altered using certain neuropathic pain medications that also modulate neurotransmitters in these sensory tracts. We hypothesize that neuropathic pain medications may alter the response to SCS therapy.

Coverage of Nonpharmacologic Treatments for Low Back Pain Among US Public and Private Insurers

Key Points Question Among US insurers, what are the coverage and utilization management policies for nonpharmacologic treatments for chronic, noncancer low back pain? Findings In this cross-sectional study of 45 Medicaid, commercial, and Medicare Advantage plans, most plans covered at least physical and occupational therapy and chiropractic care for chronic noncancer pain, but there was little evidence of coverage of acupuncture and psychological interventions. Utilization management strategies such as visit limits and prior authorization were common, but criteria varied widely across the plans examined. Meaning The lack of consistent coverage and utilization management policies underscores the need for best practices to improve comprehensive, multimodal coverage of treatments for chronic, noncancer low back pain.