The interdisciplinary management of coccydynia: A narrative review.

Pain that develops in the coccyx or surrounding tissues is known as coccydynia, which occurs as a result of many etiologies both traumatic and nontraumatic. Although coccydynia most commonly affects middle-aged women, it may be found in both sexes and in all age groups. The aim of this article is to provide an overview of the presentation, diagnostic imaging, and pathophysiology of coccydynia, and to comprehensively review the current treatment options. A review of publications from 1990 to 2020 using search words related to the treatment of coccydynia in PubMed and Google Scholar was completed. Level II evidence was found supporting stretching, manipulation, and extracorporeal shock wave therapy. There are no data from high-quality studies to support injection-based therapy including corticosteroids, prolotherapy, nerve blocks, and radiofrequency ablation, although there are small retrospective and prospective observational studies suggesting benefit. Level III evidence was found supporting coccygectomy for chronic/refractory coccydynia. There are no data from randomized controlled trials to support the use of neuromodulation (sacral burst and dorsal root ganglion stimulation), although there are case reports suggesting benefit. High-level, comparative studies are lacking to guide the treatment of coccydynia and should be a focus for future research studies.

Treatment of chronic axial back pain with 60-day percutaneous medial branch PNS: Primary end point results from a prospective, multicenter study.

BACKGROUND: The objective of this prospective, multicenter study is to characterize responses to percutaneous medial branch peripheral nerve stimulation (PNS) to determine if results from earlier, smaller single-center studies and reports were generalizable when performed at a larger number and wider variety of centers in patients recalcitrant to nonsurgical treatments. MATERIALS & METHODS: Participants with chronic axial low back pain (LBP) were implanted with percutaneous PNS leads targeting the lumbar medial branch nerves for up to 60 days, after which the leads were removed. Participants were followed long-term for 12 months after the 2-month PNS treatment. Data collection is complete for visits through end of treatment with PNS (primary end point) and 6 months after lead removal (8 months after start of treatment), with some participant follow-up visits thereafter in progress. RESULTS: Clinically and statistically significant reductions in pain intensity, disability, and pain interference were reported by a majority of participants. Seventy-three percent of participants were successes for the primary end point, reporting clinically significant (≥30%) reductions in back pain intensity after the 2-month percutaneous PNS treatment (n = 54/74). Whereas prospective follow-up is ongoing, among those who had already completed the long-term follow-up visits (n = 51), reductions in pain intensity, disability, and pain interference were sustained in a majority of participants through 14 months after the start of treatment. CONCLUSION: Given the minimally invasive, nondestructive nature of percutaneous PNS and the significant benefits experienced by participants who were recalcitrant to nonsurgical treatments, percutaneous PNS may provide a promising first-line neurostimulation treatment option for patients with chronic axial back pain.

Anesthesia Workspace Cleanliness and Safety: Implementation of a Novel Syringe Bracket Using 3D Printing Techniques.

PURPOSE: Wide variability persists in the preparation and storage of common anesthetic medications despite the recognition of anesthesia workspace standardization as a national quality improvement priority. Syringe contamination and medication swaps continue to pose significant hazards to patient safety. METHODS: We assessed differences in practice related to the availability of commonly prepared anesthetic medications. Using baseline provider surveys (n = 87) and anesthesia workspace audits (n = 80), we designed a custom syringe organization device using 3D printing techniques to serve as a cognitive aid and organizational tool. We iteratively tested and then deployed this device in all 60 operating rooms at a single institution, and then, repeated postintervention surveys (n = 79) and workspace audits (n = 75) one year after introduction. RESULTS: Implementation was associated with significant improvements in provider-reported medication availability during coverage and handoff situations (43.7% versus 76.2% reporting 95% confidence preintervention versus postintervention, p < 0.001). This was substantiated by audits of the anesthesia workspace which demonstrated reduced variability in the location (p < 0.001) and availability (p < 0.001) of key medications. Provider confidence in the cleanliness of syringes was also improved (p=0.01). A high degree of acceptance and compliance with the intervention was reported, with 80.4% of syringes observed to be stored in the device one year after implementation and approximately 95% of respondents reporting positive measures of usability and convenience. CONCLUSION: Use of a simple organizational device for syringes in the anesthesia workspace has numerous safety benefits. 3D printing offers improvements in adaptability and affordability compared with prior approaches.

Opioid Use Disorders and the Risk of Postoperative Pulmonary Complications.

BACKGROUND: As the rate of opioid use disorders continues to rise, perioperative physicians are increasingly faced with the challenge of providing analgesia to these patients after surgery. Due to the likelihood of opioid dose escalation in the perioperative period, we hypothesized that opioid-dependent patients would be at increased risk for postoperative pulmonary complications. METHODS: A retrospective cross-sectional analysis of patients undergoing 6 representative elective surgical procedures was performed using the Nationwide Inpatient Sample from 2002 to 2011. The primary outcome was a composite including prolonged mechanical ventilation, reintubation, and acute respiratory failure. Secondary outcomes were length of stay, in-hospital mortality, and total hospital costs. Both multivariable logistic regression and propensity score matching were used to determine the impact of opioid use disorder on outcomes. RESULTS: The total sample-weighted cohort consisted of 7,533,050 patients. Patients with opioid use disorders were more likely to suffer pulmonary complications, with a frequency of 4.2% compared to 1.6% in the nonopioid-dependent group (P < .001), and had a 1.62 times higher odds (95% confidence interval [CI], 1.16-2.27) in multivariable regression analysis. In a secondary subgroup analysis, only patients undergoing a colectomy had a greater odds of suffering pulmonary complications (odds ratio, 2.64; 95% CI, 1.42-4.91; P = .0021). Additionally, patients with an opioid use disorder had a longer length of stay (0.84 days [95% CI, 0.52-1.16; P < .001]) and greater costs ($1816 [95% CI, 935-2698; P < .001]). CONCLUSIONS: This study demonstrates that patients with opioid use disorders are at increased risk for postoperative pulmonary complications, and have prolonged length of stay and resource utilization. Further research is needed regarding interventions to reduce the risk of complications in this subset of patients.

The effectiveness of nasal mask vs face mask ventilation in anesthetized, apneic pediatric subjects over 2 years of age: a randomized controlled trial.

BACKGROUND: We hypothesized that anesthetized, apneic children could be ventilated equivalently or more efficiently by nasal mask ventilation (NMV) than face mask ventilation (FMV). The aim of this randomized controlled study was to test this hypothesis by comparing the expiratory tidal volume (Vte) between NMV and FMV. METHODS: After the induction of anesthesia, 41 subjects, 3-17 years of age without anticipated difficult mask ventilation, were randomly assigned to receive either NMV or FMV with neck extension. Both groups were ventilated with pressure control ventilation (PCV) at 20 cmH2 O of peak inspiratory pressure (PIP) with positive end-expiratory pressure (PEEP) levels of 0, 5, and 10 cmH2 O. An additional mouth closing maneuver (MCM) was applied for the NMV group. RESULTS: The Vte was higher in the FMV group compared with the NMV group (median difference [95% CI]: 8.4 [5.5-11.6] ml·kg(-1) ; P < 0.001) when MCM was not applied. NMV achieved less PEEP than FMV (median difference [95% CI]: 5.0 [4.3-5.3] cmH2 O at 10 cmH2 O; P < 0.001) though both groups achieved the set PIP level. In the NMV group, MCM markedly increased Vte (median increase [95% CI]: 5.9 [2.5-9.0] ml·kg(-1) ; P < 0.005) and PEEP (median increase [95% CI]: 5.0 [0.6-8.6] cmH2 O at 10 cmH2 O; P < 0.005); however, PEEP was highly variable and lower than that of FMV (median difference [95% CI]: 2.5 [0.8-8.5] cmH2 O at 10 cmH2 O; P < 0.05). CONCLUSIONS: In anesthetized, apneic children greater than 2 years of age ventilated with an anesthesia ventilator and neck extension, FMV established a greater Vte than NMV regardless of mouth status. NMV could not maintain the set PEEP level due to an air leak from the mouth. The MCM increased the Vte and PEEP.

Intervertebral disc temperature mapping during disc biacuplasty in the human cadaver.

BACKGROUND: Intradiscal biacuplasty (IDB) is a novel heating therapy using cooled radiofrequency (RF), which may offer relief for discogenic pain. Effective neuroablation may be achieved intradiscally at higher lesion temperatures. The safety of intradiscal heating at elevated temperatures using cooled RF has never been reported. OBJECTIVE: The purpose of this study is to map the intradiscal and peridiscal temperatures when IDB is performed at increased temperature using a modified lesion approach. The resulting temperature profiles are used to assess the safety and theoretical efficacy of this approach to ablate nociceptors in the posterior annulus. STUDY DESIGN: Research article. METHODS: Eleven lumbar discs in a non-perfused human cadaver were treated by IDB. Temperature profiles in the disc during bipolar lesion at 50°C followed by 2 monopolar lesions at 60°C were mapped using custom thermocouples. Temperatures inside the disc, at the nerve roots, and in the midline ventral epidural space were monitored in real-time using a data-collection system with custom RF filters. SETTING: Human research laboratory. RESULTS: Higher maximum temperature was reached intradiscally, and a larger volume of tissue was exposed to neuroablative temperature (> 45°C). Temperature at the nerve roots and in the epidural space increased by 2.4°C ± 2.6°C and 4.9°C ± 1.9°C (mean ± SD), respectively, during bipolar lesion. Similarly, temperature increased by 2.2°C ± 1.9°C and 0.8°C ± 1.3°C at the nerve roots and in the epidural space, respectively, during monopolar lesion. LIMITATIONS: Limitations include the ex vivo setting which lacks perfusion and may not reproduce in vivo conditions such as cerebrospinal fluid dynamics. CONCLUSIONS: The modified treatment paradigm showed intradiscal heating is achieved and is concentrated in the posterior annulus, suggesting minimal risk of thermal damage to the neighboring neural structures. Clinical benefits should be evaluated.

Protamine requirements in cardiac surgery: effect of changes in the heparin reference standard.

OBJECTIVE: UFH (unfractionated heparin) and protamine are integral to cardiac surgery, and inappropriate dosing can predispose to coagulopathy and hemorrhage. The FDA (Food and Drug Administration) recently has instituted changes to UFH formulation and it is not known if this has influenced its susceptibility to neutralization by protamine. Hence, the authors sought to compare 2 commercial preparations of UFH (old and new) with regard to their neutralization by protamine in patients undergoing cardiopulmonary bypass (CPB). DESIGN: Prospective, observational, cohort study. SETTING: Tertiary care university hospital and associated research laboratory PARTICIPANTS: Twenty adult patients undergoing elective cardiac surgery with CPB. INTERVENTIONS: Blood samples were drawn preinduction, prior to, and 5 and 30 minutes following protamine, and 0 and 2 hours after ICU admission. Protamine titration assays were conducted in vitro on samples drawn prior to and following protamine administration. Anti-IIa and anti-Xa activity were assayed in all samples. RESULTS: Anti-IIa and anti-Xa activity were detected ubiquitously at all time points following CPB, and there were no differences in susceptibility to protamine neutralization between the 2 groups. In vitro protamine titration studies revealed that anti-IIa was more resistant to protamine neutralization compared to anti-Xa activity. CONCLUSIONS: The 'old' and 'new' formulations of UFH evaluated in this study were similar in their susceptibility to protamine neutralization. Circulating UFH is detected as early as 5 minutes after protamine administration and anti-IIa is more resistant to protamine neutralization as compared to anti-Xa activity. Further studies are required to quantify the precise dose of protamine following CPB.

Lumbar zygapophyseal pain during extension-based stabilization protocol following lumbar transdiscal biacuplasty.

INTRODUCTION: Transdiscal biacuplasty (TDB) is a minimally invasive procedure for the treatment of lumbar discogenic pain. Theoretically, TDB ablates the aberrant ingrowth of nerve fibers beyond the outer third of the annulus fibrosis of the lumbar intervertebral disk and treats annular tears via collagen reformation. Typically, recovery involves a robust rehabilitation protocol that emphasizes lumbar stabilization exercises, focusing on extension maneuvers while also strengthening the multifidi and transverse abdominus. New-onset postprocedural pain during recovery may occur; evaluation of nondiscogenic causes should be considered. We report 3 of 12 patients who developed zygapophyseal-mediated pain during the recovery period. CASES: Three of 12 patients who underwent TDB over a 1-year period, developed zygapophyseal-mediated back pain at the level of the original discogenic pathology. All three underwent unilateral intra-articular zygapophyseal injections with resolution of their new-onset symptoms. DISCUSSION: Novel postprocedural low back pain should provoke re-evaluation of potential etiologies such as persistent discogenic pathology, zygapophyseal or sacroiliac joint involvement, and other mechanical sources of pain. We postulate that extension maneuvers during rehabilitation, combined with lumbar bracing in extension, inadvertently triggered and potentially exacerbated pre-existing zygapophyseal irritation. The clinical implication of this scenario is novel distracting pain, caused by an alternative etiology to the original discogenic pain, and may present a confounder to the assessment of the efficacy of TDB.

Hypoglycemia adverse events in PICUs and cardiac ICUs: differentiating preventable and nonpreventable events*.

OBJECTIVES: To describe the use of an adverse event detection system to identify, characterize, and categorize preventable versus nonpreventable hypoglycemia AEs in PICUs and cardiac ICUs. DESIGN: Retrospective observational study. SETTING: PICU and cardiac ICU of a tertiary pediatric hospital. SUBJECTS: All hypoglycemia triggers generated over a 3-year period. INTERVENTIONS: All hypoglycemia triggers generated via an electronic health record-driven surveillance system were investigated to determine if they represented a true adverse event and if that event was preventable or nonpreventable. Clinical and demographic variables were analyzed to identify characteristics of patients who developed a preventable or nonpreventable hypoglycemia adverse event. MEASUREMENTS AND MAIN RESULTS: There were 197 hypoglycemia adverse events in 90 patients. Thirty percent of the adverse events in the PICU and 36% of the adverse events in the cardiac ICU were characterized as preventable. Of the adverse events, 118 (59.9%) necessitated an intravenous dextrose bolus. No adverse events were associated with reporting of symptoms of hypoglycemia including apnea, altered mental status, or seizures. Events were more likely to be preventable (p < 0.001) if the patient was receiving only parenteral sources of nutrition (intravenous fluids or total parenteral nutrition). Controlling for weekends and holidays, adverse events associated with sole parenteral nutrition source had an increased odds ratio of 9.5 (95% confidence interval: 2.8-31.9) of being preventable. Stratifying by ICU, cardiac ICU events occurring on a weekend or holiday were more likely to be preventable (p = 0.001). Stratifying by unit and controlling for parenteral nutrition source, adverse events in the cardiac ICU occurring on weekends or holidays had an increased odds ratio of 11.6 (95% confidence interval: 2.7-50.2) of being preventable. CONCLUSIONS: Preventable hypoglycemia adverse events are associated with patients receiving sole parenteral sources of nutrition in both the PICU and cardiac ICU. In the cardiac ICU, there is an association between weekend and holiday time periods and the development of preventable hypoglycemia adverse events.

Epidural contrast flow patterns of transforaminal epidural steroid injections stratified by commonly used final needle-tip position.

OBJECTIVE: To evaluate the relationship between commonly used final needle-tip positions and subsequent contrast flow and patient-reported pain relief in transforaminal epidural steroid injections (TFESIs). DESIGN: Retrospective cross-sectional study. METHODS: Medical records of subjects (N = 83) having undergone a TFESI between January 2008 and January 2009 were reviewed to compare TFESIs using the superior-anterior (SA) vs. the superior-posterior (SP) quadrant. OUTCOME MEASURES: Outcome measures included ventral and dorsal epidural contrast flow as well as near-to-complete pain relief as measured by numerical rating scale pain score pre- and post-procedure. RESULTS: SA TFESIs were associated with greater ventral epidural contrast flow as compared with SP TFESIs (100% vs 61.4%, P < 0.001). SA TFESIs with ventral epidural contrast flow were also associated with flow to a greater number of vertebral levels than SP TFESIs with ventral epidural contrast flow (41% vs 14.8%, P < 0.001). SP TFESIs were associated with greater dorsal epidural contrast flow than SA TFESIs (95.5% vs 43.6%, P < 0.05). SA TFESIs were also associated with a larger proportion of patients who achieved near-to-complete pain relief (P < 0.05) and greater reduction than SP TFESIs in post-procedure pain score relative to pre-procedure (3.3 vs 1.5, P < 0.01). DISCUSSION: The evolution of TFESIs must balance both safety and efficacy. The efficacy of SA TFESIs is demonstrated to be superior to that of SP TFESIs with regards to ventral epidural flow and patient-reported pain relief. Further efforts should focus on demonstrating efficacy while optimizing safety.