Zachary McCormick

Acute pain control challenges with buprenorphine/naloxone therapy in a patient with compartment syndrome secondary to McArdle's disease: a case report and review.

OBJECTIVE We report the first case of non-iatrogentic exertional rhabdomyolysis leading to acute compartment syndrome in a patient with McArdles disease. We describe considerations of concurrent buprenorphine/naloxone therapy during episodes of severe acute pain. DESIGN Case report. CASE PRESENTATION A 50-year-old male with a history of McArdles disease, taking buprenorphine/naloxone for chronic pain and opioid dependence, presented to the Emergency Department with severe bilateral anterior thigh pain. Over the following 8 hours, he was given a total of 12 mg of intravenous hydromorphone with minimal pain relief. The decision was made to initiate patient-controlled analgesia (PCA) with hydromorphone started at 0.5 mg as needed with a 15-minute lockout. Subsequently, the patients anterior thighs were found to be extremely tense. His creatine kinase level rose to 198,688 units/L and compartment pressures were greater than 90 mm Hg bilaterally. The patient was taken for emergent bilateral fasciotomies. The hydromorphone PCA was increased to 0.8 mg as needed with a 15-minute lockout and a basal rate of 0.5 mg/h. The patients reported pain plateaued at 3/10 intensity 2 days after surgery, and he was transitioned to oxycodone and hydrocodone/acetaminophen. He followed up with his pain management physician 2 months later who restarted suboxone and a buphrenorphine transdermal patch. DISCUSSION Buprenorphine/naloxone is being prescribed off-label with increasing frequency for pain management in patients with or without a history of opioid abuse. Severe acute pain is more difficult to control with opioid analgesics in patients taking buprenorphine/naloxone, requiring higher than usual doses. If buprenorphine/naloxone is discontinued to better treat acute pain with other opioids, monitoring for overdose must take place for at least 72 hours.

The Effect of Body Mass Index on Fluoroscopic Time and Radiation Dose During Sacroiliac Joint Injections

Sacroiliac joint (SIJ) injections are commonly performed under fluoroscopic guidance. Radiation exposure to patients and providers has not been comprehensively studied, particularly the effect of body mass index (BMI).

Adverse events associated with fluoroscopically guided lumbosacral transforaminal epidural steroid injections.

BACKGROUND CONTEXT Although the types and incidence of adverse events (AEs) associated with transforaminal epidural steroid injection (TFESI) have been described, no study has used a systematic standardized questionnaire to solicit AEs from patients to capture an accurate range and incidence of complications. PURPOSE The aim was to systematically identify the types and incidence of AEs associated with TFESI. Additionally, this study evaluated demographic and clinical factors that may predict a higher risk of an AE. STUDY DESIGN/SETTING This was a retrospective cohort study from a multiphysician academic PM&R clinic. PATIENT SAMPLE Patients, aged 19 to 89, who underwent a fluoroscopically guided TFESI for lumbosacral radicular pain between 2004 and 2007 were included. OUTCOME MEASURES The relationship of AEs with gender, age, trainee presence, steroid type, preprocedure visual analog scale (VAS) pain score, systolic blood pressure, fluoroscopy time, and corticosteroid injectate volume was analyzed. METHODS Adverse event data were collected using a survey both immediately and at 24 to 72 hours after TFESI. Statistical analysis was performed using the chi-square, Fisher exact, or Wilcoxon rank sum two-sided tests. Logistic regression analysis was also performed. C.P. is the owner of Rehabilitation Institute of Chicago Physiatric Log & Analysis System computer software. RESULTS In 1,295 consecutive patients undergoing 2,025 TFESI procedures, immediate AEs and delayed AEs occurred after 182 (9.2%) and 305 (20.0%) injections, respectively. The most common immediate AEs were: vasovagal reaction (4.2%) and interrupted procedure from intravascular flow (1.7%). Common delayed AEs included: pain exacerbation (5.0%), injection site soreness (3.9%), headache (3.9%), facial flushing/sweating (1.8%), and insomnia (1.6%). Significant associations were identified between AEs and gender, age, preprocedure VAS, steroid type, and fluoroscopy time. Trainee involvement in the procedure did not impact the complication rate. CONCLUSIONS Fluoroscopically guided lumbosacral TFESI is associated with a similar rate of minor AEs both immediately and 24 to 72 hours after procedure that are typical of other axial corticosteroid injections. Permanent AEs were not found in this sample. The most common AEs associated with TFESI include vasovagal episodes, procedure interruption from intravascular flow, pain exacerbation, injection site soreness, headache, and insomnia.

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.

Factors Associated With Pain Reduction After Transforaminal Epidural Steroid Injection for Lumbosacral Radicular Pain

OBJECTIVE To identify demographic and clinical factors associated with pain improvement after a lumbosacral transforaminal epidural steroid injection (TFESI) for the treatment of radicular pain. DESIGN Retrospective cohort study. SETTING Outpatient center. PARTICIPANTS Adults (N=188) who underwent a fluoroscopically guided TFESI for lumbosacral radicular pain. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Pain reduction from preinjection to 2-week follow-up was measured by visual analog scale (VAS). Patients were grouped by those who experienced no pain relief or worsened pain (≤0%), pain relief but <50% relief (>0%-<50%), or significant pain relief (≥50%) on the VAS. RESULTS The mean duration of pain prior to injection was 45.8±81 weeks. The mean time to follow-up after TFESI was 20±14.2 days. Significantly more patients who experienced ≥50% pain relief at follow-up reported higher preinjection pain on the VAS (P=.0001) and McGill Pain Inventory Questionnaire (P=.0358), reported no worsening of their pain with walking (P=.0161), or had a positive femoral stretch test (P=.0477). No significant differences were found between VAS pain reduction and all other demographic and clinical factors, including a radiologic diagnosis of disk herniation versus stenosis or other neural tension signs on physical examination. CONCLUSIONS Greater baseline pain on the VAS and McGill Pain Inventory, a history of a lack of worsening pain with walking, and a positive femoral stretch test predict a greater likelihood of pain reduction after TFESI for lumbosacral radicular pain at short-term follow-up. Greater baseline pain on the McGill Pain Inventory and a lack of worsening pain with walking predict a magnitude of >50% pain reduction.

Intrathecal Versus Oral Baclofen: A Matched Cohort Study of Spasticity, Pain, Sleep, Fatigue, and Quality of Life

Baclofen commonly is used to manage spasticity caused by central nervous system lesions or dysfunction. Although both intrathecal and oral delivery routes are possible, no study has directly compared clinical outcomes associated with these 2 routes of treatment.

The effect of body mass index on fluoroscopic time and radiation dose during lumbar transforaminal epidural steroid injections

OBJECTIVE Transforaminal epidural steroid injections (TFESIs) are a commonly used, effective treatment for radicular pain. Accurate delivery of the injected medication helps to ensure maximum therapeutic efficacy and to decrease possible adverse events, and fluoroscopy is the preferred and most common image-guidance modality used to ensure accurate needle placement during lumbar TFESIs. However, fluoroscopic-guided lumbar TFESIs put patients at risk because of radiation exposure. The purpose of this study was to determine the relationship between body mass index (BMI) and fluoroscopy time and radiation dose during lumbar TFESIs. DESIGN A retrospective study design was used. SETTING The study was conducted at an academic orthopedic center. All procedures were performed by physicians board-certified in Physical Medicine and Rehabilitation (PM&R) and with subspecialty certification in sports medicine, or by a trainee under close supervision from an attending physician. PARTICIPANTS Participants were patients who underwent fluoroscopic-guided lumbar TFESIs between February 2013 and March 2015 with a documented height/weight, fluoroscopy time, and radiation dose. INTERVENTIONS All patients received unilateral or bilateral lumbar TFESIs with fluoroscopic guidance. Fluoroscopy time and dose were recorded. MAIN OUTCOME MEASURES The main outcome measures were fluoroscopy time and radiation dose. A Bonferroni correction was implemented for multiple comparisons, defining statistical significance at p<.01. RESULTS A total of 2,443 injections were performed on 1,548 patients. There were 419 normal, 572 overweight, and 557 obese patients, respectively. There were 1,426 first-time injections and 1,017 repeat injections. Sixty-nine percent (1,681) were unilateral injections, and 26.4% (645) were single level injections. A trainee was involved in 1,361 (55.7%) of the injections performed. The mean fluoroscopy time for all injections was 30.0±17.5 seconds, and the mean radiation dose was 2,164±1,484 mGy-cm(2). The mean fluoroscopy time was 27.7±15.2 seconds for normal weight patients, 30.0±21.0 seconds for overweight patients, and 32.2±15.1 seconds for obese patients, showing a significant difference between groups (p<.001). The mean radiation doses for each group were 1,376±450, 1,911±653, and 3,029±640 mGy-cm(2), respectively, with a significant increase in radiation dose with increasing BMI (p<.001). CONCLUSIONS The findings of this study demonstrate that fluoroscopy radiation dose and fluoroscopy time during lumbar TFESIs are increased in patients with an elevated BMI, and in patients of greater age, but the presence of a trainee had no effect on fluoroscopy time.

The Effect of Body Mass Index on Fluoroscopic Time and Radiation Dose During Intra-articular Hip Injections

Intra‐articular hip injections are commonly performed for both diagnostic and therapeutic interventions. Because of the risk of damage to neurovascular structures, fluoroscopic guidance with injection of contrast material has been established as the gold standard to ensure proper needle placement into the intra‐articular space. However, fluoroscopically guided intra‐articular hip injections put patients at risk due to radiation exposure.

Comparison of Pain Score Reduction Using Triamcinolone vs. Betamethasone in Transforaminal Epidural Steroid Injections for Lumbosacral Radicular Pain.

ObjectiveAlthough the comparative efficacy of particulate vs. nonparticulate steroids for the treatment of radicular pain with transforaminal epidural steroid injection has been investigated, there is minimal literature comparing particulate steroids. The authors aimed to determine whether transforaminal epidural steroid injection with triamcinolone or betamethasone, two particulate corticosteroids, more effectively reduces lumbosacral radicular pain. DesignThis is a longitudinal cohort study of 1021 patients (1568 transforaminal epidural steroid injections) who received betamethasone or triamcinolone between January 2006 and October 2007 in an academic spine center. The frequency of greater than 50% pain reduction was compared between groups. ResultsThis study included 42.4% (433) male and 57.6% (588) female patients, with a mean (SD) age of 54.1 (16.7) yrs. Betamethasone and triamcinolone were used in 78.8% (1235) and 21.2% (333) of subjects, respectively. Significantly more patients who received triamcinolone (44.4% [95% confidence interval, 36.2%–52.8%]) experienced greater than 50% pain reduction at short-term follow-up (1–4 wks) compared with patients who received betamethasone (26.8% [95% confidence interval, 22.7%–31.4%]). ConclusionsPatients who received transforaminal epidural steroid injection with triamcinolone reported more frequent pain relief of greater than 50% at short-term follow-up compared with those who received betamethasone. These findings further develop the literature on comparative effectiveness in epidural steroid injections. However, given the exploratory and retrospective nature of this investigation, further study is needed.

Outcomes of Acute Inpatient Rehabilitation of Patients With Left Ventricular Assist Devices

OBJECTIVE To investigate the benefits of comprehensive inpatient rehabilitation for patients after left ventricular assist device (LVAD) implantation. DESIGN A retrospective cohort study. SETTING An urban academic inpatient rehabilitation hospital. PATIENTS This study included 58 patients admitted to inpatient rehabilitation after LVAD implantation between 2009 and 2012. METHODS Chart review of demographic, clinical, and functional data for patients admitted to inpatient rehabilitation after LVAD implantation was performed. MAIN OUTCOME MEASUREMENTS Length of stay, admission and discharge Functional Independence Measure (FIM), and FIM efficiency. RESULTS The study included 47 male and 11 female patients ages 21.8-84.1 years (mean [standard deviation {SD}], 64.2 ± 11.2 years). The mean (SD) length of time between LVAD implantation and admission to rehabilitation was 27.0 ± 15.3 days. Twenty-one patients (36%) required transfer to an acute care hospital. Ten patients returned after transfer and completed inpatient rehabilitation. For the 47 total patients who completed inpatient rehabilitation, the mean (SD) length of stay was 20.3 ± 10.8 days (range, 7-50 days). Mean (SD) admission and discharge FIM scores were 68.4 ± 13.6 and 91.7 ± 11.8, respectively, with a mean (SD) difference between admission and discharge FIM scores of 23.4 ± 11.2. The mean (SD) FIM efficiency was 1.33 ± 0.65. Complications during rehabilitation included anemia that required transfusion, respiratory distress, epistaxis, gout flare, automated implantable cardioverter defibrillator firing, and gastrointestinal bleeding. CONCLUSIONS Patients with LVADs demonstrate functional gains in inpatient rehabilitation. However, there is a high incidence of complications in this population, which often requires transfer to an acute care setting.