RESUMO
Recently, basivertebral nerve (BVN) radiofrequency ablation has been developed for the treatment of chronic low back pain (CLBP) thought to arise from the vertebral body endplates (VEPs). This review describes the relevant neuroanatomy and pathobiology of VEP degeneration and injury, imaging correlates of presumed VEP pain, randomized controlled trials performed, appropriate patient selection, and safety. Anatomic, histological, and clinical evidence supports the concept of the VEP as a source of CLBP and the nociceptive role of the BVN. BVN radiofrequency ablation appears to be an effective treatment for a subset of patients with CLBP and evidence of Modic change types 1 and 2 in the L3 to S1 VEPs who have failed to respond to conservative treatment. However, all studies performed to date have been industry sponsored, and future non-industry-funded trials will be needed to confirm these results.
Assuntos
Dor Crônica , Dor Lombar , Ablação por Radiofrequência , Humanos , Dor Lombar/cirurgia , Vértebras Lombares , Imageamento por Ressonância Magnética , Resultado do Tratamento , Corpo VertebralRESUMO
This Practice Advisory presents a comprehensive and evidence-based set of position statements and recommendations for the use of contrast media in interventional pain procedures. The advisory was established by an international panel of experts under the auspices of 11 multinational and multispecialty organizations based on a comprehensive review of the literature up to December 31, 2019. The advisory discusses the risks of using gadolinium-based contrast agents. These include nephrogenic systemic fibrosis, gadolinium brain deposition/retention, and encephalopathy and death after an unintentional intrathecal gadolinium injection. The advisory provides recommendations on the selection of a specific gadolinium-based contrast agent in patients with renal insufficiency, those who had multiple gadolinium-enhanced magnetic resonance imaging examinations, and in cases of paraspinal injections. Additionally, recommendations are made for patients who have a history of mild, moderate, or severe hypersensitivity reactions to contrast medium.
Assuntos
Encefalopatias/induzido quimicamente , Encéfalo/efeitos dos fármacos , Meios de Contraste/efeitos adversos , Hipersensibilidade a Drogas/etiologia , Dermopatia Fibrosante Nefrogênica/induzido quimicamente , Manejo da Dor/efeitos adversos , Encéfalo/metabolismo , Encefalopatias/diagnóstico , Encefalopatias/metabolismo , Consenso , Meios de Contraste/administração & dosagem , Meios de Contraste/metabolismo , Técnica Delphi , Hipersensibilidade a Drogas/diagnóstico , Humanos , Dermopatia Fibrosante Nefrogênica/diagnóstico , Prognóstico , Medição de Risco , Fatores de Risco , Distribuição TecidualRESUMO
OBJECTIVES: The S1 dorsal foramen is the route for 30% of lumbar transforaminal epidural injections; it is therefore important to identify structures impeding S1 foraminal access. The study objective was to characterize the imaging findings, prevalence, and anatomic origin of synovial cysts presenting within the S1 neural foramen. METHODS: A case series (N = 14) established imaging characteristics of S1 synovial cysts. Imaging studies of 400 patients undergoing epidural injections were reviewed for lesions compromising S1 foraminal access. Cadaveric dissections defined the relationship of the inferior recess of the L5-S1 facet to the S1 dorsal foramen. RESULTS: Elderly patients (mean age = 76) exhibited S1 synovial cysts. Synovial cysts were typically 1-2 cm in diameter, hyperintense on sagittal T2 weighted magnetic resonance images (MRIs), fluid-density on computed tomography, and dorsal to the S1 spinal nerve. Sixty percent of cysts exhibited complex MRI signal characteristics (thick wall, internal structure). Tarlov cysts, in contrast, were larger, lobular, and exhibited pure fluid intensity. Lesions impeded access to the S1 dorsal foramina in 5% of reviewed imaging studies (16 Tarlov cysts, three synovial cysts, one conjoint S1-S2 nerve root). The multifidus muscle was interposed between the L5-S1 facet inferior recess and the S1 dorsal foramen on dissection specimens; severe atrophy of the ipsilateral multifidus was noted on imaging in 17/18 synovial cysts. CONCLUSIONS: The S1 neural foramina should be inspected on sagittal MRI, when available, for confounding lesions before performing S1 epidural injections. Tarlov cysts are more common than synovial cysts; the latter are seen in elderly patients with severe multifidus atrophy.
Assuntos
Injeções Epidurais , Sacro/cirurgia , Cisto Sinovial/diagnóstico por imagem , Cisto Sinovial/epidemiologia , Corticosteroides/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Região Lombossacral , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Neuralgia/tratamento farmacológico , Prevalência , Radiculopatia/tratamento farmacológico , Estudos RetrospectivosRESUMO
OBJECTIVE: This study modeled image-guided epidural drug delivery to test whether intraprocedural distribution of pre-injected contrast reliably predicts the neuroanatomical reach of resiniferatoxin-mediated nociceptive neurolysis. METHODS: Swine (N = 12) received unilateral L4-S2 computed tomography fluoroscopy injections by a blinded neuroradiologist; 0.25 mL of contrast was pre-injected to confirm dorsal periganglionic targeting, followed by a 0.5-mL injection of 5 µg of resiniferatoxin/Tween80 or vehicle control. Epidural contrast distribution was graded according to maximum medial excursion. Spinal cord substance P immunostaining quantified the magnitude and anatomical range of resiniferatoxin activity. RESULTS: Periganglionic injection was well tolerated by all animals without development of neurological deficits or other complications. Swine were a suitable model of human clinical spinal intervention. The transforaminal approach was used at all L4 and 50% of L5 segments; the remaining segments were approached by the interlaminar route. All injections were successful with unilateral contrast distribution for all resiniferatoxin injections (N = 28). Immunohistochemistry showed bilateral ablation of substance P+ fibers entering the spinal cord of all resiniferatoxin-treated segments. The intensity of substance P immunostaining in treated segments fell below the lower 99% confidence interval of controls, defining the knockout phenotype. Substance P knockout occurred over a narrow range and was uncorrelated to the anatomical distribution of pre-injected contrast. CONCLUSIONS: Periganglionic resiniferatoxin/Tween80 induced bilateral ablation of spinal cord substance P despite exclusively unilateral targeting. These data suggest that the location of pre-injected contrast is an imperfect surrogate for the neuroanatomical range of drugs delivered to the dorsal epidural compartment that may fail to predict contralateral drug effects.
Assuntos
Diterpenos/administração & dosagem , Bloqueio Nervoso/métodos , Neurotoxinas/administração & dosagem , Animais , Feminino , Fluoroscopia/métodos , Injeções Epidurais , Raízes Nervosas Espinhais/efeitos dos fármacos , Suínos , Terapia Assistida por Computador/métodosRESUMO
INTRODUCTION: Intrathecal interleukin (IL)-10 delivered by plasmid or viral gene vectors has been proposed for clinical testing because it is effective for chronic pain in rodents, is a potential therapeutic for various human diseases, and was found to be nontoxic in dogs, when the human IL-10 ortholog was tested. However, recent studies in swine testing porcine IL-10 demonstrated fatal neurotoxicity. The present study aimed to deliver vector-encoded human IL-10 in swine, measure expression of the transgene in cerebrospinal fluid and monitor animals for signs of neurotoxicity. RESULTS: Human IL-10 levels peaked 2 weeks after vector administration followed by a rapid decline that occurred concomitant with the emergence of anti-human IL-10 antibodies in the cerebrospinal fluid and serum. Animals remained neurologically healthy throughout the study period. CONCLUSIONS: The findings of the present study suggest that swine are not idiosyncratically sensitive to intrathecal IL-10 because, recapitulating previous reports in dogs, they suffered no clinical neurotoxicity from the human ortholog. These results strongly infer that toxicity of intrathecal IL-10 in large animal models was previously overlooked because of a species mismatch between transgene and host. The present study further suggests that swine were protected from interleukin-10 by a humoral immune response against the xenogeneic cytokine. Future safety studies of IL-10 or related therapeutics may require syngeneic large animal models.
Assuntos
Dependovirus/genética , Técnicas de Transferência de Genes , Vetores Genéticos/genética , Interleucina-10/genética , Transgenes , Animais , Anticorpos Antivirais/imunologia , Capsídeo/imunologia , Capsídeo/metabolismo , Dependovirus/imunologia , Expressão Gênica , Vetores Genéticos/administração & dosagem , Vetores Genéticos/efeitos adversos , Humanos , Injeções Espinhais , Interleucina-10/imunologia , Masculino , Modelos Animais , Suínos , Distribuição Tecidual , Transdução GenéticaRESUMO
Objective: The aim of this paper is to review the available literature investigating the effect of epidural steroid injections (ESIs) on bone mineral density (BMD) and vertebral fracture risk. Study design: Systematic review of current literature. Methods: The sources of the data were PubMed, Embase, Cochrane, and Scopus. Papers included in the review were original research articles in peer-reviewed journals. Results: A total of 7,233 patients (eight studies) with a mean age ranging between 49 and 74 years and an average follow-up between six and 60 months were studied. Steroids that were used included triamcinolone, dexamethasone, and methylprednisolone (MP), with a mean number of injections ranging from one to 14.7 and an average cumulative dose in MP equivalents between 80 and 8,130 mg. Epidural steroids were associated with significantly decreased BMD in four out of six included studies, and with increased risk of vertebral fracture in one out of two included studies. Significant reductions in BMD were associated with a cumulative MP dose of 200 mg over a one-year period and 400 mg over three years, but not in doses of less than 200 mg of MP equivalents for postmenopausal women and at least 3 g for healthy men. The risk of osteopenia and osteoporosis was lower in patients who were receiving anti-osteoporotic medication during the treatment course. Conclusions: ESIs should be recommended with caution, especially in patients at risk for osteoporotic fractures, such as women of postmenopausal age. Anti-osteoporotic medication might be considered prior to ESI.
Assuntos
Anti-Inflamatórios/efeitos adversos , Densidade Óssea/efeitos dos fármacos , Dexametasona/administração & dosagem , Metilprednisolona/administração & dosagem , Fraturas da Coluna Vertebral/induzido quimicamente , Triancinolona/efeitos adversos , Anti-Inflamatórios/administração & dosagem , Dexametasona/efeitos adversos , Feminino , Humanos , Injeções Epidurais , Masculino , Metilprednisolona/efeitos adversos , Fraturas da Coluna Vertebral/epidemiologia , Triancinolona/administração & dosagemRESUMO
Interleukin-10 (IL-10) delivered by intrathecal (i.t.) gene vectors is a candidate investigational new drug (IND) for several chronic neurological disorders such as neuropathic pain. We performed a preclinical safety study of IL-10. A syngeneic large animal model was used delivering porcine IL-10 (pIL-10) to the i.t. space in swine by adeno-associated virus serotype 8 (AAV8), a gene vector that was previously found to be nontoxic in the i.t. space. Unexpectedly, animals became ill, developing ataxia, seizures, and an inability to feed and drink, and required euthanasia. Necropsy demonstrated lymphocytic meningitis without evidence of infection in the presence of normal laboratory findings for body fluids and normal histopathology of peripheral organs. Results were replicated in a second animal cohort by a team of independent experimenters. An extensive infectious disease and neuropathology workup consisting of comprehensive testing of tissues and body fluids in a specialized research veterinary pathology environment did not identify a pathogen. These observations raise the concern that i.t. IL-10 therapy may not be benign, that previously used xenogeneic models testing the human homolog of IL-10 may not have been sensitive enough to detect toxicity, and that additional preclinical studies may be needed before clinical testing of IL-10 can be considered.
Assuntos
Ataxia/imunologia , Dependovirus/imunologia , Vetores Genéticos/administração & dosagem , Meningite Asséptica/imunologia , Convulsões/imunologia , Animais , Ataxia/induzido quimicamente , Ataxia/mortalidade , Ataxia/patologia , Dependovirus/genética , Avaliação Pré-Clínica de Medicamentos , Drogas em Investigação , Feminino , Terapia Genética/métodos , Vetores Genéticos/química , Vetores Genéticos/imunologia , Injeções Espinhais , Interleucina-10/genética , Interleucina-10/imunologia , Masculino , Meningite Asséptica/induzido quimicamente , Meningite Asséptica/mortalidade , Meningite Asséptica/patologia , Convulsões/induzido quimicamente , Convulsões/mortalidade , Convulsões/patologia , Análise de Sobrevida , SuínosRESUMO
Objective: To assess the relative radiographic conspicuity of gadolinium-based contrast agents (GBCAs) that may be used in spinal injection procedures when iodine-based contrast agents are contraindicated. Methods: Eight GBCAs and three iodinated agents of varying iodine concentrations were radiographed under conditions representative of lumbar spinal injections at four kilovoltage peak (kVp) values. Radiographic contrast of each agent was measured as the percent pixel value difference with respect to background. Results: Gadobutrol (Gadovist, 1 mM/mL) had the highest radiographic contrast among the gadolinium agents tested. Measured radiographic contrast correlated with the molar concentration of gadolinium. Gadobutrol radiographic contrast lies between the contrast of iohexol concentrations of 240 and 140 mgI/mL. All agents have decreasing contrast as kVp increases, but GBCAs decrease less than iodine-based agents. Conclusions: Gadobutrol is the GBCA with the greatest conspicuity for use in spinal injection procedures. It also has the highest molar concentration of gadolinium, and potential neural toxicity from intrathecal delivery must be considered.
Assuntos
Gadolínio/administração & dosagem , Aumento da Imagem/métodos , Injeções Espinhais/métodos , Iodo/administração & dosagem , Imagem por Ressonância Magnética Intervencionista/métodos , Medula Espinal/diagnóstico por imagem , Meios de Contraste/administração & dosagem , Meios de Contraste/química , Gadolínio/química , Gadolínio/farmacologia , Humanos , Iodo/farmacologia , Imagem por Ressonância Magnética Intervencionista/instrumentação , Manejo da Dor , Imagens de Fantasmas , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Medula Espinal/efeitos dos fármacos , Resultado do TratamentoRESUMO
Transforaminal epidural steroid injections (TFESIs) are associated with rare but devastating neurologic complications. Every published case has been associated with a particulate steroid suspension, and the presumed but not proven mechanism is embolization and occlusion of end arterioles. Through an in vivo murine model and in vitro experiments on human red blood cells (RBCs), the study by Laemmel et al (1) in this issue of Radiology elucidates the potential mechanisms for steroid-induced vascular compromise. Unlike dexamethasone (a nonparticulate steroid solution), saline, and the particulate steroid cortivazol, other particulate steroids (prednisolone, methylprednisolone, and triamcinolone) caused often immediate and complete cessation of capillary blood flow, with RBC (not steroid particle) aggregates and alteration of RBC morphologic structure into spiculated RBCs. Thus, the study strengthens evidence in support of the higher safety profile in TFESI for dexamethasone, the nonparticulate and U.S. Food and Drug Administration-recommended steroid of choice, compared with particulate steroids. The results should not be considered proof that cortivazol has not or could not cause neurologic infarction during a TFESI. Rather, experiments such as those by Laemmel et al should foster more research, particularly in the arena of novel therapeutic agents (nonparticulate steroids and nonsteroidal drugs alike).
Assuntos
Injeções Epidurais , Radiculopatia , Animais , Dexametasona/uso terapêutico , Humanos , Infarto , Triancinolona/uso terapêutico , Estados UnidosRESUMO
Beyond the familiar disk herniations with typical clinical features, intervertebral disk pathologic conditions can have a wide spectrum of imaging and clinical manifestations. The goal of this review is to illustrate and discuss unusual manifestations of intervertebral disk pathologic conditions that radiologists may encounter, including disk herniations in unusual locations, those with atypical imaging features, and those with uncommon pathophysiologic findings. Examples of atypical disk herniations presented include dorsal epidural, intradural, symptomatic thoracic (including giant calcified), extreme lateral (retroperitoneal), fluorine 18 fluorodeoxyglucose-avid, acute intravertebral (Schmorl node), and massive lumbar disk herniations. Examples of atypical pathophysiologic conditions covered are discal cysts, fibrocartilaginous emboli to the spinal cord, tiny calcified disks or disk-level spiculated osteophytes causing spinal cerebrospinal fluid (CSF) leak and intracranial hypotension, and pediatric acute calcific discitis. This broad gamut of disease includes a variety of sizes of disk pathologic conditions, from the tiny (eg, the minuscule calcified disks causing high-flow CSF leaks) to the extremely large (eg, giant calcified thoracic intradural disk herniations causing myelopathy). A spectrum of clinical acuity is represented, from hyperacute fibrocartilaginous emboli causing spinal cord infarct, to acute Schmorl nodes, to chronic intradural herniations. The entities included are characterized by a range of clinical courses, from the typically devastating cord infarct caused by fibrocartilaginous emboli, to the usually spontaneously resolving pediatric acute calcific discitis. Several conditions have important differential diagnostic considerations, and others have relatively diagnostic imaging findings. The pathophysiologic findings are well understood for some of these entities and poorly defined for others. Radiologists' knowledge of this broad scope of unusual disk disease is critical for accurate radiologic diagnoses. Online supplemental material is available for this article. (©)RSNA, 2016.
Assuntos
Diagnóstico por Imagem , Degeneração do Disco Intervertebral/diagnóstico por imagem , Degeneração do Disco Intervertebral/fisiopatologia , Deslocamento do Disco Intervertebral/diagnóstico por imagem , Deslocamento do Disco Intervertebral/fisiopatologia , HumanosRESUMO
SETTING: Interventional procedures directed toward sources of pain in the axial and appendicular musculoskeletal system are performed with increasing frequency. Despite the presence of evidence-based guidelines for such procedures, there are wide variations in practice. Case reports of serious complications such as spinal cord infarction or infection from spine injections lack appropriate context and create a misleading view of the risks of appropriately performed interventional pain procedures. OBJECTIVE: To evaluate adverse event rate for interventional spine procedures performed at three academic interventional spine practices. METHODS: Quality assurance databases at three academic interventional pain management practices that utilize evidence-based guidelines [1] were interrogated for immediate complications from interventional pain procedures. Review of the electronic medical record verified or refuted the occurrence of a complication. Same-day emergency department transfers or visits were also identified by a records search. RESULTS: Immediate complication data were available for 26,061 consecutive procedures. A radiology practice performed 19,170 epidural steroid (primarily transforaminal), facet, sacroiliac, and trigger point injections (2006-2013). A physiatry practice performed 6,190 spine interventions (2004-2009). A second physiatry practice performed 701 spine procedures (2009-2010). There were no major complications (permanent neurologic deficit or clinically significant bleeding [e.g., epidural hematoma]) with any procedure. Overall complication rate was 1.9% (493/26,061). Vasovagal reactions were the most frequent event (1.1%). Nineteen patients (<0.1%) were transferred to emergency departments for: allergic reactions, chest pain, symptomatic hypertension, and a vasovagal reaction. CONCLUSION: This study demonstrates that interventional pain procedures are safely performed with extremely low immediate adverse event rates when evidence-based guidelines are observed.
Assuntos
Dor nas Costas/terapia , Ablação por Cateter/efeitos adversos , Injeções Epidurais/efeitos adversos , Bloqueio Nervoso/efeitos adversos , Manejo da Dor/efeitos adversos , Corticosteroides/administração & dosagem , Adulto , Idoso , Axotomia/efeitos adversos , Axotomia/métodos , Feminino , Humanos , Injeções Intra-Articulares , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Estudos RetrospectivosRESUMO
OBJECTIVE: To examine associations between imaging characteristics of compressive lesions and patient outcomes after lumbar transforaminal epidural steroid injections (TFESIs) stratified by steroid formulation (solution versus suspension). DESIGN/SUBJECTS: Retrospective observational study, academic radiology practice. A 516-patient sample was selected from 2,634 consecutive patients receiving lumbar TFESI for radicular pain. METHODS: The advanced imaging study(s) preceding sampled TFESI were reviewed. Compressive lesions were described by a) nature of the lesion [disc herniation, fixed stenosis, synovial cyst, epidural fibrosis, no lesion] b) degree of neural compression [4 part scale], and c) presence of a tandem lesion. Associations between 2-month categorical outcomes (responder rates for pain, functional recovery) and imaging characteristics, stratified by steroid formulation, were examined with chi-squared tests of categorical outcomes and multivariable logistic regression models. RESULTS: Disc herniation patients had more responders for functional recovery than patients with fixed lesions (54% versus 38%, P = 0.01). Patients with fixed lesions receiving steroid solution (dexamethasone) had more responders for pain relief, with a similar trend for functional recovery, than patients receiving suspensions (59% versus 40%, P = 0.01). Outcomes for patients with fixed lesions treated with dexamethasone were not statistically different from those for disc herniation patients. Patients with single compressive lesions had more responders than those with tandem lesions (55% versus 41%, P = 0.03). CONCLUSION: In the entire sample, outcomes for disc herniations were more favorable than for fixed lesions. However, fixed lesions treated with dexamethasone had outcomes indistinguishable from disc herniations. Single lesions had better outcomes than tandem lesions.
Assuntos
Glucocorticoides/administração & dosagem , Radiculopatia/diagnóstico por imagem , Radiculopatia/tratamento farmacológico , Radiculopatia/etiologia , Adulto , Idoso , Betametasona/administração & dosagem , Dexametasona/administração & dosagem , Diagnóstico por Imagem/métodos , Feminino , Fibrose/complicações , Humanos , Injeções Epidurais , Deslocamento do Disco Intervertebral/complicações , Região Lombossacral , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica/efeitos dos fármacos , Estudos Retrospectivos , Estenose Espinal/complicações , Cisto Sinovial/complicações , Triancinolona/administração & dosagemRESUMO
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.
Assuntos
Anestesia Epidural/efeitos adversos , Anestesia Epidural/tendências , Esteroides/administração & dosagem , Esteroides/efeitos adversos , Adulto , Idoso , Estudos de Coortes , Feminino , Hematoma Epidural Espinal/induzido quimicamente , Humanos , Injeções Epidurais/efeitos adversos , Injeções Epidurais/tendências , Masculino , Pessoa de Meia-Idade , Debilidade Muscular/induzido quimicamenteAssuntos
Vértebras Lombares/cirurgia , Região Lombossacral/cirurgia , Radiculopatia/cirurgia , Esteroides/uso terapêutico , Feminino , Humanos , Injeções Epidurais/métodos , Vértebras Lombares/efeitos dos fármacos , Masculino , Pessoa de Meia-Idade , Radiculopatia/tratamento farmacológico , Esteroides/administração & dosagemRESUMO
OBJECTIVE: The aim of this study was to determine 1) if repeat lumbar transforaminal epidural steroid injections (TFESIs) resulted in recovery of pain relief, which has waned since an index injection, and 2) if cumulative benefit could be achieved by repeat injections within 3 months of the index injection. DESIGN: Retrospective observational study with statistical modeling of the response to repeat TFESI. SETTING: Academic radiology practice. PATIENTS: Two thousand eighty-seven single-level TFESIs were performed for radicular pain on 933 subjects. Subjects received repeat TFESIs >2 weeks and <1 year from the index injection. METHODS: Hierarchical linear modeling was performed to evaluate changes in continuous and categorical pain relief outcomes after repeat TFESI. Subgroup analyses were performed on patients with <3 months duration of pain (acute pain), patients receiving repeat injections within 3 months (clustered injections), and in patients with both acute pain and clustered injections. RESULTS: Repeat TFESIs achieved pain relief in both continuous and categorical outcomes. Relative to the index injection, there was a minimal but statistically significant decrease in pain relief in modeled continuous outcome measures with subsequent injections. Acute pain patients recovered all prior benefit with a statistically significant cumulative benefit. Patients receiving clustered injections achieved statistically significant cumulative benefit, of greater magnitude in acute pain patients. CONCLUSION: Repeat TFESI may be performed for recurrence of radicular pain with the expectation of recovery of most or all previously achieved benefit; acute pain patients will likely recover all prior benefit. Repeat TFESIs within 3 months of the index injection can provide cumulative benefit.
Assuntos
Corticosteroides/administração & dosagem , Injeções Epidurais/métodos , Neuralgia/tratamento farmacológico , Adulto , Idoso , Feminino , Humanos , Vértebras Lombares , Masculino , Pessoa de Meia-Idade , Radiculopatia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: To assess whether computed tomography (CT)-guided injections of local anesthetic and corticosteroid into chronic lumbar pars interarticularis defects may identify and provide benefit to a cohort of patients where the pars defects act as a primary axial pain generator. DESIGN: Retrospective practice audit. SETTING: Single academic radiology pain management practice. PATIENTS: 59 consecutive patients undergoing CT-guided injections of lumbar pars defects. METHODS: Patients were assessed with a pain numerical rating scale (NRS, 0-10) and Roland-Morris disability questionnaire (R-M) prior to injection and at 2 weeks and 2 months follow-up. For categorical outcomes, successful pain relief response was defined as either ≥50% reduction in NRS or pain 0/10; functional response was defined as ≥40% reduction in R-M score. Continuous outcomes (mean NRS, R-M scores) were assessed for significant change following injection. RESULTS: For categorical outcomes, 37.9% of patients were responders at 2 months' follow-up; 20.7 % had complete relief of index pain. For functional recovery, 34.5% were responders at 2 months. Using continuous outcomes, mean NRS was 5.4 ± 2.1 prior to injection and 3.6 ± 2.6 at 2 months (P < 0.0001). Mean R-M score was 11.7 ± 6.0 prior to injection and 9.0 ± 5.4 at 2 months (P = 0.001). There were no complications. CONCLUSIONS: This practice audit suggests that in patients with axial low back pain and chronic pars defects, the pars defects may be implicated as the primary axial pain generator in a small subgroup of patients. Local deposition of corticosteroids into the pars defect may provide significant pain relief in one out of three patients, and complete relief in one out of five patients. This data suggest there may be benefit to pursuing randomized controlled trials of pars injections comparing steroid injection with placebo.
Assuntos
Corticosteroides/administração & dosagem , Anestésicos Locais/administração & dosagem , Dor Lombar/diagnóstico por imagem , Dor Lombar/tratamento farmacológico , Vértebras Lombares/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Adulto , Dor Crônica/diagnóstico por imagem , Dor Crônica/tratamento farmacológico , Feminino , Seguimentos , Humanos , Injeções Intralesionais/métodos , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Projetos Piloto , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
Recent studies have described the safety and efficacy of computed tomography (CT)-guided cervical transforaminal epidural steroid injections with both the anterolateral and posterior approach. Although fluoroscopy is the most common form of image guidance for these procedures, CT guidance offers many advantages. However, some key features of CT guidance in these procedures need to be considered to ensure safe and technically successful outcomes.
Assuntos
Corticosteroides/administração & dosagem , Vértebras Cervicais/diagnóstico por imagem , Injeções Epidurais/métodos , Cervicalgia/terapia , Intensificação de Imagem Radiográfica/métodos , Radiografia Intervencionista/métodos , Tomografia Computadorizada por Raios X/métodos , Humanos , Cervicalgia/diagnóstico por imagemRESUMO
Background: Recent studies have questioned the validity of targeting the thoracic medial branch via anesthetic blocks or radiofrequency neurotomy for the diagnosis or treatment of pain from the thoracic zygapophysial joints. Purpose: To define the origin and course of the articular branches to the thoracic zygapophysial joints at all levels. Design: Cadaveric dissection. Setting: The Gross Anatomy Laboratory at the University of New England College of Osteopathic Medicine. Subjects: One cadaveric thoracic spine. Methods: Gross and stereoscopic dissection of the bilateral dorsal rami T1-T12 was performed on one embalmed cadaver. The medial and lateral branches were traced from their cutaneous distribution to the origin at the dorsal ramus. The articular branches were identified using stereoscopic dissection by tracing their origin from the dorsal ramus or medial branch to the capsule of the zygapophysial joint. The images were recorded using digital photography. Results: Twenty-two of the twenty-four articular branches were identified in a single cadaveric specimen. Articular branches at T7 on the right side and T9 on the left side were not identified. 5 of the 22 (18%) articular branches were observed to arise from the proximal segment of the medial branch of the dorsal ramus. Of the remainder, 17 of the 22 (78%) articular branches were observed to arise from the dorsal primary ramus itself. At levels T1-9, the articular branch coursed inferiorly along the lamina to reach the joint capsule. At levels T10-T12, the articular branch traversed the intervertebral foramen to reach the facet joint. The T12 medial branch on the left was seen to travel inferior to innervate the L1/L2 zygapophysial joint. Conclusion: The source of the innervation for the thoracic zygapophysial is variable and can arise from the dorsal ramus itself or from the proximal segment of the medial branch. Unlike the cervical and lumbar medial branches, which innervate two joints each, in this case, the thoracic dorsal rami appear to innervate only the zygapophysial joint at the level of the nerve exit. It should be noted that the findings may be limited in their generalizability due to the reliance on a single cadaver study.
RESUMO
Background: True lateral imaging (TLI), obtained by superimposing bilateral lumbar spine structures and aligning superior endplate cortical bone, requires deliberate rotational adjustments of the laterally positioned fluoroscope in both the axial and longitudinal planes. True lateral segmental imaging is necessary to depict true and accurate radiofrequency (RF) cannula positioning relative to bony anatomy during lumbar medial branch radiofrequency neurotomy (LMBRFN). Objective: To determine the interobserver reliability of TLI during LMBRFN. Methods: This was a retrospective review of a prospectively generated collection of lateral fluoroscopic images to determine the interobserver reliability of TLI during LMBRFN. Lateral fluoroscopic images were prospectively collected from 34 consecutive L4-5 and L5-S1 LMBRFN procedures during routine clinical practice. Employing International Pain and Spine Intervention Society (IPSIS) LMBRFN and TLI techniques, an RF cannula was positioned parallel to the L3 and L4 medial branches and the L5 dorsal rami. During the normal course of TLI, untrue and final true lateral segmental images were obtained and saved. An original data set of 100 pairs of true and untrue lateral images was reviewed to verify true laterality using established criteria; disagreement was resolved by consensus or discarding ambiguous cases. To measure interobserver reliability (Cohen's Kappa), two blinded expert reviewers independently reviewed the image set, identifying the true lateral image and the plane requiring correction. Results: The observers agreed upon 98/98 true lateral RF-segment images (Kappa score 1.0 [1.00,1.00]). The observers agreed upon 86/98 maneuvers to correct the untrue RF-segment image. The Kappa score for determining the most appropriate corrective maneuver was 0.76 (0.63,0.89), showing substantial interobserver agreement. Conclusions: The true lateral image of the targeted RF segment during LMBRFN was reliably determined with perfect interobserver agreement. Interobserver agreement was substantial regarding the maneuver to achieve TLI.