Long-Term Outcomes of Epidurals with Lidocaine With or Without Steroids for Lumbar Disc Herniation and Spinal Stenosis: A Meta-Analysis.

BACKGROUND: Previous meta-analyses examined only the short-term differences between lidocaine and steroids vs lidocaine alone in treating lumbar degenerative diseases. Long-term outcomes (1-2 years) in patients with lumbar disc herniation (LDH) and lumbar central spinal stenosis (LCSS) have not yet been systematically evaluated. OBJECTIVE: The objective of our study was to assess quantitatively the difference in efficacy at 1 to 2 years between lidocaine alone vs lidocaine and steroids for the management of LDH or LCSS. STUDY DESIGN: We conducted a meta-analysis. METHODS: PubMed, EMBASE, and the Cochrane library were electronically searched up to July 22, 2016, for randomized controlled trials comparing lidocaine alone vs in combination with steroids for the treatment of LDH and LCSS. Effective pain relief (EPR), Numeric Rating Scale (NRS-11), Oswestry Disability Index (ODI), opioid intake (OI), and total employed increased rate (TEIR) were the endpoints. Risk ratios (RRs) or weighted mean difference (WMD) with 95% confidence intervals (CIs) were calculated, and the pooled analysis was conducted using RevMan 5.2. RESULTS: Seven trials were included. EPR was not significantly different at 1 and 2 years, with RR = 1.08 (95% CI, 0.90-1.30; P = .39) and RR = 1.04 (95% CI, 0.92-1.18; P = .51), respectively, in patients treated with lidocaine alone vs in combination with steroids. The NRS-11 was also similar at 1 and 2 years. ODI and OI were not significantly different at 1 and 2 years. A similar TEIR effect was also observed for the 2 treatments. LIMITATIONS: This meta-analysis relied on a small sample size of trials. Significant heterogeneity among studies was observed. Several significant differences in terms of age of the patients were reported in one included trial. CONCLUSION: This meta-analysis confirmed the similar effects associated with lidocaine alone vs in combination with steroids for the management of LDH and LCSS. Studies with longer follow-up periods are still recommended. KEY WORDS: Effective pain relief, lidocaine, long-term, lumbar central spinal stenosis, lumbar disc herniation, Numeric Rating Scale, opioid intake, Oswestry Disability Index, steroids, total employed increased rate.

An Updated Analysis of Utilization of Epidural Procedures in Managing Chronic Pain in the Medicare Population from 2000 to 2018.

BACKGROUND: With increasing costs of health care in the United States, attention is focused on expensive conditions. Musculoskeletal disorders with low back and neck pain account for the third highest amount of various disease categories. Minimally invasive interventional techniques for managing spinal pain, including epidural injections, have been considered to be growing rapidly. However, recent analyses of utilization of interventional techniques from 2000 to 2018 has shown a decline of 2.6% and a decline of 21% from 2009 to 2018 for epidural and adhesiolysis procedures. OBJECTIVES: The objectives of this analysis of epidural procedures from 2000 to 2018 are to provide an update on utilization of epidural injections in managing chronic pain in the fee-for-service (FFS) Medicare population, with a comparative analysis of 2000 to 2009 and 2009 to 2018. STUDY DESIGN: Utilization patterns and variables of epidural injections in managing chronic spinal pain from 2000 to 2009 and from 2009 to 2018 in the FFS Medicare population in the United States. METHODS: This analysis was performed by utilizing master data from CMS, physician/supplier procedure summary from 2000 to 2018. The analysis was performed by the assessment of utilization patterns using guidance from Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). RESULTS: Overall, epidural procedures declined at a rate of 20.7% per 100,000 Medicare enrollees in FFS Medicare in the United States from 2009 to 2018, with an annual decline of 2.5%. However, from 2000 to 2009, there was an increase of 89.2%, with an annual increase of 7.3%. This analysis showed a decline in all categories, with an annual decrease of 4.7% for lumbar interlaminar and caudal epidural injections, 4.7% decline for cervical/thoracic transforaminal epidural injections, 1.1% decline for lumbar/sacral transforaminal epidural injections, and finally 0.4% decline for cervical/thoracic interlaminar epidural injections. Overall declines from 2009 to 2018 were highest for cervical and thoracic transforaminal injections with 35.1%, followed by lumbar interlaminar and caudal epidural injections of 34.9%, followed by 9.4% for lumbar/sacral transforaminal epidurals, and 3.5% for cervical and thoracic interlaminar epidurals. LIMITATIONS: This analysis was limited by noninclusion of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. In addition, utilization data for individual states continues to be sparse and may not be accurate or representative of the population. CONCLUSIONS: The declining utilization of epidural injections in all categories with an annual of 2.5% and overall decrease of 20.7% from 2009 to 2018 compared with annual increases of 7.3% and overall increase of 89.2% from 2000 to 2009 shows a slow decline of utilization of all epidural injections. KEY WORDS: Chronic spinal pain, interlaminar epidural injections, caudal epidural injections, transforaminal epidural injections, utilization patterns.

Heterogeneity Among Hospitals in the Percentages of All Lumbosacral Epidural Steroid Injections Where the Patient Had Received 4 or More in the Previous Year.

BACKGROUND: Current guidelines for the administration of therapeutic epidural injections suggest that these be limited to a maximum of 4 per year. We sought to gain an understanding of the proportion of lumbosacral epidural injections administered to patients who had received ≥4 such injections during the preceding 364 days, and whether these proportions varied among hospitals. METHODS: This observational cohort study included data from all facilities owned by the 121 nonfederal hospitals in the State of Iowa, July 2012 through September 2017. One end point was the percentage of all lumbar or sacral transforaminal or interlaminar epidural injections where the patient had received ≥4 such injections during the preceding 364 days. Comparisons also were made among hospitals' percentages of injections that were the fifth or greater (ie, patient had already received ≥4 during preceding 364 days) using Bonferroni-adjusted conservative 95% confidence intervals. RESULTS: There were 48,270 unique patients who underwent at least 1 lumbosacral epidural steroid injection. The patients received care at 112 hospitals' facilities. Most patients received no additional steroid injections within 364 subsequent calendar days after the first steroid injection (54.1%). There were ≥5 steroid injections for 1.27% of patients (ie, the injection was the fifth or greater). Among the 39 hospitals in Iowa that performed overall at least 1 steroid injection every 4 days, there were 6 hospitals at which the percentages of injections that were the fifth or greater significantly exceeded the overall prevalence of 1.91% (range: 3.0%-6.4%). There were 14 of the 39 hospitals with prevalences significantly less. CONCLUSIONS: Although most patients received only 1 lumbosacral steroid injection within 1 year, 1.27% of patients received 5 or more, and 1.91% of injections were the fifth or greater. Several hospitals had significantly greater than the overall average percent of steroid injections which were fifth or more. This heterogeneity warrants study of whether annual steroid injections per patient should be a clinical quality measure for the care received by patients with lower back pain or whether payment should be greater when injections are in accordance with guidelines.

Effects of implementing evidence-based appropriateness guidelines for epidural steroid injection in chronic low back pain: the EAGER (Esi Appropriateness GuidElines pRotocol) study.

Objective: Chronic low back pain is very common and often treated with epidural steroid injections (ESIs). As ESI referrals had been rapidly increasing at our Veterans' Administration hospital, we were concerned that they were supplanting more comprehensive care. The objective was to determine how referral patterns and multidisciplinary care might change with the implementation of evidence-based guidelines. Methods: In this retrospective observational study, multidisciplinary evidence-based guidelines were implemented in 2014 (EAGER: Esi Appropriateness GuidElines pRotocol) as part of the ordering process for an ESI. Time series analysis was performed to assess the primary outcome of subspecialty referral pattern, that is, the number of patients receiving referrals to ancillary services which might serve to provide a more comprehensive approach to their back pain. Secondary outcomes included patient-level changes (ie, body mass index, number of injections, opioid use), which were compared before and after protocol implementation. Results: Comparing preimplementation and postimplementation protocol periods, referrals to physical medicine/rehabilitation increased 11.7% (p=0.003) per year and integrative health increased 2.1% (p<0.001) per year among the 2294 individual patients who received ESI through the neurointerventional radiology service. Of 100 randomly selected patients for patient-level analysis, the median body mass index decreased from 31.57 to 30.22 (p=<0.001) and the mean number of injections decreased from 1.76 to 0.73 (p<0.001). The percentage of patients using oral opioid analgesics decreased from 72% to 49% (p=<0.001). Conclusion: Implementation of evidence-based guidelines for ESI referral helps guide patients into a more comprehensive care pathway for chronic low back pain and is correlated with patient-level changes such as decreased body mass index and decreased opioid usage.

Retrospective cohort study of usage patterns of epidural injections for spinal pain in the US fee-for-service Medicare population from 2000 to 2014.

OBJECTIVE: To assess the usage patterns of epidural injections for chronic spinal pain in the fee-for-service (FFS) Medicare population from 2000 to 2014 in the USA. DESIGN: A retrospective cohort. METHODS: The descriptive analysis of the administrative database from Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) master data from 2000 to 2014 was performed. The guidance from Strengthening the Reporting of Observational studies in Epidemiology (STROBE) was applied. Analysis included multiple variables based on the procedures, specialties and geography. RESULTS: Overall epidural injections increased 99% per 100 000 Medicare beneficiaries with an annual increase of 5% from 2000 to 2014. Lumbar interlaminar and caudal epidural injections constituted 36.2% of all epidural injections, with an overall decrease of 2% and an annual decrease of 0.2% per 100 000 Medicare beneficiaries. However, lumbosacral transforaminal epidural injections increased 609% with an annual increase of 15% from 2000 to 2014 per 100 000 Medicare population. CONCLUSIONS: Usage of epidural injections increased from 2000 to 2014, with a decline thereafter. However, an escalating growth has been seen for lumbosacral transforaminal epidural injections despite numerous reports of complications and regulations to curb the usage of transforaminal epidural injections.

Adverse Event Rates Associated with Transforaminal and Interlaminar Epidural Steroid Injections: A Multi-Institutional Study.

BACKGROUND: Transforaminal epidural steroid injections (TFESI) have demonstrated efficacy and effectiveness in treatment of radicular pain. Despite little evidence of efficacy/effectiveness, interlaminar epidural steroid injections (ILESI) are advocated by some as primary therapy for radicular pain due to purported greater safety. OBJECTIVE: To assess immediate and delayed adverse event rates of TFESI and ILESI injections at three academic medical centers utilizing International Spine Intervention Society practice guidelines. METHODS: Quality assurance databases from a Radiology and two physical medicine and rehabilitation (PM&R) practices were interrogated. Medical records were reviewed, verifying immediate and delayed adverse events. RESULTS: There were no immediate major adverse events of neurologic injury or hemorrhage in 16,638 consecutive procedures in all spine segments (14,956 TFESI; 1,682 ILESI). Vasovagal reactions occurred in 1.2% of procedures, more frequently (P = 0.004) in TFESI (1.3%) than ILESI (0.5%). Dural punctures occurred in 0.06% of procedures, more commonly after ILESI (0.2% vs 0.04%, P = 0.006). Delayed follow up on PM&R patients (92.5% and 78.5, next business day) and radiology patients (63.1%, 2 weeks) identified no major adverse events of neurologic injury, hemorrhage, or infection. There were no significant differences in delayed minor adverse event rates. Central steroid response (sleeplessness, flushing, nonpositional headache) was seen in 2.6% of both TFESI and ILESI patients. 2.1% of TFESI and 1.8% of ILESI patients reported increased pain. No long-term sequelae were seen from any immediate or delayed minor adverse event. CONCLUSIONS: Both transforaminal and ILESI are safely performed with low immediate and delayed adverse event rates when informed by evidence-based procedural guidelines. By demonstrating comparable safety, this study suggests that the choice between ILESI and TFESIs can be based on documented efficacy and effectiveness and not driven by safety concerns.

Percutaneous adhesiolysis procedures in the medicare population: analysis of utilization and growth patterns from 2000 to 2011.

BACKGROUND: Multiple reviews have shown that interventional techniques for chronic pain have increased dramatically over the years. Of these interventional techniques, both sacroiliac joint injections and facet joint interventions showed explosive growth, followed by epidural procedures. Percutaneous adhesiolysis procedures have not been assessed for their utilization patterns separately from epidural injections. STUDY DESIGN: An analysis of the utilization patterns of percutaneous adhesiolysis procedures in managing chronic low back pain in the Medicare population from 2000 to 2011. OBJECTIVE: To assess the utilization and growth patterns of percutaneous adhesiolysis in managing chronic low back pain. METHODS: The study was performed utilizing the Centers for Medicare and Medicaid Services (CMS) Physician Supplier Procedure Summary Master of Fee-For-Service (FFS) Data from 2000 to 2011. RESULTS: Percutaneous adhesiolysis procedures increased 47% with an annual growth rate of 3.6% in the FFS Medicare population from 2000 to 2011. These growth rates are significantly lower than the growth rates for sacroiliac joint injections (331%), facet joint interventions (308%), and epidural injections (130%), but substantially lower than lumbar transforaminal injections (665%) and lumbar facet joint neurolysis (544%). LIMITATIONS: Study limitations include lack of inclusion of Medicare Advantage patients. In addition, the statewide data is based on claims which may include the contiguous or other states. CONCLUSION: Percutaneous adhesiolysis utilization increased moderately in Medicare beneficiaries from 2000 to 2011. Overall, there was an increase of 47% in the utilization of adhesiolysis procedures per 100,000 Medicare beneficiaries, with an annual geometric average increase of 3.6%.

Inyección intradiscal durante un procedimiento epidural transforaminal lumbar / Intradiscal injection during a lumbar transforaminal epidural

Se describe un caso de inyección intradiscal inesperada durante un procedimiento epidural transforaminal lumbar. Se observó en un paciente con lumbociatalgia por extrusión discal coordinado para inyección transforaminal a nivel de raíces L4 y L5 izquierdas. Con la aguja ubicada debajo del pedículo en el foramen L4-L5 izquierdo, al inyectar el medio de contraste se observó la habitual imagen perirradicular de L4 acompañada de llenado del disco L4-L5 y dolor lumbar transitorio. Al retirar mínimamente la aguja se visualizó únicamente la imagen perirradicular, procediéndose a la administración de corticoide peridural y de un antibiótico profiláctico intravenoso. La inyección a nivel de la raíz L5 se realizó sin complicaciones. Tuvo una evolución sin elementos de infección clínica o de laboratorio. Es una complicación de muy baja frecuencia pero con potencial riesgo de discitis. Se discuten los factores de riesgo de inyección intradiscal entre los que se señalan la ubicación de la aguja, la hernia ascendente, la hernia lateral y la estenosis foraminal. Se trata de una complicación que puede presentarse aún con la realización de una técnica apropiada. Se recomienda la administración de antibióticos profilácticos y un seguimiento para descartar la infección.

Epidural injections: past, present and future.

In the past, if someone had pain and a "defect" was noted on the myelogram or CT, surgery was immediately warranted. During this era, neural compression was considered to be the sole reason for all spinal pain. The surgical community firmly believed in the presence of a concrete-structural alteration to explain the pain and spinal arthrodesis was introduced. Over time, it became obvious that many patients did not improve after surgical interventions. Epidural injections were performed, formerly without fluoroscopic localization, and then with precise targeting.The spine care clinicians incorporated mediation of inflammation and neuromodulation as pathways to achieve pain control in order to pave the way for functional restoration. Epiduroscopy is presented as the most recent , complete and effective means for treating persistent low-back pain.

Analysis of the growth of epidural injections and costs in the Medicare population: a comparative evaluation of 1997, 2002, and 2006 data.

BACKGROUND: Interventional techniques for the treatment of spinal techniques are commonly used and are increasing exponentially. Epidural injections and facet joint interventions are the 2 most commonly utilized procedures in interventional pain management. The current literature regarding the effectiveness of epidural injections is sparse with highly variable outcomes based on the technique, outcome measures, patient selection, and methodology. Multiple reports have illustrated the exponential growth of lumbosacral injections with significant geographic variations in the administration of epidural injections in Medicare patients. However, an analysis of the growth of epidural injections and costs in the Medicare population has not been performed with recent data and has not been looked at from an interventional pain management perspective. STUDY DESIGN: Analysis of epidural injection growth and costs in Medicare's population 1997, 2002, and 2006. OBJECTIVES: The primary purpose of this study was to evaluate the use of all types of epidural injections (i.e. caudal, interlaminar, and transforaminal in lumbar, cervical and thoracic regions), and other epidural procedures, including epidural adhesiolysis. In addition, the purpose was to identify trends in the number of procedures, reimbursement, specialty involvement, fluoroscopy use, and indications from 1997 to 2006. METHODS: The Centers for Medicare and Medicaid Services (CMS) 5% national sample carrier claim record data from 1997, 2002, and 2006 was utilized. OUTCOMES ASSESSMENT: Outcome measures included Medicare beneficiaries' characteristics receiving epidural injections, epidural injections by place of service, type of specialty, reimbursement characteristics, and other variables. RESULTS: Epidural injections increased significantly in Medicare beneficiaries from 1997 to 2006. Patients receiving epidurals increased by 106.3%; visits per 100,000 population increased 102.7%. Hospital outpatient department (HOPD) payments increased significantly; ASC average payments decreased; overall payments increased. The increase in procedures performed by general physicians outpaced that of interventional pain management (IPM) physicians. LIMITATIONS: Study limitations include no Medicare Advantage patients; potential documentation, coding, and billing errors. CONCLUSIONS: Epidural injections grew significantly. This growth appears to coincide with chronic low back pain growth and other treatments for low back pain. Since many procedures are performed without fluoroscopy, continued growth and inappropriate provision of services might reduce access.

Past, present, and future of therapeutic lumbar spine interventional procedures.

This article discusses in detail lumbar epidural injections, in all their manifestations, and pain management procedures related to the lumbar zygapophyseal joints are discussed in detail as relates to their formulation, current use, and potential future endeavors.

Actualización en anestesia y analgesia epidural y subaracnoidea enadultos / Epidural and subarachnoid anesthesia and analgesia in adults: an update

Se presenta una puesta al día actualizada de los últimosavances en manejo clínico e imágenes de las técnicasneuroaxiales más utilizadas en la actualidad: anestesiay analgesia epidural, subaracnoidea y la combinadaespinal-epidural (AU)

We present an update of the latest advances in clinicalmanagement and images of the most commonly usedneuraxial techniques in epidural, subarachnoid, andcombined spinal-epidural anesthesia and analgesia (AU)

Influencia sobre altura metamérica de bloqueo alcanzado en dos posiciones durante el bloqueo caudal en niños / Influence in metameric height blockade in two positions during caudal block in children

Se realizó un trabajo de investigación clínica en población de edad pediátrica atendida en un Hospital de Ortopedia, la cual requirió de tratamiento quirúrgico en miembros inferiores y para el logro del mismo se administró anestesia regional del tipo de bloqueo caudal, el cual fue estudiado, en cuanto a dos posiciones: Sims modificada (decúbito lateral y una de las extremidades flexionadas) y la posición genupectoral. El resto del método las dosis y concentraciones fueron similares en ambos grupos. Los resultados mostraron que la posición de Sims es la que permitió mayor altura metamérica.