Interventional Pain Medicine最新文献

Pain in osteoarthritis (OA) results from erosion of joint cartilage, resulting in bone contacting bone without an intervening cushion. The periosteum, including its nociceptive innervation, ends at the border of the cartilage. No other innervated tissue is present between the denuded articular bone ends that could serve as a neuronal pathway to carry a bone-on-bone pain signal to the brain. The pain signaling pathway must therefore originate in afferent axons with electrogenic nociceptive sensory endings that reside within the bone itself, specifically in the opposing surfaces of epiphyseal subchondral bone. Selective ablation of this intrinsic nerve pathway, using any of a variety of approaches, is expected to permanently eliminate OA pain.

Objective

Lumbar medial branch denervation is commonly used to treat chronic facetogenic low back pain. Controversy exists regarding risk to adjacent neural structures. The objectives of this cadaveric study were to: (1) dissect, digitize, and model in 3D the branches of the first (L1) to fifth (L5) lumbar dorsal rami located near the junction of the transverse process and lateral neck of the superior articular process; and (2) quantify the minimal distance between the lateral/intermediate and medial branches at the anterior quarter and midpoint of the lateral neck of the superior articular process.

Design

Eighteen formalin-embalmed specimens were dissected, digitized and modeled in 3D. The high-fidelity 3D models were used to compare branching patterns and quantify the mean minimal distance between the lateral/intermediate and medial branches of the lumbar dorsal ramus at the anterior quarter and midpoint of the lateral neck of the superior articular process. A Two-way ANOVA was performed to determine if difference of mean distances was significant.

Results

There was variability in the branching pattern of the lumbar dorsal rami. In 46 cases (51.1%) the lumbar dorsal ramus divided into 2 branches, in 41 cases (45.6%) into 3, and in 3 cases (3.3%) 4. The mean minimal distance between the lateral/intermediate and medial branches was significantly greater at the midpoint (3.2 ± 2.5 mm) than the anterior quarter (1.2 ± 1.8 mm) of the lateral neck of superior articular process.

Conclusion

Minimal distance measurements between the branches of the lumbar dorsal rami at the anterior quarter and midpoint of the lateral neck of the superior articular process were computed. When placing the distal end of the needle tip at the anterior quarter of the lateral neck of the superior articular process, the smaller mean minimal distance between the branches suggests there is a greater risk for inadvertent denervation of the lateral/intermediate branches. Further anatomical and clinical investigations are required.

Background

Transforaminal and interlaminar approaches are both common means of performing epidural steroid injection. Comparative effectiveness data on outcomes of these approaches is available but has yielded mixed results.

Objective

Compare the effect of transforaminal vs interlaminar delivery of epidural steroids on patient-reported pain severity.

Design

Retrospective Cohort Study.

Methods

A retrospective review of prospectively collected interventional spine procedure registry data between December 2011 and July 2017 from a single academic medical center. Those who received epidural steroid injections and had prospectively collected index pain data (11-point Numeric Rating Scale [NRS]) recorded in the patient's chart prior to the procedure and at a 3 month follow up appointment were included. The outcome of interest was ≥50% reduction in pain as measured using a NRS for back and/or leg pain. To evaluate true predictive odds of success, multivariable logistic regression modeling was used to determine the odds of achieving improved pain.

Results

Of the 73 patients included in the study, 61 (84%) reported radicular pain, 49 (67%) reported back pain, and eleven (15%) had symptoms consistent with claudication, pain characteristics were not mutually exclusive. Fifty-one (70%) underwent transforaminal epidural steroid injection, while 22 (30%) underwent interlaminar injection. When claudication and radicular pain groups were combined into a single “leg pain” category (n = 66), 26/46 (57% 95% CI 41–71%) patients undergoing transforaminal and 6/20 (30% 95% CI 12–54%) patients undergoing interlaminar injections achieved ≥50% leg pain reduction on NRS (p = 0.048). Transforaminal epidural steroid injections were associated with higher odds of ≥50% reduction in leg pain in both the unadjusted model (OR 3.2, p = 00.034) and after adjustment for presence of radicular pain on presentation and the type of steroid used (OR 3.6, p = 0.042).

Conclusion

In this clinical practice registry, patients treated with transforaminal epidural steroid injection were more likely to achieve ≥50% reduction in radicular or neurogenic/claudicatory leg pain compared to those treated with interlaminar epidural steroid injection.

Background

Genicular nerve radiofrequency ablation (GNRFA) is a popular and effective procedure to treat arthritic knee pain. For refractory arthritic pain that fails conservative treatment, total knee arthroplasty (TKA) has been an excellent option. Unfortunately, 15–30% of people who undergo a TKA continue to experience pain and stiffness in the knee. The treatment options for post-TKA knee pain are limited. Pain providers have been trialing GNRFA on this pain condition. However, convincing evidence of its efficacy in treating post-TKA pain is still lacking.

Methods

This is a retrospective study of 73 patients who had undergone genicular nerve RFA, 46 (63.01%) with osteoarthritic pain, and 27 (36.99%) with post-TKA pain. We compared the outcomes (pain relief, function, and complications) between these two groups at 3 months and 6 months after RFA.

Results

Before RFA, there was no significant difference in initial pain and functional level between these two groups. After RFA, the two groups had comparable pain relief at 3 months (p = 0.68) and 6 months (p = 0.53), and similar functionality at 3 months (p = 0.36) and 6 months (p = 0.65).

The overall success rate (≥50% pain relief after RFA) was 80.82%, 95% CI: 70.34%–88.22% (osteoarthritic group 80.43%, 95% CI: 66.83%–89.35%, post-TKA 81.48%, 95% CI: 63.30%–91.82%, P = 0.91) at 3-month follow-up and 56.16%, 95% CI: 44.76%–66.95% (osteoarthritic group 56.52%, 95% CI: 42.25%–69.79%, post-TKA 55.56%, 95% CI: 37.31%–72.41%, P = 0.94) at 6-month follow-up.

There were no reported complications in either group.

Conclusions

Genicular Nerve Radiofrequency Ablation (GNRFA) holds the potential to be equally effective for both post-TKA knee pain and osteoarthritic knee pain.

Background

The overall aim of this study was to assess the effectiveness of endoscopic decompression for outcomes in patients with lumbar spinal stenosis (LSS).

Methods

We conducted a retrospective cohort, single-institution study of n = 139 patients from 2019 to 2022 who underwent endoscopic decompression for LSS. The primary outcome was improvement of Oswestry Disability Index (ODI) between baseline and 12-month follow-up.

Results

In the present sample (n = 139) the average age was 57.6 years (SD = 17.4, with even distribution of men (49%) vs. women (51%). In patients with LSS, lumbar disc herniation was the most common diagnosis in 49 patients followed by lumbar radiculopathy in 25 patients. Lumbar radicular pain was the 3rd most common diagnosis in 21 patients with all other diagnosis listed in Table S1. There was a significant improvement (i.e., decrease) in ODI following endoscopic decompression (mean change: −8.3, 95% CI: −9.4, −7.2, P < 0.001, Fig. 1). Prior lumbar spine surgery (P = 0.048), BMI (P = 0.053), and age (P = 0.022) were associated with changes in ODI. Nearly half (47%) of the sample had prior lumbar spine surgery. Those with prior lumbar spine surgery (−7.5, 95% CI: −8.3, −6.6) showed less improvement than those without prior lumbar spine surgery (−9.1, 95% CI: −10.9, −7.2, Fig. 2). For BMI, 23% had normal BMI while 24% were overweight and 53% were obese. Patients with normal BMI (−10.3, 95% CI: −13.4, −7.2) showed greater improvements compared to overweight (−7.9, 95% CI: −9.4, −6.4) and obese (−7.6, 95% CI: −9.0, −6.3, Fig. 3) patients. Patients under 40 years old (−10.2, 95% CI: −13.6, −6.8) showed greater improvements in ODI compared to those 40 years and older (−7.8, 95% CI: −8.6, −6.8, Fig. 4).

Conclusions

In patients with lumbar spinal stenosis, endoscopic decompression was associated with reduced disability. Patients with no prior lumbar spine surgery, normal BMI, and who were under 40 years old showed greater improvements.

Crohn's disease is a chronic inflammatory bowel condition causing symptoms, notably pain, due to ongoing intestinal inflammation or complications like abscesses, strictures, and fistulas, which are common in IBD patients. Abdominal pain affects up to 60 % of IBD patients, irrespective of disease severity, prompting medical attention. Various medications like NSAIDs, antidepressants, antispasmodics, anticonvulsants, and opioids are used to manage pain, but they have limited effectiveness and potential side effects, even during remission. In this case, a 20-year-old Caucasian female college student [height 5′4″, weight 120lbs (54.4 kg)] with juvenile idiopathic arthritis and Crohn's disease experienced severe daily abdominal pain, negatively impacting her life. Despite a multimodal regimen, including gabapentin, nortriptyline, duloxetine, and acetaminophen, her pain persisted, significantly affecting her appetite, sleep, mood, activity level, and overall quality of life (QOL). To address this, dorsal root ganglion (DRG) stimulation was considered. The patient aimed for a 20 % pain reduction and improved QOL. Trial leads were placed along the T10 and T12 DRG, resulting in a 25 % pain reduction (8–6 out of 10) and substantial QOL improvement. She could eat, sleep without interruptions, walk longer distances, and be more active. The T12 lead was more effective than the T10, targeting upper abdomen stimulation. The patient and her mother were highly satisfied and opted for permanent implantation for the T11 and T12 DRG. While DRG stimulation was approved in 2016 for chronic pain, to our knowledge, this is the first reported case of its use in a patient with debilitating Crohn's disease.

Phantom and residual limb pain are commonly experienced by the majority of amputees, and are often difficult to treat not adequately relieved with medical treatment alone. While extensively studied, the pathophysiology of refractory pain is still unclear, with many proposed mechanisms under investigation (Wilkes et al., 2008). Limited existing literature suggests percutaneous interventions including radiofrequency ablation (RFA) may be promising treatment modalities for patients who have pain refractory to oral agents (Sperry et al., 2023). We present a patient with persistent phantom limb and cancer-associated acetabular pain following hip disarticulation who underwent sciatic-notch RFA for pain management.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to improve our understanding and management of patients with potential contraindications to epidural steroid injections.