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Manchikanti L, Pasupuleti R, Pampati V, Sanapati MR, Hirsch JA. Assessment of Radiation Exposure with Mandatory Two Fluoroscopic Views for Epidural Procedures. Pain Physician 2023; 26:557-567. [PMID: 37976484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Various regulations and practice patterns develop on the basis of Local Coverage Determination (LCD), which are variably perceived as guidelines and/or mandated polices/ regulations. LCDs developed in 2021 and effective since December 2021 mandated a minimum of 2 views for final needle placement with contrast injection which includes both anteroposterior (AP) and lateral or oblique view. Radiation safety has been a major concern for pain physicians and multiple tools have been developed to reduce radiation dose, along with improvement in technologies to limit radiation exposure while performing fluoroscopically guided interventional procedures, with implementation of principles of As Low As Reasonably Achievable (ALARA). The mandated 2 views of epidural injections have caused concern among some physicians, because of the potential of increased exposure to ionizing radiation, despite application of various principles to minimize radiation exposure. Others, including policymakers are of the opinion that it reduces potential abuse and improves safety. OBJECTIVE To assess variations in the performance of epidural procedures prior to the implementation of the new LCD compared with after the implementation of the new LCD by comparing time and dosage for all types of epidural procedures. STUDY DESIGN A retrospective, case controlled, comparative evaluation of radiation exposure during epidural procedures in interventional pain management. SETTING An interventional pain management practice and a specialty referral center in a private practice setting in the United States. METHODS The study was performed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria. The main outcome measure was radiation exposure time measured in seconds and dose measured in mGy-kG2 (milligray to kilogray squared per procedure). RESULTS Changes in exposure and dose varied by procedural type and location. Exposure time in seconds increased overall by 21%, whereas radiation dose mGy-kG increased 133%. Fluoroscopy time increased most for lumbar interlaminar epidural injections of 43%, followed by 29% for cervical interlaminar epidural injections, 20% for caudal epidural injections, and 14% for lumbar transforaminal epidural injections. In contrast, highest increases were observed in the radiation dose mGy of 191% for caudal epidural injections, followed by 173% for lumbar interlaminar epidural injections, 113% for lumbar transforaminal epidural injections, and the lowest being cervical interlaminar epidural injections of 94%. This study also shows lesser increases for cervical interlaminar epidural injections because an oblique view is utilized rather than a lateral view resulting in a radiation dosage increase of 94% compared to overall increase of 133%, whereas the duration of time of 29% was higher than the overall combined duration of all procedures which only increased by 21%. LIMITATIONS A retrospective evaluation utilizing the experience of a single physician. CONCLUSION The results of this study showed significant increases in radiation exposure time and dosage; however, increase of dosage was overall 21% median Interquartile Range (IQR) compared to 133% of radiation dose median IQR. In addition, the results also showed variations for procedure, overall showing highest increases for lumbar interlaminar epidural injections for time (43%) and caudal epidural injections for dosage (191%).
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Jedi F, Krysiak R, Hirsch JA, Ventura F, De Vivo E, Manfrè L. Chronic sacroiliac joint dysfunction and CT-guided percutaneous fixation: a 6-year experience. Neuroradiology 2023; 65:1527-1534. [PMID: 37289228 DOI: 10.1007/s00234-023-03171-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 05/21/2023] [Indexed: 06/09/2023]
Abstract
PURPOSE Reporting the clinical outcomes, patient satisfaction, and complications following an imaging-guided percutaneous screw fixation in the treatment of sacroiliac joint dysfunction and evaluating the safety and effectiveness of this method. METHODS We performed a retrospective study on a prospectively gathered cohort of patients with physiotherapy-resistant pain due to sacroiliac joint incompetence that underwent percutaneous screw fixation, between 2016 and 2022 in our center. A minimum of two screws were used in all patients to obtain fixation of the sacroiliac joint, using percutaneous screw insertion under CT guidance, coupled with a C-arm fluoroscopy unit. RESULTS The mean visual analog scale significantly improved at 6 months of follow-up (p < 0.05). One hundred percent of the patients reported significant improvement in pain scores at the final follow-up. None of our patients experienced intraoperative or postoperative complications. CONCLUSION The use of percutaneous sacroiliac screws provides a safe and effective technique for the treatment of sacroiliac joint dysfunction in patients with chronic resistant pain.
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D'Anna G, Shah L, Kranz PG, Hirsch JA, Khan M, Johnson M, Feydy A, Nathan J, Manfre L, Nguyen DT, Sze G, Goethem JV, Vanhoenacker FM. Results of an International Survey on Spinal Imaging by the ASNR/ASSR/ESNR/ESSR "Nomenclature 3.0" Working Group. Semin Musculoskelet Radiol 2023; 27:561-565. [PMID: 37816364 DOI: 10.1055/s-0043-1768247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
Our goal was to determine if "Nomenclature 2.0," the classification of lumbar disk pathology consensus, should be updated. We conducted a social media and e-mail-based survey on preferences regarding the use of classification on magnetic resonance spine reporting. Members of the European Society of Neuroradiology, European Society of Musculoskeletal Radiology, American Society of Neuroradiology, and American Society of Spine Radiology received a 15-question online survey between February and March 2022. A total of 600 responses were received from 63 countries. The largest number of responses came from Italy and the United States. We found that 71.28% of respondents used Nomenclature 2.0, Classification of Lumbar Disk Pathology. But classification on stenosis is used less often: 53.94% and 60% of respondents do not use any classification of spinal canal stenosis and foraminal stenosis, respectively. When queried about which part of Nomenclature needs improving, most respondents asked for a Structured Reporting Template (SRT), even though 58.85% of respondents do not currently use any template and 54% routinely use a clinical information questionnaire. These results highlight the importance of an updated Nomenclature 3.0 version that integrates the classifications of lumbar disk disease and spinal canal and foraminal stenosis. Further attention should also be directed toward developing a robust endorsed SRT.
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Christensen EW, Nicola GN, Rula EY, Nicola LP, Hemingway J, Hirsch JA. Budget Neutrality and Medicare Physician Fee Schedule Reimbursement Trends for Radiologists, 2005 to 2021. J Am Coll Radiol 2023; 20:947-953. [PMID: 37656075 DOI: 10.1016/j.jacr.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/16/2023] [Accepted: 07/08/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE The Medicare program, by law, must remain budget neutral. Increases in volume or relative value units (RVUs) for individual services necessitate declines in either the conversion factor or assigned RVUs for other services for budget neutrality. This study aimed to assess the contribution of budget neutrality on reimbursement trends per Medicare fee-for-service beneficiary for services provided by radiologists. METHODS The study used aggregated 100% of Medicare Part B claims from 2005 to 2021. We computed the percentage change in reimbursement per beneficiary, actual and inflation adjusted, to radiologists. These trends were then adjusted by separately holding constant RVUs per beneficiary and the conversion factor to demonstrate the impact of budget neutrality. RESULTS Unadjusted reimbursement to radiologists per beneficiary increased 4.2% between 2005 and 2021, but when adjusted for inflation, it declined 24.9%. Over this period, the conversion factor declined 7.9%. Without this decline, the reimbursement per beneficiary would have been 9 percentage points higher in 2021 compared with actual. RVUs per beneficiary performed by radiologists increased 13.1%. Keeping RVUs per beneficiary at 2005 levels, reimbursement per beneficiary would have been 12.1 percentage points lower than observed in 2021. CONCLUSIONS Given budget neutrality, a substantial decline has occurred in inflation-adjusted reimbursement to radiologists per Medicare beneficiary. Decreases due to both inflation and the decline in conversion factor are only partially offset by increased RVUs per beneficiary, meaning more services per patient with less overall pay, an equation likely to heighten access challenges for Medicare beneficiaries and shortages of radiologists.
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Manchikanti L, Knezevic E, Knezevic NN, Pasupuleti R, Sanapati MR, Janapala RN, Kaye AD, Hirsch JA. Medial Branch Blocks and the Effectiveness of Radiofrequency Neurotomy in Managing Chronic Thoracic Pain: A Systematic Review and Meta-Analysis. Pain Physician 2023; 26:413-435. [PMID: 37774177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
BACKGROUND Extensive research into potential sources of thoracic pain with or without referred pain into the chest wall has demonstrated that thoracic facet joints can be a potential source of pain confirmed by precise, diagnostic blocks.The objective of this systematic review and meta-analysis is to evaluate the effectiveness of medial branch blocks and radiofrequency neurotomy as a therapeutic thoracic facet joint intervention. METHODS Systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies of medial branch blocks and the radiofrequency neurotomy in managing thoracic pain utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was performed. A comprehensive literature search of multiple databases of RCTs and observational studies of medial branch blocks and radiofrequency neurotomy in managing chronic thoracic pain were identified from 1996 to December 2022 with inclusion of manual searches of the bibliography of known review articles and multiple databases. Methodologic quality and risk of bias assessment was also conducted. Evidence was synthesized utilizing principles of quality assessment and best evidence synthesis, with conventional and single meta-analysis. The primary outcome measure of success was 3 months of pain reduction for medial branch blocks and 6 months for radiofrequency thermoneurolysis for a single treatment. Short-term success was defined as up to 6 months and long-term was more than 6 months. RESULTS This literature search yielded 11 studies meeting the inclusion criteria, of which 3 were RCTs and 8 were observational studies. Of the 3 RCTs, 2 of them assessed medial branch blocks and one trial assessed radiofrequency for thoracic pain. The evidence for managing thoracic pain with qualitative analysis and single-arm meta-analysis and GRADE system of appraisal, with the inclusion of 2 RCTs and 3 observational studies for medial branch blocks was Level II. For radiofrequency neurotomy, with the inclusion of one RCT of 20 patients in the treatment group and 5 observational studies, the evidence was Level III in managing thoracic pain. LIMITATIONS There was a paucity of literature with RCTs and real-world pragmatic controlled trials. Even observational studies had small sample sizes providing inadequate clinically applicable results. In addition, there was heterogeneity of the available studies in terms of their inclusion and exclusion criteria, defining their endpoints and the effectiveness of the procedures. CONCLUSION This systematic review and meta-analysis show Level II evidence of medial branch blocks and Level III evidence for radiofrequency neurotomy on a long-term basis in managing chronic thoracic pain. KEY WORDS Chronic spinal pain, thoracic facet or zygapophysial joint pain, facet joint nerve blocks, medial branch blocks, controlled comparative local anesthetic blocks, diagnostic accuracy, radiofrequency neurotomy.
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Riegger M, Le H, van Kuijk SMJ, Guyenes G, Candrian C, Cianfoni A, Hirsch JA, Koetsier E. Intradiscal Glucocorticoid Injection in Discogenic Back Pain and Influence on Modic Changes: A Systematic Review and Meta-analysis of RCTs. Pain Physician 2023; 26:E449-E465. [PMID: 37774181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
BACKGROUND The benefit of intradiscal glucocorticoid injection (IGI) for discogenic low back pain (LBP) remains controversial. OBJECTIVES The objective of this study was to systematically assess and meta-analyze the efficacy of IGI compared with these control groups. STUDY DESIGN Systematic review and meta-analysis. METHODS A comprehensive literature search was performed screening PubMed and Embase through May 2022. Only randomized controlled trials (RCTs) comparing IGI to control groups in adult patients with discogenic lumbar back pain were included. A random effects model was used to pool mean differences of pain intensity (visual analaog scale [VAS] 0-100), and physical function assessed with the Oswestry Disability Index (ODI). Subgroup analyses were stratified by Modic magnetic resonance imaging findings. RESULTS Seven studies met inclusion criteria with a total of 626 patients. The short-term (< 3 months) follow-up showed a significant pooled mean difference in both pain intensity (-20.1; 95% CI, -25.5 to -14.7) and physical function (-9.9; 95% CI, -16.1 to -3.6). In the intermediate -term follow-up (3 to < 6 months), only physical function remained significantly better in the glucocorticoid group (-13.1; 95% CI, -22.3 to -3.9). There was no clinically meaningful or significant difference in pain scores and physical function at the long-term (>= 6 months) follow-up. A subgroup analysis did not demonstrate an effect of Modic (type I) changes on the efficacy of IGI. LIMITATIONS A limited number of studies was available and consequently publication bias could not be evaluated using a funnel plot. Statistical heterogeneity was detected among the included studies. CONCLUSION We conclude that IGI reduces discogenic LBP intensity and improves physical function effectively at short-term follow-up, and continues to improve physical function at intermediate-term. However, 6 months posttreatment, outcomes are similar in comparison to the control groups. The type of Modic change does not appear to be related with the response to IGI. KEY WORDS Low back pain, lumbar back pain, intradiscal glucocorticoid injection, modic changes, meta-analysis.
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Manchikanti L, Pampati V, Knezevic NN, Kaye AD, Abdi S, Sanapati MR, Abd-Elsayed A, Kosanovic R, Soin A, Beall DP, Shah S, Hirsch JA. The Influence of COVID-19 on Utilization of Epidural Procedures in Managing Chronic Spinal Pain in the Medicare Population. Spine (Phila Pa 1976) 2023; 48:950-961. [PMID: 36728775 DOI: 10.1097/brs.0000000000004574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/19/2022] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN A retrospective cohort study of utilization patterns and variables of epidural injections in the fee-for-service (FFS) Medicare population. OBJECTIVES To update the utilization of epidural injections in managing chronic pain in the FFS Medicare population, from 2000 to 2020, and assess the impact of COVID-19. SUMMARY OF BACKGROUND DATA The analysis of the utilization of interventional techniques also showed an annual decrease of 2.5% per 100,000 FFS Medicare enrollees from 2009 to 2018, contrasting to an annual increase of 7.3% from 2000 to 2009. The impact of the COVID-19 pandemic has not been assessed. METHODS This analysis was performed by utilizing master data from the Centers for Medicare and Medicaid Services, physician/supplier procedure summary from 2000 to 2020. The analysis was performed by the assessment of utilization patterns using guidance from Strengthening the Reporting of Observational Studies in Epidemiology. RESULTS Epidural procedures declined at a rate of 19% per 100,000 Medicare enrollees in the FFS Medicare population in the United States from 2019 to 2020, with an annual decline of 3% from 2010 to 2019. From 2000 to 2010, there was an annual increase of 8.3%. This analysis showed a decline in all categories of epidural procedures from 2019 to 2020. The major impact of COVID-19, with closures taking effect from April 1, 2020, through December 31, 2020, will be steeper and rather dramatic compared with April 1 to December 31, 2019. However, monthly data from the Centers for Medicare and Medicaid Services is not available as of now. Overall declines from 2010 to 2019 showed a decrease for cervical and thoracic transforaminal injections with an annual decrease of 5.6%, followed by lumbar interlaminar and caudal epidural injections of 4.9%, followed by 1.8% for lumbar/sacral transforaminal epidurals, and 0.9% for cervical and thoracic interlaminar epidurals. CONCLUSION Declining utilization of epidural injections in all categories was exacerbated to a decrease of 19% from 2019 to 2020, related, in part, to the COVID-19 pandemic. This followed declining patterns of epidural procedures of 3% overall annually from 2010 to 2019.
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Kraft AW, Awad A, Rosenthal JA, Dmytriw AA, Vranic JE, Bonkhoff AK, Bretzner M, Hirsch JA, Rabinov JD, Stapleton CJ, Schwamm LH, Rost NS, Leslie-Mazwi TM, Patel AB, Regenhardt RW. In a hub-and-spoke network, spoke-administered thrombolysis reduces mechanical thrombectomy procedure time and number of passes. Interv Neuroradiol 2023; 29:315-320. [PMID: 35317663 PMCID: PMC10369105 DOI: 10.1177/15910199221087498] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The utility of intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT) in large vessel occlusion stroke (LVO) is controversial. Some data suggest IVT increases MT technical difficulty. Within our hub-and-spoke telestroke network, we examined how spoke-administered IVT affected hub MT procedure time and pass number. METHODS Patients presenting to 25 spoke hospitals who were transferred to the hub and underwent MT from 2018 to 2020 were identified from a prospectively maintained database. MT procedure time, fluoroscopy time, and pass number were obtained from operative reports. RESULTS Of 107 patients, 48 received IVT at spokes. Baseline characteristics and NIHSS were similar. The last known well (LKW)-to-puncture time was shorter among IVT patients (4.3 ± 1.9 h vs. 10.5 ± 6.5 h, p < 0.0001). In patients that received IVT, mean MT procedure time was decreased by 18.8 min (50.5 ± 29.4 vs. 69.3 ± 46.7 min, p = 0.02) and mean fluoroscopy time was decreased by 11.3 min (21.7 ± 15.8 vs. 33.0 ± 30.9 min, p = 0.03). Furthermore, IVT-treated patients required fewer MT passes (median 1 pass [IQR 1.0, 1.80] vs. 2 passes [1.0, 2.3], p = 0.0002) and were more likely to achieve reperfusion in ≤2 passes (81.3% vs. 59.3%, p = 0.01). An increased proportion of IVT-treated patients achieved TICI 2b-3 reperfusion after MT (93.9% vs. 83.8%, p = 0.045). There were no associations between MT procedural characteristics and LKW-to-puncture time. CONCLUSION Within our network, hub MT following spoke-administered IVT was faster, required fewer passes, and achieved improved reperfusion. This suggests spoke-administered IVT does not impair MT, but instead may enhance it.
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Manchikanti L, Knezevic NN, Knezevic E, Pasupuleti R, Kaye AD, Sanapati MR, Hirsch JA. Efficacy of Percutaneous Adhesiolysis in Managing Low Back and Lower Extremity Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Pain Ther 2023:10.1007/s40122-023-00508-y. [PMID: 37227685 DOI: 10.1007/s40122-023-00508-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/27/2023] [Indexed: 05/26/2023] Open
Abstract
INTRODUCTION Chronic refractory low back and lower extremity pain recalcitrant to conservative management and epidural injections secondary to postsurgery syndrome, spinal stenosis, and disc herniation are sometimes managed with percutaneous adhesiolysis. Consequently, this systematic review and meta-analysis was undertaken to assess the efficacy of percutaneous adhesiolysis in managing low back and lower extremity pain. METHODS A systematic review and meta-analysis of randomized controlled trials (RCTs) utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was performed. A comprehensive literature search of multiple databases from 1966 to July 2022, including manual searches of the bibliography of known review articles was performed. Quality assessment of the included trials, meta-analysis, and best evidence synthesis was performed. The primary outcome measure was a significant reduction in pain (short term up to 6 months and long term more than 6 months). RESULTS The search identified 26 publications, with 9 trials meeting the inclusion criteria. The results of dual-arm and single-arm analyses showed significant improvement in pain and function at 12 months. Opioid consumption was also significantly reduced at 6 months with dual-arm analysis, whereas single-arm analysis showed a significant decrease from baseline to treatment at the 3-, 6-, and 12-month analyses. At 1 year follow-up, seven of seven trials were positive for improvements in pain relief, function, and diminution of opioid use. DISCUSSION Based on the present systematic review of nine RCTs, the evidence level is I to II, with moderate to strong recommendation for percutaneous adhesiolysis in managing low back and lower extremity pain. The limitations of the evidence include paucity of literature, lack of placebo-controlled trials, and the majority of the trials studying post lumbar surgery syndrome. CONCLUSION The evidence is level I to II or strong to moderate based on five high-quality and two moderate-quality RCTs, with 1 year follow-up that percutaneous adhesiolysis is efficacious in the treatment of chronic refractory low back and lower extremity pain.
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Milburn JM, Fiorella D, Hirsch JA. Betwixt and between: an idiomatic understanding of anesthesia in stroke intervention. J Neurointerv Surg 2023; 15:411-412. [PMID: 37055071 DOI: 10.1136/jnis-2023-020364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 04/15/2023]
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Manchikanti L, Kaye AD, Latchaw RE, Sanapati MR, Pampati V, Gharibo CG, Albers SL, Hirsch JA. Impact of the COVID-19 Pandemic on Utilization Patterns of Facet Joint Interventions in Managing Spinal Pain in a Medicare Population. Pain Ther 2023; 12:505-527. [PMID: 36723804 PMCID: PMC9890434 DOI: 10.1007/s40122-023-00476-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/10/2023] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic resulted in major disruptions in all aspects of human life including a decline of medical services utilized during 2020. An analysis of the impact of COVID-19 pandemic showed an 18.7% reduction in utilization patterns of interventional techniques in managing chronic pain in the Medicare population from 2019 to 2020. However, specific changes in utilization patterns of facet joint interventions have not been studied. Thus, we sought to assess the utilization patterns including an update of facet joint interventions from 2018 to 2020, with analysis of the impact of COVID-19 pandemic in managing chronic spinal pain utilizing facet joint interventions in the fee-for-service Medicare population of the United States. METHODS The present investigation was designed to assess utilization patterns and variables of facet joint interventions, in managing chronic spinal pain from 2010 to 2020 in the fee-for-service (FFS) Medicare population in the United States (US), and how the COVID-19 pandemic impacted these utilization patterns. Data for the analysis were obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2020. RESULTS Results of this analysis showed significant impact of COVID-19 with overall decrease of 18.5% of all facet joint interventions per 100,000 Medicare population compared to 20.2 and 20.5% decrease for lumbar and cervical facet joint injections, 15 and 13.1% decrease per 100,000 Medicare population of lumbosacral and cervicothoracic facet joint neurolysis procedures. The results are significant in that comparative analysis from 2000 to 2010 and 2010 to 2019 showing an annual increase of 14.4 vs. 2.2%, illustrating a decelerating pattern. There were also significant growth patterns noted with decreases in facet joint injections and nerve blocks compared to facet joint neurolytic procedures. CONCLUSIONS This analysis shows a significant effect of COVID-19 producing an overall decrease in utilization of facet joint interventions relative to pre-COVID data. Further, the analysis demonstrates continued deceleration of utilization patterns of facet joint interventions compared to the periods of 2000-2010 and 2010-2019.
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Jayaraman K, Santavicca S, Hughes DR, Hirsch JA, Duszak R, Chatterjee AR. Recent trends in high-volume Medicare stroke thrombectomy provider characteristics. J Neurointerv Surg 2023; 15:399-401. [PMID: 35210330 DOI: 10.1136/neurintsurg-2021-018611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 02/03/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Intracranial mechanical thrombectomy (MT) is increasingly indicated for use in acute ischemic stroke patients. We analyzed recent trends in the characteristics and geographic distributions of physicians providing this service with frequency to Medicare beneficiaries. METHODS We linked public data sources to elucidate and visualize trends in high-volume MT providers between 2016 and 2019. RESULTS High-volume MT providers increased by 184% between 2016 and 2019. The number of neurosurgeons, neurologists, and radiologists in this physician population increased by 251%, 205%, and 139%, respectively. Male practitioners accounted for 96% of providers in the most recent year of analysis. International medical graduates accounted for roughly one-third of these physicians across all 4 years of analysis. As of 2019, the three states with the most high-volume MT providers were Florida, California, and Texas, accounting for 7%, 7%, and 6% of providers, respectively. CONCLUSIONS High-volume providers of MT services for Medicare beneficiaries represent a dynamic and rapidly expanding subset of physicians with diverse specialty backgrounds.
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Fargen KM, Hui F, Hirsch JA. Cerebral venous disorders: the path forward. J Neurointerv Surg 2023; 15:309. [PMID: 36918201 DOI: 10.1136/jnis-2023-020251] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2023] [Indexed: 03/16/2023]
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Chen M, Leslie-Mazwi TM, Hirsch JA, Albuquerque FC. Large core stroke thrombectomy: paradigm shift or futile exercise? J Neurointerv Surg 2023; 15:413-414. [PMID: 36810356 DOI: 10.1136/jnis-2023-020219] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 02/23/2023]
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Cheng D, Ghoshal S, Zattra O, Flash M, Lang M, Liu R, Lev MH, Hirsch JA, Saini S, Gee MS, Succi MD. Trends in oncological imaging during the COVID-19 pandemic through the vaccination era. Cancer Med 2023; 12:9902-9911. [PMID: 36775966 PMCID: PMC10166903 DOI: 10.1002/cam4.5678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/22/2023] [Accepted: 01/31/2023] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND This study examines the impact that the COVID-19 pandemic has had on computed tomography (CT)-based oncologic imaging utilization. METHODS We retrospectively analyzed cancer-related CT scans during four time periods: pre-COVID (1/5/20-3/14/20), COVID peak (3/15/20-5/2/20), post-COVID peak (5/3/20-12/19/20), and vaccination period (12/20/20-10/30/21). We analyzed CTs by imaging indication, setting, and hospital type. Using percentage decrease computation and Student's t-test, we calculated the change in mean number of weekly cancer-related CTs for all periods compared to the baseline pre-COVID period. This study was performed at a single academic medical center and three affiliated hospitals. RESULTS During the COVID peak, mean CTs decreased (-43.0%, p < 0.001), with CTs for (1) cancer screening, (2) initial workup, (3) cancer follow-up, and (4) scheduled surveillance of previously treated cancer dropping by 81.8%, 56.3%, 31.7%, and 45.8%, respectively (p < 0.001). During the post-COVID peak period, cancer screenings and initial workup CTs did not return to prepandemic imaging volumes (-11.4%, p = 0.028; -20.9%, p = 0.024). The ED saw increases in weekly CTs compared to prepandemic levels (+31.9%, p = 0.008), driven by increases in cancer follow-up CTs (+56.3%, p < 0.001). In the vaccination period, cancer screening CTs did not recover to baseline (-13.5%, p = 0.002) and initial cancer workup CTs doubled (+100.0%, p < 0.001). The ED experienced increased cancer-related CTs (+75.9%, p < 0.001), driven by cancer follow-up CTs (+143.2%, p < 0.001) and initial workups (+46.9%, p = 0.007). CONCLUSIONS AND RELEVANCE The pandemic continues to impact cancer care. We observed significant declines in cancer screening CTs through the end of 2021. Concurrently, we observed a 2× increase in initial cancer workup CTs and a 2.4× increase in cancer follow-up CTs in the ED during the vaccination period, suggesting a boom of new cancers and more cancer examinations associated with emergency level acute care.
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Chan A, Flash MJ, Guo T, Zattra O, Boms O, Succi MD, Hirsch JA. Trends in Academic Productivity Among Radiologists During the COVID-19 Pandemic. J Am Coll Radiol 2023; 20:276-281. [PMID: 36496090 PMCID: PMC9729584 DOI: 10.1016/j.jacr.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/21/2022] [Accepted: 10/03/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE There is a scarcity of literature examining changes in radiologist research productivity during the COVID-19 pandemic. The current study aimed to investigate changes in academic productivity as measured by publication volume before and during the COVID-19 pandemic. METHODS This single-center, retrospective cohort study included the publication data of 216 researchers consisting of associate professors, assistant professors, and professors of radiology. Wilcoxon's signed-rank test was used to identify changes in publication volume between the 1-year-long defined prepandemic period (publications between May 1, 2019, and April 30, 2020) and COVID-19 pandemic period (May 1, 2020, to April 30, 2021). RESULTS There was a significantly increased mean annual volume of publications in the pandemic period (5.98, SD = 7.28) compared with the prepandemic period (4.98, SD = 5.53) (z = -2.819, P = .005). Subset analysis demonstrated a similar (17.4%) increase in publication volume for male researchers when comparing the mean annual prepandemic publications (5.10, SD = 5.79) compared with the pandemic period (5.99, SD = 7.60) (z = -2.369, P = .018). No statistically significant changes were found in similar analyses with the female subset. DISCUSSION Significant increases in radiologist publication volume were found during the COVID-19 pandemic compared with the year before. Changes may reflect an overall increase in academic productivity in response to clinical and imaging volume ramp down.
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Di Caterino F, Koetsier E, Hirsch JA, Isalberti M, San Millan D, Marchi F, La Barbera L, Pileggi M, Cianfoni A. Middle column Stent-screw Assisted Internal Fixation (SAIF): a modified minimally-invasive approach to rescue vertebral middle column re-fractures. J Neurointerv Surg 2023; 15:jnis-2022-019752. [PMID: 36593116 DOI: 10.1136/jnis-2022-019752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/26/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND There is limited literature regarding the re-fracture of a previously augmented vertebral compression fracture (VCF). These re-fractures may present as an asymptomatic remodeling of the vertebral body around the cement cast while in other cases they involve the middle column, at the transition zone between the cement-augmented and non-augmented vertebral body. In the latter, a posterior wall retropulsion is possible and, if left untreated, might progress to vertebral body splitting, central canal stenosis, and kyphotic deformity. There is no consensus regarding the best treatment for these re-fractures. There are cases in which a repeated augmentation relieves the pain, but this is considered an undertreatment in cases with middle column involvement, posterior wall retropulsion, and kyphosis. METHODS We report four cases of re-fracture with middle column collapse of a previously augmented VCF, treated with the stent-screw assisted internal fixation (SAIF) technique. A modified more postero-medial deployment of the anterior metallic implants was applied, to target the middle column fracture. This modified SAIF allowed the reduction and stabilization of the middle column collapse as well as the partial correction of the posterior wall retropulsion and kyphosis. RESULTS Complete relief of back pain with stable clinical and radiographic findings at follow-up was obtained in all cases. CONCLUSIONS In selected cases, the middle column SAIF technique is safe and effective for the treatment of the re-fracture with middle column collapse of a previously cement-augmented VCF. This technique requires precision in trocar placement and could represent a useful addition to the technical armamentarium for VCF treatment.
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Nguyen TH, Heller RE, Keysor K, Milburn JM, Rula EY, Spangler R, Hirsch JA. The No Surprises Act: What Neuroradiologists Should Know. AJNR Am J Neuroradiol 2023; 44:7-10. [PMID: 36549854 PMCID: PMC9835917 DOI: 10.3174/ajnr.a7739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 11/10/2022] [Indexed: 12/24/2022]
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Singh N, Menon BK, Dmytriw AA, Regenhardt RW, Hirsch JA, Ganesh A. Replacing Alteplase with Tenecteplase: Is the Time Ripe? J Stroke 2023; 25:72-80. [PMID: 36746381 PMCID: PMC9911848 DOI: 10.5853/jos.2022.02880] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/15/2022] [Indexed: 02/04/2023] Open
Abstract
Thrombolysis for acute ischemic stroke has predominantly been with alteplase for over a quarter of a century. In recent years, with trials showing evidence of higher rates of successful reperfusion, similar safety profile and efficacy of tenecteplase (TNK) as compared to alteplase, TNK has now emerged as another potential choice for thrombolysis in acute ischemic stroke. In this review, we will focus on these recent advances, aiming: (1) to provide a brief overview of thrombolysis in stroke; (2) to provide comparisons between alteplase and TNK for clinical, imaging, and safety outcomes; (3) to focus on key subgroups of interest to understand if there is an advantage of using TNK over alteplase or vice-versa, to review available evidence on role of TNK in intra-arterial thrombolysis, as bridging therapy and in mobile stroke units; and (4) to summarize what to expect in the near future from recently completed trials and propose areas for future research on this evolving topic. We present compelling data from several trials regarding the safety and efficacy of TNK in acute ischemic stroke along with completed yet unpublished trials that will help provide insight into these unanswered questions.
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Kraft AW, Regenhardt RW, Awad A, Rosenthal JA, Dmytriw AA, Vranic JE, Bonkhoff AK, Bretzner M, Hirsch JA, Rabinov JD, Stapleton CJ, Schwamm LH, Singhal AB, Rost NS, Leslie-Mazwi TM, Patel AB. Spoke-administered thrombolysis improves large vessel occlusion early recanalization: the real-world experience of a large academic hub-and-spoke telestroke network. STROKE (HOBOKEN, N.J.) 2023; 3:e000427. [PMID: 36816048 PMCID: PMC9936963 DOI: 10.1161/svin.122.000427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/11/2022] [Indexed: 11/16/2022]
Abstract
Introduction Intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke is increasingly controversial. Recent trials support MT without IVT for patients presenting directly to MT-capable "hub" centers. However, bypassing IVT has not been evaluated for patients presenting to IVT-capable "spoke" hospitals that require hub transfer for MT. A perceived lack of efficacy of IVT to result in LVO early recanalization (ER) is often cited to support bypassing IVT, but ER data for IVT in patients that require interhospital transfer is limited. Here we examined LVO ER rates after spoke-administered IVT in our hub-and-spoke stroke network. Methods Patients presenting to 25 spokes before hub transfer for MT consideration from 2018-2020 were retrospectively identified from a prospectively maintained database. Inclusion criteria were pre-transfer CTA-defined LVO, ASPECTS ≥6, and post-transfer repeat vessel imaging. Results Of 167 patients, median age was 69 and 51% were female. 76 received spoke IVT (+spokeIVT) and 91 did not (-spokeIVT). Alteplase was the only IVT used in this study. Comorbidities and NIHSS were similar between groups. ER frequency was increased 7.2-fold in +spokeIVT patients [12/76 (15.8%) vs. 2/91 (2.2%), P<0.001]. Spoke-administered IVT was independently associated with ER (aOR=11.5, 95% CI=2.2,99.6, p<0.05) after adjusting for timing of last known well, interhospital transfer, and repeat vessel imaging. Interval NIHSS was improved in patients with ER (median -2 (IQR -6.3, -0.8) vs. 0 (-2.5, 1), p<0.05). Conclusion Within our network, +spokeIVT patients had a 7.2-fold increased ER relative likelihood. This real-world analysis supports IVT use in eligible patients with LVO at spoke hospitals before hub transfer for MT.
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Manchikanti L, Knezevic NN, Knezevic E, Abdi S, Sanapati MR, Soin A, Wargo BW, Navani A, Atluri S, Gharibo CG, Simopoulos TT, Kosanovic R, Abd-Elsayed A, Kaye AD, Hirsch JA. A Systematic Review and Meta-analysis of the Effectiveness of Radiofrequency Neurotomy in Managing Chronic Neck Pain. Pain Ther 2022; 12:1-48. [PMID: 36465720 PMCID: PMC9686245 DOI: 10.1007/s40122-022-00455-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/28/2022] [Indexed: 11/25/2022] Open
Abstract
Background Extensive research into potential sources of neck pain and referred pain into the upper extremities and head has shown that the cervical facet joints can be a potential pain source confirmed by precision, diagnostic blocks. Study Design Systematic review and meta-analysis utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, quality assessment of the included studies, conventional and single-arm meta-analysis, and best evidence synthesis. Objective The objective of this systematic review and meta-analysis is to evaluate the effectiveness of radiofrequency neurotomy as a therapeutic cervical facet joint intervention in managing chronic neck pain. Methods Available literature was included. Methodologic quality assessment of studies was performed from 1996 to September 2021. The level of evidence of effectiveness was determined. Results Based on the qualitative and quantitative analysis with single-arm meta-analysis and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system of appraisal, with inclusion of one randomized controlled trial (RCT) of 12 patients in the treatment group and eight positive observational studies with inclusion of 589 patients showing positive outcomes with moderate to high clinical applicability, the evidence is level II in managing neck pain with cervical radiofrequency neurotomy. The evidence for managing cervicogenic headache was level III to IV with qualitative analysis and single-arm meta-analysis and GRADE system of appraisal, with the inclusion of 15 patients in the treatment group in a positive RCT and 134 patients in observational studies. An overwhelming majority of the studies produced multiple lesions. Limitations There was a paucity of literature and heterogeneity among the available studies. Conclusion This systematic review and meta-analysis shows level II evidence with radiofrequency neurotomy on a long-term basis in managing chronic neck pain with level III to IV evidence in managing cervicogenic headaches. Supplementary Information The online version contains supplementary material available at 10.1007/s40122-022-00455-0.
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Regenhardt RW, Rosenthal JA, Dmytriw AA, Vranic JE, Bonkhoff AK, Bretzner M, Hirsch JA, Rabinov JD, Stapleton CJ, Patel AB, Singhal AB, Rost NS, Leslie-Mazwi TM, Etherton MR. Direct to angio-suite large vessel occlusion transfers achieve faster arrival-to-puncture times and improved outcomes. STROKE (HOBOKEN, N.J.) 2022; 2:e000327. [PMID: 36571077 PMCID: PMC9787192 DOI: 10.1161/svin.121.000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 05/16/2022] [Indexed: 12/30/2022]
Abstract
Introduction For patients with large vessel occlusion (LVO) stroke, time to treatment with endovascular thrombectomy (EVT) is crucial to prevent infarction and improve outcomes. We sought to evaluate the hub arrival-to-puncture times and outcomes for transferred patients accepted directly to the angio-suite (LVO2OR) versus those accepted through the emergency department (ED) in a hub-and-spoke telestroke network. Methods Consecutive patients transferred for EVT with spoke CTA-confirmed LVO, spoke ASPECTS >6, and LKW-to-hub arrival <6 hours were identified. Our LVO2OR protocol began implementation in January 2017. The LVO2OR cohort includes patients who underwent EVT from July 2017 to October 2020; the ED cohort includes those from January 2011 to December 2016. Hub arrival-to-puncture time and 90-day modified Rankin Scale (mRS) were prospectively recorded. Results The LVO2OR cohort was comprised of 91 patients and the ED cohort 90. LVO2OR patients had more atrial fibrillation (AF, 51% vs 32%, p=0.02) and more M2 occlusions (27% vs 10%, p=0.01). LVO2OR patients had faster median hub arrival-to-puncture time (11 vs 92 minutes, p<0.001), faster median telestroke consult-to-puncture time (2.4 vs 3.6 hours, p<0.001), greater TICI 2b-3 reperfusion (92% vs 69%, p<0.001), and greater 90-day mRS <2 (35% vs 21%, p=0.04). In a multivariable model, LVO2OR significantly increased the odds of 90-day mRS <2 (aOR 2.77, 95%CI 1.07,7.20; p=0.04) even when controlling for age, baseline mRS, AF, NIHSS, M2 location, and TICI 2b-3. Conclusion In a hub-and-spoke telestroke network, accepting transferred patients directly to the angio-suite was associated with dramatically reduced hub arrival-to-puncture time and may lead to improved 90-day outcomes. Direct-to-angio-suite protocols should continue to be evaluated in other regions and telestroke models.
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Christensen EW, Liu CM, Duszak R, Hirsch JA, Swan TL, Rula EY. Association of State Share of Nonphysician Practitioners With Diagnostic Imaging Ordering Among Emergency Department Visits for Medicare Beneficiaries. JAMA Netw Open 2022; 5:e2241297. [PMID: 36355374 PMCID: PMC9650604 DOI: 10.1001/jamanetworkopen.2022.41297] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
IMPORTANCE The use of nonphysician practitioners (NPPs) in the emergency department (ED) continues to expand, yet little is known about associations between NPPs and ED imaging use. OBJECTIVE To investigate whether the state share of ED visits for which an NPP was the clinician of record is associated with imaging studies ordered, given that state NPP share is associated with state-level NPP scopes of practice. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study compared diagnostic imaging ordering patterns associated with ED visits based on 2005-2020 Medicare claims for a nationally representative 5% sample of fee-for-service beneficiaries. For all 50 states and the District of Columbia, the state NPP share of ED visits by year was used to represent state-specific practice patterns for NPPs and physicians and how those patterns have evolved over time. The analysis controlled for patient demographic characteristics, Charlson Comorbidity Index scores, ED visit severity, year, and principal diagnosis. EXPOSURES The share of ED visits in each state in each year (state share) for which an NPP was the evaluation and management clinician. MAIN OUTCOMES AND MEASURES The main outcomes were the number and modality of imaging studies associated with ED visits. Analyses were by logistic regression and generalized linear model with γ-distribution and log-link function. RESULTS Among 16 922 274 ED visits, 60.0% involved women, and patients' mean (SD) age was 70.3 (16.1) years. The share of all ED visits with an NPP as the clinician increased from 6.1% in 2005 to 16.6% in 2020. Compared with no NPPs, the presence of NPPs in the ED was associated with 5.3% (95% CI, 5.1%-5.5%) more imaging studies per ED visit, including a 3.4% (95% CI, 3.2%-3.5%) greater likelihood of any imaging order per ED visit and 2.2% (95% CI, 2.0%-2.3%) more imaging studies ordered per visit involving imaging. CONCLUSIONS AND RELEVANCE In this study, use of NPPs in the ED was associated with higher imaging use compared with the use of only physicians in the ED. Although expanded use of NPPs in the ED may improve patient access, the costs and radiation exposure associated with more imaging warrants additional study.
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Hirsch JA, Zini C, Anselmetti GC, Ardura F, Beall D, Bellini M, Brook A, Cianfoni A, Clerk-Lamalice O, Georgy B, Maestretti G, Manfré L, Muto M, Ortiz O, Saba L, Kelekis A, Filippiadis DK, Marcia S, Masala S. Vertebral Augmentation: Is It Time to Get Past the Pain? A Consensus Statement from the Sardinia Spine and Stroke Congress. Medicina (B Aires) 2022; 58:medicina58101431. [PMID: 36295591 PMCID: PMC9609022 DOI: 10.3390/medicina58101431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/21/2022] [Accepted: 09/29/2022] [Indexed: 11/16/2022] Open
Abstract
Vertebral augmentation has been used to treat painful vertebral compression fractures and metastatic lesions in millions of patients around the world. An international group of subject matter experts have considered the evidence, including but not limited to mortality. These considerations led them to ask whether it is appropriate to allow the subjective measure of pain to so dominate the clinical decision of whether to proceed with augmentation. The discussions that ensued are related below.
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Manchikanti L, Knezevic E, Latchaw RE, Knezevic NN, Abdi S, Sanapati MR, Staats PS, Gharibo CG, Simopoulos TT, Shah S, Abd-Elsayed A, Navani A, Kaye AD, Albers SL, Hirsch JA. Comparative Systematic Review and Meta-Analysis of Cochrane Review of Epidural Injections for Lumbar Radiculopathy or Sciatica. Pain Physician 2022; 25:E889-E916. [PMID: 36288577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Epidural injections are among the most commonly performed procedures for managing low back and lower extremity pain. Pinto et al and Chou et al previously performed systematic reviews and meta-analyses, which, along with a recent update from Oliveira et al showing the lack of effectiveness of epidural steroid injections in managing lumbar disc herniation, spinal stenosis, and radiculopathy. In contrast to these papers, multiple other systematic reviews and meta-analyses have supported the effectiveness and use of epidural injections utilizing fluoroscopically guided techniques. A major flaw in the review can be related to attributing active-controlled trials to placebo-controlled trials. The assumption that local anesthetics do not provide sustained benefit, despite extensive evidence that local anesthetics provide long-term relief, similar to a combination of local anesthetic with steroids is flawed. STUDY DESIGN The Cochrane Review of randomized controlled trials (RCTs) of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy were reanalyzed using systematic methodology and meta-analysis. OBJECTIVES To re-evaluate Cochrane data on RCTs of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy utilizing qualitative and quantitative techniques with dual-arm and single-arm analysis. METHODS In this systematic review, we have used the same RCTs from the Cochrane Review of a minimum of 20% change in pain scale or significant pain relief of >= 50%. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Our review was performed utilizing the Cochrane Review methodologic quality assessment and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Evidence was summarized utilizing the principles of best evidence synthesis and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Clinical relevance of the pragmatic nature of each study was assessed. RESULTS In evaluating the RCTs in the Cochrane Review, 10 trials were performed with fluoroscopic guidance. Utilizing conventional dual-arm and single-arm meta-analysis, the evidence is vastly different from the interpretation of the data within the Cochrane Review. The overall combined evidence is Level I, or strong evidence, at one and 3 months, and Level II, or moderate evidence, at 6 and 12 months. LIMITATIONS The limitation of this study is that only data contained in the Cochrane Review were analyzed. CONCLUSION A comparative systematic review and meta-analysis of the Cochrane Review of randomized controlled trials (RCTs) of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy yielded different results. This review, based on the evidence derived from placebo-controlled trials and active-controlled trials showed Level I, or strong evidence, at one and 3 months and Level II at 6 and 12 months. This review once again emphasizes the importance of the allocation of studies to placebo-control and active-control groups, utilizing standards of practice with inclusion of only the studies performed under fluoroscopic guidance.
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