Interventional Pain Medicine最新文献

Background

Percutaneous rhizotomy is a group of techniques used to treat trigeminal neuralgia. Radiofrequency thermocoagulation (RF) and Chemical Rhizotomy (CR) using glycerol are among the most frequently used methods. We have recently refined Ethanol Rhizotomy (ER) under Digital Subtraction Angiography (DSA) guidance.

Objective

A descriptive, retrospective study was conducted to compare our refined ER and RF ablation in patients with trigeminal neuralgia in terms of long-term pain relief and side effects.

Method

Between 2012 and 2014, 33 patients with typical trigeminal neuralgia were enrolled, 10 of whom received RF and 23 received ER under (DSA) guidance with ethanol injected while in the supine position. The pain relief, duration of pain-free period, need for repeat injection, and recurrence of pain were recorded together with procedure-related complications within 7 years after the procedures.

Results

After a single intervention or, in some cases, a maximum of two repeated interventions, all 33 patients experienced complete pain relief. Nevertheless, following a single procedure, the success rate was 95.6% (22/23) in the ER group and 60% (6/10) in the RF group. Notably, complete numbness was the most significant side effect, with a higher incidence in the ER group (30.4%) compared to the RF group (0%) (p = 0.02). The recurrence rate was statistically different (p = 0.01) between the two groups, with 4.4% and 40% recorded in the ER and RF groups, respectively.

Conclusion

We demonstrated the usefulness of our refined ER procedure as a safe, cost-effective, and efficient second-line treatment for TN.

Cancer pain has a substantial impact on the quality of life and functional capacity with a prevalence of up to 70 % in patients with advanced, metastatic, or terminal disease [1]. The WHO pain ladder has been used in practice to guide cancer pain management. A three-step ladder starts with NSAIDs and non-opioids for mild pain, weak opioids for mild to moderate pain and strong opioids for moderate to severe pain with the use of adjuvant medications such as TCAs and muscle relaxants at any stage for optimization (Fallon et al., Dec 2022) [2]

We present a case of a patient with metastatic colon cancer who was admitted for intractable pain crisis and right sided L-5 radiculopathy secondary to epidural metastasis (Figs. 1 and 2). The patient's pain left her bedridden, unable to walk and remained refractory to an escalating intravenous opioid regimen and caudal epidural steroids. The patient subsequently underwent spinal cord stimulation (SCS) trial at level T-7 and achieved >80 % pain relief resulting in a markedly decreased opioid requirement and tremendous recovery of ambulatory function (Fig. 3). After sustained results, a permanent implant was placed at T-8 and patient remains discharged with functional restoration and continued pain improvement (Fig. 4).

To our knowledge, this is a novel application of SCS for a refractory pain crisis secondary to a metastatic colon cancer induced radiculopathy presenting with severe functional impairment. As we transition away from opioid use, it is imperative as pain physicians, to investigate the potential of current as an alternative means of cancer pain management: a ubiquitous and challenging clinical conundrum.

Introduction

Interlaminar epidural steroid injections (ILESIs) are mainstay in the management of low back, neck and radicular pain and are a commonly performed pain management procedure in the United States. Our survey aims to provide an update in practice patterns of ILESIs among interventional pain physicians.

Methods

We distributed a 91-item survey nationwide to private and academic interventional pain physicians who perform epidural steroid injections (ESIs). The survey was distributed via REDCap with a series of questions inquiring about current practices in epidural steroid injections from March 2021 to March 2022. Cross sectional data from survey responses specific to ILESI-related practices were captured and synthesized.

Results

Of 103 complete survey responses, 96 physicians perform ILESIs (cervical, 87.5 %; thoracic, 82.3 %; lumbar 99 %). Nearly all surveyed physicians utilize fluoroscopy (98.1 %) over other modalities like MRI and ultrasound. For CIESIs, dexamethasone was the preferred steroid (52.4 %) over methylprednisolone (23.7 %); the converse was true for LIESIs in which methylprednisolone (44.2 %) was preferred over dexamethasone (32.6 %). The majority of providers performing ILESI's (91.7 %) preferred a Tuohy/Weiss needle while only a small fraction preferred the Quincke needle (7.2 %). Sedation practices were more varied with only about half of providers (47.6 %) offering medications. Furthermore, a great fraction of providers continue to use contrast for LIESIs (97.9 %) and CIESIs (89.6 %).

Discussion

Our survey suggests that despite updated consensus recommendations, variability continues to exist in procedural practice patterns. Highlighting areas of variable adherence to current safety guidelines can assist with what is emphasized in the generation of future evidence-based guidelines. Though our survey was conducted in the context of the COVID-19 pandemic with resultant supply chain shortages, more research is needed to elucidate what variables may factor into why proceduralists may stray from guideline concordant care.

Introduction

Knee joint osteoarthritis is a well-known cause of pain and disability in patients above 40 years of age. It is treated by use of non-steroidal inflammatory drugs, corticosteroids, glucosamine, chondroitin sulfate, physiotherapy with limited success. The platelet rich plasma (PRP) contains a large amount of platelet derived growth factors, cytokines and anti-inflammatory molecules which showed promising results in recent studies to relieve pain of knee joint osteoarthritis. The present study aims to determine the efficacy of intraarticular PRP for pain relief and functional improvement in patients with early knee joint osteoarthritis.

Methods

It is a retrospective observation study involving patients who underwent single intraarticular administration of PRP for knee pain with Kellgren-Lawrence (KL) grades I or II knee joint osteoarthritis. The Visual analogue scale (VAS) score and Oxford knee score (OKS) were recorded pre-procedure and at 1- and 6-month post-procedure.

Results

A total of 31 patients (20 females, 11 males) underwent PRP therapy for knee pain (16 kL grade I, 15 kL grade II). The mean age and duration of symptoms were of 53.9 years (range: 79–42 years) and 5.53 ± 2.35 years respectively. There was a significant reduction (p < 0.05) in VAS scores from pre-procedure (68.06 ± 8.33) to post procedure at 1 month (37.74 ± 11.16) and 6 months (54.52 ± 11.78). There was also significant improvement (p < 0.05) in OKS score from pre-procedure (31.1 ± 3.47) to post-procedure at 1 month (39.06 ± 3.37) and 6 months (34.10 ± 3.75). No adverse effects were reported in patients during the study period.

Conclusion

This small retrospective study suggests that a single administration of intraarticular PRP may be safe and effective for pain relief and functional improvement for up to 6 months in patients of early-stage osteoarthritis.

Objective

To evaluate the improvement of pain and function after cervical transforaminal epidural steroid injections (CTFESI) for radicular pain.

Design

This is a retrospective observational study of patients receiving fluoroscopically-guided cervical transforaminal epidural steroid injections under a single provider at a tertiary referral center from December 2013 to December 2020. Primary outcome measures were Numeric Rating Scale (NRS), patient reported percent of pain relief, the Patient Health Questionnaire, the Patient Reported Outcome Measurement Information System (PROMIS) Global Health Physical and Mental Health score, and the Pain Disability Questionnaire.

Results

A total of 219 individual patients underwent 261 CTFESI and were included in the analyses. The average subject age was 51.9 years (SD = 11.3) and 50.9 % were male. Following the intervention, average pain relief by NRS at 3 months, 6 months, 1 year, and 2 years was −4.07, −3.82, −4.20, and −4.45, respectively. The average functional improvement with PROMIS-GH physical at 3-months, 6-months, 1- year, and 2-years was 2.23, 2.35, 3.15, and 3.29, respectively.

Conclusions

Our results suggest that patients with cervical radiculopathy report significant pain relief and functional improvement following CTFESI. They can also report clinically important improvement in their health-related quality of life.

Objective

This study investigated whether patients with Modic changes (MC) of types I, I/II, and II would respond to an anti-inflammatory-based, stepped care treatment with three treatment steps: first, oral administration of NSAIDs, 2 × 200 mg celecoxib daily for two weeks; second, an intradiscal steroid injection (ID) with dexamethasone and cefazolin; and third, oral treatment with antibiotics (AB), 3 × 1 g amoxicillin daily for 100 days.

Design

This was an observational clinical study based on analyses of categorical data of patient-reported outcome measurements.

Subjects

Subjects were consecutive patients with chronic low back pain (CLBP), diagnosed by assessment of anamnestic signs of inflammation; a pain score ≥6 on the Numeric Pain Rating Scale (NPRS); a mechanical assessment; MC I, I/II, or II based on MRI; and lack of response to conservative treatment.

Methods

From January 1, 2015, to December 31, 2021, 833 eligible patients were selected for the stepped care treatment. A total of 332 patients completed requested follow-up questionnaires at baseline and 12 months (optional at 3 and 6 months). Primary outcomes were pain (at least 50 % pain relief) and/or a minimum of 40 % improvement in functionality as measured by the Roland Morris Disability Questionnaire (RMDQ) or the Oswestry Disability Questionnaire (ODI). Secondary outcome measures were use of pain medication and return to work.

Results

At 1 year of follow-up, 179 (53.6 %) of 332 patients reported improvement according to the responder criteria. Of the 138 patients that had received only NSAIDs, 88 (63.8 %) had improved. In addition, 50 (56.8 %) of the 183 patients that had received ID had improved, and 41 (38.7 %) of the 106 patients treated with AB had improved. None of the patients reported complications. 12.0 % of patients using AB stopped preterm due to undesirable side effects.

Conclusion

Treatment with a stepped care model for inflammatory pain produced clinically relevant, positive reported outcomes on pain and/or function. Our stepped care model appears to be a useful, safe, and cost-saving treatment option that is easily reproducible. Further studies, including randomized controlled trials and analyses of subgroups, may help to develop a more patient-tailored approach and further avoidance of less-effective treatments and costs.