Assessing the impact of adding bupivacaine on immediate and delayed post-procedure pain scores in interlaminar epidural steroid injections.

OBJECTIVE: A local anesthetic is frequently administered as part of a lumbar epidural steroid injection (LESI); however, there is a rare potential for this to result in transient paralysis if administered incorrectly. The purpose of this retrospective study is to determine if the addition of bupivacaine significantly improves patient-reported pain scores. MATERIALS AND METHODS: This retrospective review includes patients undergoing LESI over an approximately 1 year time span. Pre-procedure, immediate post-procedure, and 1-week integer scaled pain scores were recorded. Ordinal regression was used to compare the distributions of the aggregated ordinal pain score categories between bupivacaine- and non-bupivacaine-injected patients. RESULTS: Two hundred fifty-eight patients met the inclusion criteria (126F:132 M, mean age 64.7 years) with 164 receiving bupivacaine and steroids and 94 receiving steroids alone. The relative frequency distributions for pre-injection pain did not differ between the bupivacaine patients and the non-bupivacaine patients (p = 0.114). Similarly, the relative frequency distributions for immediate and 1-week post-procedure pain did not differ between the bupivacaine patients and the non-bupivacaine patients (p = 0.293 at immediate time point and p = 0.306 at 1-week time point). Odds ratios comparing pain severity change between the bupivacaine and non-bupivacaine patients also were not significantly different at either the immediate post-procedure (p = 0.769) or 1-week (p = 0.203) time points. CONCLUSION: The lack of a significant downward shift in the bupivacaine patients' post-procedure pain scores compared to the non-bupivacaine patients' post-procedure pain scores raises doubts about bupivacaine's utility as a standard component of a lumbar epidural injection.

Impact of fluoroscopic injection location on immediate and delayed pain relief in patients with greater trochanteric pain syndrome.

OBJECT: The purpose of this study was to assess whether fluoroscopically guided corticosteroid injections into the extrabursal tissues, trochanteric (subgluteus maximus) bursa, or subgluteus medius bursa provide better immediate and short-term pain relief. MATERIALS AND METHODS: All fluoroscopically guided corticosteroid injections performed over a 67-month period for greater trochanteric pain syndrome were retrospectively reviewed. Procedural images were reviewed by two musculoskeletal radiologists to determine the dominant injection site based on final needle positioning and contrast spread pattern, with discrepancies resolved by consensus. Statistical analysis of the association between pain score reduction and dominant injection site was performed. RESULTS: One hundred forty injections in 121 patients met the inclusion criteria. The immediate and 1-week post-injection pain reduction was statistically significant for trochanteric bursa, subgluteus medius bursa, and non-bursal injections. However, there was no statistically significant difference in the degree of pain reduction between the groups. There was statistically significant increase in the 1-week post-injection mean pain score compared with immediate post-injection mean pain score in the subgluteus medius bursa and non-bursal injection groups (p < 0.01) but not in the trochanteric bursa group. CONCLUSION: Fluoroscopy is frequently chosen over blind injection or ultrasound guidance for trochanteric steroid injections in patients with a high body mass index. Our results indicate that fluoroscopically guided steroid injections into the trochanteric bursa and subgluteus medius bursa significantly reduced immediate and 1-week post-injection pain scores, as do non-bursal injections. Steroid injection into the subgluteus medius bursa and non-bursal sites may be less effective in maintaining pain reduction at 1-week post-injection.

Spinal Hematomas: What a Radiologist Needs to Know.

Spinal hematomas are a frequent indication for radiologic evaluation and can be a diagnostic dilemma for many radiologists and surgeons. There are four types of spinal hematomas: epidural, subdural, subarachnoid, and intramedullary (spinal cord) hematomas. Because they differ by their location in relationship to the meningeal membranes and spinal cord, unique radiologic appearances can be recognized to distinguish these types of spinal hemorrhage. Anatomic knowledge of the spinal compartments is essential to the radiologist for confident imaging diagnosis of spinal hematomas and to specify correct locations. MRI is the modality of choice to diagnose the location of the hematoma, characterize important features such as age of the hemorrhage, and detect associated injury or disease. Each type of spinal hematoma has imaging patterns and characteristics that distinguish it from the others, as these specific spinal compartments displace and affect the adjacent anatomic structures. Early detection and accurate localization of spinal hematomas is critical for the surgeon to address the proper treatment and surgical decompression, when necessary, as neurologic deficits may otherwise become permanent. Online supplemental material is available for this article. ©RSNA, 2018.