Interventional Pain Medicine最新文献

Background: Spinal Cord Stimulation (SCS) is a widely recognized treatment for Complex Regional Pain Syndrome (CRPS), particularly in cases where traditional methods are ineffective. This paper systematically reviews randomized controlled trials to analyze the efficacy of SCS, as well as Dorsal Root Ganglion (DRG) Stimulation in treating CRPS, focusing on its long-term effectiveness.

Methods: This systematic review focused exclusively on randomized controlled trials to assess a primary outcome of improvement in pain symptoms in patients diagnosed with CRPS. The primary outcomes assessed were pain reduction and patient satisfaction, with attention to functional improvement, quality of life improvement, preference for waveform settings, and complications when such data was made available.

Results: The results showed significant pain reduction in CRPS patients treated with SCS and DRG. Preference for specific SCS settings varied among patients, with no clear superiority of one setting over another. Innovations in SCS technology, including novel waveforms and frequencies, demonstrated potential for enhanced efficacy and patient comfort.

Conclusions: The review underscores the importance of SCS and DRG as significant treatment options to reduce pain for patients suffering from CRPS. It highlights the need for ongoing research to optimize SCS therapy, focusing on individual patient preferences and responses to different stimulation parameters. This personalized approach could lead to improved patient outcomes in CRPS management. Additionally, as this study only contained data from Randomized Controlled Trials, inclusion of well-conducted observational studies may help to provide stronger evidence for use of this therapy in CRPS patients.

Background: Cervical interlaminar epidural steroid injections (CIESI) are frequently used to treat cervical radiculopathy due to cervical nerve root impingement.

Objective: The purpose of this study was to evaluate the therapeutic effect of CIESI for patients with cervical radiculopathy.

Methods: We conducted a retrospective review of consecutive adult patients with cervical radicular pain and corroborative cervical spondylotic foraminal stenosis on MRI that failed at least 6 weeks of conservative management consisting of medication and physical rehabilitation seen at a multidisciplinary, tertiary academic spine center. Patient Reported Outcome Measurement Information System (PROMIS) domains of Physical Function (PF) v1.2/v2.0 and Pain Interference (PI) v1.1 were collected at all patient visits. Scores were recorded at baseline, 3-months, 6-months and 12-months post-procedure. Statistical analysis comparing baseline scores with follow-up postprocedural PROMIS scores was performed. The percentage of patients reporting improvement greater than the minimal clinically important difference (MCID) was calculated for responders and for the worst case scenario.

Results: 179 patients met inclusion criteria. PROMIS PI at 3-, 6-, and 12-month follow-up statistically improved by 1.5 (95 % confidence interval [CI] 1.4-1.6; p = 0.02), 1.5 (95 % CI 1.4-1.6; p = 0.03) and 1.7 (95 % CI 1.6-1.8; p = 0.4), respectively. Follow-up PROMIS PF at 3-month follow-up improved by 1.6 (95 % CI 1.5-1.7; p = 0.04) but did not significantly differ at 6- or 12-month follow-up. The percentage of patients that exceeded MCID thresholds of clinical significance was 44 % (95 % CI 36%-53 %) at 3-months, 49 % (95 % CI 39%-59 %) at 6-months, and 54 % (95 % CI 41%-66 %) at 12-months. Worst case scenario analysis demonstrated that 32 % (95 % CI 36%-53 %) of patients exceeded the MCID thresholds at 3-months, 31 % (95 % CI 24%-37 %) at 6-months, and 21 % (95 % CI 15%-27 %) at 12-months.

Discussion/conclusions: Our study demonstrated that CIESI leads to an improvement in function and pain for patients with cervical radiculopathy. This study was limited by retrospective design, loss to follow-up, and variation in steroids used.

Objective: To compare the safety and effectiveness in improving function and reducing pain of autologous PRP to corticosteroid (CS) zygapophyseal (Z-joint) intra-articular (IA) injections at six months for patients with chronic osteoarthritis Z-joint mediated low back pain (LBP).

Design: Prospective triple-blinded multicentric randomized controlled trial.

Methods: Fifty participants with radiological signs of Z-joint OA and chronic Z-joint mediated LBP confirmed by a ≥80 % pain improvement after two IA local anesthetic injections were randomized into PRP and CS groups, using a 1:1 ratio. Participants completed questionnaires at baseline, and at 1-, 3- and 6-month post-treatment, with adverse effect data collected at 1 month. Function (Oswestry disability index (ODI)), pain (Numeric Rating Scale (NRS)), treatment satisfaction (modified MacNab criteria), and quality of life (Short Form survey 36 (SF-36)) were assessed at each follow-up. The primary outcome was the percentage of participants improving their function (ODI score) above the minimal clinically important difference (MCID) of 17 points. The secondary outcomes were the percentage of participants with a >50 % NRS improvement, satisfaction to treatment and mean score improvement. Proportions were compared between groups using a chi-square test. Mean scores were compared using a two-way ANOVA or the nonparametric Brunner & Langer test.

Results: Both groups were similar at baseline, no major adverse effects occurred, and no participants were lost at follow-up. The proportion of participants improving their ODI scores above the MCID, the proportion of participants with a >50 % NRS improvement, and mean ODI scores were significantly different between groups in favor of PRP at 6 months. Modified MacNab satisfaction scale, NRS and SF36 mean scores were not statistically different between groups, but all followed the same pattern: the CS groups had a greater improvement a one month, both groups were equivalent at three months and the PRP group had a greater improvement at six months.

Conclusion: This first triple-blinded multicentric RCT demonstrates the safety of PRP IA Z-joint injections and its superiority in improving pain and function at six months post-treatment compared to CS for patients with chronic OA Z-joint mediated LBP. To perform a blinded control study, two intra-articular treatments were compared. However, knowing that radiofrequency neurotomy (RFN) of the medial branch diagnosed by branch blocks has been standard of care for pain originating from Z-joints, further studies comparing PRP to RFN are still needed.

Clinicaltrials gov registry number: NCT05188820.

Background: Complex Regional Pain Syndrome (CRPS) is a condition that causes persistent and debilitating pain. It is often associated with physical injury but can also occur without identifiable trauma or ongoing injury. There are no published guidelines for CRPS treatment in the pediatric population, but interdisciplinary care, medication, and physical therapy are common approaches. Sometimes, interventional procedures such as regional anesthesia may be required to manage symptoms.

Objective: The objective of this literature review is to explore the different interventional pain management approaches that are currently being used and have shown effectiveness in the management of CRPS in the pediatric population.

Methods: We conducted a comprehensive search strategy with an experienced librarian and input from the study's principal investigator from January 1st, 2000 to April 2nd, 2024. The search was conducted in multiple databases using controlled vocabulary and keywords to identify studies relevant to invasive treatments for pediatric CRPS.

Results: Of 825 studies screened, 27 met inclusion criteria, predominantly case reports (70%). The analysis included 183 patients aged 7-18 years, with female predominance (81.4%). Lower extremities were most commonly affected (70.49%), and most cases (83.06%) were triggered by identifiable trauma. IASP and Budapest criteria, though not validated for pediatric populations, were inconsistently utilized across studies for CRPS diagnosis. Interventional procedures were typically implemented after failed conservative management (92.89%), which included multiple medications (e.g., pregabalin, amitriptyline, NSAIDs) combined with physical and psychological therapy. Multiple interventional procedures were often required to achieve pain relief or functional improvement. Follow-up periods were not reported in most studies and, when reported, were short, limiting the assessment of long-term intervention efficacy.

Conclusions: This review summarizes the different interventional pain management methods utilized to treat pediatric CRPS. While techniques such as continuous epidural anesthesia, lumbar sympathetic blocks, peripheral procedures, and spinal cord stimulation have been safely and successfully used as part of a multimodal treatment strategy, the lack of high-quality evidence and specific protocols for CRPS diagnosis and management in pediatric patients calls for further research.

A 78-year-old female with a remote history of L3-4 decompression and fusion presented with several months of low back and radicular leg pain. MRI revealed moderate L2-L3 spinal canal stenosis, ligamentum flavum infolding, moderate bilateral foraminal stenosis, and a grade I retrolisthesis. A right sided L2-L3 TFESI was performed using multiplanar fluoroscopic imaging with a subpedicular supraneural approach. During live iodinated contrast injection, imaging revealed concomitant epidural and central arterial contrast spread. The needle was retracted and repeat live fluoroscopic imaging demonstrated no vascular uptake. Desired epidural and nerve root contrast spread remained in place with repeat still imaging. Dexamethasone and lidocaine were then injected. The patient suffered no adverse events. This case demonstrates that during a lumbar TFESI, it is possible to have an inadvertent arterial injection with desired epidural contrast spread, despite appropriate needle placement. It emphasizes the importance of necessary precautions, including real-time live fluoroscopy, in order to detect arterial uptake before the delivery of injectate. Without live fluoroscopy, optimal epidural flow at the targeted level can distract interventionalists from the fleeting vascular flow multiple vertebral levels away and risks continuation of the procedure with delivery of injectate.

Background: Crohn's disease (CD) is a chronic relapsing-remitting, immunological, inflammatory bowel disease involving any part of the gastrointestinal tract, most commonly, the terminal ileum. Abdominal pain is a prominent debilitating symptom of CD due to continuous intestinal inflammation, associated with disease severity and complications. However, abdominal pain has shown to occur even with disease remission.

Case presentation: A female college student with a history of Crohn's Disease was referred for severe, chronic abdominal pain, with frequent flare-ups and hospitalizations. Due to her refractory debilitating pain, DRG stimulation was initiated with leads placed at right T11 and T12. Twelve months post-implantation, the patient reports 50-60 % reduction in pain, tolerance of an oral diet without postprandial pain, no occurrence of flares since implant, and an overall improvement in function and quality of life.

Conclusion: This report showcases the therapeutic potential of DRG stimulation in managing intractable chronic abdominal pain in inflammatory bowel diseases such as Crohn's disease.