Current pain and headache reports
-
Curr Pain Headache Rep · Apr 2020
Review Meta Analysis Comparative StudyDoes Epidural Bupivacaine with or Without Steroids Provide Long-Term Relief? A Systematic Review and Meta-analysis.
Low back and lower extremity pain have been treated since 1901 with local anesthetics alone and since 1952 in combination with steroids. Over the years, multiple randomized controlled trials, systematic reviews with or without meta-analysis have been reaching discordant conclusions regarding the effectiveness of sodium chloride solution, local anesthetics, and steroids in managing spinal pain. Further, related to lack of understanding, multiple reviewers have considered local anesthetics including lidocaine and bupivacaine as equivalent to placebo based on theory that steroid is the only drug effective in the epidural space. In this review, we assessed effectiveness of epidurally administered bupivacaine with or without steroids to rule out misconceptions of placebo and to show the comparative effectiveness of epidural bupivacaine alone compared to epidural bupivacaine with steroids. ⋯ Multiple systematic reviews performed in assessing the effectiveness of epidural injections have converted epidurally administered lidocaine and bupivacaine to placebo. This led to inappropriate conclusions of lack of effectiveness of epidural local anesthetics with or without steroids as showing equal effectiveness when analyzed with conventional dual-arm meta-analysis. Thus, true placebo control trials with injection of an inactive substance into unrelated structures have been almost non-existent. Epidurally administered bupivacaine alone or with steroids are effective in managing low back and lower extremity pain. The findings of this review provide appropriate information of epidurally administered bupivacaine as an active agent (not a placebo) with level 1 evidence and almost equally effective as bupivacaine with steroids with level II evidence.
-
Curr Pain Headache Rep · Apr 2020
Review Clinical TrialEffects of Tourniquets in the Development of Pain States: a Novel Clinical Pilot Study and Review of Utilization of Tissue Oximetry to Measure Neural Ischemia.
Approximately 20% of patients undergoing surgery develop persistent lower extremity pain following total knee arthroplasty. Animal studies have confirmed that prolonged tourniquet time increases the risk of endoneural ischemia and can mediate or modulate the development of chronic pain. The use of Near InfraRed Spectroscopy (NIRS) adjacent to nerve tissue, previously described as ONG has been shown to detect early neural compromise and has demonstrated clinical utility in carpal tunnel diagnosis. ⋯ In this pilot study, we recruited 10 healthy adult volunteers to undergo oxyneurography (ONG) and sensory nerve conduction testing (sNCT). We performed testing on the upper and lower extremities in each individual. The tourniquet was applied followed by measurements of sNCT and ONG as described. We observed a significant drop in the mean ONG index at 3 and 5 min following tourniquet inflation in upper and lower extremities. Similar to raw ONG values, there was significant variability in sNCT measurements, which in general increased from baseline with tourniquet inflation. In the upper extremity, there was a significant increase in sNCT with tourniquet inflation, while in the lower extremity, there was a trend towards significance. The use of ONG can be supported as a diagnostic tool to detect nerve ischemia and to potentially reduce the incidence of tourniquet-mediated or -modulated neural ischemia and reduce the development of chronic post-tourniquet pain.
-
Curr Pain Headache Rep · Apr 2020
ReviewA Comprehensive Update on the Treatment and Management of Postdural Puncture Headache.
The purpose of this manuscript is to provide a comprehensive review of postdural puncture headache (PDPH) with a focus on epidemiology, pathophysiology, treatment, and prophylaxis. ⋯ PDPH is an adverse iatrogenic complication of neuraxial anesthesia that occurs following inadvertent puncture of the dura after epidural or spinal anesthesia. The overall incidence of PDPH after neuraxial procedures varies from 6 to 36%. The occurrence of PDPH can lead to increased patient morbidity, delayed discharge, and increased readmission. PDPH is a self-limiting postural headache that most often will resolve within 1 week, without need for treatment. Various prophylactic measures have been studied; however, more studies have been recommended to be undertaken in order to establish a proven benefit. For mild PDPH, conservative treatments are currently focused around bed rest, as well as oral caffeine. For moderate-to-severe PDPH, epidural blood patch (EBP) remains the most effective treatment; however, this invasive treatment is not without inherent risks. Further less invasive treatments have been explored such as epidural saline, dextran 40 mg solutions, hydration, caffeine, sphenopalatine ganglion blocks, greater occipital nerve blocks, and surgical closure of the gap; all have shown promise. Further studies are essential to prove efficacy as well as safety over the proven treatment of epidural blood patches. There is still limited evidence in literature about the understanding of PDPH and optimal treatment.
-
Curr Pain Headache Rep · Apr 2020
ReviewIs a One Prognostic Block Sufficient to Proceed with Radiofrequency Ablation? A Single Center Experience.
We performed this study and associated review to examine whether a one prognostic block is sufficient to proceed with radiofrequency ablation. ⋯ To perform one or two prognostic blocks before performing radiofrequency ablation is a very controversial issue. The practice is inconsistent and insurance companies even do not follow same regulations. We found in our research that majority of patients who receive a successful first prognostic block also receive a successful second prognostic block. We think one prognostic block can be sufficient to move forward with radiofrequency ablation.
-
Curr Pain Headache Rep · Apr 2020
Review Comparative StudyUtilization of Vertebral Augmentation Procedures in the USA: a Comparative Analysis in Medicare Fee-for-Service Population Pre- and Post-2009 Trials.
To review the utilization patterns of vertebral augmentation procedures in the US Medicare population from 2004 to 2017 surrounding concurrent developments in the literature and the enactment of the Affordable Care Act (ACA). ⋯ The analysis of vertebroplasty and kyphoplasty utilization patterns was carried out using specialty utilization data from the Centers for Medicare and Medicaid Services Database. Of note, over the period of time between 2009 and 2017, the number of people aged 65 or older showed a 3.2% rate of annual increase, and the number of Medicare beneficiaries increased by 27.6% with a 3.1% rate of annual increase. Concurrently, vertebroplasty utilization decreased 72.8% (annual decline of 15% per 100,000 Medicare beneficiaries), and balloon kyphoplasty utilization decreased 19% (annual decline of 2.6% per 100,000 Medicare beneficiaries). This translates to a 38.3% decrease in vertebroplasty and balloon kyphoplasty utilization (annual decline of 5.9% per 100,000 Medicare beneficiaries) from 2009 to 2017. By contrast, from 2004 to 2009, there was a total 188% increase in vertebroplasty and balloon kyphoplasty utilization (annual increase rate of 23.6% per 100,000 Medicare beneficiaries). The majority of vertebroplasty procedures were done by radiologists, and the majority of kyphoplasties were done by aggregate groups of spine surgeons. These results illustrate a significant decline in vertebral augmentation procedures in the fee-for-service Medicare population between 2004 and 2017, with dramatic decreases following the publication of two 2009 trials that failed to demonstrate benefit of vertebroplasty over sham and the enactment of the ACA.