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1.
N Engl J Med ; 382(12): 1093-1102, 2020 03 19.
Artigo em Inglês | MEDLINE | ID: mdl-32187469

RESUMO

BACKGROUND: The treatment of chronic sciatica caused by herniation of a lumbar disk has not been well studied in comparison with acute disk herniation. Data are needed on whether diskectomy or a conservative approach is better for sciatica that has persisted for several months. METHODS: In a single-center trial, we randomly assigned patients with sciatica that had lasted for 4 to 12 months and lumbar disk herniation at the L4-L5 or L5-S1 level in a 1:1 ratio to undergo microdiskectomy or to receive 6 months of standardized nonoperative care followed by surgery if needed. Surgery was performed by spine surgeons who used conventional microdiskectomy techniques. The primary outcome was the intensity of leg pain on a visual analogue scale (ranging from 0 to 10, with higher scores indicating more severe pain) at 6 months after enrollment. Secondary outcomes were the score on the Oswestry Disability Index, back and leg pain, and quality-of-life scores at 6 weeks, 3 months, 6 months, and 1 year. RESULTS: From 2010 through 2016, a total of 790 patients were screened; of those patients, 128 were enrolled, with 64 in each group. Among the patients assigned to undergo surgery, the median time from randomization to surgery was 3.1 weeks; of the 64 patients in the nonsurgical group, 22 (34%) crossed over to undergo surgery at a median of 11 months after enrollment. At baseline, the mean score for leg-pain intensity was 7.7 in the surgical group and 8.0 in the nonsurgical group. The primary outcome of the leg-pain intensity score at 6 months was 2.8 in the surgical group and 5.2 in the nonsurgical group (adjusted mean difference, 2.4; 95% confidence interval, 1.4 to 3.4; P<0.001). Secondary outcomes including the score on the Owestry Disability Index and pain at 12 months were in the same direction as the primary outcome. Nine patients had adverse events associated with surgery, and one patient underwent repeat surgery for recurrent disk herniation. CONCLUSIONS: In this single-center trial involving patients with sciatica lasting more than 4 months and caused by lumbar disk herniation, microdiskectomy was superior to nonsurgical care with respect to pain intensity at 6 months of follow-up. (Funded by Physicians' Services Incorporated Foundation; ClinicalTrials.gov number, NCT01335646.).


Assuntos
Tratamento Conservador , Discotomia , Glucocorticoides/administração & dosagem , Deslocamento do Disco Intervertebral/cirurgia , Modalidades de Fisioterapia , Ciática/terapia , Adulto , Tratamento Conservador/métodos , Estudos Cross-Over , Discotomia/efeitos adversos , Feminino , Seguimentos , Humanos , Injeções Epidurais , Análise de Intenção de Tratamento , Deslocamento do Disco Intervertebral/complicações , Deslocamento do Disco Intervertebral/tratamento farmacológico , Masculino , Dor/etiologia , Medição da Dor , Satisfação do Paciente , Complicações Pós-Operatórias , Qualidade de Vida , Ciática/etiologia , Ciática/cirurgia , Resultado do Tratamento
2.
Medicine (Baltimore) ; 99(7): e19266, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32049868

RESUMO

Despite many clinical trials on cervical epidural steroid injections, the indications for and long-standing outcomes of this treatment remain controversial. We evaluated the outcomes and indications for transforaminal cervical epidural steroid injection (TCESI) in patients with moderate to severe disability.We prospectively gathered data from patients with 1 or 2-level cervical degenerative disease (herniated disc, foraminal stenosis) with moderate to severe disability (3.5 < initial visual analog scale < 6.5, 15 < Neck Disability Index < 35) and greater than 12 weeks of pain, despite conservative treatment. Patients with persistent disability and those who desired surgical intervention underwent decompression surgery. The clinical and demographic characteristics were compared between groups.Of the 309 patients who underwent TCESI, 221 (72%) did not receive surgical treatment during the 1-year follow-up period. The remaining 88 patients (28%) underwent surgery at a mean of 4.1 months after initial TCESI. Patients who underwent injection alone showed a significant decrease in disability and pain that persisted until the 1-year follow-up visit (P < .05). In patients who underwent surgery, the mean disability and pain scores after injection did not decrease for several months, although the scores significantly decreased up to 1 year after surgery (P < .05).The TCESI significantly decreased pain and disability in the moderate to severe disability group up to 1 year after injection. We recommend cervical TCESI as an initial treatment with moderate to severe disability patients.


Assuntos
Vértebras Cervicais , Dexametasona/administração & dosagem , Glucocorticoides/administração & dosagem , Degeneração do Disco Intervertebral/tratamento farmacológico , Feminino , Humanos , Injeções Epidurais , Degeneração do Disco Intervertebral/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento
4.
World Neurosurg ; 133: e443-e447, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31526885

RESUMO

BACKGROUND: S1 transforaminal epidural steroid injection (S1-TFESI) results in positive clinical outcomes for the treatment of pain associated with the S1 nerve root. S1-TFESI via the transforaminal approach is commonly performed under fluoroscopic guidance. Ultrasound guidance is an alternative to mitigate radiation exposure. However, performing spinal procedures under ultrasound guidance has some limitations in confirming the position of the needle tip and vascular uptake. New techniques are therefore needed to make ultrasound and fluoroscopy complementary. Our objective was to describe a novel technique for S1-TFESI and confirm its reproducibility. METHODS: Records of patients with S1 radiculopathy were reviewed retrospectively; those treated using the new S1-TFESI technique were selected. Initially, ultrasound was used to distinguish anatomy of the sacral foramen and guide initial placement of the needle entry point. Fluoroscopy was subsequently used to confirm needle tip position and vascular injection. The number of times the needle required reinsertion was recorded, and ultrasound and C-arm images were stored. RESULTS: Sixty-seven S1-TFESIs were performed in 56 patients. All injections exhibited epidural spread of contrast media, not only to the S1 nerve. The cephalad angle was 16.25 ± 6.75° (range, 5-27°), the oblique angle was 2.48 ± 2.62° (range, 0-7°), and the mean number of attempts was 1.24 ± 1.25. CONCLUSIONS: The new technique, involving the use of ultrasound to guide initial placement of the needle entry point, followed by confirmatory imaging and any needed adjustment with the use of fluoroscopy, can be a technique to complement the shortcomings of using ultrasound or fluoroscopy alone.


Assuntos
Corticosteroides/administração & dosagem , Fluoroscopia/métodos , Injeções Epidurais/métodos , Bloqueio Nervoso/métodos , Radiculopatia/tratamento farmacológico , Radiografia Intervencionista/métodos , Ultrassonografia de Intervenção/métodos , Corticosteroides/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestésicos Locais/administração & dosagem , Anestésicos Locais/uso terapêutico , Meios de Contraste , Feminino , Humanos , Vértebras Lombares , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sacro , Adulto Jovem
6.
Medicine (Baltimore) ; 98(50): e18233, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31852086

RESUMO

Percutaneous epidural neuroplasty (PEN) is an effective interventional treatment for radicular pain. However, in some cases, contrast runoff to the spinal nerve root does not occur. We investigated whether contrast runoff to the spinal nerve root affects the success rate of PEN and whether additional transforaminal epidural blocks for intentional contrast runoff affect the success rate of PEN in cases in which contrast runoff is absent.This study was registered at ClinicalTrials.gov (Identifier: NCT03867630) in March 2019. We reviewed the medical records of 112 patients who underwent PEN with a wire-type catheter from May 2016 to August 2018. Patients were divided in 3 groups (Runoff group, Non-runoff group, Transforaminal group).Patients with low back pain and leg radicular pain who did not respond to lumbar epidural steroid injectionsPEN was performed in 112 patients with a wire-type catheter in target segment. We compared the success rate of PEN betweenThe success rate was significantly different between the Runoff group and the Non-runoff group (P < .0007) and between the Non-runoff group and the Transforaminal group (P = .0047), but not between the Runoff group and the Transforaminal group (P = .57).Contrast runoff influenced the success rate of PEN. In cases without contrast runoff, additional transforaminal epidural blocks for intentional contrast runoff increased the success rate of PEN with a wire-type catheter.


Assuntos
Anestesia Epidural/instrumentação , Cateteres , Dor Lombar/terapia , Procedimentos Neurocirúrgicos/métodos , Manejo da Dor/métodos , Raízes Nervosas Espinhais/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Fluoroscopia , Seguimentos , Humanos , Injeções Epidurais/métodos , Dor Lombar/diagnóstico , Região Lombossacral , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
7.
Medicine (Baltimore) ; 98(50): e18299, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31852108

RESUMO

RATIONALE: Cervical transforaminal epidural steroid injection (TFESI), can be an effective tool to improve pain associated with cervical radiculopathy. However, complications related to the procedure have been reported. PATIENT CONCERNS: A 50-year-old woman who experienced acute cervical myelopathy with quadriparesis after cervical TFESI under fluoroscopic guidance. DIAGNOSES: The initial post-procedure cervical MRI revealed acute cervical myelopathy INTERVENTIONS:: She received 1000 mg of methylprednisolone was injected intravenously daily for 3 days OUTCOMES:: Improvement in pain, with the only remaining complaints consisting of lingering mild pain in the left hand and occasional hypoesthesia LESSONS:: Cervical TFESI, despite careful fluoroscopic localization, resulted in spinal cord injury. A spinal cord injury may be treated with conservative treatments, such as medication and rehabilitation.


Assuntos
Injeções Epidurais/efeitos adversos , Metilprednisolona/efeitos adversos , Quadriplegia/etiologia , Radiculopatia/complicações , Doença Aguda , Vértebras Cervicais , Feminino , Glucocorticoides/administração & dosagem , Glucocorticoides/efeitos adversos , Humanos , Imagem por Ressonância Magnética , Metilprednisolona/administração & dosagem , Pessoa de Meia-Idade , Quadriplegia/diagnóstico , Radiculopatia/diagnóstico
8.
JBJS Case Connect ; 9(4): e0028, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31850954

RESUMO

CASE: A 62-year-old man with no comorbidities presented with back and bilateral leg pain and progressive paraplegia that developed over a 1-week period. He had received 2 lumbar epidural steroid injections (LESIs) for lumbar stenosis 39 and 25 days before presentation. Workup revealed osteomyelitis of L4 and L5 with epidural abscesses. He ultimately underwent all-posterior L4 and L5 corpectomy with reconstruction and L1-pelvis arthrodesis, followed by 8 weeks of intravenous antibiotics. His weakness improved, but neurological deficits persisted. CONCLUSIONS: This case illustrates a catastrophic complication after LESI, resulting in permanent neurological injury in a patient with no apparent risk factors.


Assuntos
Injeções Epidurais/efeitos adversos , Vértebras Lombares , Osteomielite , Doenças da Coluna Vertebral , Anti-Inflamatórios/administração & dosagem , Anti-Inflamatórios/uso terapêutico , Dor nas Costas/tratamento farmacológico , Humanos , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/fisiopatologia , Vértebras Lombares/cirurgia , Masculino , Pessoa de Meia-Idade , Osteomielite/diagnóstico por imagem , Osteomielite/etiologia , Osteomielite/cirurgia , Doenças da Coluna Vertebral/diagnóstico por imagem , Doenças da Coluna Vertebral/etiologia , Doenças da Coluna Vertebral/cirurgia , Esteroides/administração & dosagem , Esteroides/uso terapêutico
9.
J Chromatogr B Analyt Technol Biomed Life Sci ; 1130-1131: 121831, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31669630

RESUMO

A novel nano-titania modified covalent organic frameworks (NTM-COFs) has been synthesized and characterized by transmission electron microscopy (TEM) and scanning electron micrographs (SEM). Besides, NTM-COFs, as efficient sorbent, has also been evaluated in the on-line pass-through cleanup procedure prior to the analysis of local anesthetic drugs (lidocaine, bupivacaine and tetracaine) in human plasma by liquid chromatography-tandem quadrupole mass spectrometry (LC-MS/MS). Under optimum conditions, the level of matrix effects can be dramatically reduced by the NTM-COFs based on-line pass-through cleanup procedure, with acceptable recoveries ranging from 88.8% to 103%. Satisfactory trueness and precision of the proposed method were also obtained, with the within- and between-run RSDs less than 7.0% and relative error (REs) less than 12%. The limits of detections (LODs) of lidocaine, bupivacaine and tetracaine were 0.029 µg·L-1, 0.027 µg·L-1 and 0.016 µg·L-1, respectively. The analytical method has been successfully applied for the determination of the plasma concentrations of bupivacaine in five parturients who received an epidural administration of bupivacaine hydrochloride during vaginal delivery. Results demonstrate the applicability of the developed NTM-COFs on-line pass-through cleanup procedure coupled with LC-MS/MS method to clinical studies.


Assuntos
Anestésicos Locais/sangue , Cromatografia Líquida/métodos , Espectrometria de Massas em Tandem/métodos , Anestésicos Locais/administração & dosagem , Anestésicos Locais/química , Anestésicos Locais/farmacocinética , Feminino , Humanos , Injeções Epidurais , Limite de Detecção , Modelos Lineares , Nanopartículas Metálicas/química , Estruturas Metalorgânicas/química , Reprodutibilidade dos Testes , Titânio/química
10.
Neuroimaging Clin N Am ; 29(4): 539-551, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31677729

RESUMO

This article reviews image-guided approaches for the treatment of common spine pain generators. The following treatment targets are discussed: epidural space (interlaminar and transforaminal approaches), facet joint, sacroiliac joint, and synovial cysts.


Assuntos
Corticosteroides/administração & dosagem , Dor Lombar/tratamento farmacológico , Radiografia Intervencionista/métodos , Ultrassonografia de Intervenção/métodos , Corticosteroides/uso terapêutico , Fluoroscopia , Humanos , Injeções Epidurais , Vértebras Lombares/diagnóstico por imagem , Articulação Sacroilíaca/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Articulação Zigapofisária/diagnóstico por imagem
11.
Agri ; 31(3): 150-152, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31736023

RESUMO

Epidural steroid injection is a very common intervention in the treatment of low back pain and sciatic symptoms. The most common complication for epidural steroid injection is transient headache with or without identifiable dural puncture. Other complications have also been reported, including intravascular entry, local hematoma, bleeding, increased back pain, facial flushing, vasovagal reactions, nausea, and fever. We report a case of rhabdomyolysis following epidural steroid injection for lumbar radiculopathy.


Assuntos
Anti-Inflamatórios/uso terapêutico , Dexametasona/uso terapêutico , Rabdomiólise/diagnóstico , Ciática/tratamento farmacológico , Anti-Inflamatórios/administração & dosagem , Anti-Inflamatórios/efeitos adversos , Dexametasona/administração & dosagem , Dexametasona/efeitos adversos , Diagnóstico Diferencial , Feminino , Humanos , Injeções Epidurais , Vértebras Lombares , Pessoa de Meia-Idade , Rabdomiólise/induzido quimicamente , Ciática/patologia
12.
Pain Physician ; 22(6): 521-536, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31775397

RESUMO

BACKGROUND: The cost of US health care continues to increase, with treatments related to low back and neck pain and other musculoskeletal disorders accounting for the third highest amount of various disease categories. Interventional techniques for managing pain apart from conservative modalities and surgical interventions, have generally been thought to be growing rapidly. However, a recent analysis of utilization of interventional techniques from 2000 to 2016 has shown a modest decline from 2009 to 2016, compared to 2000 to 2009. OBJECTIVES: The objectives of this analysis include providing an update on utilization of interventional techniques in managing chronic pain in the Medicare population from 2009 to 2018 in the fee-for-service (FFS) Medicare population of the United States. STUDY DESIGN: Utilization patterns and variables of interventional techniques in managing chronic pain were assessed from 2000 to 2009 and from 2009 to 2018 in the FFS Medicare population of the United States. METHODS: The data for the analysis was obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2018. The analysis of data showed that there was a decline in utilization of interventional techniques from 2009 to 2018 of 6.7%, with an annual decline of 0.8% per 100,000 FFS Medicare population, despite an increase of 0.7% per year of population growth (3.2% of those 65 years or older) and a 3% annual increase in Medicare participation from 2009 to 2018. Medicare data from 2000 to 2009 showed an increase of 11.8% per year per 100,000 individuals of the Medicare population. The 2009 to 2018 data also showed a 2.6% annual decrease in the rate of utilization of epidural and adhesiolysis procedures per 100,000 population of FFS Medicare, and a 1% decrease for disc procedures and other types of nerve blocks, while there was an increase of 0.9% annually for facet joint interventions and sacroiliac joint blocks. LIMITATIONS: Limitations of this analysis include: only the Medicare population was utilized, and among the Medicare population, only the FFS population was evaluated; utilization patterns in Medicare Advantage Plans, which constitutes almost 30% of the population were not considered. Further, the utilization data for individual states was sparse and may not be accurate. CONCLUSION: The decline in utilization of interventional techniques continued from 2009 to 2018 with 6.7% per 100,000 Medicare population, with an annual decline of 0.8%, despite an increase in the population rate and Medicare enrollees of 0.7% and 3% annually. KEY WORDS: Interventional pain management, chronic spinal pain, interventional techniques, epidural injections, adhesiolysis, facet joint interventions, sacroiliac joint injections, disc procedures, other types of nerve blocks.


Assuntos
Injeções Epidurais/estatística & dados numéricos , Medicare , Bloqueio Nervoso/estatística & dados numéricos , Manejo da Dor/tendências , Dor Crônica/terapia , Bases de Dados Factuais , Feminino , Humanos , Manejo da Dor/métodos , Articulação Sacroilíaca , Estados Unidos , Articulação Zigapofisária/cirurgia
13.
Pain Physician ; 22(6): E523-E550, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31775400

RESUMO

BACKGROUND: Symptomatic lumbar spinal stenosis is a condition affecting a growing number of individuals resulting in significant disability and pain, leading to a multitude of interventions ranging from simple over the counter medication to opioids, and, finally, to complex surgical fusions. After failure of conservative treatment with drug therapy, physical therapy, and other conservative modalities including epidural injections, percutaneous adhesiolysis with targeted delivery of drugs into the epidural space can be offered in lumbar central spinal stenosis prior to minimally invasive surgical options or complex surgical fusions. To date there has been only one systematic review which has assessed the role of percutaneous adhesiolysis in treating central spinal stenosis, compared to post lumbar surgery syndrome which has multiple systematic reviews and randomized controlled trials (RCTs). STUDY DESIGN: A systematic review of RCTs and observational studies assessing the role of percutaneous adhesiolysis in managing lumbar central spinal stenosis. OBJECTIVE: To evaluate the effectiveness of percutaneous adhesiolysis in managing central lumbar spinal stenosis, utilizing currently available literature. METHODS: This systematic review was performed utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for literature search, Cochrane review criteria, Interventional Pain Management techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB), and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR) to assess methodologic quality assessment and qualitative analysis utilizing best evidence synthesis principles, and meta-analysis.PubMed, Cochrane library, US National Guideline Clearinghouse, Google Scholar, and prior systematic reviews and reference lists were utilized in the literature search from 1966 through June 2019. The evidence was summarized utilizing principles of the best evidence synthesis on a scale of 1 to 5. OUTCOME MEASURES: The primary outcome or hard endpoint was defined as the proportion of patients with 50% pain relief and improvement in functionality, whereas the secondary outcome measures or soft endpoints were pain relief and/or improvement in functionality. Short-term effectiveness was defined as improvement of 6 months or less, whereas long-term effectiveness was defined as more than 6 months. RESULTS: Based on search criteria, 9 manuscripts were identified and considered for inclusion with final inclusion of 2 RCTs and 4 observational studies in this systematic review and 5 studies for single arm meta-analysis. The results showed Level II evidence for short-term and long-term improvement in pain and function with application of percutaneous adhesiolysis in managing central lumbar spinal stenosis. LIMITATIONS: There was a significant paucity of evidence assessing the role of percutaneous adhesiolysis in managing lumbar central spinal stenosis, leading to Level II or strong evidence. CONCLUSION: Overall, the present analysis shows Level II (moderate) evidence for percutaneous adhesiolysis in managing lumbar central spinal stenosis based on relevant high quality RCTs and observational studies. KEY WORDS: Lumbar central spinal stenosis, percutaneous adhesiolysis, randomized controlled trials, systematic reviews, neuroplasty.


Assuntos
Analgésicos/administração & dosagem , Vértebras Lombares , Manejo da Dor/métodos , Estenose Espinal/tratamento farmacológico , Gerenciamento Clínico , Espaço Epidural/efeitos dos fármacos , Humanos , Injeções Epidurais/métodos , Dor Lombar/diagnóstico , Dor Lombar/tratamento farmacológico , Estudos Observacionais como Assunto/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Reprodutibilidade dos Testes , Estenose Espinal/diagnóstico , Resultado do Tratamento
14.
Pain Physician ; 22(6): 561-573, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31775403

RESUMO

BACKGROUND: Epidural steroid injections (ESIs) are commonly used for management of lumbosacral radicular pain. Midline interlaminar (MIL) or transforaminal (TF) routes are commonly used. The TF route, although associated with higher delivery of drug to the ventral epidural space, has serious complications including spinal cord injury and permanent paralysis reported in literature. Therefore, there is a search for a technically better route with fewer complications and greater drug delivery into the ventral epidural space. Recently, a parasagittal interlaminar (PIL) approach has been defined. OBJECTIVES: We conducted this study to compare therapeutic effectiveness of 3 techniques of ESIs in patients having unilateral lumbar radiculopathy. Further, effect of ESI on bone mineral density (BMD) and serum osteocalcin levels were studied. STUDY DESIGN: Randomized double-blind trial. SETTING: Pain clinic of a tertiary care hospital. METHODS: Sixty-five patients were randomly allocated into group MIL, group PIL, and group TF to receive epidural injection with 80 mg of methylprednisolone and 2 mL of 2% lidocaine. Effective pain relief and improvement in disability were assessed using Visual Analog Scale (VAS) and Modified Oswestry Disability Questionnaire (MODQ) scores at 2 weeks, 4 weeks, 3 months, and 6 months, respectively. Patients with < 50% relief received additional injection. Primary outcome of study was effective pain relief at 6 months. Mean change in VAS and MODQ scores, BMD, and serum osteocalcin levels were secondary outcome assessed. RESULTS: Patients having effective pain relief were significantly higher in group PIL (16 of 20 [80%]) and group TF (15 of 20 [75%]) compared with group MIL. Patients receiving ESI in group PIL and group TF showed significantly lower VAS scores than group MIL (P = 0.02, P = 0.50 at 3 months and P = 0.00, P = 0.02 at 6 months, respectively). Mean MODQ scores in group PIL and group TF were significantly lower than group MIL. However, group PIL and group TF did not significantly differ in MODQ scores. There was no significant change in serum osteocalcin and BMD, as assessed by dual energy x-ray absorptiometry scan at 3 months. LIMITATIONS: The absence of a placebo control group, small sample size, and relatively short follow-up of 6 months were limitations. CONCLUSIONS: PIL approach is equivalent to TF and superior to MIL approach in terms of effective pain relief and decrease in disability in patients with unilateral lumbar radiculopathy. This study showed no deleterious effect on BMD. KEY WORDS: Epidural steroid, technique, efficacy, bone marrow density, serum osteocalcin.


Assuntos
Injeções Epidurais/métodos , Dor Lombar/tratamento farmacológico , Radiculopatia/tratamento farmacológico , Esteroides/administração & dosagem , Adulto , Método Duplo-Cego , Espaço Epidural , Feminino , Humanos , Lidocaína/administração & dosagem , Masculino , Metilprednisolona/administração & dosagem , Pessoa de Meia-Idade , Clínicas de Dor , Manejo da Dor/métodos , Resultado do Tratamento , Escala Visual Analógica
17.
AANA J ; 87(1): 71-79, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31587747

RESUMO

The Institute of Medicine has reported that greater than 115 million adults in the United States are living with some form of chronic pain. Back pain is the most prevalent and is associated with high individual morbidity and increased healthcare costs. One approach for the management of chronic back pain involves the injection of corticosteroids in the epidural space.This interventional approach requires advanced training with techniques that vary according to the level of the vertebral column where the injection is to be performed. The primary rationale for epidural steroid injection is to reduce the inflammation surrounding the spinal nerve root as it exits the neuroforamen.Injections are performed at levels that correspond most appropriately with the patient's clinical presentation,physical findings, and radiographic findings. Epidural steroid injections are considered safe and effective, and are supported by evidence for the treatment of radicular pain. Complications from epidural steroid injections are rare but can be catastrophic, including permanent disability and death. The focus of this article is to understand how technique and selection of specific corticosteroids used for epidural injection can manage chronic back and radicular pain effectively while minimizing risk that leads to unnecessary harm.


Assuntos
Corticosteroides/uso terapêutico , Analgésicos/uso terapêutico , Dor Crônica/prevenção & controle , Dor Lombar/prevenção & controle , Corticosteroides/administração & dosagem , Analgésicos/administração & dosagem , Humanos , Injeções Epidurais/efeitos adversos , Vértebras Lombares
18.
World Neurosurg ; 132: 67-68, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31479794

RESUMO

Ehlers-Danlos syndrome can be associated with cerebrospinal fluid (CSF) disturbances including recurrent CSF leak and Chiari I malformations. Persistent pseudomeningoceles are known to be associated with raised intracranial pressure. We present an unusual case of a compressive epidural CSF collection occurring after a computed tomography-guided L5 nerve root block and describe an effective management strategy.


Assuntos
Vazamento de Líquido Cefalorraquidiano/etiologia , Síndrome de Ehlers-Danlos/complicações , Injeções Epidurais/efeitos adversos , Hipertensão Intracraniana/complicações , Compressão da Medula Espinal/etiologia , Adulto , Malformação de Arnold-Chiari/complicações , Vazamento de Líquido Cefalorraquidiano/diagnóstico por imagem , Vazamento de Líquido Cefalorraquidiano/cirurgia , Feminino , Humanos , Vértebras Lombares , Bloqueio Nervoso , Radiculopatia/tratamento farmacológico , Radiculopatia/etiologia , Compressão da Medula Espinal/diagnóstico por imagem , Compressão da Medula Espinal/cirurgia , Espondilolistese/complicações , Tomografia Computadorizada por Raios X
19.
WMJ ; 118(2): 91-94, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31532936

RESUMO

INTRODUCTION: Neuropsychiatric symptoms are a well-described side effect of systemic corticosteroid therapy and can range from mild to severe. CASE PRESENTATION: We describe a case of substance-induced psychosis following epidural injection of 10 mg dexamethasone. Three days after the procedure, the patient developed symptoms including anger, hostility, insomnia, paranoia, and delusions. Symptoms resolved between 7 and 17 days. DISCUSSION: In the past 50 years, there have been several case reports of severe neuropsychiatric effects following intraarticular or other interventional pain injections with various corticosteroids. More recent reviews have identified possible risk factors, including corticosteroid dose, patient age, sex, and history of neuropsychiatric disorder, among others, although these conclusions are not duplicated across all studies. CONCLUSION: Recommendations for practice include patient and family education on possible adverse effects of corticosteroid administration, utilization of minimum effective doses for interventional procedures, and the consideration of close follow-up and multidisciplinary coordination, especially in high-risk patients.


Assuntos
Corticosteroides/efeitos adversos , Injeções Epidurais , Dor Lombar/tratamento farmacológico , Psicoses Induzidas por Substâncias/etiologia , Humanos , Masculino , Pessoa de Meia-Idade
20.
Pain Physician ; 22(5): 421-431, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31561644

RESUMO

BACKGROUND: Neck pain is one of the major conditions attributing to overall disability in the United States. There have been multiple publications assessing clinical and cost effectiveness of multiple modalities of interventions in managing chronic neck pain. Even then, the literature has been considered sparse in relation to cervical interlaminar epidural injections in managing chronic neck pain. In contrast, cost utility studies of lumbar interlaminar injections, caudal epidural injections, cervical and lumbar facet joint nerve blocks, percutaneous adhesiolysis demonstrated costs of less than $3,500 for quality-adjusted life year (QALY). OBJECTIVES: To assess the cost utility of cervical interlaminar epidural injections in managing chronic neck and/or upper extremity pain secondary to cervical disc herniation, post-surgery syndrome in neck, and axial or discogenic neck pain. STUDY DESIGN: Analysis based on 3 previously published randomized trials of the effectiveness of cervical interlaminar epidural injections assessing their role in disc herniation, cervical post-surgery syndrome, and axial or discogenic pain. SETTING: A contemporary, private, specialty referral interventional pain management center in the United States. METHODS: Cost utility of cervical interlaminar epidural injections with or without steroids in managing cervical disc herniation, cervical post-surgery syndrome, and cervical discogenic or axial neck back pain was conducted with data derived from 3 randomized controlled trials (RCTs) that included a 2-year follow-up, with inclusion of 356 patients. The primary outcome was significant improvement defined as at least 50% in pain reduction and disability status. Direct payment data from all carriers from 2018 was utilized for the assessment of procedural costs. Overall costs, including drug costs, were determined by multiplication of direct procedural payment data by a factor of 1.67 to accommodate for indirect payments respectively for disc herniation, discogenic pain, and cervical post-surgery syndrome. RESULTS: The results of the 3 RCTs showed direct cost utility for one year of QALY of $2,412.31 for axial or discogenic pain without disc herniation, $2,081.07 for disc herniation, and $2,309.20 for post surgery syndrome, with an average cost per one year QALY of $2,267.57, with total estimated overall costs with addition of indirect costs of $3,475.38, $4,028.55, $3,856.36, and $3,785.89 respectively. LIMITATIONS: The limitation of this cost utility analysis includes that it is a single center evaluation. Indirect costs were extrapolated. CONCLUSION: This cost utility analysis of cervical interlaminar epidural injections in patients nonresponsive to conservative management in the treatment of disc herniation, post surgery syndrome and axial or discogenic neck pain shows $2,267.57 for direct costs with a total cost of $3,785.89 per QALY. KEY WORDS: Cervical interlaminar epidural injections, chronic neck pain, cervical disc herniation, cervical discogenic pain, post surgery syndrome, cost utility analysis, cost effectiveness analysis, quality-adjusted life years.


Assuntos
Injeções Epidurais/economia , Cervicalgia/tratamento farmacológico , Manejo da Dor/economia , Manejo da Dor/métodos , Vértebras Cervicais , Dor Crônica/tratamento farmacológico , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cervicalgia/etiologia , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto
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