Techniques in Regional Anesthesia & Pain Management RSS feed: Current Issue. Techniques in Regional Anesthesia and Pain Management is a journal unlike any in the specialty. The concept underlying the publication is to combine the timeliness of a quarterly journal with the illustrative aspects of a procedure oriented atlas. Exact techniques are well-illustrated, giving precise drug dosages and helpful clinical pearls. In addition, common complications of regional anesthesia and pain management procedures and their appropriate treatments are described. New and Forthcoming Issues: January Pain and Rehabilitation Steven Stanos April Headaches: Diagnosis and Treatment Brian McGeeney http://www.techreganesth.org/?rss=yesElsevier Inc.en © 2009 Published by Elsevier Inc. All rights reserved. Techniques in Regional Anesthesia & Pain Management1084-208X134October 2009 © 2009 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.techreganesth.org/article/PIIS1084208X09000913/abstract?rss=yesEditorial Board10.1053/S1084-208X(09)00091-3Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4iihttp://www.techreganesth.org/article/PIIS1084208X09000925/abstract?rss=yesTable of Contents10.1053/S1084-208X(09)00092-5Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4iiiiihttp://www.techreganesth.org/article/PIIS1084208X0900069X/abstract?rss=yesWe have come a long way, but we have a long way to go. The epidural steroid injection (ESI) therapy has been offered to the patients with radicular pain secondary to herniated disc. Evans was reportedly the first physician who published in Lancet in 1930. Since then, we have gone the entire spectrum of revisions and modifications. The technique is directly derived from the education of epidural anesthesia. For a long period, blind epidural was a routine practice, until the fluoroscopy added the advantage of confirmation of placement. The literature supports that the fluoroscopic-guided techniques have much higher chances of delivery of the medication into the epidural space. This is the target area where the nerve roots are located, the pathophysiological source of pain. According to White, the false-positive loss of resistance (LOR) is as high as 25%, and that can be decreased by 10-fold if fluoroscopy is used. However, there are some situations where fluoroscopy is contraindicated (first trimester) or not feasible due to gravid uterus.Epidural steroid injections: What's new?Sudhir A. Diwan10.1053/j.trap.2009.08.001Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4203204http://www.techreganesth.org/article/PIIS1084208X09000378/abstract?rss=yesThis paper assesses the multiple mechanisms of action of epidural steroids in the treatment of back pain on the mechanical, cellular, and molecular levels and reviews the systemic side effects of epidural steroid usage. A review of contemporary literature was performed using a computer-aided search of recently published articles within the last 10 years to find the most recent information on the mechanism of action of epidural steroids. The studies discussed in this paper focus on the theories underlying the various anti-inflammatory actions of glucocorticoids, as well as their systemic involvement in side effects, including diabetes, hypertension, and osteoporosis.The mechanism of action and side effects of epidural steroidsAisha Baqai, Rajpreet Bal10.1053/j.trap.2009.06.009Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4205211http://www.techreganesth.org/article/PIIS1084208X09000573/abstract?rss=yesSteroids are well recognized for their excellent anti-inflammatory actions. After first steroid was used to treat painful arthritis, it became apparent that epidural steroid administration may be effective for management of sciatica pain and low back pain. Later on, other types of neural blockade techniques, such as facet joint injections, were described as the treatment option for low back pain. The most commonly used steroid preparations for the neuraxial blockade are methylprednisolone acetate (Depo-Medrol, Pfizer, New York, NY), triamcinolone acetonide and diacetate (Kenalog, Bristol-Myers Squibb, Princeton, NJ), betamethasone acetate (Celestone, Schering-Plough Corporation, Kenilworth, NJ), and dexamethasone (Decadron, Merch & Company Inc, West Point, PA). Glucocorticoids are postulated to improve immunologic activity and wound healing. They are also required to maintain normal carbohydrate, lipid, and protein metabolism. The formulations available for injectable steroids contain various chemicals, which include buffers, polyethylene glycol, benzyl alcohol, and benzalkonium chloride. Toxicities that are associated with epidural steroid injections (ESIs) are often delayed. There have been several cases that reported injury to the central nervous system following transforaminal ESIs. The most accepted explanation for this is an occlusion of the segmental artery by the steroid particulate matter or embolization through the vertebral artery.Pharmacology of steroids used during epidural steroid injectionsVadim Kushnerik, Glen Altman, Paul Gozenput10.1053/j.trap.2009.07.004Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4212216http://www.techreganesth.org/article/PIIS1084208X09000408/abstract?rss=yesEpidural steroid injections (ESIs) are routinely used for the treatment of a variety of spinal ailments. Various methods for accessing the epidural space have been described over the decades. In the recent past, more and more emphasis has been on targeted delivery of drugs to the site of pain generation. Techniques differ according to the level of epidural space accessed. Use of fluoroscopic guidance can provide the most precise delivery of the drug. Although relatively safe, these injections can lead to morbidity and mortality if performed in a wrong manner. Several reports have been published recently describing disastrous results from transforaminal injections in the cervical spine. The importance of monitoring the spread of the injectate with injection of radio-opaque contrast material cannot be underestimated. The following chapter will summarize these techniques and highlight various technical considerations for the epidural injections.Techniques for epidural injectionsVikram B. Patel10.1053/j.trap.2009.06.012Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4217228http://www.techreganesth.org/article/PIIS1084208X09000354/abstract?rss=yesUltrasound (US) guidance is practiced widely in regional anesthesia. It is becoming increasingly used for pain medicine interventions. US-guided neuraxial analgesia has also been demonstrated despite many technical challenges. The applicability of US guidance for neuraxial steroid injections adds the dimension of complications secondary to particulate steroids. This review will discuss the available evidence for the use of US in neuraxial analgesia and for epidural steroid injections (ESIs), the technique and limitations, and the potential uses of US for ESIs.Ultrasound guidance for epidural steroid injectionsHariharan Shankar, Christine M. Zainer10.1053/j.trap.2009.06.007Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4229235http://www.techreganesth.org/article/PIIS1084208X09000391/abstract?rss=yesEpidural steroid injections (ESIs) are a form of interventional therapy broadly used worldwide for the treatment of pain. Although generally considered a safe treatment, with a low incidence of complications, these may range from very mild and transient symptoms to truly catastrophic events, including brain damage, spinal cord injury and death. Even when proper technique is used, sufficient training in interventional pain medicine is obtained, and adequate safety measures are taken, fatal events can occur. The purpose of this review article is to examine the reported complications of ESIs and suggested negative outcome management.Epidural steroid injections: Complications and managementEsther M. Benedetti, Rapipen Siriwetchadarak, John Stanec, Richard W. Rosenquist10.1053/j.trap.2009.06.011Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4236250http://www.techreganesth.org/article/PIIS1084208X0900041X/abstract?rss=yesBack pain during pregnancy is a common problem experienced by many pregnant women. Physiological changes during pregnancy are a contributing factor for the development of back pain. Laxity of the sacroiliac joints causes instability and development of sacroiliac pain. The pain may be severe and can interfere with daily activities. Neurological examination is usually normal. A positive straight leg-rising test may indicate herniated disc, which is rare during pregnancy. Noncontrast magnetic resonance imaging is safe in pregnancy. To date, there are no identified adverse effects of the magnetic resonance on the developing fetus, but long-term effects need to be examined. Most back pain in pregnancy can be treated conservatively. Acetaminophen is the drug of choice to treat pain during pregnancy. Epidural steroid injection (ESI) may be considered in certain cases. Data in the literature are deficient regarding the use of ESI in pregnancy, but it appears to be safe based on expert clinical experience. More work is needed to examine the long-term effect of ESI on the mother and the fetus. Surgery is usually postponed until the postpartum period, unless there is progressive neurological deficits or cauda equina syndrome.Management of back pain in pregnancyAlaeldin A. Darwich, Sudhir A. Diwan10.1053/j.trap.2009.06.017Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4251254http://www.techreganesth.org/article/PIIS1084208X0900055X/abstract?rss=yesBack pain is one of the most disabling conditions affecting people of all ages, including children and adolescents. School absenteeism—parallel to missed work days in adults—increased health care utilization, sleep problems, eating problems, and restriction in hobbies are some of the issues these patients face. For many, the inability to identify the source of pain—as is the case in more than 50% of cases—can be frustrating. It is important to emphasize that a history of back pain in childhood/adolescence represents increased risk of low back pain and potential disability in adulthood. Teaching healthy lifestyle habits is crucial for functional rehabilitations of these patients. Focusing on the “physical” aspect of the pain has led to treatment failures and increased frustration, for both patients and physicians. In our institution, a multidisciplinary approach has been used successfully in the care of these psychosocially complex patients. Only a minority of patients are candidates for interventional pain procedures. Lumbar epidural steroid injection (ESI), followed by facet joint injection, is the most frequent intervention we use in patients with discogenic pain associated with radiculopathy.Epidural steroid injection in the management of chronic pain in pediatric patientsAlexandra Szabova, Nagy Mekhail10.1053/j.trap.2009.06.024Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4255257http://www.techreganesth.org/article/PIIS1084208X09000342/abstract?rss=yesSpinal pain syndromes are major causes of morbidity and disability globally. Epidural steroid injections (ESIs) play a vital role in the nonsurgical management of radiculopathy pain. These are simple, cost-effective, minimally invasive, percutaneous interventions routinely performed by a Pain physician. ESIs can be a diagnostic tool in patients where clinical, radiological, and electrophysiological criteria do not clearly establish a causal relationship. Use of image guidance and transforaminal approach are found to be more efficacious in comparison to the conventional blind and interlaminar approach. The rationale behind ESIs is to deliver focused high concentration of the drug close to the inflamed nerve root, making it more effective than when given by oral or intramuscular route. The main objective of this article is to evaluate and analyze the current practice trends for ESIs in different geographic locations of the world outside of the USA. It may be interesting to compare it with the practice in the USA to find similarities and differences.Practice of epidural steroid injections outside of the United StatesPreeti P. Doshi, Jalpa D. Makwana10.1053/j.trap.2009.06.006Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4258265http://www.techreganesth.org/article/PIIS1084208X09000561/abstract?rss=yesEpidural steroid injections (ESIs) are the most commonly performed intervention in the United States to manage chronic and subacute low back and neck pain with radiculopathy. ESIs have been used for decades for the treatment of discogenic and osteoarthritic radicular conditions originating from the cervical, thoracic, and lumbar spine, as well as spondylosis, nonspecific radiculitis, and spinal stenosis.With the ever-increasing use of epidural steroids, there has been a disproportionate increase in popularity of transforaminal ESIs in particular. Since 2002, there has been a growing body of largely transforaminal epidural steroid case report literature that describes paralysis, stroke, and death that immediately follows the performance of these procedures. These complications are thought to be related to a combination of factors, which may include the technique used, underlying pathophysiology that is being treated, anatomical variations in the blood supply, as well as the specific injectate used.This article discusses the pathogenesis of these complications and puts the role of steroids in their causation into perspective.Epidural steroid injections: An update on mechanisms of injury and safetyChristopher Gharibo, Caroline Koo, Jennifer Chung, Alex Moroz10.1053/j.trap.2009.06.025Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4266271http://www.techreganesth.org/article/PIIS1084208X09000366/abstract?rss=yesObjectives: The clinical use of epidural steroid injection and related legal claims have increased over time. Practitioners in the field of Pain Medicine must be aware of their ethical and legal responsibilities to their patients. Physicians must also be cognizant of how their own behavior may be a liability.Methods: We performed a literature search using the PubMed and American Society of Anesthesiologists database for articles and guidelines related to epidural steroid injections and/or chronic pain. Further information was obtained via the LexisNexis database, including legal cases in which complications resulting from an epidural steroid injection had formed the basis of a medical malpractice action. The legal duties of physicians, as set forth in United States law, were also reviewed.Conclusions: Legal claims are filed against people who do everything correctly and those who do not—their outcome does not necessarily reflect justice. The practice of medicine is an art, which combines knowledge, technical skill, and interpersonal relations. Physicians must take a leading role not only in the medical care of their patients, but as educators in the legal arena. Where physicians fail to do so, others who lack medical training and an appreciation of the subtleties of the art will, of necessity, dictate the standards of medical care.Medicolegal aspects of epidural steroid injectionsSeth A. Waldman, Abiona Berkeley10.1053/j.trap.2009.06.008Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4272280http://www.techreganesth.org/article/PIIS1084208X09000457/abstract?rss=yesEpidural administration of corticosteroids is one of the commonly used interventions in managing low back pain with or without radiculopathy. Approaches used to access the lumbar epidural space include the caudal, interlaminar, and transforaminal injections. Reports of effectiveness have varied from 18% to 90%. However, most of the analyses have failed to separate the three approaches, not only mixing the various procedures but also results and outcomes. Recent guidelines by the American Society of Interventional Pain Physicians and others have evaluated effectiveness of caudal epidural steroid injections (ESIs), transforaminal, and interlaminar injections separately. The consensus from these reviews is that caudal ESIs are superior to the interlaminar epidural injections and equal to transforaminal epidural injections. In addition, the response to epidural injections for various pathologic conditions (disc herniation and/or radiculitis, discogenic pain without disc herniation, spinal stenosis, postsurgery syndrome) is variable. The systematic reviews indicated Level I evidence for caudal ESIs in managing disc herniation or radiculitis, and discogenic pain without disc herniation or radiculitis. They also indicated evidence is Level II-1 or II-2 evidence for caudal epidural injections in managing pain of postlumbar surgery syndrome and lumbar spinal stenosis. They also provided strong recommendations of 1B or 1C for caudal ESIs in managing pain secondary to disc herniation and radiculitis, or discogenic pain without disc herniation or radiculitis, postlumbar laminectomy syndrome, and spinal stenosis.Evidence-based practice of lumbar epidural injectionsSukdeb Datta, Ramsin M. Benyamin, Laxmaiah Manchikanti10.1053/j.trap.2009.06.015Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4281287http://www.techreganesth.org/article/PIIS1084208X0900038X/abstract?rss=yesThe use of epidural steroids has been a cornerstone of interventional pain medicine as it has evolved as a specialty over the past few decades. These injections, which have been documented in the literature for more than 50 years, have been used for both radicular and axial pain throughout the neuroaxis. Studies have been performed that both support and distract from the evidence for these interventions. Many of the studies that have shown little or no support for the therapies have been flawed, by poor methodologies, lack of fluoroscopic guidance, and use of proceduralists with minimal training. Some clinicians have used these injections in excessive numbers in inappropriate patients. It is the goal of this paper to give guidelines for the proper use of this important therapy. Recommendations have been made on the frequency, route of administration, use of fluoroscopy, and type and dose of steroid but there does not currently exist a specific set of guidelines to address these issues. An extensive review of the available literature was performed, and evidence-based guidelines are established for the first time in an attempt to provide the interventional pain physician with specific guidelines concerning the administration of epidural steroids in patients with axial and radicular pain of spinal origin.Guidelines for the proper use of epidural steroid injections for the chronic pain patientTimothy Deer, Matthew Ranson, Leonardo Kapural, Sudhir A. Diwan10.1053/j.trap.2009.06.010Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4288295http://www.techreganesth.org/article/PIIS1084208X09000305/abstract?rss=yesIn considering the future of pain medicine, it is imperative to consider existing and evolving technologies that can assist in performing complex and challenging procedures. Applications of new technologies are becoming the mainstay in many medical specialties. Computer- and/or robotic-assisted procedures allow clinicians to perform safe and reproducible procedures using minimally invasive techniques. In conjunction with image guidance these procedures are gaining wider acceptance and are becoming welcomed tools in medicine. The field of pain management is ideal for the incorporation of computer and/or robotic assistance in its procedures. Most of the procedures entail delivering the treatment via small access points. The goal of reducing tissue trauma makes it even more challenging to reach the targeted location. The use of computer and/or robotics will allow for precision, accuracy, and reproducibility, factors often unattainable due to the multitude of uncontrolled variables. This is a model that allows physicians to augment their critical thinking with the robot's ability to promote accurate and efficient procedures. In addition, formal training sessions and multiple hours logged using the system will help with the clinicians' learning curve. The pain medicine platform will consist of a unit that is mobile, light, and versatile, allowing the use of multiple robotic arms with multiple degrees of freedom. In the future, the platform-specific costs and specialized instrumentation will need to be determined. If the precision of this system allows for no injuries to neurovascular structures, then the financial burden may be well worth considering.Future of pain medicine: Computer- and robotic-assisted proceduresVineet P. Shah, Nikhil L. Shah, Sudhir A. Diwan10.1053/j.trap.2009.06.002Techniques in Regional Anesthesia & Pain Management 13, 4 (2009)2009-10-01Techniques in Regional Anesthesia & Pain Management2009-10-01134S1084-208X(09)X0005-4296298