Latest Advances in Regional Anaesthesia

Training and expertise in regional anaesthesia have increased significantly in tandem with increased interest over the past two decades. This review outlines the most recent advances in regional anaesthesia and focuses on novel areas of interest including fascial plane blocks. Pharmacological advances in the form of the prolongation of drug duration with liposomal bupivacaine are considered. Neuromodulation in the context of regional anaesthesia is outlined as a potential future direction. The growing use of regional anaesthesia outside of the theatre environment and current thinking on managing the rebound plane after regional block regression are also discussed. Recent relevant evidence is summarised, unanswered questions are outlined, and priorities for ongoing investigation are suggested.

Update of Utilization Patterns of Facet Joint Interventions in Managing Spinal Pain from 2000 to 2018 in the US Fee-for-Service Medicare Population

BACKGROUND

Interventional techniques for managing spinal pain, from conservative modalities to surgical interventions, are thought to have been growing rapidly. Interventional techniques take center stage in managing chronic spinal pain. Specifically, facet joint interventions experienced explosive growth rates from 2000 to 2009, with a reversal of these growth patterns and in some settings, a trend of decline after 2009.

OBJECTIVES

The objectives of this assessment of utilization patterns include providing an update of facet joint interventions in managing chronic spinal pain in the fee-for-service (FFS) Medicare population of the United States from 2000 to 2018.

STUDY DESIGN

The study was designed to assess utilization patterns and variables of facet joint interventions in managing chronic spinal pain from 2000 to 2018 in the FFS Medicare population in the United States.

METHODS

Data for the analysis were obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2018.

RESULTS

Facet joint interventions increased 1.9% annually and 18.8% total from 2009 to 2018 per 100,000 FFS Medicare population compared with an annual increase of 17% and overall increase of 309.9% from 2000 to 2009. Lumbosacral facet joint nerve block sessions or visits decreased at an annual rate of 0.2% from 2009 to 2018, with an increase of 15.2% from 2000 to 2009. In contrast, lumbosacral facet joint neurolysis sessions increased at an annual rate of 7.4% from 2009 to 2018, and the utilization rate also increased at an annual rate of 23.0% from 2000 to 2009. The proportion of lumbar facet joint blocks sessions to lumbosacral facet joint neurolysis sessions changed from 6.7 in 2000 to 1.9 in 2018. Cervical and thoracic facet joint injections increased at an annual rate of 0.5% compared with cervicothoracic facet neurolysis sessions of 8.7% from 2009 to 2018. Cervical facet joint injections increased to 4.9% from 2009 to 2018 compared with neurolysis procedures of 112%. The proportion of cervical facet joint injection sessions to neurolysis sessions changed from 8.9 in 2000 to 2.4 in 2018.

LIMITATIONS

This analysis is limited by inclusion of only the FFS Medicare population, without adding utilization patterns of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. The utilization data for individual states also continues to be sparse and may not be accurate.

CONCLUSIONS

Utilization patterns of facet joint interventions increased 1.9% per 100,000 Medicare population from 2009 to 2018. This results from an annual decline of - 0.2% lumbar facet joint injection sessions but with an increase of facet joint radiofrequency sessions of 7.4%.

KEY WORDS

Interventional techniques, facet joint interventions, facet joint nerve blocks, facet joint neurolysis.

Devices and Endoscopic Bariatric Therapies for Obesity

PURPOSE OF REVIEW

In this review, we describe the FDA-approved and investigational devices and endoscopic bariatric therapies for the treatment of obesity. We focus on literature published in the past few years and present mechanisms of action as well as efficacy and safety data.

RECENT FINDINGS

Devices and endoscopic procedures are emerging options to fill the significant treatment gap in the management of obesity. Not only are these devices and procedures minimally invasive and reversible, but they are potentially more effective than antiobesity medications, often safer for poor surgical candidates and possibly less expensive than bariatric surgery. As many patients require a variety of management strategies (medications, devices, procedures, and/or surgery) in addition to lifestyle modifications to achieve clinically significant weight loss, the future of obesity treatment involves a multidisciplinary approach. Combinations of advanced treatment strategies can lead to additive or synergistic weight loss. This is an area that requires further investigation.

A Bier block implementation protocol

The Bier block procedure has been in use for over 100 years, but only recently has received renewed attention. As emergency departments look for ways to maximize efficiency, the use of the Bier block has been recognized as effective and fast with minimal adverse effects. This article summarizes a proposed protocol for the implementation of both pre- and posthospitalization Bier blocks by healthcare providers.

Comparative effectiveness of a one-year follow-up of thoracic medial branch blocks in management of chronic thoracic pain: a randomized, double-blind active controlled trial

BACKGROUND

Thoracic facet joints have been implicated as the source of chronic pain in the mid back or upper back in 34% to 42% of patients when the modified criteria of the International Association for the Study of Pain (IASP) is utilized. Various therapeutic techniques utilized in managing chronic thoracic pain of facet joint origin include intraarticular injections, medial branch blocks, and radiofrequency neurotomy of thoracic medial branch nerves.

STUDY DESIGN

A randomized, double-blind, active controlled trial.

SETTING

A private practice, interventional pain management setting, and a specialty referral center setting in the United States.

OBJECTIVE

To determine the clinical effectiveness of therapeutic local anesthetic medial branch blocks with or without steroid in managing chronic function-limiting mid back or upper back pain of facet joint origin.

METHODS

The study was performed in an interventional pain management private practice, a tertiary referral center, in the United States. A total of 100 participants were included, with 50 participants in each of the local anesthetic and steroid groups. All of the participants met the diagnostic criteria of thoracic facet joint pain by means of comparative, controlled diagnostic blocks and the inclusion criteria. Group I participants received thoracic medial branch blocks with bupivacaine, whereas Group II participants received thoracic medial branch blocks with bupivacaine and non-particulate betamethasone.

OUTCOMES ASSESSMENT

Outcomes measures included numeric rating scores (NRS), Oswestry Disability Index (ODI), opioid intake, and return to work status at baseline, 3 months, 6 months, and 12 months. Significant pain relief was defined as >/= 50% pain relief and/or a positive change in ODI scores.

RESULTS

In Group I and Group II 90% of participants showed significant pain relief and functional improvement at 12 months. The majority of the participants experienced significant pain relief of 47.2 ± 10.1 weeks in Group I and 46.3 ± 8.4 weeks in Group II, requiring approximately 3.5 treatments per year with an average relief of 15.8 ± 10.5 in Group I and 13.6 ± 3.6 weeks in Group II per episode of treatment.

LIMITATIONS

Study limitations include the lack of a placebo group.

CONCLUSIONS

Therapeutic thoracic medial branch blocks, with or without steroid, may provide a management option for chronic function-limiting mid back or upper back pain of facet joint origin.

CLINICAL TRIAL

NCT00355706.

The benefit of therapeutic medial branch blocks after cervical operations

BACKGROUND

Persistent neck pain is a common problem after surgery of the cervical spine. No therapy recommendation exists for these patients.

OBJECTIVE

The objective of this study was to determine if a therapeutic medial branch block is a rational treatment for patients with postoperative neck pain after cervical spine operations.

STUDY DESIGN

Retrospective practice audit.

SETTING

Review of charts of all patients who underwent cervical spine operations for degenerative reasons during a time period of 3 years.

METHODS

Patients with persistent postsurgical pain were treated with therapeutic medial branch blocks (local anesthetic and steroid). A positive treatment response was defined if at least 80% reduction of pain could be achieved or if the patient was sufficiently satisfied with the relief. All patients with a minimum follow up time of 6 months were included.

RESULTS

Of the 312 operations performed, 128 were artificial disc operations, 125 were stand alone cages, and 59 were fusions with cage and plate. Persistent neck pain occurred in 33.3% of the patients. There was no difference between the patients with neck pain and the whole group of patients. More than half of the patients with neck pain--52.9%--were treated successfully with therapeutic medial branch blocks. Since no further treatment was necessary, the initial treatment was considered successful. Nearly a third--32.2%--of the patients were initially treated successfully, but their pain recurred and further diagnostics and treatments were necessary. In this group of patients, significantly more with double level operations were found (P = 0.003). Patients not responding to the medial branch block were 14.9%.

LIMITATIONS

This audit is retrospective and observational, and therefore does not represent a high level of evidence. However, to our knowledge, since this information has not been previously reported and no recommendation for the treatment of post-operative zygapophysial joint pain exists, it appears to be the best available research upon which to recommend treatment and to plan higher quality studies.

CONCLUSION

For persistent postsurgical neck pain only limited therapy recommendations exist. This study suggests treating these patients in a first instance with therapeutic medial branch blocks. The success rate is 52.9 %.

[Ultrasound-guided peripheral nerve block--evidence based medicine and future trends]

Ultrasound-guided peripheral nerve block has been gaining popularity in the community of anesthesiologists. Despite its well-known clinical benefits, inconsistent success in block has been one of the major limita- tions of conventional peripheral nerve block. Recent development in ultrasound technology enables us to see nerves, needles and surrounding structures in real-time. We expect that ultrasound imaging may overcome the shortcoming of conventional technique. In this article, we introduce some evidences that support the clinical benefits of ultrasound-guided peripheral nerve block, including performance time, quality, onset and duration of sensory blockade, cost analysis and patient satisfaction. However, ultrasound-guidance may be even more dangerous without appropriate imaging of target nerve and surrounding structures, accurate localization of needle tip and assessment of local anesthetic spread around the target nerve. These problems will be solved by future guidelines, teaching program and further advancement in ultrasound technology.

Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain: preliminary report of a randomized, double-blind controlled trial: clinical trial NCT00355914

BACKGROUND

The prevalence of persistent low back pain with the involvement of lumbar facet or zygapophysial joints has been described in controlled studies as varying from 15% to 45% based on the criteria of the International Association for the Study of Pain. Therapeutic interventions utilized in managing chronic low back pain of facet joint origin include intraarticular injections, medial branch nerve blocks, and neurolysis of medial branch nerves.

OBJECTIVE

To determine the clinical effectiveness of therapeutic lumbar facet joint nerve blocks in managing chronic low back pain of facet joint origin.

DESIGN

A prospective, randomized, double-blind trial.

SETTING

An interventional pain management setting in the United States.

METHODS

In this preliminary analysis, data from a total of 60 patients were included, with 15 patients in each of 4 groups. Thirty patients were in a non-steroid group consisting of Groups I (control, with lumbar facet joint nerve blocks using bupivacaine ) and II (with lumbar facet joint nerve blocks using bupivacaine and Sarapin); another 30 patients were in a steroid group consisting of Groups III (with lumbar facet joint nerve blocks using bupivacaine and steroids) and IV (with lumbar facet joint nerve blocks using bupivacaine, Sarapin, and steroids). All patients met the diagnostic criteria of lumbar facet joint pain by means of comparative, controlled diagnostic blocks.

OUTCOME MEASURES

Numeric Rating Scale (NRS) pain scale, the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake.

RESULTS

Significant improvement in pain and functional status were observed at 3 months, 6 months, and 12 months, compared to baseline measurements. The average number of treatments for 1 year was 3.7 with no significant differences among the groups. Duration of average pain relief with each procedure was 14.8 +/- 7.9 weeks in the non-steroid group, and 12.5 +/- 3.3 weeks in the steroid group, with no significant differences among the groups.

CONCLUSION

Therapeutic lumbar facet joint nerve blocks with local anesthetic, with or without Sarapin or steroids, may be effective in the treatment of chronic low back pain of facet joint origin.

Ultrasound-Guided Regional Anesthesia: Current Concepts and Future Trends

The scope of ultrasound imaging guidance for regional anesthesia is growing rapidly. Preliminary data, although limited, suggest that ultrasound can improve block success rate and decrease complications. In this review, we describe the basic principles of ultrasound scanning and needling techniques for nerve blocks, highlight some of the data on clinical outcome, discuss specific limitations of ultrasound for regional anesthesia, and speculate on the future direction for physician training and competency assessment with this technology.

Lumbar retrodiscal transforaminal injection

BACKGROUND

Spinal injections are commonly used to treat lumbar radiculitis and back pain. Delivery of medication to specific targeted pathology is considered important for a successful therapeutic outcome. A variety of routes of injection have been devised for epidural injection of corticosteroid.

OBJECTIVES

The author demonstrates a variation of the transforaminal injection technique. The radiographic spread of contrast is described using a more oblique and ventral caudad approach in the epidural space "retrodiscal." It is suggested that the radiographic findings of this technique for discogenic causes of induced radiculitis and/or back pain may yield more precise targeting of putative pathologic sources of radiculopathy and back pain in selected patients.

METHODS

In patients with disc pathology and radiculitis, the anatomy of the lumbar epidural space is reviewed for its potential effect on the flow of injectate. Contrast spread was documented for lumbar transforaminal injection using a needle placement more oblique and behind the disc rather than in the cranial portion. Comparison is made to a typical contrast spread of an infra-pedicular placed transforaminal injection.

RESULTS

Retrodiscal contrast injection results in reliable coverage of the retrodiscal region, the exiting nerve at that foraminal level and the proximal portion of the transiting segmental neural sleeve.

CONCLUSIONS

The radiographic findings demonstrate a difference between classic infra-pedicular versus retrodiscal transforaminal epidural contrast injection patterns, particularly at relatively low volumes. The clinical advantage of one technique versus the other should be established in randomized prospective studies.

Therapeutic cervical medial branch blocks in managing chronic neck pain: a preliminary report of a randomized, double-blind, controlled trial: clinical trial NCT0033272

BACKGROUND

Based on the criteria established by the International Association for the Study of Pain, the prevalence of persistent neck pain, secondary to involvement of cervical facet or zygapophysial joints has been described in controlled studies as varying from 54% to 67%. Intraarticular injections, medial branch nerve blocks and neurolysis of medial branch nerves have been described in managing chronic neck pain of facet joint origin.

OBJECTIVES

To determine the clinical effectiveness of therapeutic cervical medial branch blocks in managing chronic neck pain of facet joint origin and to evaluate the effectiveness of the addition of Sarapin and steroids to local anesthetics.

DESIGN

A double-blind, randomized, controlled trial.

SETTING

An interventional pain management setting in the United States.

METHODS

In this preliminary analysis, data from a total of 60 patients were included, with 15 patients in each of the 4 groups. Thirty patients were in a non-steroid group (combined Group I and II); and 30 patients were in a steroid group (combined Group III and IV). All of the patients met the diagnostic criteria of cervical facet joint pain by means of comparative, controlled diagnostic blocks. Four types of interventions were included. Group I served as control, receiving medial branch blocks using bupivacaine. Group II consisted of cervical medial branch blocks with bupivacaine and Sarapin. Group III consisted of cervical medial branch blocks with bupivacaine and betamethasone. Group IV consisted of cervical medial branch blocks with bupivacaine, Sarapin and betamethasone.

OUTCOME MEASURES

Numeric pain scores, Neck Pain Disability Index, opioid intake, and work status were evaluated at baseline, 3 months, 6 months and 12 months.

RESULTS

Significant pain relief (> or =50%), and functional status improvement was observed at 3 months, 6 months and 12 months. The average number of treatments for 1 year was 3.8 +/- 0.7 in the non-steroid group and 3.4 +/- 1.0 in the steroid group with no significant difference among the groups. Duration of average pain relief with each procedure was 13.4 +/- 3.5 weeks in the nonsteroid group, and it was 15.9 +/- 8.0 weeks in the steroid group with no significant difference among the groups.

CONCLUSION

Therapeutic cervical medial branch nerve blocks, with or without Sarapin or steroids, may provide effective management for chronic neck pain of facet joint origin.

Neural Modulation by Blocks and Infusions

Neural blockade is widely used in clinical practice to alleviate acute or chronic pain, including neuropathic pain. However, to date there is little controlled evidence to confirm the efficacy of nerve blocks in neuropathic pain. The most common indication for nerve blocks, especially sympathetic blockade, is complex regional pain syndrome, in which success rates of up to 38% have been achieved, depending on the type of the block used. Greater efficacy has been achieved by combining a nerve block with patient-controlled analgesia. Sympathectomy is recommended for the treatment of neuropathic pain only after careful consideration of its usefulness, effectiveness, and risk of adverse effects. Current evidence and clinical experience suggest that neural blockade could be a useful adjunct in the management of refractory neuropathic pain, but further well-controlled studies would be of great benefit to support this type of therapy.

Regional anesthesia in hip surgery

Historically, general anesthesia has been the "gold standard" for surgeons and patients when major hip surgery is being done. The recent introductions of improved techniques and catheters for continuous peripheral nerve blocks have made regional anesthesia more attractive to patients and surgeons. We focus on current trends and future directions in perioperative pain management for major orthopaedic procedures done on the hip. The use of epidural or spinal anesthesia during major hip surgery has been linked to a reduced risk of perioperative complications like deep venous thrombosis, less deterioration of cerebral and pulmonary functions in patients who are at high risk for complications, and overall reduced blood loss. In addition, continuous peripheral nerve blocks showed effective and safe postoperative pain control, allowing for lower opioids consumption, improved and earlier rehabilitation, and high patient satisfaction. Accurate patient selection and patient education are fundamental for the success of any regional anesthesia technique. Modern regional anesthesia for major hip surgery includes the use of a single shot and continuous epidural injections, single-shot and continuous spinal injection, continuous lumbar plexus blockade, and continuous peripheral blockade of the femoral and sciatic nerves. Continuous peripheral nerve blocks represent an adjunctive, effective, and safe technique for postoperative pain control after total hip arthroplasty. Future directions in postoperative pain control include the creation of a comprehensive system that supervises the use of continuous peripheral nerve blocks outside the acute inpatient setting for few days following the surgical procedure.

LEVEL OF EVIDENCE

Therapeutic study, Level V (expert opinion). See the Guidelines for Authors for a complete description of levels of evidence.

Lacrimal fossa block: an audit of a minimally invasive regional anaesthetic technique for endoscopic dacryocystorhinostomy (DCR)

The lacrimal fossa block (LFB), a new development to provide regional anaesthesia for endoscopic dacryocystorhinostomy, is reported. Cadaveric study showed that the block needle, inserted as described, made direct contact with the periosteum of the frontal process of the maxilla within the lacrimal fossa. This technique enables both relevant divisions of the trigeminal nerve to be anaesthetized through a single entry site and, as this injection is confined to the anterior part of the orbit, ocular complications are minimized. An audit of 66 patients has shown that this technique, combined with standard intranasal local anaesthesia, provides good intraoperative analgesia, causes minimal diplopia and has a high level of patient acceptability.

[Peripheral nerve block. An overview of new developments in an old technique]

General anaesthesia and peripheral neuronal blockade are techniques which were introduced into clinical practice at the same time. Although general anaesthesia was accepted significantly faster due to effective new drugs and apparent ease of handling, neuronal blockade has recently gained great importance. The reasons are in particular newer aids such as industrially produced catheter sets, nerve stimulators and ultrasound guidance which have facilitated that these economical techniques can be used not only for intraoperative anaesthesia but also for perioperative analgesia without any major risks for the patients. In parallel to epidural anaesthesia a change of paradigms has recently taken place using catheter instead of single-shot techniques. This allows the loading dose of the local anaesthetics to be installed in a safe way, to reload the dose when intraoperatively required and to extend the analgesia perioperatively by this technique using lower concentrations of the same drugs or drug combinations. A great number of short, middle or long acting local anaesthetics are available to choose the right drug for any particular case. Short and middle acting drugs are characterised by a faster onset compared to long acting drugs, but toxic plasma levels are seen during long time application causing seizures or drowsiness or by using prilocaine methemoglobin. Therefore long acting local anaesthetics such as bupivacaine, ropivacaine or levobupivacaine are the first choice drugs for long time application via peripheral nerve catheters for perioperative anaesthesia and analgesia. By using low concentrations of these potent drugs even for a longer period of time, no toxic plasma levels are seen with the exception of artificial intravasal injections. Additives such as opioids and alpha 2-sympathomimetics are also used. While the use of opioids is controversial, alpha 2-sympathomimetics are able to accelerate the onset and to extend the duration of regional anaesthesia and analgesia.

Behavioral treatment for chronic low back pain: a systematic review within the framework of the Cochrane Back Review Group

STUDY DESIGN

A systematic review of randomized controlled trials.

SUMMARY OF BACKGROUND DATA

The treatment of chronic low back pain is not primarily focused on removing an underlying organic disease but at the reduction of disability through the modification of environmental contingencies and cognitive processes. Behavioral interventions are commonly used in the treatment of chronic (disabling) low back pain.

OBJECTIVES

To determine whether behavioral therapy is more effective than reference treatments for chronic nonspecific low back pain and which type of behavioral treatment is most effective.

METHODS

The authors searched the Medline and PsychLit databases and the Cochrane Controlled Trials Register up to April 1999, and Embase up to September 1999. Also screened were references of identified randomized trials and relevant systematic reviews. Methodologic quality assessment and data extraction were performed independently by two reviewers. The magnitude of effect was assessed by computing a pooled effect size for each domain (i.e., behavioral outcomes, overall improvement, back pain-specific and generic functional status, return to work, and pain intensity) using the random effects model.

RESULTS

Only six (25%) studies were high quality. There is strong evidence (level 1) that behavioral treatment has a moderate positive effect on pain intensity (pooled effect size 0.62; 95% confidence interval [CI] 0. 25, 0.98), and small positive effects on generic functional status (pooled effect size 0.35; 95% CI: 0.04, 0.74) and behavioral outcomes (pooled effect size 0.40; 95% CI: 0.10, 0.70) of patients with chronic low back pain when compared with waiting-list controls or no treatment. There is moderate evidence (level 2) that a addition of behavioral component to a usual treatment program for chronic low backpain has no positive short-term effect on generic functional status (pooled effect size 0.31; 95% CI: 0.01, 0.64), pain intensity (pooled effect size 0.03; 95% CI: 0.30,0.36), and behavioral outcomes (pooled effect size 0.19; 95% CI: 0.08, 0.45).

CONCLUSIONS

Behavioral treatment seems to be an effective treatment for patients with chronic low back pain,but it is still unknown what type of patients benefit most from what type of behavioral treatment.