Prevention of Pruritis following Spinal Morphine for Scheduled Cesarean Birth.

BACKGROUND: Intrathecal morphine provides effective analgesia after cesarean birth, yet up to 90% of women who receive it experience excessive itching, an undesirable dose-dependent effect. Pruritis may increase nursing workload, delay breastfeeding, and decrease patient satisfaction. When 0.1 mg spinal morphine is given, pruritis is markedly reduced while analgesia is preserved. PURPOSE: The purpose of this project was to determine possible causes and solutions for pruritus after cesarean birth. METHODS: Anesthesia providers were educated and encouraged to limit spinal morphine to 0.1 mg as a strategy to prevent pruritus. In a repeated measures design, the rate of treatment-required pruritus and opioid consumption were measured 24 hours after surgery. The project included an evaluation of 30 medical records before and 30 medical records after the project intervention. RESULTS: Preintervention rate of treatment-required pruritis was 37%, all received spinal morphine ≥ 1.5 mg. Postintervention rate of treatment-required pruritis was 13% and 57% after spinal morphine 0.1 mg and 0.2 mg, respectively. Opioid consumption was similar between groups. CLINICAL IMPLICATIONS: Mother-baby nurses can have an impact on the practice of anesthesia providers by advocating for evidence-based dosing of intrathecal morphine to reduce the incidence of pruritis while maintaining effective analgesia for women after cesarean birth.

Comparison of Ultrasonography and Conventional Fluoroscopy Guided Caudal Epidural Injection in Chronic Low Back Pain.

AIM: To compare the efficacies of fluoroscopy- and ultrasound (US)-guided caudal epidural steroid injections (CESIs) in patients with chronic low back pain (LBP). MATERIAL AND METHODS: This study included patients with chronic LBP who underwent US- (Group U; n = 90) or fluoroscopyguided (Group F; n = 90) CESI. The procedure time, successful injection rate on the first attempt, complication rate, Oswestry Disability Index (ODI) score, and Numeric Rating Scale (NRS) score before CESI and after 3 weeks and 3 months of CESI were analyzed. RESULTS: NRS and ODI scores improved at 3 weeks (p < 0.001) and 3 months (p < 0.001) after CESIs. No significant differences were noted between the two groups for the NRS (p=0.22 and p=0.47) and ODI (p=0.58, p=0.22) scores. Moreover, the CESI procedure time was significantly shorter (p < 0.001) and the successful injection rate on the first attempt was significantly higher (p=0.002) in Group U than in Group F. The complication rate difference was statistically insignificant between the two groups (p > 0.05). CONCLUSION: Outcomes of US-guided CESI were superior than those of fluoroscopy-guided CESI considering the successful injection rate on the first attempt and procedure time. In addition, US-guided CESI was as effective as fluoroscopy-guided CESI and did not expose patients and practitioners to radiation.

Descriptive Analysis of Federal and State Interventional Pain Malpractice Litigation in the United States: A Pilot Investigation.

BACKGROUND: The aim of this study was to examine and appreciate characteristics of malpractice lawsuits brought against interventional pain specialists. OBJECTIVES: To examine and appreciate characteristics of malpractice lawsuits brought against interventional pain specialists. STUDY DESIGN: Retrospective review. SETTING: Jury verdicts and settlement reports of state and federal malpractice cases involving interventional pain practitioners from January 1, 1988, to January 1, 2018 were gathered from the Westlaw online legal database. METHODS: Jury verdicts and settlement reports of state and federal malpractice cases involving interventional pain practitioners from January 1, 1988, to January 1, 2018 were gathered from the Westlaw online legal database. Data collected for each case included year, state, patient age, patient gender, defendant specialty, legal outcome, award amount, alleged cause of malpractice, and factors in plaintiff's decision to file. After elimination of duplicates and applying inclusion/exclusion criteria to our initial search yielding over 1,500 cases, a total of 82 cases were included in this study. RESULTS: A total of 57.3% of cases resulted in a jury verdict in favor of the defendant, whereas 41.5% favored the plaintiff. When comparing cases that were performed in the operating room to cases performed outside the operating room, we found the jury verdicts to favor the plaintiff 83.3% of the time for operating room procedures (P = 0.003). In other words, interventional pain practitioners were more likely to be found at fault for complications from procedures performed in the operating room. To eliminate confounders, a logistical regression was performed and confirmed operating room procedures were an independent predictor of a verdict awarded to the plaintiff (P = 0.008). The median amount awarded to the plaintiff for all cases was $333,000, and the single highest award amount was $36,636,288. The median payout for operating room procedures was $450,000 (P = 0.010), which was significantly different from the median payout for nonoperating room procedures. Procedure categorization demonstrated a statistically significant difference in jury verdicts (P = 0.01411) and procedural error was the leading reason for pursuing litigation, followed by lack of informed consent and unnecessary procedure performed. LIMITATIONS: There is more than one database that captures medicolegal claims brought against practitioners. Westlaw, which has been previously utilized by other studies, is only one of them and the extent to which overlap exists in unclear. For each, data input are not necessarily consistent and data capture are not complete. As a result, there could exist a skew toward more severe complications and the details of individual cases likely vary. During data extraction, we found that all details of the procedure were not always included. For example, not all cases specified the type of injectate utilized for epidural injection (i.e., local anesthetic, steroid, mixture, and others) or route of injection (i.e., transforaminal vs. interlaminar). Moreover, as previously mentioned, cases that are settled out of court or finalized prior to trial are not necessarily reported by the Westlaw database, and therefore were not always included in our data search. CONCLUSIONS: Overall, interventional pain medicine physicians were favored by jury verdicts for malpractice claims. However, when filtering by procedure or setting, jury verdicts favored the plaintiff in some cases. KEY WORDS: Interventional pain, medical, malpractice, anesthesiology.

Factors Predicting Favorable Short-Term Response to Transforaminal Epidural Steroid Injections for Lumbosacral Radiculopathy.

Background and Objectives: The purpose of this retrospective study was to identify predictors of short-term outcomes associated with a lumbosacral transforaminal epidural steroid injection (TFESI). Materials and Methods: The medical records of 218 patients, who were diagnosed with lumbosacral radiculopathy and treated with a TFESI, were reviewed in this retrospective study. A mixture of corticosteroid, lidocaine, and hyaluronidase was injected during TFESI. Patients with >50% pain relief on the numerical rating scale compared with the initial visit constituted the good responder group. Demographic, clinical, MRI, and electrodiagnostic data were collected to assess the predictive factors for short-term outcomes of the TFESI. Results: A multivariate logistic regression analysis demonstrated that a shorter duration of symptoms and a positive sharp wave (PSW)/fibrillation (Fib) observed in electrodiagnostic study (EDx) increased the odds of significant improvement 2-4 weeks after the TFESI. Conclusions: Shorter duration of symptoms and PSW/Fib on EDx were predictors of favorable short-term response to TFESI.

Epidural test dose in obstetric patients: should we still use it?

PURPOSE OF REVIEW: As the application of a test dose after epidural catheter insertion in obstetrics has recurrently been associated with serious adverse events affecting both maternal and foetal outcomes, the question whether to test or not remains a controversial issue. RECENT FINDINGS: Present guidelines do not provide clear recommendations in this regard and several recent surveys indicate a heterogeneity in clinical routine. SUMMARY: Physiological alterations during pregnancy and labour restrict the use and also the validity of traditional test agents. Epinephrine is not appropriate to detect a vascular insertion in labour and the application of a local anaesthetic test dose may lead to dose-dependent fatal consequences should the catheter be intrathecal, due to an increased sensitivity in parturients. Given the current practice of opioid-amended-low-concentration epidurals, the waiving of a test dose results at worst in a failed epidural, a stark contrast to the potentially severe to fatal complications of a 'traditional' test dose. Hence, an originally preventive measure providing potentially more harm than the consequences of the situation aimed to prevent, should not be recommended. A simple fractionated administration of the initial analgesic dose seems reasonable though.

Clinical evaluation of transforaminal epidural steroid injection in patients with gadolinium enhancing spinal nerves associated with disc herniation.

BACKGROUND: Transforaminal epidural steroid injection (TFESI) of corticosteroid is frequently employed to mitigate the painful and disabling symptoms of lumbar disc herniation. However, the treatment outcome of TFESI in patients with radicular pain and inflamed neural structures as assessed by contrast-enhanced magnetic resonance imaging (MRI) has not been forthcoming. OBJECTIVES: To investigate functional improvement and pain reduction following TFESI in patients found to have nerve inflammation as evidenced by gadolinium-enhanced (MRI). STUDY DESIGN: Retrospective assessment. SETTING: Tertiary spinal intervention center, Daegu, Korea. METHODS: Thirty-seven patients were selected by strict inclusion criteria. Patients were classified into enhancing and non-enhancing groups as evidenced by gadolinium-enhanced MRI. The enhancing group was further divided into pre-dorsal roog ganglion (DRG) only enhanced group and pre-DRG and post-DRG enhanced group. Clinical outcomes were evidenced by numeric rating scale (NRS) and Oswestry disability index (ODI) at pretreatment, one week, and 4 weeks after treatment. RESULTS: The improvement of NRS and ODI in the enhanced group was greater than those of the non-enhanced group, at one week and 4 weeks after TFESI (P < 0.05). However there was no significant difference in improvement of NRS and ODI between pre-DRG only enhanced group and pre-DRG and post-DRG enhanced group at one week and 4 weeks after TFESI. LIMITATIONS: Retrospective chart review with a small sample size. CONCLUSION: The improvement of NRS and ODI in the enhanced group was significantly greater than those of the non-enhanced group after TFESI. Radicular pain and functional impairment in the presence of gadolinium enhancing spinal neural structures and lumbar disc herniation may be more responsive to TFESI than patients without enhancing neural structures.

Patients with refractory back pain treated in the emergency department: is immediate interlaminar epidural steroid injection superior to hospital admission and standard medical pain management?

BACKGROUND: Hospital admissions for back pain are prolonged, costly, and common. Epidural steroid injections are frequently performed in an outpatient setting with an excellent safety and efficacy profile. OBJECTIVES: The purpose was to review data from patients with severe pain that did not respond to aggressive medical treatment in the emergency department (ED) and determine the effectiveness of an interlaminar epidural steroid injection (ESI) in this patient population. STUDY DESIGN: Retrospective matched cohort design. SETTING: Single urban emergency department at a tertiary referral center. METHODS: A retrospective cohort comparison pairing 2 groups that both failed aggressive pain control in the ED was performed. The epidural injection group (1ESI) received an interlaminar ESI while in the ED. The standard therapy group (2ST) was admitted for medical pain management. Groups were matched for pain intensity, age, and symptom duration. RESULTS: Thirty-five patients in 1ESI (NRS 8.8, 5 - 10, 0.35), and 28 patients in 2ST (NRS 8.9, 4 - 10, 1.7). Pain score after ESI 0.33 (0 - 2, 0.6); all were discharged. Pain score on day 1 of hospital admission for 2ST was 8.7 (7 - 10, 1.5). Total ED time was 8 hours for 1ESI and 13 hours for 2ST (P < 0.002). 1ESI patients received less narcotics while in the ED (P < 0.002) and were discharged home with less narcotics than 2ST (< 0.002). Average inpatient length of stay (LOS) for 2ST was 5 (1.5 - 15, 3.3) days. Cost of care was over 6 times greater for those patients admitted for pain management (P < 0.001). LIMITATIONS: Retrospective design, non-randomized sample, and a small patient population. CONCLUSION: An ED patient cohort with severe refractory pain was treated with an interlaminar ESI after failing maximal medical pain management while in the ED. Complete pain relief was achieved safely and rapidly. The need for inpatient admission was eliminated after injection. Costs were lower in the group that received an epidural injection. Narcotic requirements upon discharge were decreased as well.

Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations.

BACKGROUND: Epidural corticosteroid injections are a common treatment for radicular pain caused by intervertebral disc herniations, spinal stenosis, and other disorders. Although rare, catastrophic neurologic injuries, including stroke and spinal cord injury, have occurred with these injections. METHODS: A collaboration was undertaken between the U.S. Food and Drug Administration Safe Use Initiative, an expert multidisciplinary working group, and 13 specialty stakeholder societies. The goal of this collaboration was to review the existing evidence regarding neurologic complications associated with epidural corticosteroid injections and produce consensus procedural clinical considerations aimed at enhancing the safety of these injections. U.S. Food and Drug Administration Safe Use Initiative representatives helped convene and facilitate meetings without actively participating in the deliberations or decision-making process. RESULTS: Seventeen clinical considerations aimed at improving safety were produced by the stakeholder societies. Specific clinical considerations for performing transforaminal and interlaminar injections, including the use of nonparticulate steroid, anatomic considerations, and use of radiographic guidance are given along with the existing scientific evidence for each clinical consideration. CONCLUSION: Adherence to specific recommended practices when performing epidural corticosteroid injections should lead to a reduction in the incidence of neurologic injuries.

Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low-back pain, and lumbar fusion.

The medical literature continues to fail to support the use of lumbar epidural injections for long-term relief of chronic back pain without radiculopathy. There is limited support for the use of lumbar epidural injections for shortterm relief in selected patients with chronic back pain. Lumbar intraarticular facet injections are not recommended for the treatment of chronic lower-back pain. The literature does suggest the use of lumbar medial nerve blocks for short-term relief of facet-mediated chronic lower-back pain without radiculopathy. Lumbar medial nerve ablation is suggested for 3-6 months of relief for chronic lower-back pain without radiculopathy. Diagnostic medial nerve blocks by the double-injection technique with an 80% improvement threshold are an option to predict a favorable response to medial nerve ablation for facet-mediated chronic lower-back pain without radiculopathy, but there is no evidence to support the use of diagnostic medial nerve blocks to predict the outcomes in these same patients with lumbar fusion. There is insufficient evidence to support or refute the use of trigger point injections for chronic lowerback pain without radiculopathy.

Analgesic and motor effects of a high-volume intercoccygeal epidural injection of 0.125% or 0.0625% bupivacaine in adult cows.

The objectives of this study were to determine the analgesic and motor effects of a high-volume intercoccygeal epidural injection of bupivacaine at 2 concentrations in cows. A prospective, randomized, blinded, crossover trial was conducted on 6 adult cows. An indwelling epidural catheter was placed in the first intercoccygeal space and advanced 10 cm cranially. All the cows received 3 treatments with a washout period of 48 h: saline (control), 0.125% bupivacaine (high dose), or 0.0625% bupivacaine (low dose), at a final volume of 0.15 mL per kilogram of body weight, infused manually into the epidural space over a period of 15 min. The anal and tail tone and motor deficits of the pelvic limbs were evaluated in 5 of the cows with use of a numerical rating scale and a visual analogue scale (VAS). Sensory block was assessed in 4 of the cows by the response to needle pricks in different regions with the use of a VAS. Measurements were obtained before and at different time points after injection, up to 360 min. Analysis of variance for repeated measures and post-hoc Tukey's and Dunnett's tests were used. Differences were considered significant when the P-value was ≤ 0.05. One cow became recumbent 6 h after injection. Anal and tail tones were significantly decreased and motor deficits of the pelvic limbs were significantly increased after bupivacaine treatment compared with control treatment. The overall mean VASpain scores ± standard deviation were 66 ± 8 after control treatment, 52 ± 5 after low-dose bupivacaine treatment, and 43 ± 5 after high-dose bupivacaine treatment. The pain scores were significantly lower in caudal regions up to the saphenous nerve after high-dose bupivacaine treatment compared with control treatment and significantly lower in the anus, vulva, and tail after low-dose bupivacaine treatment compared with control treatment. Thus, analgesia with moderate motor deficits of the pelvic limbs may be obtained with 0.125% bupivacaine administered epidurally.

Les objectifs de la présente étude étaient de déterminer chez la vache les effets analgésiques et moteurs d'une injection épidurale inter-coccygienne d'un volume important de bupivacaïne à deux concentrations. Une étude croisée prospective, randomisée, et à l'aveugle a été réalisée chez 6 vaches adultes. Un cathéter épidural à demeure a été placé dans le premier espace inter-coccygien et avancé cranialement de 10 cm. Toutes les vaches ont reçu 3 traitements avec une période d'évacuation de 48 h : saline (témoin), 0,125 % de bupivacaïne (dose élevée) ou 0,0625 % de bupivacaïne (faible dose), à un volume final de 0,15 mL par kilo de poids corporel, infusé manuellement dans l'espace épidural sur une période de 15 min. Le tonus anal et de la queue ainsi que les déficits moteurs des membres pelviens ont été évalués chez 5 des vaches au moyen d'une échelle numérique de pointage et une échelle analogue visuelle (VAS). Le bloc sensitif a été évalué chez 4 des vaches par la réponse à des piqûres d'aiguille dans différentes régions avec l'utilisation d'une VAS. Les mesures ont été obtenues avant et à différents temps après l'injection, jusqu'à 360 min. Une analyse de variance pour mesures répétées et les tests post-hoc de Tukey et de Dunnett ont été utilisés. Les différences étaient considérées significatives lorsque la valeur de P était ≤ 0,05. Une vache est demeurée couchée 6 h après l'injection. Le tonus anal et de la queue était réduit de manière significative et les déficits moteurs des membres pelviens étaient significativement augmentés après le traitement à la bupivacaïne comparativement au traitement témoin avec la saline. Dans l'ensemble les scores moyens ± l'écart-type de VASdouleur étaient 66 ± 8 après le traitement témoin, 52 ± 5 après le traitement à faible dose de bupivacaïne, et 43 ± 5 après le traitement avec la dose élevée de bupivacaïne. Les scores de douleur étaient significativement plus faibles dans les régions caudales jusqu'au nerf saphène après le traitement avec les doses élevées de bupivacaïne comparativement au traitement témoin et significativement plus faibles au niveau de l'anus, la vulve et la queue après le traitement avec les faibles doses de bupivacaïne comparativement au traitement témoin. Ainsi, une analgésie avec des déficits moteurs modérés des membres pelviens peut être obtenue avec de la bupivacaïne à 0,125 % administrée par voie épidurale.(Traduit par Docteur Serge Messier).

Efficacy of interlaminar vs transforaminal epidural steroid injection for the treatment of chronic unilateral radicular pain: prospective, randomized study.

UNLABELLED: OBJECTIVE, DESIGN AND SETTINGS: The purpose of this randomized, prospective study is to compare the efficacy of two different routes in administering epidural steroid injections interlaminar (IL) vs transforaminal (TF) in patients with unilateral radicular pain. PATIENTS: We randomly enrolled and followed 64 patients with chronic radiculopathy. RESULTS: Significant improvements were maintained throughout 6 months (24 weeks) of follow-up (P<0.001, respectively). The average visual analog scale (VAS) pain scores at 24 weeks improved to 4.0 ± 2.2 cm in the IL group and 3.8 ± 2.1 cm in the TF group (P=0.717). Baseline functional capacity was comparable for the IL and the TF group (52% vs 53%) when assessed using Oswestry (P=0.647). At 6 months, both groups improved, 39% for the IL group and 38% for the TF group, suggesting change from severe to moderate disability scoring range. There were 24 out of the 32 (75%) patients in the IL group at 24 weeks who improved more than 2 cm on the VAS scale and 17 patients (53%) had >50% of the pain relief. In the TF group, there were 27 out of the 32 (84%) patients with >2 cm improvement on VAS pain scale, and 20 of 32 (63%) with >50% improvement at 24 weeks. Functional capacity changes were similar, 16 out of the 32 patients (50%) improved 10 points or more on the Oswestry scale in the IL group and 21 out of the 32 in the TF group (66%). CONCLUSIONS: Using either route of epidural injections to deliver steroids for unilateral chronic radiculopathy secondary to herniated intervertebral disc provided significant improvements in patients function and pain relief. However, we could not find a statistically significant difference between two indicated groups either in functional improvement or in reduction in pain, although half-dose of steroids delivered via TF route provided somewhat better long-term pain relief and functional capacity improvements.