Predictors of a Successful Outcome Following a Thoracic Erector Spinae Plane Block for Cervical Radiculopathy.

BACKGROUND: The erector spinae plane block (ESPB) is an interfascial plane block for managing neuropathic thoracic pain. Although the ESPB is applied widely in various clinical situations, no studies have evaluated the association between the analgesic outcomes of the ESPB and the numerical changes in the perfusion index (PI) and PI ratio. OBJECTIVES: The purpose of this study is to investigate the association between the clinical response following ESPB and other possible factors, including changes in the PI and PI ratio. STUDY DESIGN: A prospective, nonrandomized, and open-label study. SETTING: The pain clinic of a tertiary university hospital. METHODS: This study included 92 patients with neck or arm pain who received T2 ESPB using 20 mL of 0.2% ropivacaine. To aid in the prediction of clinical outcomes, the PI was measured at the blocked side for 30 minutes as soon as the ESPB was finished. Various demographic data were also analyzed to predict the clinical outcomes. RESULTS: Among 92 patients, 59 patients (64%) showed successful treatment outcomes (> 50% reduction in the numerical rating scale score or > 30% reduction in the neck disability index). The baseline PI of the responders was statistically higher than the nonresponders' (P < 0.05). Also, the responders' PI demonstrated statistically higher values than the nonresponders' at the time points of 4, 6, and 8 minutes after the ESPB. Multivariate logistic regression analysis revealed that a higher baseline PI (OR, 1.91; 95% CI, 1.27-2.86; P = 0.002) was an independent factor associated with a successful outcome. LIMITATIONS: Only a small number of patients with nonspinal diseases were included, except for those who had cervical radiculopathy. Therefore, it is hard to conclude that thoracic ESPB has any therapeutic benefits to patients with nonspinal diseases such as complex regional pain syndrome, adhesive capsulitis, or post-thoracotomy pain syndrome. CONCLUSION: A successful outcome at 4 weeks after T2 ESPB was achieved in 64% of patients with cervical radiculopathy. A higher baseline PI value was an independent factor associated with a successful response to T2 ESPB.

Sympatholytic Effect of the High Thoracic Erector Spinae Plane Block.

BACKGROUND: The erector spinae plane block (ESPB), which was introduced for the management of thoracic pain, is a technically easy and relatively noninvasive ultrasound (ULSD)-guided technique. Although the ESPB is used widely in variable clinical situations, its sympatholytic effect has never been studied. OBJECTIVES: The purpose of this study is to demonstrate the sympatholytic effect of the high thoracic ESPB by comparing the blocked and unblocked sides of patients' upper extremities, using the changes in the perfusion index (PI). STUDY DESIGN: Prospective, single-group, and open-label study. SETTING: The study was carried out in the pain clinic of a tertiary university hospital. METHODS: This study included 47 patients with upper extremity pain and various diseases who received T2 or T3 ESPBs using 20 mL of 0.2% ropivacaine. For the evaluation of the sympatholytic effect, measurements were taken on the numeric rating scale (NRS), the neck disability index (NDI), and the PI. RESULTS: The PIs of the blocked sides demonstrated significant increases at 10, 20, and 30 minutes compared to the PIs of the baseline and unblocked sides (P < 0.001). The PI ratio at 10 minutes was 2.74 ± 1.65, which was the highest value during the measurement period. Until 30 minutes after the ESPB, the PI ratio was significantly higher in the blocked side than in the unblocked side. During the study period, significant reductions in NRS and NDI scores were found irrespective of disease entity. LIMITATION: The period of PI measurement was only 30 minutes, so we could not determine the time point when the PI returned to the baseline value. CONCLUSION: The high thoracic ESPB was effective in relieving upper extremity pain in diverse disease entities, and the PIs of patients' blocked sides demonstrated significant increases over the baseline value and contralateral unblocked sides.

Predictors of a Favorable Response to Erector Spinae Plane Block for Lumbosacral Radiculopathy.

BACKGROUND: The erector spinae plane block (ESPB), which was introduced to manage the thoracic pain, is a technical easy and less invasive ultrasound-guided technique. Although the ESPB is used widely in various clinical situations, no studies have evaluated the association between the clinical outcomes of the ESPB and the numerical changes of the perfusion index (PI). OBJECTIVES: The purpose of this study is to investigate the association between the clinical response following ESPB and other possible factors including the changes of PI. STUDY DESIGN: Prospective, nonrandomized, and an open-label study. SETTING: The pain clinic of a tertiary university hospital. METHODS: This study included 91 patients of low back pain with degenerative spinal disease who received L4 ESPB using 20 mL of 0.2% ropivacaine. For the predication of clinical outcome, the PI was measured for 30 min at the blocked side subsequent to the ESPB. Various demographic data were also analyzed to predict the clinical outcomes. RESULTS: The PI of the responder group was higher value than that of the nonresponder group until 30 min but did not show any statistically significant differences. Multivariate logistic regression analysis revealed that the duration of pain (odds ratio [OR], 0.95; 95% CI, 0.90-1.00; P = 0.043), the right side injection (OR, 3.87; 95% CI, 1.42-10.55; P = 0.008), and the PI ratio of 1.5-3 at 10 min (OR, 3.79; 95% CI, 1.36-10.57; P = 0.011), were independent factors associated with successful outcomes. LIMITATION: The responder and the nonresponders were categorized using only changes of the numeric rating scale. The categorization based on the changes of functional disability or quality of life was not used. CONCLUSION: The right side injection, duration of pain less than 3 months, PI ratio of 1.5-3 at 10 min following the ESPB were associated with successful clinical outcomes.

Do psychosocial variables mediate the relationship between menopause symptoms and sexual function in middle-aged perimenopausal women?

AIM: To test a hypothetical path model evaluating the influence of menopause symptoms on sexual function among middle-aged perimenopausal women, as well as identify the mediating roles of body image, depression and sexual communication in this relationship. METHODS: We used a cross-sectional, correlational design. We included one exogenous variable (menopause symptoms) and four endogenous variables (body image, depression, sexual communication and sexual function) in the proposed model. All data were collected between January 19 and March 11, 2016, and analyzed using spss statistics 25.0 and AMOS 23.0. RESULTS: Eight of the nine hypothesized paths in the model were significant. Specifically, menopause symptoms were significantly associated with sexual function via the effects of body image, depression and sexual communication. CONCLUSION: This study may provide basic data for counseling and nursing programs to help improve sexual function in middle-aged perimenopausal women. Particularly, these programs should focus on the indirect paths via body image, depression and sexual communication, such as by improving body image and sexual communication and reducing depression.

Analysis of epidural waveform for cervical epidural steroid injections confirmed with fluoroscopy.

The identification of epidural space with loss of resistance (LOR) is commonly performed. But it lacks specificity. Epidural pressure waveform analysis (EPWA) provides a simple confirmative adjunct for LOR. If the needle is located within the epidural space, measurement of the pressure at its tips shows a pulsatile waveform. Previous studies demonstrated satisfactory sensitivity and specificity of EPWA. However, success or failure of epidural injection was confirmed by the pinprick test, which is limited for patients in the setting of the pain clinic. In this study, we evaluated the sensitivity, specificity, as well as positive and negative predictive values of EPWA for cervical epidural steroid injection (CESI) confirmed by fluoroscopy.One hundred and five CESIs of 75 patients suffering from neck and radicular arm pain of over 3 months duration were enrolled. The physician injected 5 mL of normal saline after a feeling of satisfactory LOR. Saline filled extension tubing, connected to a pressure transducer, was attached to the needle. A 3 mL bolus of contrast medium was injected to confirm the success of CESI.The incorrect identification of epidural space with LOR (false LOR) was 29.5%. Of these 31 failed CESIs, 2 showed epidural waveform and 29 did not. The sensitivity, specificity, positive and negative predictive value of EPWA was 94.5%, 93.5%, 97.2%, and 87.7%, respectively.EPWA shows satisfactory reliability and is a simple adjunct to decrease false LOR for CESI. Further confirmative studies are required before its routine use in clinical practice.

Analysis of inadvertent intradiscal and intravascular injection during lumbar transforaminal epidural steroid injections: a prospective study.

BACKGROUND AND OBJECTIVES: Inadvertent intradiscal injection during a lumbar transforaminal epidural steroid injection (TFESI) can be critical given the possibility of discitis and disc degeneration. Intravascular steroid injection can result in devastating neurologic complications. We sought to identify the incidence of intradiscal and intravascular injection during lumbar TFESI and determine whether an aspiration test and static fluoroscopic image can be used to predict intravascular needle placement. METHODS: We evaluated 251 TFESIs in 219 patients. All TFESIs were performed by one of the authors using classic TFESI technique. After final needle position was confirmed using biplanar fluoroscopy, 1 mL of contrast was injected after negative blood or cerebrospinal fluid aspiration. Using static and real-time fluoroscopy, we assessed the incidences of intradiscal injection, blood flashback, and the presence of intravascular contrast spread. RESULTS: The incidence of intradiscal injections was 2.3% (6/251). Six intradiscal injections were observed, all among patients who had not previously undergone disc surgery. Five intradiscal injections occurred at the L4-5 level and 1 at the L5-S1 level. The incidence of overall intravascular injection was 15.5% (39/251), of which the incidence of simultaneous vascular and epidural injection was 12.7% (32/251), whereas intravascular injection only was 2.8% (7/251). The sensitivities for detecting intravascular access via aspiration or static fluoroscopic image with contrast were 20.5% and 51.2%, respectively. CONCLUSIONS: Inadvertent intradiscal injection during TFESI is not rare. Physicians who perform interventional pain procedures should increase their awareness of related potential complications. The aspiration test and static image of fluoroscope often fail to detect the intravascular injection during the TFESI. Real-time fluoroscopy should be the gold standard for confirming intravascular injection.

A prospective evaluation of psoas muscle and intravascular injection in lumbar sympathetic ganglion block.

BACKGROUND: Intravascular and intramuscular injection of local anesthetics during lumbar sympathetic ganglion block (LSGB) can cause false positive or negative results in a diagnostic block, and complications. In the present study, we prospectively evaluated the incidence and possible factors causing intravascular and IM injection during LSGB. METHODS: We evaluated 216 LSGBs in 83 patients. All LSGBs were performed by 1 of the authors using a 3-needle technique. After final needle position was confirmed by biplanar fluoroscopy, an aspiration test was conducted, and 1 mL of contrast was injected sequentially. Incidences of psoas muscle injection, blood flashback, and the presence of intravascular contrast spread on static and real-time fluoroscopy were assessed. RESULTS: The incidence of psoas muscle injection of contrast was 21.3% (46/216), and it was associated with the level of injection (L2) significantly (chi(2) = 14.773, P = 0.001). The incidence of intravascular injection of contrast was 12.5% (27/216). Among 27 cases of documented intravascular injections, 5.1% (11/216) of patients showed contrast spread at the area where the sympathetic ganglion was presumed to be and to the vessels simultaneously, and 7.4% (16/216) of patients showed only intravascular injection of contrast. The sensitivity of the aspiration test and static radiography were 40.7% and 70.4%, respectively. CONCLUSIONS: LSGB at the L2 level showed the lowest incidence of psoas muscle injection of contrast in comparison with LSGB at L3 and L4. The aspiration test and static radiography frequently missed the intravascular injection of contrast during LSGBs.