Interventional Pain Medicine最新文献

With the introduction of modern cone beam computed tomography in the operating room, the benefits of imaging modalities in daily practice are recognized by an increasing number of clinicians. Newer generation imaging modalities include CT needle guidance software, which can aid the operator place the needle correctly during percutaneous intervention. This technique has several advantages over traditional percutaneous interventions, especially for high risk procedures like thoracic sympathectomy.

We describe and discuss outcomes and possible advantages of applying CT guided needle placement using needle guidance software (XperGuide®) for percutaneous thoracic sympathetic blockade in 8 patients. Based on our findings, we conclude that the use of high quality imaging and needle guidance software such as XperGuide® may improve patient outcomes, and reduce the risk of adverse effects, providing a relatively easy, safe, and valuable alternative treatment strategy for thoracic sympathectomies.

Objective

To retrospectively assess the Thoracolumbar Injury Classification and Severity Score (TLICS) in patients with osteoporotic vertebral compression fractures (OVCF) and compare the treatment given with that predicted by the TLICS score.

Methods

All medical records of patients presenting from January 2014 to November 2017 for acute atraumatic or low impact OVCF were screened, and eligible patients were retrospectively reviewed. The TLICS score was determined based upon magnetic resonance imaging (MRI) findings and clinical records. Clinical records (including pain score data), imaging data, operative procedures, and stability of neurological examination were tracked over three months for each patient.

Results

Of the 56 patients included, 36 patients had a TLICS score of 1, 18 had a TLICS score of 2, and two had a TLICS score of 4. Only one patient with a TLICS score of 4 underwent surgical stabilization, while the rest of the cohort was managed non-operatively, with or without kyphoplasty. TLICS score 1 corresponded to simple compression and TLICS score 2 corresponded to burst morphology with retropulsion and without neurological deficits. Of the patients with a TLICS score of 1 and 2 who underwent kyphoplasty, there was a statistically significant improvement in pain scores in both groups; however no significant difference was observed, between each TLICS score (i.e., 1 or 2). None of the patients developed instability or neurological decline.

Conclusion

TLICS score correctly predicted operative versus non-operative management in all patients with OVCF. TLICS may be used in making management decisions, and in the triage of these patients for operative versus non-operative evaluations. Our study suggests that patients with TLICS score of 4 or higher require surgical evaluation, while those with TLICS of 1 or 2 are likely to have satisfactory non-surgical management with augmentation or conservative care. In general, patients with OVCF typically present with low TLICS score. Kyphoplasty appears to be similarly beneficial in patients with a TLICS score of 1 or a TLICS score of 2. A modification of the TLICS score by adding TLICS Zero to include uncompressed OVCF with edema is suggested. The limitations of this study include a small size; a larger study is needed to confirm these findings.

Background

Clinical evaluation in the determination of the etiology of axial spine pain is limited.

Objective

To determine if a set of three features of the clinical history are indicative of C1-2 joint edema on MRI.

Methods

All patients from one physician's practice who had axial cervical spine pain from 2021 to 2023 were evaluated. Cases were defined as those with all 3 of the ASL criteria, defined as Age >65, Superior cervical/suboccipital pain, and exacerbation of pain primarily by Lateral cervical spine rotation. Age-matched controls had axial cervical spine pain without meeting the ASL criteria. Edema around the atlantoaxial joint and/or odontoid was evaluated by STIR MR sequences.

Results

The ASL criteria had a sensitivity of 82 % [95 % CI: 64–100 %], specificity of 79 %, [95 % CI: 63–95 %], positive predictive value of 74 % [95 % CI: 54–94 %], and negative predictive value of 86 % [95 % CI: 72–100 %] in diagnosing C1-2 joint edema.

Conclusion

A positive ASL criteria is sensitive and specific in the diagnosis of C1-2 joint edema, which may have clinical implications.

Background

Epidural steroid injections (ESI) are utilized for the management of radicular pain, but there are no previous published studies that detail the specific timeline of patient response to an ESI.

Purpose

To describe patients’ temporal response in pain relief following an ESI.

Study design/setting

Prospective in vivo study of consecutive patients at an outpatient physical medicine and rehabilitation clinic at a single academic spine center.

Patient sample

134 consecutive patients who received an ESI between January 2020 through June 2020.

Methods

Patients were contacted every 3 days ± 1 day for 21 days post ESI to assess pain as measured via 11-point numeric pain score and subjective percentage pain relief question.

Results

134 consecutive patients were enrolled, with 108 (80.6 %) having follow-up data through 3 weeks post ESI. At 3 weeks, 51/108 patients (47.2 %) had reported a successful response as defined by at least 50 % reduction of their pain index. Of these 51 patients, 37 (72.5 %) reported >50 % relief on day 1, a further 11 (21.6 %) first reported >50 % relief on day 4, and the remaining 3 (5.9 %) successes first reported >50 % relief on days 13, 16, and 22. 57/108 patients (52.8 %) were non-responders, most of whom never reached the 50 % threshold at any time point. Of these non-responders, 19/57 (33.3 %) did report >50 % relief on day 1. Those patient's pain relief fell below 50 % on day 4 (12/19 patients, 63.2 %), day 7 (5/19 patients, 26.3 %), day 13 (1 patient, 5.3 %), and day 16 (1 patient, 5.3 %). A positive response or negative response at each follow up point was looked at as a predictor of a concordant three-week outcome for the population. The positive likelihood ratio at follow-up day 1, day 4, day 7, and day 10, was 2.14, 6.12, 7.97, and 40 respectively. The negative likelihood ratio at follow-up day 1, day 4, day 7, and day 10 was 0.42, 0.15, 0.16, and 0.24 respectively.

Discussion/conclusion

This is the first study to meticulously follow up patients every 72 h after ESI. A patient's response on day 4, either positive or negative, is predictive of their 3-week outcome. Sustained relief at day 7 or 10 further increases the likelihood of a positive 3-week outcome.

Background

Lumbar medial branch (MB) radiofrequency ablation is a common intervention to treat facetogenic low back pain. The consensus among spine pain interventionalists is that capturing a greater length of the MB correlates with a longer duration of pain relief. Therefore, there has been interest in defining optimal needle angles to achieve parallel cannula placement. Presently, there is inconsistency regarding the optimal caudal needle angles.

Objectives

The objectives of this study were to: 1) use a dissection-based 3D modelling methodology to quantify optimal caudal needle angles from cadaveric models; and 2) compare optimal cadaver-derived caudal needle angles with real-world patient-derived needle angles.

Methods

Eighteen formalin embalmed lumbosacral spine specimens were dissected, digitized, and modelled in 3D. Virtual needles were simulated and placed parallel with the L1-L5 MBs. Cadaver-derived caudal needle angles were measured from the high-fidelity 3D models with optimally placed virtual needles. Lateral fluoroscopic images of patients (n = 200) that received lumbar MB denervation were reviewed to measure patient-derived caudal needle angles (L3-L5 MB levels). Descriptive statistics were used to analyze the cadaver (L1-L5 MB levels) and patient-derived (L3-L5 MB levels) caudal needle angles. The cadaver and patient-derived mean caudal needle angles for L3-L5 MB levels were compared.

Results

There was variability in the cadaver-derived mean caudal needle angles. The lowest mean caudal needle angle was the L1 MB level measured at 41.57 ± 8.56° (range: 27.14° - 53.96°). The highest was the L5 MB level with a mean caudal needle angle of 60.79 ± 8.55° (range: 46.97° - 79.74°). A total of 123 patients were included and 369 caudal needle angles (L3-L5 MB levels) were measured and analyzed. There was variability in the patient-derived mean caudal needle angles. The patient-derived mean caudal needle angles were 29.18 ± 8.77° (range: 11.80° - 61.31°), 33.34 ± 7.23° (range: 16.40° - 54.15°), and 49.08 ± 8.87° (range: 26.45° - 76.95°) for the L3, L4, and L5 MB levels, respectively. There was a significant difference in mean caudal needle angle between cadaver and patient-derived needle angles at the L3, L4, and L5 MB levels.

Conclusions

Analysis of cadaver-derived needle angles versus patient-derived data suggests optimization of lumbar MB denervation requires greater caudal angulation to achieve parallel needle placement. Further research is required to assess the clinical implications.