A systematic review and network meta-analysis comparing different epidural steroid injection approaches.

BACKGROUND: Low back pain (LBP) and lumbosacral radiculopathy are frequent disorders that cause nerve root injury, resulting in a variety of symptoms ranging from loss of sensation to loss of motor function depending on the degree of nerve compression. OBJECTIVES: The goal of this study was to investigate the effectiveness of various epidural injection procedures in adult LBP patients. STUDY DESIGN: Systematic review and network meta-analysis. SETTING: Egypt. METHODS: PubMed, Scopus, Web of Science, Cochrane Database, and Embase were used to conduct an electronic literature search. We included RCTs, cohorts, case controls, patients 30 years old with a clinical presentation of low back pain, and comprehensive data on the effects of the intervention on patients with lumbosacral radicular pain who got epidural steroid injections via various techniques. Only papers written in English were eligible. RESULTS: Our analysis showed that parasagittal intralaminar (PIL) was the most effective approach in decreasing VAS (0-10) in the short term (< 6 months) (MD = -1.16 [95% CI -2.04, -0.28]). The next significant approach was transforaminal (TF) (MD = -0.37 [95% CI -1.14, -0.32]) in the long term; TF was the most effective approach (MD = -0.56 [95% CI -1, -0.13]). According to VAS (0-100) in the short term (< 6 months), our analysis showed an insignificant difference among the injection approaches and in the long term; TF was the most effective approach (MD = -24.20 [95% CI -43.80, -4.60]) and the next significant approach was PIL (MD = -23.89 [95% CI -45.78, -1.99]). LIMITATIONS: The main limitations are the heterogeneity encountered in some of our analyses in addition to studies assessed as high risk of bias in some domains. CONCLUSION: TF was the most effective steroid injection approach. In decreasing VAS for short-term PIL and TF were the most significant approaches, but TF was the most effective approach in decreasing VAS for the long term. Also, TF was the most effective approach in decreasing ODI for the long term.

Combined Infraclavicular-Suprascapular Nerve Blocks Compared With Interscalene Block for Arthroscopic Rotator Cuff Repair: A Prospective, Randomized, Double-blind, and Comparative Clinical Trial.

BACKGROUND: The gold standard postoperative analgesia protocol for arthroscopic rotator cuff repair procedures is the interscalene block (ISB), which prevents the significant consequences of phrenic nerve block associated with hemidiaphragmatic paralysis (HDP). The infraclavicular brachial plexus block (BPB) combined with the suprascapular nerve block (SSNB) had the same analgesic efficacy as the infraclavicular BPB alone, with no effect on respiration. OBJECTIVES: Therefore, the study aimed to assess the HDP and analgesic efficacy of both approaches in controlling pain following arthroscopic rotator cuff repair surgeries. STUDY DESIGN: A prospective, randomized, double-blind, and comparative clinical trial. SETTING: The study comprised 66 patients. They were separated into 2 equal parallel groups 33 patients each: the ISB group and the costoclavicular and suprascapular block (CSB) group. METHODS: The ISB group obtained the ISB followed by the general anesthesia. The CSB group received infraclavicular blockade using the costoclavicular approach and SSNB followed by general anesthesia. RESULTS: Considering morphine utilization during the first day following the operation, the groups demonstrated an insignificant difference. The CSB group showed a decreased rate of diaphragmatic paralysis. LIMITATIONS: There was no control group. And, the blocks might take a long time to be performed up to 30 minutes. Also, there were no validated criteria to define HDP based on M-mode ultrasound measurements. CONCLUSIONS: The employment of the costoclavicular block in combination with the suprascapular block may provide a comparable analgesic potency to the sole use of the standard ISB with no HDP.

The Efficacy of Erector Spinae Plane Block Compared With Intrathecal Morphine in Postoperative Analgesia in Patients Undergoing Lumbar Spine Surgery: A Double-blind Prospective Comparative Study.

BACKGROUND: Severe postoperative pain is experienced by most patients who undergo spine surgery. Erector spinae plane block (ESPB) is a successful method for postoperative analgesia and has only minor complications. Intrathecal morphine (ITM) demonstrates high efficacy for analgesia up to 24 hours postsurgery. ESPBs and ITM for postoperative analgesia in lumbar spine surgeries have never been compared in prior studies. OBJECTIVES: This study aimed to compare the efficacy of ESPB and ITM in postoperative analgesia after lumbar spine surgeries. STUDY DESIGN: A double-blind prospective comparative study. SETTING: This study was performed at Al Fayoum University Hospital after being confirmed by the local institutional ethical committee (#80) with approval number M520 and retrospectively registered at clinicaltrials.gov number (NCT05123092). METHODS: A prospective randomized double-blinded interventional trial was conducted with 82 patients, 41 in each group. In the ESPB group, a 0.25% bupivacaine injection was used to conduct a bilateral ultrasound-guided ESPB. In the ITM group, an injection of 0.3 mg morphine intrathecally was done. The Visual Analog Scale (VAS) was recorded as the primary outcome. The time to the first analgesic request, intra- and postoperative opioid consumption, hemodynamics, sedation score, and complications were also recorded as secondary outcomes. RESULTS: Postoperative VAS scores were significantly lower in the intrathecal group throughout the postoperative period at all recorded study time points until 48 hours (P < 0.001). Time to the first rescue analgesia and doses of postoperative analgesic required were significant, with a P value of 0.000. Significant differences were found in postoperative oxygen saturation up to 24 hours (P < 0.001) and the sedation score up to 6 hours (P < 0.01). A higher incidence of complications was recorded in the ITM group (P = 0.000). LIMITATIONS: We did not measure patient preoperative VAS scores to ensure that the 2 groups were matched in pain severity. Also, we did not compare patient satisfaction. Another limitation was the inability to determine the degree of pain relief of ESPB since there was no control group in our study. CONCLUSION: We concluded that ITM 0.3 mg provides more potent analgesia up to 48 hours postoperatively than an ESPB, based upon VAS score, analgesic durations, and postoperative analgesic requirements.

Comparison between Two Low Doses of Amitriptyline in the Management of Chronic Neck Pain: A Randomized, Double-Blind, Comparative Study.

Chronic neck pain (CNP) is a major concern for pain therapists. Many drugs including antidepressants such as amitriptyline have been used in the management of CNP. This study compared the efficacy and safety of 2 different doses of amitriptyline (5 mg and 10 mg at bedtime) in patients with CNP. A total of 80 patients of both sexes with idiopathic CNP, ranging in age from 18 to 75 years, were divided into 2 groups that received 5 or 10 mg oral amitriptyline at bedtime for 120 days. The primary outcome measure was neck pain disability index (NPDI). Neck pain intensity, Athens Insomnia Scale score, Hospital Anxiety and Depression Scale (HADS), side effects of the drug, and patient satisfaction were secondary outcome measures. NPDI decreased by 71.9% ± 13.4% in the 10 mg group compared to 47.3% ± 17.3% in the 5 mg group, representing a statistically significant difference (95% confidence interval: 27.3-12.6). Additionally, the 10 mg group showed greater mean reductions in pain score and HADS scores (both the anxiety and depression subscales), as well as improvement in sleep disturbance compared to the 5 mg group. A higher dose (10 mg) of amitriptyline at bedtime significantly reduced neck pain intensity, sleep disturbance, and anxiety and depression compared to a lower dose (5 mg) in patients with idiopathic and nontraumatic CNP after 120 days of treatment, with no significant difference between groups in the rate of side effects.

Analgesic Efficacy of Erector Spinae Plane Block Compared with Intrathecal Morphine After Elective Cesarean Section: A Prospective Randomized Controlled Study.

BACKGROUND: We aimed to assess the efficacy of ultrasound-guided bilateral erector spinae plane block (ESPB) compared to intrathecal morphine (ITM) for analgesia after elective cesarean delivery under spinal anesthesia. METHODS: In total, 140 parturients scheduled for elective cesarean section under spinal anesthesia were randomly allocated into two equal groups. The ESPB-group received 10 mg hyperbaric bupivacaine intrathecally through spinal anesthesia, followed by an ESPB at the ninth thoracic transverse process with 20 mL of 0.5% bupivacaine immediately after the operation. The ITM-group received 10 mg hyperbaric bupivacaine with 100 mcg morphine intrathecally through spinal anesthesia, followed by a sham block at the end of the surgery. The visual analogue scale (VAS) score for pain at several postoperative time points, total opioid consumption, and time to the first analgesic request were evaluated. Statistical analysis was performed with the independent t-test and linear mixed-effects models. The Kaplan-Meier estimator and the log-rank test were used to compare the primary and secondary outcomes of the groups. RESULTS: No significant differences were observed between the groups regarding patient characteristics; in the post-operative period (0-24 hrs), VAS scores (at rest) were, on average, 0.25 units higher in the ITM group. The total tramadol consumption in the first 24 hrs was significantly higher in the ITM group than in the ESPB group (101.71 ± 25.67 mg vs 44 ± 16.71 mg, respectively). The time to the first analgesic request was 4.93±0.82 hrs in the ITM group and 12±2.81 hrs in the ESPB group. Patient satisfaction did not differ significantly. CONCLUSION: ESPB has a successful postoperative analgesic effect and may limit opioid consumption in parturients undergoing elective caesarean delivery.

Comparison between the Effects of Sumatriptan Versus Naratriptan in the Treatment of Postdural Puncture Headache in Obstetric Patients: A Randomized Controlled Trial.

BACKGROUND: Postdural puncture headache (PDPH) in the obstetric anesthesia practice is one of the most annoying, common, and important problems. AIM: This comparative study was designed to assess the efficacy of naratriptan in relieving PDPH in parturients who gave birth by cesarean section under intrathecal anesthesia and to compare its efficacy with sumatriptan. SETTINGS AND DESIGN: One hundred and eighty-nine adult parturients who complained of PDPH in the first 3 days postpartum period were enrolled in this study. They were divided into three equal parallel groups of 63 each. MATERIALS AND METHODS: Group-1 controlled (C-group) received multivitamin tablets, Group-2 sumatriptan (S-group) received sumatriptan tablets and Group-3 naratriptan (N-group) received naratriptan tablets. The efficacy of naratriptan in relieving PDPH was studied and compared with that of sumatriptan. Incidences of complications of both drugs were also noted. STATISTICAL ANALYSIS: The collected data were organized, tabulated, and statistically analyzed using SPSS software statistical computer package version 18 (SPSS Inc., USA). RESULTS: After the first 6 h, there were statistically significant differences between Groups S and N from one side and control group from the other side (P < 0.0001 and 0.001), respectively, and the difference between Group S and Group N was statistically significant (P = 0.004). After 12 h, there were statistically significant differences between Groups S and N from one side and the control group from the other side (P < 0.0001) and the difference between Group S and Group N was statistically significant (P = 0.002). After 72 h, there were statistically significant differences between Groups S and N from one side and control group from the other side (P < 0.001 and 0.009), respectively. The difference was nonsignificant between S and N group (P = 0.717). CONCLUSION: The study revealed that anti-migraine drug naratriptan in combination with supportive treatment was effective in relieving PDPH in parturients.

Comparative study between Dexmedetomidine and Ondansteron for prevention of post spinal shivering. A randomized controlled trial.

BACKGROUND: Regional anesthesia could affect the homeostatic system functions resulting frequently in perioperative hypothermia and consequently shivering. The objective of this trial was to evaluate the efficacy of dexmedetomidine and ondansetron to reduce the incidence and severity of shivering after intrathecal blocks. METHODS: This randomized placebo-controlled trial included 120 patients allocated equally in three groups. All patients were anesthetized by standard intrathecal blocks for surgical procedure at lower half of the body and received one of the study drugs intravenously (IV) according to the group assignments. Group S patients (placebo) were administered saline, Group O (ondansetron) were given 8 mg ondansetron, and Group D (dexmedetomidine) were given 1 µg/kg of dexmedetomidine. Shivering incidence and scores, sedation scores, core body temperature, hemodynamic variables, and incidence of complications (nausea, vomiting, hypotension, bradycardia, over-sedation, and desaturation) were recorded. RESULTS: The incidence and 95% confidence interval (95% CI) of shivering in group S 57.5% (42.18-72.82%) was significantly higher than that of both group O 17.5% (5.73-29.27%), P < 0.001 and group D 27.5% (13.66-41.34%), P = 0.012. However, the difference in the incidence of shivering between group O and group D was comparable, P = 0.425. The sedation scores were significantly higher in group D than those of both group S and group O, P < 0.001. Sedation scores between group S and group O were comparable, P = 0.19. Incidences of adverse effects were comparable between the three groups. CONCLUSION: Prophylactic administrations of dexmedetomidine or ondansetron efficiently decrease the incidence and severity of shivering after spinal anesthesia as compared to placebo without significant difference between their efficacies when compared to each other. TRIAL REGISTRATION: Pan African Clinical Trial Registry (PACTR) under trial number (PACTR201710002706318). 18-10-2017. 'retrospectively registered'.