1
|
Gross AR, Lee H, Ezzo J, Chacko N, Gelley G, Forget M, Morien A, Graham N, Santaguida PL, Rice M, Dixon C. Massage for neck pain. Cochrane Database Syst Rev 2024; 2:CD004871. [PMID: 38415786 PMCID: PMC10900303 DOI: 10.1002/14651858.cd004871.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
BACKGROUND Massage is widely used for neck pain, but its effectiveness remains unclear. OBJECTIVES To assess the benefits and harms of massage compared to placebo or sham, no treatment or exercise as an adjuvant to the same co-intervention for acute to chronic persisting neck pain in adults with or without radiculopathy, including whiplash-associated disorders and cervicogenic headache. SEARCH METHODS We searched multiple databases (CENTRAL, MEDLINE, EMBASE, CINAHL, Index to Chiropractic Literature, trial registries) to 1 October 2023. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing any type of massage with sham or placebo, no treatment or wait-list, or massage as an adjuvant treatment, in adults with acute, subacute or chronic neck pain. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. We transformed outcomes to standardise the direction of the effect (a smaller score is better). We used a partially contextualised approach relative to identified thresholds to report the effect size as slight-small, moderate or large-substantive. MAIN RESULTS We included 33 studies (1994 participants analysed). Selection (82%) and detection bias (94%) were common; multiple trials had unclear allocation concealment, utilised a placebo that may not be credible and did not test whether blinding to the placebo was effective. Massage was compared with placebo (n = 10) or no treatment (n = 8), or assessed as an adjuvant to the same co-treatment (n = 15). The trials studied adults aged 18 to 70 years, 70% female, with mean pain severity of 51.8 (standard deviation (SD) 14.1) on a visual analogue scale (0 to 100). Neck pain was subacute-chronic and classified as non-specific neck pain (85%, including n = 1 whiplash), radiculopathy (6%) or cervicogenic headache (9%). Trials were conducted in outpatient settings in Asia (n = 11), America (n = 5), Africa (n = 1), Europe (n = 12) and the Middle East (n = 4). Trials received research funding (15%) from research institutes. We report the main results for the comparison of massage versus placebo. Low-certainty evidence indicates that massage probably results in little to no difference in pain, function-disability and health-related quality of life when compared against a placebo for subacute-chronic neck pain at up to 12 weeks follow-up. It may slightly improve participant-reported treatment success. Subgroup analysis by dose showed a clinically important difference favouring a high dose (≥ 8 sessions over four weeks for ≥ 30 minutes duration). There is very low-certainty evidence for total adverse events. Data on patient satisfaction and serious adverse events were not available. Pain was a mean of 20.55 points with placebo and improved by 3.43 points with massage (95% confidence interval (CI) 8.16 better to 1.29 worse) on a 0 to 100 scale, where a lower score indicates less pain (8 studies, 403 participants; I2 = 39%). We downgraded the evidence to low-certainty due to indirectness; most trials in the placebo comparison used suboptimal massage doses (only single sessions). Selection, performance and detection bias were evident as multiple trials had unclear allocation concealment, utilised a placebo that may not be credible and did not test whether blinding was effective, respectively. Function-disability was a mean of 30.90 points with placebo and improved by 9.69 points with massage (95% CI 17.57 better to 1.81 better) on the Neck Disability Index 0 to 100, where a lower score indicates better function (2 studies, 68 participants; I2 = 0%). We downgraded the evidence to low-certainty due to imprecision (the wide CI represents slight to moderate benefit that does not rule in or rule out a clinically important change) and risk of selection, performance and detection biases. Participant-reported treatment success was a mean of 3.1 points with placebo and improved by 0.80 points with massage (95% CI 1.39 better to 0.21 better) on a Global Improvement 1 to 7 scale, where a lower score indicates very much improved (1 study, 54 participants). We downgraded the evidence to low-certainty due to imprecision (single study with a wide CI that does not rule in or rule out a clinically important change) and risk of performance as well as detection bias. Health-related quality of life was a mean of 43.2 points with placebo and improved by 5.30 points with massage (95% CI 8.24 better to 2.36 better) on the SF-12 (physical) 0 to 100 scale, where 0 indicates the lowest level of health (1 study, 54 participants). We downgraded the evidence once for imprecision (a single small study) and risk of performance and detection bias. We are uncertain whether massage results in increased total adverse events, such as treatment soreness, sweating or low blood pressure (RR 0.99, 95% CI 0.08 to 11.55; 2 studies, 175 participants; I2 = 77%). We downgraded the evidence to very low-certainty due to unexplained inconsistency, risk of performance and detection bias, and imprecision (the CI was extremely wide and the total number of events was very small, i.e < 200 events). AUTHORS' CONCLUSIONS The contribution of massage to the management of neck pain remains uncertain given the predominance of low-certainty evidence in this field. For subacute and chronic neck pain (closest to 12 weeks follow-up), massage may result in a little or no difference in improving pain, function-disability, health-related quality of life and participant-reported treatment success when compared to a placebo. Inadequate reporting on adverse events precluded analysis. Focused planning for larger, adequately dosed, well-designed trials is needed.
Collapse
Affiliation(s)
- Anita R Gross
- Faculty of Health Sciences, School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
- School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Haejung Lee
- Department of Physical Therapy, Silla University, Busan, Korea, South
| | - Jeanette Ezzo
- Research Director, JME Enterprises, Baltimore, Maryland, USA
| | - Nejin Chacko
- Faculty of Health Sciences, School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - Geoffrey Gelley
- Applied Health Sciences PhD Program, University of Manitoba, Winnipeg, MB, Canada
- Integrative Medicine, University of Manitoba, Winnipeg, Canada
| | - Mario Forget
- Canadian Forces Health Services Group | Groupe de services de santé des Forces Canadiennes, National Defense | Défense Nationale, Kingston, Canada
| | - Annie Morien
- Research Department, Florida School of Massage, Gainesville, FL, USA
| | - Nadine Graham
- Faculty of Health Sciences, School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - Pasqualina L Santaguida
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Craig Dixon
- Faculty of Health Sciences, School of Rehabilitation Sciences, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
2
|
Wadhwa H, Varshneya K, Stienen MN, Veeravagu A. Do Epidural Steroid Injections Affect Outcomes and Costs in Cervical Degenerative Disease? A Retrospective MarketScan Database Analysis. Global Spine J 2023; 13:1812-1820. [PMID: 34686085 PMCID: PMC10556907 DOI: 10.1177/21925682211050320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To investigate the effect of preoperative epidural steroid injection (ESI) on quality outcomes and costs in patients undergoing surgery for cervical degenerative disease. METHODS We queried the MarketScan database, a national administrative claims dataset, to identify patients who underwent cervical degenerative surgery from 2007 to 2016. Patients under 18 and patients with history of tumor or trauma were excluded. Patients were stratified by ESI use at 3, 6, 12, 18, and 24 or more months preoperative. Propensity score matched controls for these groups were obtained. Baseline demographics, postoperative complications, reoperations, readmissions, and costs were compared via univariate and multivariate analysis. RESULTS 97 117 patients underwent cervical degenerative surgery, of which 29 963 (30.7%) had ESI use at any time preoperatively. Overall, 90-day complication rate was not significantly different between groups. The ESI cohorts had shorter length of stay, but higher 90-day readmission and reoperation rates. ESI use was associated with higher total payments through the 2-year follow-up period. Among patients who received preoperative ESI, male sex, history of cancer, obesity, PVD, rheumatoid arthritis, nonsmokers, cervical myelopathy, BMP use, anterior approach, 90-day complication, 90-day reoperation, and 90-day readmission were independently associated with increased 90-day total cost. CONCLUSION ESI can offer pain relief in some patients refractory to other conservative management techniques, but those who eventually undergo surgery have greater healthcare resource utilization. Certain characteristics can predispose patients who receive preoperative ESI to incur higher healthcare costs.
Collapse
Affiliation(s)
- Harsh Wadhwa
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
| | - Kunal Varshneya
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
| | - Martin N. Stienen
- Department of Neurosurgery, Kantonsspital St.Gallen, St.Gallen, Switzerland
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA, USA
| |
Collapse
|
3
|
Peene L, Cohen SP, Brouwer B, James R, Wolff A, Van Boxem K, Van Zundert J. 2. Cervical radicular pain. Pain Pract 2023; 23:800-817. [PMID: 37272250 DOI: 10.1111/papr.13252] [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] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Cervical radicular pain is pain perceived in the upper limb, caused by irritation or compression of a cervical spine nerve, the roots of the nerve, or both. METHODS The literature on the diagnosis and treatment of cervical radicular pain was retrieved and summarized. RESULTS The diagnosis is made by combining elements from the patient's history, physical examination, and supplementary tests. The Spurling and shoulder abduction tests are the two most common examinations used to identify cervical radicular pain. MRI without contrast, CT scanning, and in some cases plain radiography can all be appropriate imaging techniques for nontraumatic cervical radiculopathy. MRI is recommended prior to interventional treatments. Exercise with or without other treatments can be beneficial. There is scant evidence for the use of paracetamol, nonsteroidal anti-inflammatory drugs, and neuropathic pain medications such as gabapentin, pregabalin, tricyclic antidepressants, and anticonvulsants for the treatment of radicular pain. Acute and subacute cervical radicular pain may respond well to epidural corticosteroid administration, preferentially using an interlaminar approach. By contrast, for chronic cervical radicular pain, the efficacy of epidural corticosteroid administration is limited. In these patients, pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered. CONCLUSIONS There is currently no gold standard for the diagnosis of cervical radicular pain. There is scant evidence for the use of medication. Epidural corticosteroid injection and pulsed radiofrequency adjacent to the dorsal root ganglion may be considered. [Correction added on 12 June 2023, after first online publication: The preceding sentence was corrected.].
Collapse
Affiliation(s)
- Laurens Peene
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
| | - Steven P Cohen
- Pain Medicine Division, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, USA
| | - Brigitte Brouwer
- Department of Anesthesiology, Pain Medicine and Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rathmell James
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Leroy D. Vandam Professor of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Andre Wolff
- Department of Anesthesiology, UMCG Pain Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Koen Van Boxem
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
- Department of Anesthesiology, Pain Medicine and Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
- Department of Anesthesiology, Pain Medicine and Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| |
Collapse
|
4
|
Cohen SP, Doshi TL, Dolomisiewicz E, Reece DE, Zhao Z, Anderson-White M, Kasuke A, Wang EJ, Hsu A, Davis SA, Yoo Y, Pasquina PF, Moon JY. Nonorganic (Behavioral) Signs and Their Association With Epidural Corticosteroid Injection Treatment Outcomes and Psychiatric Comorbidity in Cervical Radiculopathy: A Multicenter Study. Mayo Clin Proc 2023; 98:868-882. [PMID: 36803892 PMCID: PMC10358758 DOI: 10.1016/j.mayocp.2022.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/18/2022] [Accepted: 11/22/2022] [Indexed: 02/17/2023]
Abstract
OBJECTIVE To determine the association between cervical nonorganic pain signs and epidural corticosteroid injection outcomes and coexisting pain and psychiatric conditions. PATIENTS AND METHODS Seventy-eight patients with cervical radiculopathy who received epidural corticosteroid injection were observed to determine the effects that nonorganic signs have on treatment outcome. A positive outcome was a decrease of 2 or more points in average arm pain, coupled with a score of 5 on a 7-point Patient Global Impression of Change scale 4 weeks after treatment. Nine tests in 5 categories (abnormal tenderness, regional disturbances deviating from normal anatomy, overreaction, discrepancies in examination findings with distraction, and pain during sham stimulation) were modified from previous studies and standardized. Other variables examined for their association with nonorganic signs and outcomes included disease burden, psychopathology, coexisting pain conditions, and somatization. RESULTS Of the 78 patients, 29% (n=23) had no nonorganic signs, 21% (n=16) had signs in 1 category, 10% (n=8) had signs in 2 categories, 21% (n=16) had signs in 3 categories, 10% (n=8) had signs in 4 categories, and 9% (n=7) had signs in 5 categories. The most common nonorganic sign was superficial tenderness (44%; n=34). Mean number of positive nonorganic categories was higher in individuals with negative treatment outcomes (2.5±1.8; 95% CI, 2.0 to 3.1) compared with those with positive outcomes (1.1±1.3; 95% CI, 0.7 to 1.5; P=.0002). Negative treatment outcomes were most strongly associated with regional disturbances and overreaction. Positive associations were noted between nonorganic signs and multiple pain (P=.011) and multiple psychiatric (P=.028) conditions. CONCLUSION Cervical nonorganic signs correlate with treatment outcome, pain, and psychiatric comorbidities. Screening for these signs and psychiatric symptoms may improve treatment outcomes. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT04320836.
Collapse
Affiliation(s)
- Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Pain Medicine Division, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Anesthesiology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD; Department of Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD.
| | - Tina L Doshi
- Department of Anesthesiology and Critical Care Medicine, Pain Medicine Division, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Edward Dolomisiewicz
- Department of Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - David E Reece
- Department of Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Zirong Zhao
- Departments of Neurology and Internal Medicine, District of Columbia Veterans Affairs Medical Center, Washington, DC
| | - Mirinda Anderson-White
- Department of Anesthesiology and Critical Care Medicine, Pain Medicine Division, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Angelia Kasuke
- Department of Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Eric J Wang
- Department of Anesthesiology and Critical Care Medicine, Pain Medicine Division, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Annie Hsu
- Department of Anesthesiology and Critical Care Medicine, Pain Medicine Division, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shelton A Davis
- Department of Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Yongjae Yoo
- Department of Anesthesiology, Seoul National University, Seoul, Korea
| | - Paul F Pasquina
- Department of Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD; Department of Orthopedic Surgery, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Jee Youn Moon
- Department of Anesthesiology, Seoul National University, Seoul, Korea
| |
Collapse
|
5
|
Abstract
Chronic neck and back pain are two of the most common and disabling complaints seen in primary care and neurology practices. Most commonly these come in the form of cervical and lumbar radiculopathy, lumbar spinal stenosis, and cervical and lumbar facet arthropathy. Treatment options are widespread and include nonpharmacological, pharmacological, surgical, and interventional options. The focus of this review will be to discuss the most common interventional procedures performed for chronic cervical and lumbar back pain, common indications for performing these interventions, as well as associated benefits and risks. These interventions alone may not suffice to improve the quality of life in those suffering from chronic pain. However, an understanding of the interventional pain options available and the evidence behind performing these interventions can help providers incorporate these into a multimodal approach to provide effective pain management that may allow patients an improved quality of life.
Collapse
Affiliation(s)
- Robert McCormick
- Department of Neurology, Boston Medical Center, Boston, Massachusetts
| | - Sunali Shah
- Department of Neurology, Boston Medical Center, Boston, Massachusetts
| |
Collapse
|
6
|
Plener J, da Silva-Oolup S, To D, Csiernik B, Hofkirchner C, Cox J, Chow N, Hogg-Johnson S, Ammendolia C. Eligibility Criteria of Participants in Randomized Controlled Trials Assessing Conservative Management of Cervical Radiculopathy: A Systematic Review. Spine (Phila Pa 1976) 2023; 48:E132-E157. [PMID: 36730764 DOI: 10.1097/brs.0000000000004537] [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: 04/06/2022] [Accepted: 08/13/2022] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE The aim of this study was to evaluate the inclusion and exclusion criteria for participants in randomized control trials (RCTs) assessing conservative management for cervical radiculopathy (CR), to determine if any consensus exists within the literature. SUMMARY OF BACKGROUND DATA A 2012 systematic review identified a lack of uniformity for the eligibility criteria of participants in RCTs evaluating conservative interventions for CR. Since then, a large number of RCTs have been published, signaling the need for an updated evaluation of this topic. MATERIALS AND METHODS We electronically searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022, to identify RCTs assessing conservative management of CR. Information extracted was analyzed to determine the level of homogeneity and/or heterogeneity of the inclusion and exclusion criteria across studies. RESULTS Seventy-six RCTs met our inclusion criteria with 68 distinct trials identified. The inclusion of arm pain with or without another symptom ( i.e. numbness, paresthesia, or weakness) was required in 69.12% of trials, 50% of trials required participants to exhibit neck symptoms, and 73.53% of studies required some form of clinical examination findings, but inconsistencies existed for the number and type of tests used. Furthermore, 41.18% of trials included imaging, with 33.82% of trials requiring magnetic resonance imaging findings. The most common exclusion criteria included were the presence of red flags and cervical myelopathy in 66.18% and 58.82% of trials, respectively. CONCLUSIONS Overall, there is still a lack of uniformity for the inclusion/exclusion criteria of trials assessing the conservative management of CR, with some improvements noted compared with the 2012 review. Based on the current literature assessing the diagnostic utility of clinical symptoms and confirmatory tests, we proposed inclusion criteria for trials assessing conservative interventions. Future research should aim to develop standardized classification criteria to improve consistency among studies.
Collapse
Affiliation(s)
- Joshua Plener
- Division of Graduate Education, Canadian Memorial Chiropractic College, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Sophia da Silva-Oolup
- Division of Graduate Education, Canadian Memorial Chiropractic College, Toronto, ON, Canada
| | - Daphne To
- Department of Clinical Education, Canadian Memorial Chiropractic College, Toronto, ON, Canada
| | - Ben Csiernik
- Department of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, ON, Canada
| | | | - Jocelyn Cox
- Department of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, ON, Canada
| | - Ngai Chow
- Private Practice, Toronto, ON, Canada
| | - Sheilah Hogg-Johnson
- Department of Research and Innovation, Canadian Memorial Chiropractic College, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Institute for Disability and Rehabilitation Research, Oshawa, ON, Canada
- Faculty of Health Sciences, Ontario Tech University, Oshawa, ON, Canada
| | - Carlo Ammendolia
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
7
|
Plener J, Csiernik B, To D, da Silva-Oolup S, Hofkirchner C, Cox J, Cancelliere C, Chow N, Hogg-Johnson S, Ammendolia C. Conservative Management of Cervical Radiculopathy: A Systematic Review. Clin J Pain 2023; 39:138-146. [PMID: 36599029 DOI: 10.1097/ajp.0000000000001092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/13/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The purpose of this systematic review was to assess the effectiveness and safety of conservative interventions compared with other interventions, placebo/sham interventions, or no intervention on disability, pain, function, quality of life, and psychological impact in adults with cervical radiculopathy (CR). METHODS We searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022 to identify studies that were randomized controlled trials, had at least one conservative treatment arm, and diagnosed participants with CR through confirmatory clinical examination and/or diagnostic tests. Studies were appraised using the Cochrane Risk of Bias 2 tool and the quality of the evidence was rated using the Grades of Recommendations, Assessment, Development, and Evaluation approach. RESULTS Of the 2561 records identified, 59 trials met our inclusion criteria (n = 4108 participants). Due to clinical and statistical heterogeneity, the findings were synthesized narratively. There is very-low certainty evidence supporting the use of acupuncture, prednisolone, cervical manipulation, and low-level laser therapy for pain and disability in the immediate to short-term, and thoracic manipulation and low-level laser therapy for improvements in cervical range of motion in the immediate term. There is low to very-low certainty evidence for multimodal interventions, providing inconclusive evidence for pain, disability, and range of motion. There is inconclusive evidence for pain reduction after conservative management compared with surgery, rated as very-low certainty. DISCUSSION There is a lack of high-quality evidence, limiting our ability to make any meaningful conclusions. As the number of people with CR is expected to increase, there is an urgent need for future research to help address these gaps.
Collapse
Affiliation(s)
- Joshua Plener
- Division of Graduate Education
- Institute of Health Policy, Management and Evaluation
| | | | | | | | | | | | - Carol Cancelliere
- Institute for Disability and Rehabilitation Research
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada
| | | | - Sheilah Hogg-Johnson
- Department of Research and Innovation, Canadian Memorial Chiropractic College
- Institute of Health Policy, Management and Evaluation
- Dalla Lana School of Public Health
- Institute for Disability and Rehabilitation Research
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada
| | - Carlo Ammendolia
- Institute of Health Policy, Management and Evaluation
- Department of Surgery, University of Toronto
- Department of Medicine, Mount Sinai Hospital, Toronto
| |
Collapse
|
8
|
Lee Y, Kim DH, Park J, Shin JW, Choi SS. Stellate ganglion block versus cervical epidural steroid injection for cervical radiculopathy: a comparative-effectiveness study. Reg Anesth Pain Med 2022; 47:501-503. [DOI: 10.1136/rapm-2022-103532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/21/2022] [Indexed: 11/04/2022]
|
9
|
Hurley RW, Adams MCB, Barad M, Bhaskar A, Bhatia A, Chadwick A, Deer TR, Hah J, Hooten WM, Kissoon NR, Lee DW, Mccormick Z, Moon JY, Narouze S, Provenzano DA, Schneider BJ, van Eerd M, Van Zundert J, Wallace MS, Wilson SM, Zhao Z, Cohen SP. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. PAIN MEDICINE (MALDEN, MASS.) 2021; 22:2443-2524. [PMID: 34788462 PMCID: PMC8633772 DOI: 10.1093/pm/pnab281] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial. METHODS In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4-5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement. RESULTS Twenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation. CONCLUSIONS Cervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.
Collapse
Affiliation(s)
- Robert W Hurley
- Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Meredith C B Adams
- Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Meredith Barad
- Anesthesiology, Perioperative and Pain Medicine, Stanford Hospital and Clinics, Redwood City, California, USA
| | - Arun Bhaskar
- Anesthesiology, Imperial College Healthcare NHS Trust Haemodialysis Clinic, Hayes Satellite Unit, Hayes, UK
| | - Anuj Bhatia
- Anesthesia and Pain Management, University of Toronto and University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Andrea Chadwick
- Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Timothy R Deer
- Spine and Nerve Center of the Virginias, West Virginia University - Health Sciences Campus, Morgantown, West Virginia, USA
| | - Jennifer Hah
- Anesthesiology, Stanford University School of Medicine, Palo Alto, California, USA
| | | | | | - David Wonhee Lee
- Fullerton Orthopaedic Surgery Medical Group, Fullerton, California, USA
| | - Zachary Mccormick
- Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jee Youn Moon
- Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongno-gu, South Korea
| | - Samer Narouze
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - David A Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania, USA
- Pain Diagnostics and Interventional Care, Edgeworth, Pennsylvania, USA
| | - Byron J Schneider
- Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee, USA
| | - Maarten van Eerd
- Anesthesiology, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Jan Van Zundert
- Anesthesiology, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Mark S Wallace
- Anesthesiology, UCSD Medical Center - Thornton Hospital, San Diego, California, USA
| | | | - Zirong Zhao
- Neurology, VA Healthcare Center District of Columbia, Washington, District of Columbia, USA
| | - Steven P Cohen
- Anesthesia, WRNMMC, Bethesda, Maryland, USA
- Physical Medicine and Rehabilitation, WRNMMC, Bethesda, Maryland, USA
- Anesthesiology, Neurology, Physical Medicine and Rehabilitation and Psychiatry, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
10
|
Hurley RW, Adams MCB, Barad M, Bhaskar A, Bhatia A, Chadwick A, Deer TR, Hah J, Hooten WM, Kissoon NR, Lee DW, Mccormick Z, Moon JY, Narouze S, Provenzano DA, Schneider BJ, van Eerd M, Van Zundert J, Wallace MS, Wilson SM, Zhao Z, Cohen SP. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group. Reg Anesth Pain Med 2021; 47:3-59. [PMID: 34764220 PMCID: PMC8639967 DOI: 10.1136/rapm-2021-103031] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/02/2021] [Indexed: 01/03/2023]
Abstract
Background The past two decades have witnessed a surge in the use of cervical spine joint
procedures including joint injections, nerve blocks and radiofrequency ablation to treat
chronic neck pain, yet many aspects of the procedures remain controversial. Methods In August 2020, the American Society of Regional Anesthesia and Pain Medicine and the
American Academy of Pain Medicine approved and charged the Cervical Joint Working Group
to develop neck pain guidelines. Eighteen stakeholder societies were identified, and
formal request-for-participation and member nomination letters were sent to those
organizations. Participating entities selected panel members and an ad hoc steering
committee selected preliminary questions, which were then revised by the full committee.
Each question was assigned to a module composed of 4–5 members, who worked with
the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent
to the full committee after revisions. We used a modified Delphi method whereby the
questions were sent to the committee en bloc and comments were returned in a non-blinded
fashion to the Chairs, who incorporated the comments and sent out revised versions until
consensus was reached. Before commencing, it was agreed that a recommendation would be
noted with >50% agreement among committee members, but a consensus
recommendation would require ≥75% agreement. Results Twenty questions were selected, with 100% consensus achieved in committee on 17
topics. Among participating organizations, 14 of 15 that voted approved or supported the
guidelines en bloc, with 14 questions being approved with no dissensions or abstentions.
Specific questions addressed included the value of clinical presentation and imaging in
selecting patients for procedures, whether conservative treatment should be used before
injections, whether imaging is necessary for blocks, diagnostic and prognostic value of
medial branch blocks and intra-articular joint injections, the effects of sedation and
injectate volume on validity, whether facet blocks have therapeutic value, what the
ideal cut-off value is for designating a block as positive, how many blocks should be
performed before radiofrequency ablation, the orientation of electrodes, whether larger
lesions translate into higher success rates, whether stimulation should be used before
radiofrequency ablation, how best to mitigate complication risks, if different standards
should be applied to clinical practice and trials, and the indications for repeating
radiofrequency ablation. Conclusions Cervical medial branch radiofrequency ablation may provide benefit to well-selected
individuals, with medial branch blocks being more predictive than intra-articular
injections. More stringent selection criteria are likely to improve denervation
outcomes, but at the expense of false-negatives (ie, lower overall success rate).
Clinical trials should be tailored based on objectives, and selection criteria for some
may be more stringent than what is ideal in clinical practice.
Collapse
Affiliation(s)
- Robert W Hurley
- Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Meredith C B Adams
- Anesthesiology, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Meredith Barad
- Anesthesiology, Perioperative and Pain Medicine, Stanford Hospital and Clinics, Redwood City, California, USA
| | - Arun Bhaskar
- Anesthesiology, Imperial College Healthcare NHS Trust Haemodialysis Clinic, Hayes Satellite Unit, Hayes, UK
| | - Anuj Bhatia
- Anesthesia and Pain Management, University of Toronto and University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Andrea Chadwick
- Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Timothy R Deer
- Spine and Nerve Center of the Virginias, West Virginia University - Health Sciences Campus, Morgantown, West Virginia, USA
| | - Jennifer Hah
- Stanford University School of Medicine, Palo Alto, California, USA
| | | | | | - David Wonhee Lee
- Fullerton Orthopaedic Surgery Medical Group, Fullerton, California, USA
| | - Zachary Mccormick
- Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jee Youn Moon
- Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea.,Anesthesiology and Pain Medicine, Seoul National University Hospital, Jongno-gu, South Korea
| | - Samer Narouze
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - David A Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, Pennsylvania, USA.,Pain Diagnostics and Interventional Care, Edgeworth, Pennsylvania, USA
| | - Byron J Schneider
- Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee, USA
| | - Maarten van Eerd
- Anesthesiology, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Jan Van Zundert
- Anesthesiology, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
| | - Mark S Wallace
- Anesthesiology, UCSD Medical Center - Thornton Hospital, San Diego, California, USA
| | | | - Zirong Zhao
- Neurology, VA Healthcare Center District of Columbia, Washington, District of Columbia, USA
| | - Steven P Cohen
- Anesthesiology, Neurology, Physical Medicine and Rehabilitation and Psychiatry, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
11
|
Van Boxem K, Cohen SP, van Kuijk SMJ, Hollmann MW, Zuidema X, Kallewaard JW, Benzon HT, Van Zundert J. Systematic Review on Epidural Steroid Injections: Quo Vadis? Clin J Pain 2021; 37:863-865. [PMID: 34419976 DOI: 10.1097/ajp.0000000000000973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Koen Van Boxem
- Department of Anesthesiology, Critical Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Bessemerstraat, Lanaken Belgium
- Department of Anesthesiology and Pain Medicine
| | - Steven P Cohen
- Departments of Anesthesiology and Critical Care Medicine, Neurology, Physical Medicine and Rehabilitation and Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore
- Departments of Physical Medicine and Rehabilitation and Anesthesiology Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Sander M J van Kuijk
- Department Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht
| | - Marcus W Hollmann
- Department of Anesthesiology Amsterdam University Medical Center, location AMC Amsterdam
| | - Xander Zuidema
- Department of Anesthesiology and Pain Medicine
- Department of Anesthesiology and Pain Medicine, Diakonessenziekenhuis, Utrecht/Zeist
| | - Jan W Kallewaard
- Department of Anesthesiology Amsterdam University Medical Center, location AMC Amsterdam
- Department of Anesthesiology, Rijnstate Hospital, AZ Velp, The Netherlands
| | - Honorio T Benzon
- Department of Anesthesiology Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jan Van Zundert
- Department of Anesthesiology, Critical Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Bessemerstraat, Lanaken Belgium
- Department of Anesthesiology and Pain Medicine
| |
Collapse
|
12
|
Cohen SP, Vase L, Hooten WM. Chronic pain: an update on burden, best practices, and new advances. Lancet 2021; 397:2082-2097. [PMID: 34062143 DOI: 10.1016/s0140-6736(21)00393-7] [Citation(s) in RCA: 672] [Impact Index Per Article: 224.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 07/08/2020] [Accepted: 07/29/2020] [Indexed: 12/19/2022]
Abstract
Chronic pain exerts an enormous personal and economic burden, affecting more than 30% of people worldwide according to some studies. Unlike acute pain, which carries survival value, chronic pain might be best considered to be a disease, with treatment (eg, to be active despite the pain) and psychological (eg, pain acceptance and optimism as goals) implications. Pain can be categorised as nociceptive (from tissue injury), neuropathic (from nerve injury), or nociplastic (from a sensitised nervous system), all of which affect work-up and treatment decisions at every level; however, in practice there is considerable overlap in the different types of pain mechanisms within and between patients, so many experts consider pain classification as a continuum. The biopsychosocial model of pain presents physical symptoms as the denouement of a dynamic interaction between biological, psychological, and social factors. Although it is widely known that pain can cause psychological distress and sleep problems, many medical practitioners do not realise that these associations are bidirectional. While predisposing factors and consequences of chronic pain are well known, the flipside is that factors promoting resilience, such as emotional support systems and good health, can promote healing and reduce pain chronification. Quality of life indicators and neuroplastic changes might also be reversible with adequate pain management. Clinical trials and guidelines typically recommend a personalised multimodal, interdisciplinary treatment approach, which might include pharmacotherapy, psychotherapy, integrative treatments, and invasive procedures.
Collapse
Affiliation(s)
- Steven P Cohen
- Johns Hopkins School of Medicine, Baltimore, MD, USA; Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Lene Vase
- Neuroscientific Division, Department of Psychology and Behavioural Sciences, Aarhus University Hospital, Aarhus, Denmark
| | | |
Collapse
|
13
|
Davison MA, Lilly DT, Eldridge CM, Singh R, Bagley C, Adogwa O. Comparison of Postoperative Opioid Utilization in an ACDF Cohort: Narcotic Naive Patients Versus Preoperative Opioid Users. Clin Spine Surg 2021; 34:E86-E91. [PMID: 33633064 DOI: 10.1097/bsd.0000000000001053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 06/19/2020] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE To compare the postoperative opioid utilization rates and costs after anterior cervical discectomy and fusion (ACDF) procedures between groups of patients who were preoperative opioid users versus opioid naive. SUMMARY OF BACKGROUND DATA Opioid medications are frequently prescribed after ACDF procedures. Given the current opioid epidemic, there is increased emphasis on early identification of patients at risk for prolonged postoperative opioid use. METHODS Records from patients diagnosed with cervical stenosis who underwent a ≤3-level index ACDF surgery between 2007 and 2017 were collected from a large insurance database. International Classification of Diseases diagnosis/procedure codes, Current Procedural Terminology codes, and generic drug codes were used to search clinical records. Two cohorts were established: a group of patients who utilized opioids preoperatively and a group of patients who were opioid naive at the time of surgery. The 1-year utilization and costs of postoperative therapies were documented for each group. RESULTS The preoperative opioid use cohort contained 4485 patients (61.6%), whereas the opioid-naive cohort included 2799 patients (38.4%). Postoperatively, 86.6% of the preoperative opioid use group continued to use opioids, whereas 59.0% of the opioid-naive group began using opioids. Patients who utilized opioids preoperatively were 4.48 times more likely (95% confidence interval, 3.99-5.02, P<0.001) to use opioids postoperatively and 4.30 times more likely (95% confidence interval, 3.10-5.94, P<0.001) to become opioid dependent compared with opioid-naive patients. In addition, after normalization, patients in the preoperative opioid use group utilized 3.7 times more opioid units/patient and billed for 5.3 times more dollars/patient than opioid-naive patients. CONCLUSIONS In patients with cervical stenosis who undergo an ACDF procedure, the postoperative utilization and costs of opioids seem to be substantially higher in patients with preoperative opioid use compared with opioid-naive patients. Efforts should be made to avoid opioid use as a component of conservative management before surgery. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Mark A Davison
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH
| | - Daniel T Lilly
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH
| | - Cody M Eldridge
- Department of Neurosurgery, University of Texas, Southwestern Medical Center, Dallas, TX
| | - Ravinderjit Singh
- Department of Neurosurgery, University of Texas, Southwestern Medical Center, Dallas, TX
| | - Carlos Bagley
- Department of Neurosurgery, University of Texas, Southwestern Medical Center, Dallas, TX
| | - Owoicho Adogwa
- Department of Neurosurgery, University of Texas, Southwestern Medical Center, Dallas, TX
| |
Collapse
|
14
|
Xu Y, Mauer KM, Singh A. Pain Management in Neurosurgery: Back and Lower Extremity Pain, Trigeminal Neuralgia. Anesthesiol Clin 2021; 39:179-194. [PMID: 33563380 DOI: 10.1016/j.anclin.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Interventional anesthetic techniques are an integral component of a biopsychosocial approach and multidisciplinary treatment. Injection techniques are often used to diagnose disorders, decrease the need for surgery, or increase the time to surgery. The role of neural blockade techniques using local anesthetics and steroids in the assessment and treatment of pain continues to be refined. With the current opioid crisis and an aging population with increasing medical comorbidities, there is an emphasis on the use of nonopioid, nonsurgical, and multimodal therapies to treat chronic pain. This article reviews indications, goals, and methods of common injection techniques.
Collapse
Affiliation(s)
- Yifan Xu
- Anesthesiology, Oregon Health and Science University, Portland, OR, USA.
| | - Kimberly M Mauer
- Comprehensive Pain Center, Anesthesiology and Perioperative Medicine, Oregon Health and Sciences University, 3303 South West Bond Avenue Suite Ch4p Floor 4, Portland, OR 97239, USA
| | - Amit Singh
- Anesthesiology, Medical College of Wisconsin, Milwaukee, 959 North Mayfair Road, Wauwatosa, WI 53226, USA
| |
Collapse
|
15
|
Shanthhanna H, Cohen SP, Narouze S. Upper limb weakness and importance of immediate pain relief after cervical epidural steroid injections: more questions than answers? Reg Anesth Pain Med 2021; 46:1113. [PMID: 33483424 PMCID: PMC8606434 DOI: 10.1136/rapm-2020-102386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 12/16/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Harsha Shanthhanna
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Steven P Cohen
- Department of Anesthesiology and Critical Care Medicine, Neurology and Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Samer Narouze
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| |
Collapse
|
16
|
Ehsanian R, Schneider BJ, Kennedy DJ, Koshkin E. Ultrasound-guided cervical selective nerve root injections: a narrative review of literature. Reg Anesth Pain Med 2021; 46:416-421. [PMID: 33441430 DOI: 10.1136/rapm-2020-102325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND/IMPORTANCE Ultrasound (US)-guided cervical selective nerve root injections (CSNRI) have been proposed as an alternative to fluoroscopic (FL) -guided injections. When choosing US guidance, the proceduralist should be aware of potential issues confirming vertebral level, be clear regarding terminology, and up to date regarding the advantages and disadvantages of US-guided CSNRI. OBJECTIVE Review the accuracy and effectiveness of US guidance in avoiding vascular puncture (VP) and/or intravascular injection (IVI) during CSNRI. EVIDENCE REVIEW Queries included PubMed, CINAHL and Embase databases from 2005 to 2019. Three authors reviewed references for eligibility, abstracted data, and appraised quality. FINDINGS The literature demonstrates distinct safety considerations and limited evidence of the effectiveness of US guidance in detecting VP and/or IVI. As vascular flow and desired injectate spread cannot be visualized with US, the use of real-time fluoroscopy, and if needed digitial subraction imaging, is indicated in cervical transforaminal epidural injections (CTFEIs). Given the risk of VP and/or IVI, the ability to perform and to retain FL images to document that the procedure was safely conducted is valuable in CTFEIs. CONCLUSION US guidance remains to be proven as a non-inferior alternative to FL guidance or other imaging modalities in the prevention of VP and/or IVI with CTFEIs or cervical selective nerve root blocks. There is a paucity of adequately powered clinical studies evaluating the accuracy and effectiveness of US guidance in avoiding VP and/or IVI. US-guided procedures to treat cervical radicular pain has limitations in visualization of anatomy, and currently with the evidence available is best used in a combined approach with FL guidance.
Collapse
Affiliation(s)
- Reza Ehsanian
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedics & Rehabilitation, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Byron J Schneider
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David J Kennedy
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eugene Koshkin
- Department of Anesthesia & Critical Care Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| |
Collapse
|
17
|
Affiliation(s)
- Arianne P Verhagen
- Discipline of Physiotherapy, Graduate School of Health, University of Technology Sydney, Sydney, Australia.
| |
Collapse
|
18
|
Kleimeyer JP, Koltsov JCB, Smuck MW, Wood KB, Cheng I, Hu SS. Cervical epidural steroid injections: incidence and determinants of subsequent surgery. Spine J 2020; 20:1729-1736. [PMID: 32565316 DOI: 10.1016/j.spinee.2020.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Cervical epidural steroid injections (CESIs) are sometimes used in the management of cervical radicular pain in order to delay or avoid surgery. However, the rate and determinants of surgery following CESIs remain uncertain. PURPOSE This study sought to determine: (1) the proportion of patients having surgery following CESI, and (2) the timing of and factors associated with subsequent surgery. STUDY DESIGN Retrospective analysis of a large, national administrative claims database. PATIENT SAMPLE The study included 192,777 CESI patients (age 50.9±11.3 years, 55.2% female) who underwent CESI for imaging-based diagnoses of cervical disc herniation or stenosis, a clinical diagnosis of radiculopathy, or a combination thereof. OUTCOME MEASURES The primary outcome was the time from index CESI to surgery. METHODS Inclusion criteria were CESI for cervical disc herniation, stenosis, or radiculopathy, age ≥18, and active enrollment for 1 year before CESI to screen for exclusions. Patients were followed until they underwent cervical surgery, or their enrollment lapsed. Rates of surgery were assessed with Kaplan-Meier survival curves and 99% confidence intervals. Factors associated with subsequent surgery were assessed with multivariable Cox proportional hazard models. RESULTS Within 6 months of CESI, 11.2% of patients underwent surgery, increasing to 14.5% by 1 year and 22.3% by 5 years. Male patients and those aged 35 to 54 had an increased likelihood of subsequent surgery. Patients with radiculopathy were less likely to undergo surgery following CESI than those with stenosis or herniation, while patients with multiple diagnoses were more likely. Patients with comorbidities including CHF, other cardiac comorbidities or chronic pain were less likely to undergo surgery, as were patients in the northeast US region. Some 33.5% of patients underwent >1 CESI, with 84.6% of these occurring within 1 year. Additional injections were associated with reduced rates of subsequent surgery. CONCLUSIONS Following CESI, over one in five patients underwent surgery within 5 years. Multiple patient-specific risk factors for subsequent surgery were identified, and patients undergoing repeated injections were at lower risk. Determining which patients may progress to surgery can be used to improve resource utilization and to inform shared decision-making.
Collapse
Affiliation(s)
- John P Kleimeyer
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway Street MC 6342, Redwood City, CA 94063, USA
| | - Jayme C B Koltsov
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway Street MC 6342, Redwood City, CA 94063, USA
| | - Matthew W Smuck
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway Street MC 6342, Redwood City, CA 94063, USA
| | - Kirkham B Wood
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway Street MC 6342, Redwood City, CA 94063, USA
| | - Ivan Cheng
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway Street MC 6342, Redwood City, CA 94063, USA
| | - Serena S Hu
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway Street MC 6342, Redwood City, CA 94063, USA.
| |
Collapse
|
19
|
Abstract
INTRODUCTION Musculoskeletal injury can substantially affect orthopaedic surgeons and productivity. The objective of this study was to assess occupation-related neck pain and cervical radiculopathy/myelopathy among orthopaedic surgeons and to identify the potential risk factors for injury. METHODS An online survey was sent to orthopaedic surgeons via their state orthopaedic society. The survey consisted of items related to orthopaedic practices, such as the number of arthroscopic procedures done and the use of microscopes/loupes. The prevalence, potential causes, and reporting practices of neck pain and cervical radiculopathy/myelopathy among orthopaedic surgeons were also assessed. RESULTS There were 685 responses from surgeons representing 27 states. A total of 59.3% of respondents reported neck pain and 22.8% reported cervical radiculopathy. After adjusting for age and sex, surgeons performing arthroscopy had an odds ratio of 3.3 (95% confidence interval: 1.4 to 8.3, P = 0.007) for neck pain. Only five of the surgeons with neck pain and one of the surgeons with cervical radiculopathy/myelopathy had ergonomic evaluations. CONCLUSION Neck pain and cervical radiculopathy/myelopathy are common among orthopaedic surgeons. Associated factors included older age, higher stress levels, and performing arthroscopy. Cervical injuries are rarely reported, and ergonomic workplace evaluations are infrequent.
Collapse
|
20
|
Cohen SP, Bhaskar A, Bhatia A, Buvanendran A, Deer T, Garg S, Hooten WM, Hurley RW, Kennedy DJ, McLean BC, Moon JY, Narouze S, Pangarkar S, Provenzano DA, Rauck R, Sitzman BT, Smuck M, van Zundert J, Vorenkamp K, Wallace MS, Zhao Z. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Reg Anesth Pain Med 2020; 45:424-467. [PMID: 32245841 PMCID: PMC7362874 DOI: 10.1136/rapm-2019-101243] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/07/2020] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial. METHODS After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, letters were sent to a dozen pain societies, as well as representatives from the US Departments of Veterans Affairs and Defense. A steering committee was convened to select preliminary questions, which were revised by the full committee. Questions were assigned to 4-5 person modules, who worked with the Subcommittee Lead and Committee Chair on preliminary versions, which were sent to the full committee. We used a modified Delphi method, whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chair, who incorporated the comments and sent out revised versions until consensus was reached. RESULTS 17 questions were selected for guideline development, with 100% consensus achieved by committee members on all topics. All societies except for one approved every recommendation, with one society dissenting on two questions (number of blocks and cut-off for a positive block before RFA), but approving the document. Specific questions that were addressed included the value of history and physical examination in selecting patients for blocks, the value of imaging in patient selection, whether conservative treatment should be used before injections, whether imaging is necessary for block performance, the diagnostic and prognostic value of medial branch blocks (MBB) and intra-articular (IA) injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for a prognostic block, how many blocks should be performed before RFA, how electrodes should be oriented, the evidence for larger lesions, whether stimulation should be used before RFA, ways to mitigate complications, if different standards should be applied to clinical practice and clinical trials and the evidence for repeating RFA (see table 12 for summary). CONCLUSIONS Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.
Collapse
Affiliation(s)
- Steven P Cohen
- Anesthesiology, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Arun Bhaskar
- Anesthesiology, Imperial College Healthcare NHS Trust Haemodialysis Clinic Hayes Satellite Unit, Hayes, UK
| | - Anuj Bhatia
- Anesthesia and Pain Management, University of Toronto and University Health Network-Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Tim Deer
- Spine & Nerve Centers, Charleston, West Virginia, USA
| | - Shuchita Garg
- Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Robert W Hurley
- Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - David J Kennedy
- Physical Medicine & Rehabilitation, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Brian C McLean
- Anesthesiology, Tripler Army Medical Center, Tripler Army Medical Center, Hawaii, USA
| | - Jee Youn Moon
- Dept of Anesthesiology, Seoul National University College of Medicine, Seoul, The Republic of Korea
| | - Samer Narouze
- Center for Pain Medicine, Summa Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Sanjog Pangarkar
- Dept of Physical Medicine and Rehabilitation, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Richard Rauck
- Carolinas Pain Institute, Winston Salem, North Carolina, USA
| | | | - Matthew Smuck
- Dept.of Orthopaedic Surgery, Division of Physical Medicine & Rehabilitation, Stanford Medicine, Stanford, California, USA
| | - Jan van Zundert
- Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Lanaken, Belgium
- Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Mark S Wallace
- Anesthesiology, UCSD Medical Center-Thornton Hospital, San Diego, California, USA
| | - Zirong Zhao
- Neurology, VA Healthcare Center District of Columbia, Washington, District of Columbia, USA
| |
Collapse
|
21
|
Jamison DE, Cohen SP. Critically Evaluating the Evidence for Epidural Injections for Failed Back Surgery Syndrome: Should Pain Physicians Be Bracing for Impact? PAIN MEDICINE 2020; 19:1299-1301. [PMID: 29800245 DOI: 10.1093/pm/pny101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- David E Jamison
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Anesthesiology
| | - Steven P Cohen
- Department of Anesthesiology and Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Department of Anesthesiology and Critical Care Medicine.,Department of Neurology.,Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
22
|
Abstract
Neck pain is the fourth leading cause of disability. Acute neck pain largely resolves within 2 months. History and physical examination play a key role in ruling out some of the more serious causes for neck pain. The evidence for pharmacologic interventions for acute and chronic musculoskeletal neck pain is limited. Lower back pain is the leading cause of disability and productivity loss. Consultation with a physical medicine and rehabilitation spine specialist within 48 hours for acute pain and within 10 days for all patients with lower back pain may significantly decrease rate of surgical interventions and increase patient satisfaction.
Collapse
Affiliation(s)
- Adrian Popescu
- Department of Physical Medicine and Rehabilitation, Hospital of the University of Pennsylvania, Perelman School of Medicine, 1800 Lombard Street, Philadelphia, PA 19146, USA.
| | - Haewon Lee
- Physical Medicine & Rehabilitation, Department of Orthopedic Surgery, University of California San Diego, 200 West Arbor Drive, #8894, San Diego, CA 92103, USA
| |
Collapse
|
23
|
Hong JY, Park JS, Suh SW, Yang JH, Park SY, Kim BT. Transforaminal epidural steroid injections in cervical spinal disease with moderate to severe disability: Comparative study in patients with or without surgery. Medicine (Baltimore) 2020; 99:e19266. [PMID: 32049868 PMCID: PMC7035037 DOI: 10.1097/md.0000000000019266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Despite many clinical trials on cervical epidural steroid injections, the indications for and long-standing outcomes of this treatment remain controversial. We evaluated the outcomes and indications for transforaminal cervical epidural steroid injection (TCESI) in patients with moderate to severe disability.We prospectively gathered data from patients with 1 or 2-level cervical degenerative disease (herniated disc, foraminal stenosis) with moderate to severe disability (3.5 < initial visual analog scale < 6.5, 15 < Neck Disability Index < 35) and greater than 12 weeks of pain, despite conservative treatment. Patients with persistent disability and those who desired surgical intervention underwent decompression surgery. The clinical and demographic characteristics were compared between groups.Of the 309 patients who underwent TCESI, 221 (72%) did not receive surgical treatment during the 1-year follow-up period. The remaining 88 patients (28%) underwent surgery at a mean of 4.1 months after initial TCESI. Patients who underwent injection alone showed a significant decrease in disability and pain that persisted until the 1-year follow-up visit (P < .05). In patients who underwent surgery, the mean disability and pain scores after injection did not decrease for several months, although the scores significantly decreased up to 1 year after surgery (P < .05).The TCESI significantly decreased pain and disability in the moderate to severe disability group up to 1 year after injection. We recommend cervical TCESI as an initial treatment with moderate to severe disability patients.
Collapse
Affiliation(s)
- Jae-Young Hong
- Department of Orthopedics, Korea University Ansan Hospital, Ansan
| | - Jin-Sung Park
- Department of Orthopedics, Korea University Ansan Hospital, Ansan
| | - Seung-Woo Suh
- Department of Orthopedics, Korea University Guro Hospital
| | - Jae-Hyuk Yang
- Department of Orthopedics, Korea University Guro Hospital
| | - Si-Young Park
- Department of Orthopedics, Korea University Anam Hospital, Seoul, South Korea
| | - Bo Taek Kim
- Department of Orthopedics, Korea University Ansan Hospital, Ansan
| |
Collapse
|
24
|
Cervical Ultrasound Utilization in Selective Cervical Nerve Root Injection for the Treatment of Cervical Radicular Pain: a Review. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00248-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
25
|
Smith GA, Pace J, Strohl M, Kaul A, Hayek S, Miller JP. Rare Neurosurgical Complications of Epidural Injections: An 8-Yr Single-Institution Experience. Oper Neurosurg (Hagerstown) 2019; 13:271-279. [PMID: 28927205 DOI: 10.1093/ons/opw014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 10/22/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Neurosurgical complications from epidural injections have rarely been reported. OBJECTIVE To define the spectrum of complications from these procedures in order to identify risk factors and strategies for prevention. METHODS A prospectively maintained database of 14 247 neurosurgical admissions over 8 yr was screened to identify patients who had suffered procedural complications associated with 1182 cervical and 4617 lumbar interlaminar epidural injection procedures performed at a single institution. Patients who developed new neurological symptoms or deficits were included. A retrospective analysis of demographic and procedural features was performed. RESULTS Thirteen patients experienced complications requiring neurosurgical treatment, accounting for an overall procedural complication rate of 0.22% (0.51% and 0.15% for cervical and lumbar injections, respectively), and representing 0.09% of all neurosurgical admissions over 8 yr. There were 3 categories: hemorrhage (n = 7), infection (n = 3), and inadvertent dural penetration (n = 3). There was significant association with anticoagulation use among patients with hemorrhagic vs nonhemorrhagic complications ( P < .01, Fisher's exact test). Six patients who developed epidural hematoma had been managed in accordance with current guidelines, either after prolonged cessation of anticoagulation (n = 3) or taking only aspirin (n = 3); all were decompressed promptly with good long-term outcome. All infections were associated with lumbar injection. Dural penetration resulted in diffuse pneumocephalus (n = 1), intramedullary air at the site of injection (n = 1), and acutely symptomatic colloid cyst (n = 1). CONCLUSION A majority of neurosurgical complications from epidural injections are hemorrhagic and associated with anticoagulation, although infection and inadvertent dural penetration also occur. Prompt treatment of compressive lesions is associated with good outcome.
Collapse
Affiliation(s)
- Gabriel A Smith
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Jonathan Pace
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Madeleine Strohl
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Anand Kaul
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Salim Hayek
- Division of Pain Medicine, Depart-ment of Anesthesiology, University Hospi-tals Case Medical Center, Cleveland, Ohio
| | - Jonathan P Miller
- Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio
| |
Collapse
|
26
|
Heres EK, Itskevich D, Wasan AD. Operationalizing Multidisciplinary Assessment and Treatment as a Quality Metric for Interventional Pain Practices. PAIN MEDICINE 2019; 19:910-913. [PMID: 28605555 DOI: 10.1093/pm/pnx079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Quality improvement (QI) is an underutilized approach among pain medicine specialists to improve comprehensive pain assessment and the delivery of multimodal pain care. We report the results of a QI program that utilized peer review and financial incentives to improve these processes in interventional pain clinics. Design Retrospective chart review. Setting Eight academic and community-based practices that included separate hospital-based and non-hospital-based interventional pain clinics. Subjects Results of chart audits by nine academic pain medicine physicians. Methods An audit of a random sample of each pain physician's charts was periodically examined for mention and discussion of specific components of multidisciplinary pain care. A portion of the physician's incentive payment was withheld if less than 70% of charts were compliant. The rates of compliance after the intervention for the group were compared. Results Before this program was instituted, an audit of 10 patient charts from each of the nine pain medicine physicians revealed only a 13% baseline rate of compliance. After the audit system was implemented, 90% of all patient charts were compliant during the first 12-month period (P < 0.01 for the change in rate of compliance). Conclusions The results of this QI project suggest that pain clinics can make this value-based transition and offer high-quality multidisciplinary assessment and treatment, with good compliance among a group of physicians in primarily intervention-based practices.
Collapse
Affiliation(s)
- Edward K Heres
- Division of Pain Medicine, Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David Itskevich
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ajay D Wasan
- Division of Pain Medicine, Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| |
Collapse
|
27
|
Davison MA, Desai SA, Lilly DT, Vuong VD, Moreno J, Bagley C, Adogwa O. A Two-Year Cost Analysis of Maximum Nonoperative Treatments in Patients with Cervical Stenosis that Ultimately Required Surgery. World Neurosurg 2019; 124:e616-e625. [PMID: 30641237 DOI: 10.1016/j.wneu.2018.12.167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 12/19/2018] [Accepted: 12/20/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study is to characterize the use and associated costs of maximal nonoperative therapy (MNT) received within 2-years before anterior cervical discectomy and fusion (ACDF) surgery in patients with symptomatic cervical stenosis. METHODS An insurance database, including private/commercially insured and Medicare Advantage beneficiaries, was queried for patients undergoing 1-level, 2-level, or 3-level ACDF procedures between 2007 and 2016. Research records were searchable by International Classification of Diseases diagnosis and procedure, Current Procedural Terminology, and generic drug codes. The use of MNTs within 2 years before index ACDF surgery was assessed by cost billed to patients, prescriptions written, and number of units billed. RESULTS Of 220,902 (7.16%) eligible patients, 15,825 underwent index surgery. Patient breakdown of the use of MNT modalities was as follows: 5731 (36.2%) used nonsteroidal antiinflammatory drugs; 9827 (62.1%) used opioids; 7383 (46.7%) used muscle relaxants; 3609 (22.8%) received cervical epidural steroid injection; 5504 (34.8%) attended physical therapy/occupational therapy; 1663 (10.5%) received chiropractor treatments; and 200 (1.3%) presented to the emergency department. During the 2-year preoperative period, there were 51,675 prescriptions for diagnostic cervical imaging. The total direct cost associated with all MNTs before ACDF was $16,056,556. Cervical spine imaging comprised the largest portion of the total MNT cost ($8,677,110; 54.0%), followed by cervical epidural steroid injection ($3,315,913; 20.7%) and opioids ($2,228,221; 13.9%). Opiates were the most frequently prescribed therapy (71,602 prescriptions). DISCUSSION Opioids are the most frequently prescribed and most used therapy in the preoperative period for cervical stenosis. Further studies and improved guidelines are necessary to determine which patients may benefit from ACDF earlier in the course of nonoperative therapies.
Collapse
|
28
|
Alvin MD, Mehta V, Halabi HA, Lubelski D, Benzel EC, Mroz TE. Cost-Effectiveness of Cervical Epidural Steroid Injections: A 3-Month Pilot Study. Global Spine J 2019; 9:143-149. [PMID: 30984492 PMCID: PMC6448201 DOI: 10.1177/2192568218764913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVES There are conflicting reports on the short- and long-term quality of life (QOL) outcomes and cost-effectiveness of cervical epidural steroid injections (ESIs). The present study analyzes the cost-effectiveness analysis of ESIs versus conservative management for patients with radiculopathy or neck pain in the short term. METHODS Fifty patients who underwent cervical ESI and 29 patients who received physical therapy and pain medication alone for cervical radiculopathy and neck pain of <6 months duration were included. Three-month postoperative health outcomes were assessed based on EuroQol-5 Dimensions (EQ-5D; measured in quality-adjusted life years [QALYs]). Medical costs were estimated using Medicare national payment amounts. Cost/utility ratios and the incremental cost-effectiveness ratio (ICER) were calculated to assess for cost-effectiveness. RESULTS The ESI cohort experienced significant (P < .01) improvement in the EQ-5D score while the control cohort did not (0.13 vs 0.02 QALYs, respectively; P = .01). There were no significant differences in costs between the cohorts. The cost-utility ratio for the ESI cohort was significantly lower ($21 884/QALY gained) than that for the control cohort ($176 412/QALY gained) (P < .01). The ICER for an ESI versus conservative management was negative, indicating that ESIs provide greater improvement in QOL at a lower cost. CONCLUSIONS ESIs provide significant improvement in QOL within 3 months for patients with cervical radiculopathy and neck pain. ESIs are more cost-effective compared than conservative management alone in the shor -term. The durability of these results must be analyzed with longer term cost-utility analysis studies.
Collapse
Affiliation(s)
| | - Vikram Mehta
- Duke University School of Medicine, Durham, NC, USA
| | - Hadi Al Halabi
- Alfaisal University College of Medicine, Riyadh, Saudi Arabia
| | | | | | - Thomas E. Mroz
- Cleveland Clinic, Cleveland, Ohio, USA,Thomas E. Mroz, Departments of Orthopaedic and
Neurological Surgery, Neurological Institute, Cleveland Clinic Center for Spine Health,
The Cleveland Clinic, 9500 Euclid Avenue, S-80, Cleveland, OH 44195, USA.
| |
Collapse
|
29
|
Maher DP, Ding W, Singh S, Opalacz A, Fishman C, Houghton M, Ahmed S, Chen L, Mao J, Zhang Y. Thermal QST Phenotypes Associated with Response to Lumbar Epidural Steroid Injections: A Pilot Study. PAIN MEDICINE 2018; 18:1455-1463. [PMID: 28340251 DOI: 10.1093/pm/pnw364] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objective Response to lumbar epidural steroid injection in lumbar radicular pain varies. The purpose of this study is to characterize the changes in quantitative sensory testing (QST) phenotypes of subjects and compare the QST characteristics in patients who do respond to treatment of radicular pain with a lumbar epidural steroid injection (ESI). Design Prospective, observational pilot study. Setting Outpatient pain center. Methods Twenty subjects with a lower extremity (LE) radicular pain who were scheduled to have an ESI were recruited. At the visit prior to and four weeks following an ESI, subjects underwent QST measurements of both the affected LE and the contralateral unaffected UE. Results Following an ESI, nine subjects reported a greater than 30% reduction in radicular pain and 11 reported a less than 30% reduction in radicular pain. Subjects who had less than 30% pain reduction response (nonresponders) to an ESI had increased pre-injection warm sensation threshold (37.30 °C, SD = 2.51 vs 40.39, SD = 3.36, P = 0.03) and heat pain threshold (47.22 °C, SD = 1.38, vs 48.83 °C, SD = 2.10, P = 0.04). Further, the nonresponders also showed increased pre-injection warm sensation threshold as measured in the difference of warm sensation detection threshold difference in the affected limb and the unaffected arm (2.68 °C, SD = 2.92 vs 5.67 °C, SD = 3.22, P = 0.045). Other QST parameters were not affected. Conclusions The results show that the nonresponders to ESIs have increased detection threshold to heat pain and warm sensation, suggesting that a preexisting dysfunction in the C fibers in this group of subjects who can be detected by QST. Such altered QST characteristics may prognosticate the response to ESIs.
Collapse
Affiliation(s)
- Dermot P Maher
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Weihua Ding
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | - Sarabdeep Singh
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Arissa Opalacz
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | - Claire Fishman
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | - Mary Houghton
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Lucy Chen
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | - Jianren Mao
- Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts
| | - Yi Zhang
- Division of Pain Medicine, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
30
|
Preoperative Opioid Use: A Risk Factor for Poor Return to Work Status After Single-level Cervical Fusion for Radiculopathy in a Workers' Compensation Setting. Clin Spine Surg 2018; 31:E19-E24. [PMID: 28538083 DOI: 10.1097/bsd.0000000000000545] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective comparative case-control study. OBJECTIVES The objectives of this study are: (1) How preoperative opioid use impacts RTW status after single-level cervical fusion for radiculopathy? and (2) What are other postsurgical outcomes affected by preoperative opioid use? SUMMARY OF BACKGROUND DATA Opioid use has increased significantly in the past decade. The use of opioids has a drastic impact on workers' compensation population, an at-risk cohort for poorer surgical and functional outcomes than the general population. METHODS AND MATERIALS Data was retrospectively collected from Ohio Bureau of Workers' Compensation between 1993 and 2011. The study population included patients who underwent single-level cervical fusion for radiculopathy as identified by current procedural terminology codes and International Classification of Diseases-9 codes. On the basis of opioid use before surgery, two groups were constructed (opioids vs. non-opioids). Using a multivariate logistic regression model, the effect of preoperative opioid use on return to work (RTW) status after fusion was analyzed and compared between the groups. RESULTS In the regression model, preoperative opioid use was a negative predictor of RTW status within 3-year follow-up after surgery. Opioid patients were less likely to have stable RTW status [odds ratio (OR), 0.50; 95% confidence interval (CI), 0.38-0.65; P=0.05] and were less likely to RTW within the first year after surgery (OR, 0.50; 95% CI, 0.37-0.66; P=0.05) compared with controls. Stable RTW was achieved in 43.3% of the opioids group and 66.6% of control group (P=0.05). RTW rate within the first year after fusion was 32.5% of opioids group and 57% of control group (P<0.05).Reoperation and permanent disability rates after surgery were higher in the opioid group compared with the control group (P<0.05). CONCLUSIONS In a workers' compensation, patients with work-related injury who underwent single-level cervical fusion for radiculopathy and received opioids before surgery had worse RTW status, a higher reoperation rate, and higher rate of awarded permanent disability after surgery.
Collapse
|
31
|
Kotb HA, Effat DA, Awad MR, Derbala SH. CT-guided transforaminal epidural steroid injection and vertebral axial decompression in management of acute lumbar disc herniation. EGYPTIAN RHEUMATOLOGIST 2018. [DOI: 10.1016/j.ejr.2017.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
32
|
Interventional Pain Management in Multidisciplinary Chronic Pain Clinics: A Prospective Multicenter Cohort Study with One-Year Follow-Up. PAIN RESEARCH AND TREATMENT 2017; 2017:8402413. [PMID: 29163990 PMCID: PMC5661079 DOI: 10.1155/2017/8402413] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/18/2017] [Indexed: 01/27/2023]
Abstract
Background Interventional Pain Management (IPM) is performed in multidisciplinary chronic pain clinics (MCPC), including a range of invasive techniques to diagnose and treat chronic pain (CP) conditions. Current patterns of use of those techniques in MCPC have not yet been reported. Objective We aimed to describe quantitatively and qualitatively the use of IPM and other therapeutic procedures performed on-site at four Portuguese MCPC. Methods A prospective cohort study with one-year follow-up was performed in adult patients. A structured case report form was systematically completed at baseline and six and 12 months. Results Among 808 patients referred to the MCPC, 17.2% had been prescribed IPM. Patients with IPM were on average younger and had longer CP duration and lower levels of maximum pain and pain interference/disability. The three main diagnoses were low back pain (n = 28), postoperative CP, and knee pain (n = 16 each). From 195 IPM prescribed, nerve blocks (n = 108), radiofrequency (n = 31), and viscosupplementation (n = 22) were the most prevalent. Some IPM techniques were only available in few MCPC. One MCPC did not provide IPM. Conclusions IPM are seldom prescribed in Portuguese MCPC. Further studies on IPM safety and effectiveness are necessary for clear understanding the role of these techniques in CP management.
Collapse
|
33
|
Abstract
BACKGROUND AND OBJECTIVES Neck pain exerts a steep personal and socioeconomic toll, ranking as the fourth leading cause of disability. The principal determinant in treatment decisions is whether pain is neuropathic or nonneuropathic, as this affects treatment at all levels. Yet, no study has sought to classify neck pain in this manner. METHODS One hundred participants referred to an urban, academic military treatment facility with a primary diagnosis of neck pain were enrolled and followed up for 6 months. Pain was classified as neuropathic, possible neuropathic, or nonneuropathic using painDETECT and as neuropathic, mixed, or nociceptive by s-LANSS (self-completed Leeds Assessment of Neuropathic Symptoms and Signs pain scale) and physician designation. Based on previous studies, the intermediate possible neuropathic pain category was considered to be a mixed condition. The final classification was based on a metric combining all 3 systems, slightly weighted toward physician's judgment, which is considered the reference standard. RESULTS Fifty percent of participants were classified as having possible neuropathic pain, 43% as having nonneuropathic pain, and 7% with primarily neuropathic pain. Concordance was high between the various classification schemes, ranging from a low of 62% between painDETECT and physician designation for possible neuropathic pain, to 83% concordance between s-LANSS and the 2 other systems for neuropathic pain. Individuals with neuropathic pain reported higher levels of baseline disability, were more likely to have a coexisting psychiatric illness, and underwent surgery more frequently than other pain categories, but were also more likely to report greater reductions in disability after 6 months. CONCLUSIONS Although pure neuropathic pain comprised a small percentage of our cohort, 50% of our population consisted of mixed pain conditions containing a possible neuropathic component. There was significant overlap between the various classification schemes.
Collapse
|
34
|
Crovo DG, Craig WY, Curry CS, Richard JM, Pisini JV. Does Pain Reduction with Oral Steroids Predict Pain Reduction after a First-Time Cervical Epidural Steroid Injection in Patients with Cervical Radicular Pain? A Pilot Study. PAIN MEDICINE 2017; 18:1873-1881. [PMID: 28340088 DOI: 10.1093/pm/pnx008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective Oral and injected steroids are used commonly in the treatment of cervical radicular pain despite a paucity of data demonstrating their efficacy. The purpose of this study is to assess whether the response to orally administered steroids among patients with acute cervical radicular pain who develop recurrent pain is associated with their subsequent response to cervical epidural steroid injections. Methods Patients referred to our center were evaluated and then referred for cervical epidural steroid injections at the clinical discretion of the provider; those who met inclusion criteria were offered participation in the study. After the injection was administered, patients were contacted by telephone and asked to complete the Brief Pain Inventory Short Form at one week, one month, three months, and six months postinjection. Results Pain reduction after cervical steroid injection was not significantly different between 49 patients who reported pain reduction with a prior course of oral steroids and 22 patients who reported no pain reduction. Average pain scores decreased over six months (P < 0.001) among 72 patients treated with epidural steroid injection for cervical radicular pain. Of the 55 who provided baseline and six-month data, 14 (25.5%) reported complete relief at six months and 20 (36.4%) reported decreased pain. Conclusions Patients can be reassured that they may experience pain reduction after a cervical epidural steroid injection even if oral steroid therapy was not effective. The majority of patients treated for cervical radicular pain with epidural steroid injection have reduced or absent pain for at least six months after treatment.
Collapse
Affiliation(s)
- Dana G Crovo
- Department of Anesthesiology and Pain Management, Maine Medical Center, Portland, Maine
| | - Wendy Y Craig
- Maine Medical Center Research Institute, Portland, Maine, USA
| | - Craig S Curry
- Department of Anesthesiology and Pain Management, Maine Medical Center, Portland, Maine
| | - Janelle M Richard
- Department of Anesthesiology and Pain Management, Maine Medical Center, Portland, Maine
| | - James V Pisini
- Department of Anesthesiology and Pain Management, Maine Medical Center, Portland, Maine
| |
Collapse
|
35
|
Virk S, Phillips FM, Khan S. Patterns of healthcare resource utilization prior to anterior cervical decompression and fusion in patients with radiculopathy. Int J Spine Surg 2017; 11:25. [PMID: 32373448 DOI: 10.14444/4025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Objective To assess patterns of healthcare resource utilization prior to anterior cervical decompression and fusion (ACDF) in patients diagnosed with radiculopathy with a retrospective cohort study design. Background ACDF is associated with improvement in quality of life among patients with cervical radiculopathy. However, little is known regarding utilization of healthcare services and total cost of care before ACDF surgery in the United States. Methods We analyzed a group of patients who received ACDF for radiculopathy during 2009-2011 using a healthcare database of over 20 million patients of all ages. Patients with fewer than two years of data prior to ACDF procedure were excluded. Inclusion criteria included patients with a diagnosis of disc displacement/degeneration and radiculopathy. All charges related to healthcare administration within two years prior to surgery were recorded and analyzed. Results Sixteen hundred seventy six patients met the inclusion criteria. Seventy-three percent of patients were in the 40-59 year age range; 55% were women and 45% were men. In the two years preceding the surgery, 34% of patients received prescription NSAIDs, and 98% received prescription narcotics for total charges of $101,188 ($174.46/patient) and $222,860 ($134.82/patient) respectively. Total pain-related interventions over two years (oral pharmacotherapy and injections) were charged at $4,368,900 at an average of $2,606/treatment. Total outpatient charges including physician office visits, other outpatient visits and emergency room visits amounted to $25,450,012. Mean total outpatient charges over the two years preceding ACDF was $15,556 per patient for 26,397 episodes of care. Injectable corticosteroids were provided for 84.7% of patients and charges related to this treatment totaled $1,137 per patient. Conclusions In the two years prior to ACDF, healthcare resource utilization is extremely high. Given that these patients ultimately undergo surgical intervention, opportunities to reduce charges of conservative care exist.
Collapse
Affiliation(s)
- Sohrab Virk
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Frank M Phillips
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Safdar Khan
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| |
Collapse
|
36
|
Joswig H, Neff A, Ruppert C, Hildebrandt G, Stienen MN. The value of short-term pain relief in predicting the 1-month outcome of 'indirect' cervical epidural steroid injections. Acta Neurochir (Wien) 2017; 159:291-300. [PMID: 27796650 DOI: 10.1007/s00701-016-2997-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 10/13/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Clinical management after epidural steroid injections (ESI) of patients with radiculopathy secondary to a cervical disc herniation (CDH) is uncertain. This study aims to determine whether short-term arm pain alleviation following computed tomography-guided 'indirect' cervical ESI can predict the 1-month outcome. METHODS We conducted a prospective observation of 45 consecutive patients at a tertiary radiological department. Study components were visual analog scale arm and neck pain at baseline, 15, 30, and 45 min, 1, 2, and 4 h, on days 1-14, 1 month, and at 1 year. Health-related quality of life and functional impairment were assessed using the short form-12 and Neck Pain and Disability Scale. Patients who reported ≥80 % persisting arm pain, as well as patients who underwent a second injection or an operation within 1 month were defined as 'non-responders'. Logistic regression was used to analyze the effect size of the relationship between >50 % pain relief at any given study visit and responder status. RESULTS Patients experiencing a >50 % pain reduction 4 h after the injection were four times as likely to be responders as those experiencing ≤50 % pain reduction (OR 4.04, 95 % CI 1.10-14.87). The effect was strongest on days 5-6 (OR 18.37, 95 % CI 3.39-99.64) and remained significant until day 14. CONCLUSIONS The results of this study can guide physicians in managing patients with CDH: a ≤50 % arm pain relief within 1 week after an 'indirect' cervical ESI predicts an unfavorable 1-month outcome and suggests that other treatment options may be considered at an earlier point in time.
Collapse
Affiliation(s)
- Holger Joswig
- Department of Neurosurgery, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007, St. Gallen, Switzerland.
| | - Armin Neff
- Department of Radiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | | | - Gerhard Hildebrandt
- Department of Neurosurgery, Cantonal Hospital St. Gallen, Rorschacher Strasse 95, 9007, St. Gallen, Switzerland
| | - Martin Nikolaus Stienen
- Department of Neurosurgery and Faculty of Medicine, University Hospital of Geneva, Geneva, Switzerland
| |
Collapse
|
37
|
Cancienne JM, Werner BC, Puvanesarajah V, Hassanzadeh H, Singla A, Shen FH, Shimer AL. Does the Timing of Preoperative Epidural Steroid Injection Affect Infection Risk After ACDF or Posterior Cervical Fusion? Spine (Phila Pa 1976) 2017; 42:71-77. [PMID: 28072635 DOI: 10.1097/brs.0000000000001661] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective database analysis. OBJECTIVE The aim of this study was to determine whether any association exists between preoperative cervical epidural steroid injections (CESIs) at various time intervals before anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF) and the incidence of postoperative infection. SUMMARY OF BACKGROUND DATA Although infectious complications following CESI are uncommon, the association between preoperative CESI and postoperative infection following ACDF or PCF has yet to be evaluated in the current literature. METHODS A national insurance database was utilized to compare postoperative infection rates within 90 days in patients who received a CESI before ACDF or PCF. Three cohorts were created for each procedure: PCF (n = 402) or ACDF (n = 4354) within 3 months, PCF (n = 586) or ACDF (n = 5183) between 3 and 6 months, and PCF (n = 629) or ACDF (3648) between 6 and 12 months following a CESI. These cohorts were compared with control cohorts who underwent PCF (n = 61,253) or ACDF (n = 241,678) without prior CESI. Postoperative infection rates within 90 days were assessed using International Classification of Disease, 9th Revision (ICD-9) and Current Procedural Terminology (CPT) codes. Odds ratios (ORs), 95% confidence intervals (95% CIs), and P values were then calculated using SPSS. A multivariate binomial logistic regression analysis was performed to determine the independent effect of preoperative injection on postoperative infection following ACDF or PCF controlling for known risk factors for infection, including age, gender, obesity, diabetes, and smoking. RESULTS Patients who underwent CESI within 3 months (OR 2.21, P < 0.0001) and within 3 to 6 months (OR 1.95, P = 0.0002) before PCF had significantly increased odds of developing a postoperative infection. Patients who underwent CESI within 3 months (OR 1.83, P < 0.0001) before ACDF had significantly increased odds of developing a postoperative infection. CONCLUSION The present study demonstrates that cervical ESI within 6 months of PCF, and within 3 months of ACDF, is independently associated with significantly increased rates of postoperative infection. LEVEL OF EVIDENCE 3.
Collapse
Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA
| | | | | | | | | | | | | |
Collapse
|
38
|
Return to Work and Multilevel Versus Single-Level Cervical Fusion for Radiculopathy in a Workers' Compensation Setting. Spine (Phila Pa 1976) 2017; 42:E111-E116. [PMID: 27224880 DOI: 10.1097/brs.0000000000001713] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective comparative cohort study. OBJECTIVE Examine the impact of multilevel fusion on return to work (RTW) status and compare RTW status after multi- versus single-level cervical fusion for patients with work-related injury. SUMMARY OF BACKGROUND DATA Patients with work-related injuries in the workers' compensation systems have less favorable surgical outcomes. Cervical fusion provides a greater than 90% likelihood of relieving radiculopathy and stabilizing or improving myelopathy. However, more levels fused at index surgery are reportedly associated with poorer surgical outcomes than single-level fusion. METHODS Data was collected from the Ohio Bureau of Workers' Compensation (BWC) between 1993 and 2011. The study population included patients who underwent cervical fusion for radiculopathy. Two groups were constructed (multilevel fusion [MLF] vs. single-level fusion [SLF]). Outcomes measures evaluated were: RTW criteria, RTW <1year, reoperation, surgical complication, disability, and legal litigation after surgery. RESULTS After accounting for a number of independent variables in the regression model, multilevel fusion was a negative predictor of successful RTW status within 3-year follow-up after surgery (OR = 0.82, 95% CI: 0.70-0.95, P <0.05).RTW criteria were met 62.9% of SLF group compared with 54.8% of MLF group. The odds of having a stable RTW for MLF patients were 0.71% compared with the SLF patients (95% CI: 0.61-0.83; P: 0.0001).At 1 year after surgery, RTW rate was 53.1% for the SLF group compared with 43.7% for the MLF group. The odds of RTW within 1 year after surgery for the MLF group were 0.69% compared with SLF patients (95% CI: 0.59-0.80; P: 0.0001).Higher rate of disability after surgery was observed in the MLF group compared with the SLF group (P: 0.0001) CONCLUSION.: Multilevel cervical fusion for radiculopathy was associated with poor return to work profile after surgery. Multilevel cervical fusion was associated with lower RTW rates, less likelihood of achieving stable return to work, and higher rate of disability after surgery. LEVEL OF EVIDENCE 3.
Collapse
|
39
|
McCormick ZL, Nelson A, Bhave M, Zhukalin M, Kendall M, McCarthy RJ, Khan D, Nagpal G, Walega DR. A Prospective Randomized Comparative Trial of Targeted Steroid Injection Via Epidural Catheter Versus Standard C7-T1 Interlaminar Approach for the Treatment of Unilateral Cervical Radicular Pain. Reg Anesth Pain Med 2017; 42:82-89. [DOI: 10.1097/aap.0000000000000521] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
40
|
Faour M, Anderson JT, Haas AR, Percy R, Woods ST, Ahn UM, Ahn NU. Neck Pain, Preoperative Opioids, and Functionality After Cervical Fusion. Orthopedics 2017; 40:25-32. [PMID: 27755643 DOI: 10.3928/01477447-20161013-02] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 08/23/2016] [Indexed: 02/03/2023]
Abstract
The use of opioids among patients with workers' compensation claims is associated with tremendous costs, especially for patients who undergo spinal surgery. This study compared return-to-work rates after single-level cervical fusion for degenerative disk disease between patients who received opioids before surgery and patients who underwent fusion with no previous opioid use. All study subjects qualified for workers' compensation benefits for injuries sustained at work between 1993 and 2011. The study population included 281 subjects who underwent single-level cervical fusion for degenerative disk disease with International Classification of Diseases, Ninth Revision, and Current Procedural Terminology code algorithms. The opioid group included 77 subjects who received opioids preoperatively. The control group included 204 subjects who had surgery with no previous opioid use. The primary outcome was meeting return-to-work criteria within 3 years of follow-up after fusion. Secondary outcome measures after surgery, surgical details, and presurgical characteristics for each cohort also were collected. In 36.4% of the opioid group, return-to-work criteria were met compared with 56.4% of the control group. Patients who took opioids were less likely to meet return-to-work criteria compared with the control group (odds ratio, 0.44; 95% confidence interval, 0.26-0.76; P=.0028). Return-to-work rates within the first year after fusion were 24.7% for the opioid group and 45.6% for the control group (P=.0014). Patients who used opioids were absent from work for 255 more days compared with the control group (P=.0001). The use of opioids for management of diskogenic neck pain, with the possibility of surgical intervention, is a negative predictor of successful return to work after fusion in a workers' compensation population. [Orthopedics. 2017; 40(1):25-32.].
Collapse
|
41
|
Randomized, double-blind, comparative-effectiveness study comparing pulsed radiofrequency to steroid injections for occipital neuralgia or migraine with occipital nerve tenderness. Pain 2016; 156:2585-2594. [PMID: 26447705 DOI: 10.1097/j.pain.0000000000000373] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Occipital neuralgia (ON) is characterized by lancinating pain and tenderness overlying the occipital nerves. Both steroid injections and pulsed radiofrequency (PRF) are used to treat ON, but few clinical trials have evaluated efficacy, and no study has compared treatments. We performed a multicenter, randomized, double-blind, comparative-effectiveness study in 81 participants with ON or migraine with occipital nerve tenderness whose aim was to determine which treatment is superior. Forty-two participants were randomized to receive local anesthetic and saline, and three 120 second cycles of PRF per targeted nerve, and 39 were randomized to receive local anesthetic mixed with deposteroid and 3 rounds of sham PRF. Patients, treating physicians, and evaluators were blinded to interventions. The PRF group experienced a greater reduction in the primary outcome measure, average occipital pain at 6 weeks (mean change from baseline -2.743 ± 2.487 vs -1.377 ± 1.970; P < 0.001), than the steroid group, which persisted through the 6-month follow-up. Comparable benefits favoring PRF were obtained for worst occipital pain through 3 months (mean change from baseline -1.925 ± 3.204 vs -0.541 ± 2.644; P = 0.043), and average overall headache pain through 6 weeks (mean change from baseline -2.738 ± 2.753 vs -1.120 ± 2.1; P = 0.037). Adverse events were similar between groups, and few significant differences were noted for nonpain outcomes. We conclude that although PRF can provide greater pain relief for ON and migraine with occipital nerve tenderness than steroid injections, the superior analgesia may not be accompanied by comparable improvement on other outcome measures.
Collapse
|
42
|
Klessinger S. Interventional pain therapy in cervical post-surgery syndrome. World J Anesthesiol 2016; 5:38-43. [DOI: 10.5313/wja.v5.i2.38] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/31/2016] [Accepted: 07/13/2016] [Indexed: 02/07/2023] Open
Abstract
Fifteen percent to forty percent of patients present with persistent disabling neck pain or radicular pain after cervical spine surgery. Persistent pain after cervical surgery is called cervical post-surgery syndrome (CPSS). This review investigates the literature about interventional pain therapy for these patients. Because different interventions with different anatomical targets exist, it is important to find the possible pain source. There has to be a distinction between radicular symptoms (radicular pain or radiculopathy) or axial pain (neck pain) and between persistent pain and a new onset of pain after surgery. In the case of radicular symptoms, inadequate decompression or nerve root adherence because of perineural scarring are possible pain causes. Multiple structures in the cervical spine are able to cause neck pain. Hereby, the type of surgery and also the number of segments treated is relevant. After fusion surgery, the so-called adjacent level syndrome is a possible pain source. After arthroplasty, the load of the facet joints in the index segment increases and can cause pain. Further, degenerative alterations progress. In general, two fundamentally different therapeutic approaches for interventional pain therapy for the cervical spine exist: Treatment of facet joint pain with radiofrequency denervation or facet nerve blocks, and epidural injections either via a transforaminal or via an interlaminar approach. The literature about interventions in CPSS is limited to single studies with a small number of patients. However, some evidence exists for these procedures. Interventional pain therapies are eligible as a target-specific therapy option. However, the risk of theses procedures (especially transforaminal epidural injections) must be weighed against the benefit.
Collapse
|
43
|
Bhatia A, Flamer D, Shah PS, Cohen SP. Transforaminal Epidural Steroid Injections for Treating Lumbosacral Radicular Pain from Herniated Intervertebral Discs: A Systematic Review and Meta-Analysis. Anesth Analg 2016; 122:857-870. [PMID: 26891397 DOI: 10.1213/ane.0000000000001155] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Steroids often are administered into the epidural space through the transforaminal epidural (TFE) route to treat lumbosacral radicular pain secondary to herniated intervertebral discs. However, their efficacy and safety compared with transforaminal epidural local anesthetics (LAs) or saline injections is unclear. METHODS We reviewed randomized controlled trials that compared TFE injections of steroids (with or without LA) with LA or saline in adult outpatients with lumbosacral radicular pain secondary to herniated intervertebral disks. Databases searched included MEDLINE, EMBASE, Cochrane central register of controlled trials, Cochrane database of systematic reviews, and Google Scholar up to February 2015. Data on scores of numerical rating scale for pain, validated scores for measuring physical disability and quality of life, and incidence of surgery measured at 1 month to 2 years after the interventions were meta-analyzed. Strength of evidence was classified with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. RESULTS Eight randomized controlled trials including 771 patients (366 in steroid and 405 in comparator groups) were included. There was variability in the studies in the dose of TFE steroids, frequency, and number of procedures. Patients who received TFE steroids reported a significant, but clinically modest, reduction in mean pain scores (0-10 scale) compared with LA/saline (-0.97 points; 95% confidence interval, -1.42 to -0.51 points; P < 0.0001, I² = 90%; GRADE weak recommendation; moderate-quality evidence) at 3 months after the interventions. TFE steroids did not decrease physical disability at 1 to 3 months after the intervention (GRADE strong recommendation ↓; high-quality evidence) or incidence of surgery at 12 months after the intervention (GRADE strong recommendation ↓; moderate-quality evidence) compared with LA/saline. CONCLUSIONS TFE steroids provide modest analgesic benefit at 3 months in patients with lumbosacral radicular pain secondary to herniated intervertebral disks, but they have no impact on physical disability or incidence of surgery. There was a high degree of heterogeneity among the publications included in this meta-analysis. Well-designed, large, randomized studies are required to evaluate appropriate dosages, adverse effects, number of procedures, and the effect of this intervention on psychological disability and quality of life.
Collapse
Affiliation(s)
- Anuj Bhatia
- From the Department of Anesthesia and Pain Management and Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Pain Management, University Health Network-Toronto Western Hospital, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Anesthesia and Pain Management, Women's College Hospital, Toronto, Ontario, Canada; Department of Paediatrics, University of Toronto, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Anesthesiology and Critical Care Medicine and Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland; and Department of Anesthesiology and Department of Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | | | | |
Collapse
|
44
|
Manchikanti L, Hirsch JA, Falco FJE, Boswell MV. Management of lumbar zygapophysial (facet) joint pain. World J Orthop 2016; 7:315-337. [PMID: 27190760 PMCID: PMC4865722 DOI: 10.5312/wjo.v7.i5.315] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 10/13/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the diagnostic validity and therapeutic value of lumbar facet joint interventions in managing chronic low back pain.
METHODS: The review process applied systematic evidence-based assessment methodology of controlled trials of diagnostic validity and randomized controlled trials of therapeutic efficacy. Inclusion criteria encompassed all facet joint interventions performed in a controlled fashion. The pain relief of greater than 50% was the outcome measure for diagnostic accuracy assessment of the controlled studies with ability to perform previously painful movements, whereas, for randomized controlled therapeutic efficacy studies, the primary outcome was significant pain relief and the secondary outcome was a positive change in functional status. For the inclusion of the diagnostic controlled studies, all studies must have utilized either placebo controlled facet joint blocks or comparative local anesthetic blocks. In assessing therapeutic interventions, short-term and long-term reliefs were defined as either up to 6 mo or greater than 6 mo of relief. The literature search was extensive utilizing various types of electronic search media including PubMed from 1966 onwards, Cochrane library, National Guideline Clearinghouse, clinicaltrials.gov, along with other sources including previous systematic reviews, non-indexed journals, and abstracts until March 2015. Each manuscript included in the assessment was assessed for methodologic quality or risk of bias assessment utilizing the Quality Appraisal of Reliability Studies checklist for diagnostic interventions, and Cochrane review criteria and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment tool for therapeutic interventions. Evidence based on the review of the systematic assessment of controlled studies was graded utilizing a modified schema of qualitative evidence with best evidence synthesis, variable from level I to level V.
RESULTS: Across all databases, 16 high quality diagnostic accuracy studies were identified. In addition, multiple studies assessed the influence of multiple factors on diagnostic validity. In contrast to diagnostic validity studies, therapeutic efficacy trials were limited to a total of 14 randomized controlled trials, assessing the efficacy of intraarticular injections, facet or zygapophysial joint nerve blocks, and radiofrequency neurotomy of the innervation of the facet joints. The evidence for the diagnostic validity of lumbar facet joint nerve blocks with at least 75% pain relief with ability to perform previously painful movements was level I, based on a range of level I to V derived from a best evidence synthesis. For therapeutic interventions, the evidence was variable from level II to III, with level II evidence for lumbar facet joint nerve blocks and radiofrequency neurotomy for long-term improvement (greater than 6 mo), and level III evidence for lumbosacral zygapophysial joint injections for short-term improvement only.
CONCLUSION: This review provides significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain.
Collapse
|
45
|
Soliman AF, Hammad GA, El-gamal RI, Al-Rabiei MA. Assessment of the implication of epidural steroid injection versus other conservative measures in the management of lumbar disc herniation. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2016. [DOI: 10.4103/1110-161x.181867] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
46
|
The Successful Practice of Evidence-based Medicine May Be Contingent Upon the Methods We Use to Measure Our Interventions. Spine (Phila Pa 1976) 2016; 41:E163-4. [PMID: 26267828 DOI: 10.1097/brs.0000000000001119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
|
47
|
|
48
|
Woods BI, Hilibrand AS. Cervical radiculopathy: epidemiology, etiology, diagnosis, and treatment. ACTA ACUST UNITED AC 2016; 28:E251-9. [PMID: 25985461 DOI: 10.1097/bsd.0000000000000284] [Citation(s) in RCA: 168] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cervical radiculopathy is a relatively common neurological disorder resulting from nerve root dysfunction, which is often due to mechanical compression; however, inflammatory cytokines released from damaged intervertebral disks can also result in symptoms. Cervical radiculopathy can often be diagnosed with a thorough history and physical examination, but an magnetic resonance imaging or computed tomographic myelogram should be used to confirm the diagnosis. Because of the ubiquity of degenerative changes found on these imaging modalities, the patient's symptoms must correlate with pathology for a successful diagnosis. In the absence of myelopathy or significant muscle weakness all patients should be treated conservatively for at least 6 weeks. Conservative treatments consist of immobilization, anti-inflammatory medications, physical therapy, cervical traction, and epidural steroid injections. Cervical radiculopathy typically is self-limiting with 75%-90% of patients achieving symptomatic improvement with nonoperative care. For patients who are persistently symptomatic despite conservative treatment, or those who have a significant functional deficit surgical treatment is appropriate. Surgical options include anterior cervical decompression and fusion, cervical disk arthroplasty, and posterior foraminotomy. Patient selection is critical to optimize outcome.
Collapse
Affiliation(s)
- Barrett I Woods
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | | |
Collapse
|
49
|
Abstract
Most patients with chronic pain receive multimodal treatment. There is scant literature to guide us, but when approaching combination pharmacotherapy, the practitioner and patient must weigh the benefits with the side effects; many medications have modest effect yet carry significant side effects that can be additive. Chronic pain often leads to depression, anxiety, and deconditioning, which are targets for treatment. Structured interdisciplinary programs are beneficial but costly. Interventions have their place in the treatment of chronic pain and should be a part of a multidisciplinary treatment plan. Further research is needed to validate many common combination treatments.
Collapse
Affiliation(s)
- Rebecca Dale
- Harborview Medical Center, Anesthesiology and Pain Medicine, Box 359724, 325 Ninth Ave, Seattle, WA 98104, USA.
| | - Brett Stacey
- Anesthesiology and Pain Medicine, UW Center for Pain Relief, University of Washington, 4225 Roosevelt Way Northeast, Box 354693, Seattle, WA 98105, USA
| |
Collapse
|
50
|
Manchikanti L, Hirsch JA. Neurological complications associated with epidural steroid injections. Curr Pain Headache Rep 2015; 19:482. [PMID: 25795154 DOI: 10.1007/s11916-015-0482-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Multiple case reports of neurological complications resulting from intraarterial injection of corticosteroids have led the Food and Drug Administration (FDA) to issue a warning, requiring label changes, warning of serious neurological events, some resulting in death. The FDA has identified 131 cases of neurological adverse events, including 41 cases of arachnoiditis. A review of the literature reveals an overwhelming proportion of the complications are related to transforaminal epidural injections, of which cervical transforaminal epidural injections constituted the majority of neurological complications. Utilization data of epidural injections in the Medicare population revealed that cervical transforaminal epidural injections constitute only 2.4 % of total epidural injections and <5 % of all transforaminal epidural injections. Multiple theories have been proposed as the cause of neurological injury including particulate steroid, arterial intimal flaps, arterial dissection, dislodgement of plaque causing embolism, arterial muscle spasm, and embolism of a fresh thrombus following disruption of the intima.
Collapse
|