Interventional Pain Medicine最新文献

Introduction

Cervical medial branch radiofrequency ablation is an effective treatment for cervical facet joint pain. It is considered a safe procedure, and permanent complications are very rare. We report a case of a patient who developed dropped-head syndrome (DHS) after bilateral treatment.

Case report

An 86-year-old man was referred to our pain clinic because of neck pain. One year before, he underwent bilateral multi-level cervical medial branch radiofrequency ablation. Within the next 24 hours, he experienced progressive neck extensor muscle weakness. After a comprehensive examination, he was diagnosed with dropped head syndrome as a complication of the radiofrequency procedure. Conservative management was chosen, resulting in partial improvement of the muscular weakness.

Conclusion

The present case, along with others reviewed in this article, supports the recommendation against performing bilateral and multilevel cervical medial branch radiofrequency ablation.

Introduction

Myofascial pain syndrome is a chronic pain condition prevalent in the general population. Muscular symptoms at the level of the trapezius and rhomboid muscles are frequent and the response to therapeutic interventions established so far is variable.

Methods

We present a case series of six patients who underwent a new technique of interfacial trapezius-rhomboid block (TRB) performed under ultrasonographic guidance by applying 10 cubic centimeters (cc) of analgesic solution (bupivacaine 0.25 % and methylprednisolone 40 mg) in the interfacial plane between the trapezius and rhomboid muscles at the level of the fifth and sixth ribs.

Results

At a follow-up of one and eight weeks, measurements of numerical rating scale (NRS) pain intensity were carried out, finding an average decrease of NRS pain intensity by 70 %.

Conclusion

This new technique may be considered for the treatment of myofascial pain syndrome of the trapezius and rhomboid muscles. Larger future studies are needed to better establish its safety and efficacy.

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

Evidence in support of the following facts is presented. (1) Epidural Steroid injections for Radicular Pain Due to Spinal Stenosis Caused by Lipomatosis -- There is low-level evidence of an association between epidural steroid injections (ESIs) and the development and/or worsening of spinal epidural lipomatosis (SEL). However, there is insufficient evidence to establish whether ESIs independently result in an increase in spinal stenosis with neurological compromise in individuals with pre-existing SEL. (2) Steroid Exposure Postpartum -- There is no absolute contraindication to steroid injections based on postpartum or lactating status, but there may be disruption of both maternal and breastfed child hypothalamic-pituitary-adrenal (HPA) axis response to steroid administration. For the duration of breastfeeding, milk production may be affected after steroid exposure, and withholding breast milk produced for several hours after exposure minimizes infant exposure.

Background

Genicular radiofrequency neurotomy (GRFN) is an effective treatment for a subset of individuals with chronic knee pain. Previous studies demonstrate that Medicare and Medicaid beneficiaries report worse outcomes following various interventional procedures compared with commercially insured patients.

Objective

Evaluate the association of payer type on GRFN treatment outcomes.

Methods

Consecutive patients who underwent GRFN at a tertiary academic center were contacted for participation. Demographic, clinical, and procedural characteristics were collected from electronic medical records. Outcome data were collected by standardized telephone survey at 6–12 months, 12–24 months and ≥24 months. Treatment success was defined as ≥50% numerical pain rating scale (NPRS) score reduction from baseline. Data were analyzed using descriptive statistics for demographic, clinical, and procedural characteristics. Logistic and Poisson regression analyses were performed to examine the association of variables of interest and pain reduction.

Results

One hundred thirty-four patients treated with GRFN (mean 65.6 ± 12.7 years of age, 59.7% female) with a mean follow-up time of 23.3 ± 11.3 months were included. Payer type composition was 48.5% commercial (n = 65), 45.5% Medicare (n = 61), 3.7% Medicaid (n = 5), 1.5% government (n = 2), and 0.8% self-pay (n = 1). Overall, 47.8% of patients (n = 64) reported ≥50% NPRS score reduction after GRFN. After adjusting for age, follow-up duration, Kellgren-Lawrence osteoarthritis grade, baseline opioid use, antidepressant/antianxiety medication use, history of knee replacement, and number of RFN lesions placed, the logistic regression model showed no statically significant association between payer type and treatment outcome (OR = 2.11; 95% CI = 0.87, 5.11; p = 0.098).

Discussion/conclusion

In this study, after adjusting for demographic, clinical, and procedural characteristics, we found no association between payer type and treatment success following GRFN. This observation contrasts findings from other interventional studies reporting an association between payer category and treatment success.

Summary of background data

Low back pain of disc origin is common yet challenging to treat. Intradiscal platelet rich plasma (PRP) has been advocated, but is associated with risk of discitis. Epidural PRP is less invasive and avoids this risk. Few studies exist evaluating effectiveness and safety of epidural PRP for discogenic low back pain without radiculopathy and the follow-up of the studies tends to be short.

Objective

prospectively evaluate for 12 months the effectiveness of PRP epidural injections for patients with low back pain without radiculopathy, suspected to be of disc origin.

Methods

11 consecutive patients with refractory low back pain suspected to be of disc origin (compatible clinical assessment; negative lumbosacral medial branch blocks (MBBs) and/or magnetic resonance imaging (MRI) with high intensity zone (HIZ), Modic 1 or 2 changes) participated. Each underwent one (n = 5) or two (n = 6) epidural injections (caudal or interlaminar). The PRP was leukocyte/red cell depleted with an average platelet concentration of ∼2X whole blood. Numerical rating scale (NRS), Pain Disability Quality-Of-Life Questionnaire (PDQQ) score, Oswestry Disability Index (ODI) score, effect on analgesic intake, treatment satisfaction and endorsement were recorded prior to and at 3, 6 and 12-months post-treatment.

Results

significant improvements in pain and disability were documented post-treatment. Pre-, 3, 6, and 12-month post mean(sd) NRS scores were 7.8(1.8), 5.8(2.7), 5.1(2.5), 4.9(2.8) respectively (F = 7.2; p = 0.002). At 12 months post PRP epidural, the mean improvement in NRS was 36%, 36% had experienced ≥50% pain relief (95% confidence interval (CI): 2%, 70%), and 73% achieved minimal clinically important differences (MCID) (95% CI: 41%, 100%). Similar magnitude improvements in disability (PDQQ and ODI) were documented. At 1-year post, 50% of analgesic users had reduced intake, 91% were satisfied with the treatment and would recommend the procedure to family and friends. No complications were reported.

Discussions/conclusion

this pilot project suggests that PRP epidural injections provide modest yet significant improvements in pain and disability that lasts at least 12 months in patients with low back pain suspected to be of disc origin. Additional research including larger sample size and robust study design is encouraged.

Pain Medicine, a field that was once considered primarily a specialty of opioid medication management, evolved into a multimodal care model with the goal of limiting reliance on pain medications. Now, we see another revolution—the advancement from percutaneous procedures to minimally invasive surgical procedures.

Despite these changes, Pain Medicine fellowships have consistently been recognized as a competitive subspecialty with more applicants than the number of available positions – until now. The most recent pain fellowship match suggests an abrupt change to the popularity of the specialty (with over 61 unmatched positions and over 35 unfilled programs) for applicants expected to matriculate in the year 2024 [1]. Unfilled positions have risen from 5% to 15% in the past three years. Similarly, unfilled programs have risen from 10% to 30% in the past three years.

Several reasons for this sudden change in popularity have been proposed, including a lucrative general anesthesiology market, increasing difficulties with insurance coverage and reimbursement for procedures, and a dearth of advanced pain procedures performed at academic medicine programs. The field is at a critical juncture, necessitating ongoing discussions and collaboration among stakeholders to ensure that trainees are attracted to this dynamic field and are ultimately equipped to meet the evolving needs of patients.

Few cases of primary Nocardial epidural abscesses have been reported in the literature over the past 50 years, with limited guidelines available for identification and management. Typically, cases involve a prior diagnosis of systemic Nocardiosis with resultant seeding of a disseminated infection to the spine. An adult with chronic low back pain and type 2 diabetes mellitus underwent three consecutive epidural steroid injections in an outpatient setting. The patient gradually developed diffuse bilateral lower extremity pain, acute urinary retention, and saddle paresthesia. Lumbar magnetic resonance imaging revealed central herniation with annular tear compressing the thecal sac and S1 nerve roots, a dorsal epidural hemorrhage, and an abscess causing severe canal stenosis at L4-L5 and L5-S1. The patient was treated with vancomycin, piperacillin-tazobactam, and methylprednisolone without improvement, ultimately requiring surgical decompression. Initial surgical cultures grew mycobacterium species prompting RIPE therapy. Symptoms continually worsened requiring repeat decompression. Final cultures grew Nocardia, which necessitated transition to linezolid and sulfamethoxazole/trimethoprim, resulting in clinical improvement. Nocardial infection is a rare cause of isolated epidural abscess that can complicate antibiotic selection, resulting in potentially delayed treatment and worsened clinical outcomes. This manuscript aims to elucidate this rare but essential caveat to epidural abscess management.

Introduction

Cervical facet arthritis is a significant source of neck pain and impaired function that is amenable to treatment with medial branch radiofrequency neurotomy (RFN). Identifying appropriate patients for this treatment requires integration of information from the history, physical exam and diagnostic imaging, but the current diagnostic standard for facet-mediated pain is positive comparative medial branch blockade (MBB). SPECT-CT has recently been evaluated as a potential predictor of positive medial branch blocks with mixed results. The purpose of this retrospective analysis was to determine if a relationship exists between increased uptake on SPECT-CT of a given cervical facet joint and a positive MBB.

Methods

A retrospective review was performed to identify all patients undergoing cervical MBB within 12 months after having a cervical SPECT-CT. Each procedure was categorized as either Concordant (all facet joints demonstrating increased ^99mTc uptake on SPECT-CT were blocked) or Discordant (at least one facet joint demonstrating increased ^99mTc uptake on SPECT-CT was not blocked or block was performed in a patient that had no increased uptake on SPECT-CT). Statistical analysis was performed to determine if concordance between facet joints demonstrating increased uptake on SPECT-CT and those undergoing MBB was associated with a positive block using cutoffs of 50% and 80% pain relief.

Results

A total of 43 procedures were analyzed (25% Concordant, 75% Discordant) and both groups demonstrated improvement in pain Numeric Rating Scale (NRS) scores. No significant association between concordance and positive MBB was identified at thresholds of 50% (p = .481) and 80% (p = 1.000) pain relief.

Conclusion

SPECT-CT findings do not accurately predict positive cervical MBB but may provide valuable information that can be considered with other factors when deciding which joints to treat.

Background

Physician turnover and job instability have profound implications for healthcare systems, private facilities, and patient outcomes. High physician turnover disrupts continuity of care, impedes establishment of patient-physician relationships, and may compromise overall healthcare quality.

Objective

This survey study explores the rate of job turnover in the field of Interventional Spine and Pain Medicine, based on a 2022 survey of physicians of the International Pain and Spine Intervention Society.

Methods

A standardized, anonymous survey was distributed by email via Research Electronic Data Capture (REDCap) software to physician members of the International Pain and Spine Interventional Society (IPSIS).

Results

Our survey results indicate that interventional spine/pain physicians with initially lower starting salaries were more likely to leave their first job. We also found that those currently in a productivity-based compensation models were more likely to have left their first job.

Conclusions

Of the interventional pain and spine physicians who had been in practice for at least three years, over 65% reported leaving their initial job after training.