Search

Objective. The purpose of this study was to perform a comparative analysis of the contralateral oblique (CLO) view and the lateral view for lumbar interlaminar epidural access. Design. After the epidural space was accessed, fluoroscopic images at eight different angles (anteroposterior view, multiple CLO, and lateral view) were prospectively obtained. Visualization and location of needle tip relative to bony landmarks were analyzed. The epidural location of the needle was subsequently confirmed by contrast injection and analysis in multiple views. Results. Visualization of the needle tip and the relevant radiologic landmarks was superior in the CLO view. The needle tip location in the epidural space was most consistent at a CLO angle of 45°. Conclusion. This study shows that the CLO view for lumbar interlaminar epidural access offers clear advantages over the lateral view on many clinically important grounds: the needle tip visualization is better, the important radiological landmarks are better visualized, and the needle tip when placed in the epidural space presents a more precise relationship to these landmarks. All of these differences were highly significant. Thus, when using this view, the needle may be directly placed in very close vicinity to the epidural space and true loss of resistance expected soon thereafter. In addition, this view provides the ability to plot the cranio-caudad needle trajectory. The combination of these factors is likely to improve the ease and efficiency of epidural access. The crisp visualization of the final moments of epidural access could also translate to improved safety and accuracy. In light of this, it is suggested that a CLO view at 45° be considered the preferred view for gauging needle depth during interlaminar lumbar epidural access. [ABSTRACT FROM AUTHOR]

The opioid epidemic has resulted from myriad causes and will not be solved by any simple solution. Consequent to a staggering increase in opioid-related deaths in the USA, various governmental inputs and stakeholder strategies have been proposed and implemented with varying success. This article summarizes the history of opioid use and explores the causes for the present day epidemic. Recent trends in opioid-related data demonstrate an almost fourfold increase in overdose deaths from 1999 to 2008. Tragically, opioids claimed over 64,000 lives just last year. Some solutions have undergone legislation, including the limitation of numbers of opioids postsurgery, as well as growing national prevalence of enhanced recovery after surgery protocols which focus on reduced postoperative opioid consumption and shortened hospital stays. Stricter prescribing practices and prescription monitoring programs have been instituted in the recent past. Improvement in abuse deterrent strategies which is a major focus of the Food and Drug Administration (FDA) for all opioid preparations will likely play an important role by increasing the safety of these medications. Future potential strategies such as additional legislative policies, public awareness, and physician education are also detailed in this review.

Background: The efficacy of epidural and facet joint injections has been assessed utilizing multiple solutions including saline, local anesthetic, steroids, and others. The responses to these various solutions have been variable and have not been systematically assessed with longterm followups. Methods: Randomized trials utilizing a true active control design were included. The primary outcome measure was pain relief and the secondary outcome measure was functional improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the criteria developed by the American Society of Interventional Pain Physicians (ASIPP) for assessing interventional techniques. An evidence analysis was conducted based on the qualitative level of evidence (Level I to IV). Results: A total of 31 trials met the inclusion criteria. There was Level I evidence that local anesthetic with steroids was effective in managing chronic spinal pain based on multiple highquality randomized controlled trials. The evidence also showed that local anesthetic with steroids and local anesthetic alone were equally effective except in disc herniation, where the superiority of local anesthetic with steroids was demonstrated over local anesthetic alone. Conclusion: This systematic review showed equal efficacy for local anesthetic with steroids and local anesthetic alone in multiple spinal conditions except for disc herniation where the superiority of local anesthetic with steroids was seen over local anesthetic alone. [ABSTRACT FROM AUTHOR]

The use of spinal cord stimulation (SCS) devices to treat chronic, refractory neuropathic pain continues to expand in application. While device-related complications have been well described, inflammatory reactions to the components of these devices remain underreported. In contrast, hypersensitivity reactions associated with other implanted therapies, such as endovascular and cardiac rhythm devices, have been detailed. The purpose of this case series is to describe the clinical presentation and course of inflammatory reactions as well as the histology of these reactions. All patients required removal of the entire device after developing inflammatory reactions over a time course of 1-3 months. Two patients developed a foreign body reaction in the lead insertion wound as well as at the implantable pulse generator site, with histology positive for giant cells. One patient developed an inflammatory dermatitis on the flank and abdomen that resolved with topical hydrocortisone. "In vivo" testing with a lead extension fragment placed in the buttock resulted in a negative reaction followed by successful reimplantation of an SCS device. Inflammatory reactions to SCS devices can manifest as contact dermatitis, granuloma formation, or foreign body reactions with giant cell formation. Tissue diagnosis is essential, and is helpful to differentiate an inflammatory reaction from infection. The role of skin patch testing for 96 hours may not be suited to detect inflammatory giant cell reactions that manifest several weeks post implantation. [ABSTRACT FROM AUTHOR]

Purpose: The objective of this study was to retrospectively evaluate the analgesic effects of continuous radio frequency lesioning of the suprascapular nerve (SSN) for chronic shoulder pain. The authors sought to obtain insight into the time-sensitive analgesic success and complications of this therapy. Patients and methods: This study was a retrospective case series involving patients with unremitting shoulder pain that had lasted for at least 12 months. Patients were selected if they showed a reduction of at least 50% in pain intensity during the anesthetic phase after SSN block, no additional motor weakness of the shoulder, and pain relief lasting for less than 2 months after separate treatments of the SSN with depot corticosteroids and pulsed radiofrequency. Nine patients were referred to the Arnold Pain Management Center. Of these nine patients, six patients who had significant chronic shoulder pain unresponsive to oral medications and intra-articular injections and who were not considered surgical candidates were selected. These patients were treated with a single radiofrequency lesion of the SSN at 80°C for 60 seconds. The primary outcome was a reduction in pain intensity by 50%, as determined by the numeric rating scale, and duration of this effect. The secondary outcome was improvement in either the passive or the active range of motion (ROM). Patients were also monitored for adverse effects such as weakness or increased pain. Results: The pooled mean numeric rating scale score before the procedure was 7.2 ± 1.2; this fell to 3.0 ± 0.9 at 5-7 weeks post procedure. The duration of pain relief ranged from 3 to 18 months, and all patients underwent at least one additional treatment. The change in baseline ROM improved from an average of 60° ± 28° (flexion) and 58° ± 28° (abduction) to 99° ± 46° (flexion) and 107° ± 39° (abduction). No adverse side effects were observed. Conclusion: Continuous radiofrequency lesioning of the SSN seems to be an effective treatment for chronic shoulder pain. There can be improved ROM of the shoulder following this treatment. More formal, controlled studies are required to confirm these observations. [ABSTRACT FROM AUTHOR]

Overdose deaths involving opioids have increased dramatically since the 1990s, leading to the worst drug overdose epidemic in U.S. history, but there is limited empirical evidence about the initial causes. In this article, we examine the role of the 1996 introduction and marketing of OxyContin as a potential leading cause of the opioid crisis. We leverage cross-state variation in exposure to OxyContin's introduction due to a state policy that substantially limited the drug's early entry and marketing in select states. Recently unsealed court documents involving Purdue Pharma show that state-based triplicate prescription programs posed a major obstacle to sales of OxyContin and suggest that less marketing was targeted to states with these programs. We find that OxyContin distribution was more than 50% lower in "triplicate states" in the years after the drug's launch. Although triplicate states had higher rates of overdose deaths prior to 1996, this relationship flipped shortly after the launch and triplicate states saw substantially slower growth in overdose deaths, continuing even 20 years after OxyContin's introduction. Our results show that the introduction and marketing of OxyContin explain a substantial share of overdose deaths over the past two decades. [ABSTRACT FROM AUTHOR]