Interventional Pain Medicine最新文献

Background

Primary hyperparathyroidism, while increasing the susceptibility to osteoporosis, also amplifies the potential for fractures in vulnerable areas such as the femoral neck. It can also serve as an infrequent etiological factor behind vertebral compression fractures.

Case report

This report discusses a case of multiple acute non-traumatic vertebral compression fractures in a patient diagnosed with primary hyperparathyroidism. The patient, a 79-year-old female with osteopenia (T Score −2.0, medically treated), had a history of left breast cancer treated with a partial mastectomy and radiation therapy. She presented with midline back pain resulting from T12 and L2 compression fractures and underwent balloon kyphoplasty. A week later, she reported severe low back pain, despite the absence of any new traumatic event. Repeat imaging showed multiple new, acute compression fractures at T10, T11, L1, and L3. Further workup revealed elevated parathyroid hormone levels and hypercalcemia, leading to a diagnosis of hyperparathyroidism.

Conclusion

Multiple acute non-traumatic vertebral body compression fractures due to hyperparathyroidism is an uncommon clinical manifestation. This case emphasizes the need for an extended work-up of secondary osteoporosis in patients who experience multiple vertebral compression fractures.

Objectives

Describe a catastrophic complication of cervical epidural injection (CEI) in a patient with prior anterior cervical discectomy with fusion (ACDF).

Setting

Interlaminar CEI at C7-T1 was performed under minimal sedation.

Discussion

Right hemiparesis, diffuse dysesthesia, and tactile allodynia were immediately described after the procedure. 24 hours after CEI, an MRI showed an increased T2 signal and decreased T1 signal in the spinal cord extending from C3-T3. Postsurgical ACDF changes, cervicovertebral ligament anomalies, repetitive microtrauma from serial CEI's, and epidural space compromise may have complicated the loss of resistance technique and increased the risk for dural puncture and intrinsic cord injury.

Conclusion

Knowledge of cervical spinal anatomy, biomechanical implications of ACDF, ligamentous inflammation, pre-operative image review, and perioperative patient feedback are valuable insights that may mitigate the risk of severe adverse events.

Background

Lumbar radiofrequency neurotomy (LRFN) effectively treats lumbar zygapophyseal joint pain by coagulating medial branch nerves (MBNs) carrying nociceptive signals. MBNs also innervate deep paraspinal muscles. There is a paucity of literature on whether LRFN accelerates the progression of vertebral displacement in patients with degenerative lumbar spondylolisthesis (DLS).

Objective

Compare the rate of spondylolisthesis progression in adults with DLS who underwent LRFN to the 2% annual rate of progression expected by natural history.

Design

Cross-sectional cohort study.

Methods

Consecutive patients with pre-existing DLS who underwent LRFN for zygapophyseal joint-mediated low back pain were identified. Patient demographics, LRFN procedure details, and radiographic images confirming Meyerding Grade (I-II) spondylolisthesis were collected from electronic medical records. The quantitative magnitude of spondylolisthesis progression and the annualized rate were calculated from pre-and post-LRFN radiographs. Data were analyzed using Wilcoxon signed-rank tests and a linear regression model.

Results

152 patients (mean age 65.9 ± 12.3 years; 59.2% female) met eligibility criteria and were included in the analyses. Average time to radiographic follow-up was 35.6 ± 24.7 months post-LRFN. The average spondylolisthesis progression rate of 1.63 ± 2.91% per year calculated for the LRFN cohort was significantly lower than the 2% annual rate of progression associated with natural history (p < 0.001). None of the included covariates, such as age, BMI, LRFN laterality, number of levels denervated, or history of prior lumbar spinal surgery, were significantly associated with the average annual rate of progression.

Conclusions

Our results suggest that spondylolisthesis progression rate is no different or worse than the expected natural progression rate in patients with pre-existing DLS who have undergone LRFN.

Summary of background data

Although evaluated within other specialties, physicians’ beliefs towards climate change and human health have not been described within Interventional Pain Medicine (IPM). Understanding belief systems is essential for developing solutions to build sustainable practices.

Objectives

Assess beliefs toward climate change within the field of IPM.

Methods

Spine Intervention Society (SIS) members were invited to participate in an anonymous RedCap survey by email, social media, and advertisement at the 2022 SIS Annual Meeting. Descriptive statistics were calculated, and associations were estimated using Chi-Square (significance: p < 0.05).

Results

One hundred and seventy-five participants responded to the survey. Participants most often identified as white (66 %; 95 % CI 57–73 %), male (78 %; 95 % CI 71–84 %), and from the United States (US) (76 %; CI 95 % 58–72 %), with 87 % (n = 123/141; 95 % CI 82–93 %) agreeing that climate change is happening (agree or strongly agree). While 78 % (95 % CI 80–92 %) agree that climate change and sustainability are important to them, only 47 % (95 % CI 34–51 %) agree that these are important to their patients. Those beliefs did not differ by age or geographical area (p > 0.05). However, physicians in non-leadership positions are more likely to disagree or strongly disagree that climate change is important to them (χ²(2) = 15.98; p < 0.05), to their patients (χ²(2) = 17.21; p < 0.05), or that societies should advocate for climate policies (χ²(2) = 9.19; p < 0.05). Non-US physicians were more likely to believe that physicians have responsibilities to bring awareness to the health effects of climate change (χ²(2) = 6.58; p < 0.05) and to agree that climate change is important to their patients (χ²(2) = 10.50; p < 0.05).

Discussion/conclusion

Understanding specialty-specific physician views on climate change is essential for developing solutions to reduce the carbon footprint of medical practice and improve sustainability. The majority of SIS members believe that climate change is happening. Non-US physicians and physician-leaders are more likely to believe that climate change impacts their patients and that societies should advocate for climate policies.

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to improve our understanding and management of several potential local anesthetic-related complications.

Evidence in support of the following facts is presented. (1) Chondrotoxicity: Which Local Anesthetics are Safest for Intraarticular Injection? -- There are drug-, concentration-, and time-dependent chondrotoxic effects that vary between local anesthetics. Current evidence related to commonly used local anesthetics indicates that with exposure to equivalent volumes, bupivacaine, at concentrations of 0.5 % or higher, is the most chondrotoxic agent, while ropivacaine, at concentrations equal to or less than 0.5 %, is the least chondrotoxic in vitro. There is minimal published evidence that confirms these findings in vivo. (2) Minimizing Risks with Stellate Ganglion Blocks -- Evidence suggests that fluoroscopic or ultrasound guidance reduces the risk and increases the accuracy of SGB. Utilizing ultrasound guidance has the added benefit of soft tissue visualization, especially vascular structures, which has the potential to prevent adverse outcomes when compared to the fluoroscopic technique.

Poor posture can lead to excessive strain of the neck and upper back musculature, leading to irritation of the dorsal scapular nerve (DSN) and spinal accessory nerve (SAN). A 5-in-1 trigger point technique has been described that specifically target trapezius, rhomboids, levator scapulae, SAN and DSN in a single percutaneous injection. We modified the technique to include hydrodissecting the DSN and SAN to provide further pain relief from possible nerve entrapments. Our retrospective review revealed that the modified 5-in-1 technique is a safe and effective way to address medial periscapular pain, often seen with anterior head carriage and upper crossed syndrome. Patients who received the modified 5-in-1 technique had statistically significant pain relief, allowing them to participate in rehabilitation programs.

Introduction

Previous studies have suggested variability in practice patterns for transforaminal epidural steroid injections (TFESIs) despite published safety guidance. The purpose of this study was to understand recent trends in periprocedural safety practices in TFESIs and how some aspects of interventional pain practice may have been influenced by the coronavirus disease 2019 (COVID-19) pandemic and related supply chain shortages.

Methods

A 91-item survey was distributed to 111 program directors of Accreditation Council for Graduate Medical Education accredited Pain Management fellowships, 42 North American Spine Society and Interventional Spine and Musculoskeletal Medicine recognized fellowship directors, and 100 private practice interventional pain physicians to capture current practices in epidural steroid injections from March 2021 to March 2022. Additional responses were obtained through advertising on social media platforms consisting of interventional pain physicians. Cross sectional data from survey responses specific to TFESI-related practices were gathered and analyzed.

Results

Of 103 complete survey responses, 102 physicians perform TFESIs (cervical, 33.3%; thoracic, 40.2%; lumbar, 100%; sacral, 89.2%). There was variability in preprocedural imaging review, sedation practices, contrast and fluoroscopy techniques, and type and dose of steroid preferred. Many physicians saw a decrease in number of procedures performed weekly as a result of the COVID-19 pandemic.

Conclusions

There remains practice variability in various periprocedural aspects of TFESIs despite existing safety recommendations. Further research is needed to identify ongoing barriers to adherence to established guidelines. Recent practice trends may have been affected by unique challenges posed by the COVID-19 pandemic, and these trends should be considered in the event of future supply chain limitations and/or need for disaster response.

Objective

To report a case of intrathecal pump failure following months of diminishing benefit from intrathecal baclofen, and to heighten awareness that intrathecal pump malfunction can occur without precipitating events.

Case report

A 40 year-old woman with multiple sclerosis and spastic paraplegia developed worsening spasticity after ten months of therapeutic stability with intrathecal baclofen. After other causes were pursued, this was discovered to be due to pump malfunction only thirteen months after implantation. After pump interrogation and discussion with the manufacturer the pump was replaced urgently and the patient regained therapeutic benefit and had no further complications.

Conclusions

We present herein what we believe to be the first report of a verified pump malfunction resulting in disruption of intrathecal baclofen delivery within thirteen months of implantation. Due to the possible severity of acute baclofen withdrawal, the pump was replaced urgently after diagnosis. Because of the patient's and her healthcare providers' vigilance, she experienced no adverse events. Healthcare providers are encouraged to acknowledge the possibility of intrathecal pump malfunction in similar scenarios, ensuring patient safety while systematically examining the underlying problem.