Comparison of Fluoroscopy and Ultrasound Guidance for Sacroiliac Joint Injection in Patients with Chronic Low Back Pain.

BACKGROUND AND OBJECTIVES: Sacroiliac joint (SIJ) arthritis is a common cause of chronic mechanical low back pain (LBP) that is often treated with injection of local anesthetic and steroids. Ultrasound (US) has emerged as a viable alternative to fluoroscopy (FL) to guide SIJ injections; however, few studies have compared these modalities. In this prospective randomized, controlled trial, we compared both accuracy and efficacy of US and FL guidance for SIJ injections. METHODS: Forty patients with chronic moderate-to-severe LBP secondary to SIJ arthritis were randomized to receive US- or FL-guided unilateral SIJ injections. Primary outcomes included pain at 1 month measured by numerical rating scale (NRS) scores. Secondary outcomes included NRS scores at 24 hours, 72 hours, 1 week, and 3 months after injection, physical functioning at 1 month after the procedure, procedure time, incidence of intra-articular and peri-articular needle placement, patient discomfort, overall patient satisfaction, and daily opioid consumption. RESULTS: There was no significant difference in NRS pain scores between the 2 groups at 1 month or at any other follow-up points. A significant reduction from baseline mean NRS scores was observed in both groups at 1 month after injection (US 22.7%, P = 0.025; FL 37.3%, P < 0.001). There was no significant difference in procedure-related variables, physical functioning, discomfort, opioid utilization, and patient satisfaction between the 2 groups. CONCLUSIONS: Ultrasound-guided SIJ injection with fluoroscopic confirmation has similar accuracy and efficacy to fluoroscopy alone for SIJ injections in patients with chronic low back pain secondary to SIJ arthritis.

Ultrasound-guided saphenous nerve block--within versus distal to the adductor canal: a proof-of-principle randomized trial.

PURPOSE: Reliable saphenous nerve blockade is a desirable complement to popliteal sciatic nerve blockade for foot and ankle surgery. We compared two promising ultrasound-guided techniques, the supine adductor canal (AC) technique and the prone peri-saphenous branch of the descending genicular artery (Peri-SBDGA) technique, using 8 mL of 2% lidocaine with epinephrine 1:400,000. METHODS: Following Research Ethics Board approval, we conducted a randomized single-blinded parallel-group trial in 102 patients undergoing foot and ankle surgery at a single centre. The primary endpoint was saphenous nerve ease of visualization (0 = not visible; 1 = visible with difficulty; and 2 = easily visible). Other endpoints included vascular landmark visualization (0 = not visible; 1= visible with colour flow Doppler; 2 = visible without colour flow Doppler), block success, onset, and complications. RESULTS: Ninety-one patients were eligible for analysis. Saphenous nerve visibility was not different between the groups (visibility score = 2: AC group, n = 24/49 [49%] vs Peri-SBDGA group, 20/42 [48%]; P = 1.00). Vascular landmark visibility was better in the AC group than in the Peri-SBDGA group (visibility score = 2: 41/49 [84%] vs 25/42 [60%], respectively; P = 0.018). Block success rates were similar (AC group, 41/49 [84%] vs Peri-SBDGA group, 34/42 [81%]; P = 0.79), as were median [interquartile range] onset times (AC group, 5 [5-10] min vs Peri-SBDGA group, 8 [5-11] min; P = 0.38). CONCLUSION: In this randomized trial, we found no differences in nerve visibility, block success rate, or onset between the AC and Peri-SBDGA techniques of ultrasound-guided saphenous nerve blockade, although the former technique provided superior vascular landmark visibility. Neither technique produced a sufficiently high success rate to provide reliable surgical anesthesia per se.

A "swing room" model based on regional anesthesia reduces turnover time and increases case throughput.

PURPOSE: Our centre recently implemented a new ambulatory care model featuring two alternate regional anesthesia "swing" operating rooms (RA-SRs) managed by a single anesthesiologist. We hypothesized that this model would be associated with decreased turnover times and improved recovery profiles when compared with a traditional model with a single operating room using general anesthesia. METHODS: We conducted a retrospective cohort study of 164 patients scheduled for hand and wrist surgery who were treated in the RA-SRs under brachial plexus blockade, and we compared the findings with a matched historical control group of patients who underwent general anesthesia in a single operating room (GA-OR). The primary endpoint was room turnover time. Secondary endpoints included home discharge time, postoperative interventions for nausea and pain, and number of cases possible per eight-hour day. RESULTS: Patients in the RA-SR group had faster turnover times than patients in the GA-OR group (median [interquartile range]: 15 min [8-22] vs 54 min [49-61], respectively) as well as faster home discharge times (28 min [20-46] vs 156 min [118-215], respectively) (P < 0.0001). In the RA-SR group, postoperative antiemetics were used in 3/164 patients (2%) vs 28/164 (17%) in the GA-OR group (P < 0.0001), and opioids were used in 1/164 (0.6%) vs 132/164 (80%), respectively (P < 0.0001). The median number of daily cases possible in the RA-SR group was 56% greater than in the GA-OR group (8.4 [7.5-9.4] vs 5.4 [5.1-5.8], respectively; P < 0.0001). CONCLUSION: Compared with a traditional model using general anesthesia in a single operating room, the implementation of a model using regional anesthesia with two swing operating rooms was associated with reduced room turnover times, improved recovery profiles, and a higher case throughput.

The Internet and clinical trials: background, online resources, examples and issues.

Both the Internet and clinical trials were significant developments in the latter half of the twentieth century: the Internet revolutionized global communications and the randomized controlled trial provided a means to conduct an unbiased comparison of two or more treatments. Large multicenter trials are often burdened with an extensive development time and considerable expense, as well as significant challenges in obtaining, backing up and analyzing large amounts of data. Alongside the increasing complexities of the modern clinical trial has grown the power of the Internet to improve communications, centralize and secure data as well as to distribute information. As more and more clinical trials are required to coordinate multiple trial processes in real time, centers are turning to the Internet for the tools to manage the components of a clinical trial, either in whole or in part, to produce lower costs and faster results. This paper reviews the historical development of the Internet and the randomized controlled trial, describes the Internet resources available that can be used in a clinical trial, reviews some examples of online trials and describes the advantages and disadvantages of using the Internet to conduct a clinical trial. We also extract the characteristics of the 5 largest clinical trials conducted using the Internet to date, which together enrolled over 26000 patients.

Preoperative gabapentin for postoperative analgesia: a meta-analysis.

PURPOSE: Gabapentin's role in the treatment of chronic neuropathic pain is well known. What is less well established is its role for managing postoperative pain. In order to clarify whether gabapentin's utility in acute pain control is more than just theoretical, we conducted a meta-analysis of all randomized trials that addressed gabapentin's role in acute postoperative pain control. We specifically addressed whether gabapentin reduces pain scores, analgesia consumption, and/or analgesia-related side effects in the first 24 hr following surgery. SOURCE: We identified eight placebo-controlled, randomized controlled trials and conducted a meta-analysis using the primary outcomes of pain scores, total analgesia consumption, and side effects over a 24-hr period. PRINCIPLE FINDINGS: Patients who received gabapentin preoperatively reported significantly lower pain scores (-11.9 at rest and -11.0 with movement on a 100-point visual analogue scale) and opioid consumption (-14.7 mg of morphine in 24 hr) with no difference in the incidence of side effects. CONCLUSION: Although gabapentin given preoperatively decreases pain scores and analgesic consumption in the first 24 hr after surgery, the clinical significance of this finding has yet to be determined. This meta-analysis could not demonstrate a significant reduction in the incidence of side effects. Due to the small numbers enrolled in the studies, larger randomized control trials are warranted.