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AbstractThe American Society of Regional Anesthesia and Pain Medicine (ASRA) 2012 survey of meeting attendees showed that existing ASRA anticoagulation guidelines for regional anesthesia were insufficient for their needs. Those surveyed agreed that procedure-specific and patient-specific factors required separate guidelines for pain and spine procedures. In response, a guidelines committee was formed. After preliminary review of published complications reports and studies, the committee stratified interventional spine and pain procedures according to potential bleeding risk: low-, intermediate-, and high-risk procedures. The ASRA regional anesthesia anticoagulation guidelines were largely deemed appropriate for the low- and intermediate-risk categories, but the high-risk category required further investigation. The first guidelines specific to interventional spine and pain procedures were published in 2015. Recent reviews evaluating bleeding complications in patients undergoing specific interventional pain procedures, the development of new regional anesthesia and acute pain guidelines, and the development of new anticoagulants and antiplatelet medications necessitate complementary updated guidelines. The authors desired coordination with the authors of the recently updated regional and acute pain anticoagulation guidelines. The latest evidence was sought through extensive database search strategies and the recommendations were evidence based when available and pharmacology driven otherwise. We could not provide strength and grading of these recommendations because there are not enough well-designed large studies concerning interventional pain procedures to support such grading. Although the guidelines could not always be based on randomized studies or on large numbers of patients from pooled databases, it is hoped that they will provide sound recommendations and the evidentiary basis for such recommendations. This publication is intended as a living document to be updated periodically with consideration of new evidence.

Interventional spine and pain procedures cover a far broader spectrum than those for regional anesthesia, reflecting diverse targets and goals. When surveyed, interventional pain and spine physicians attending the American Society of Regional Anesthesia and Pain Medicine (ASRA) 11th Annual Pain Medicine Meeting exhorted that existing ASRA guidelines for regional anesthesia in patients on antiplatelet and anticoagulant medications were insufficient for their needs. Those surveyed agreed that procedure-specific and patient-specific factors necessitated separate guidelines for pain and spine procedures.In response, ASRA formed a guidelines committee. After preliminary review of published complication reports and studies, committee members stratified interventional spine and pain procedures according to potential bleeding risk as low-, intermediate-, and high-risk procedures. The ASRA guidelines were deemed largely appropriate for the low- and intermediate-risk categories, but it was agreed that the high-risk targets required an intensive look at issues specific to patient safety and optimal outcomes in pain medicine.The latest evidence was sought through extensive database search strategies and the recommendations were evidence-based when available and pharmacology-driven otherwise. We could not provide strength and grading of these recommendations as there are not enough well-designed large studies concerning interventional pain procedures to support such grading. Although the guidelines could not always be based on randomized studies or on large numbers of patients from pooled databases, it is hoped that they will provide sound recommendations and the evidentiary basis for such recommendations.

The advent of ultrasound guidance has led to a renewed interest in regional anesthesia of the lower limb. In keeping with the American Society of Regional Anesthesia and Pain Medicine’s ongoing commitment to provide intensive evidence-based education, this article presents a complete update of the 2005 comprehensive review on lower extremity peripheral nerve blocks. The current review article strives to (1) summarize the pertinent anatomy of the lumbar and sacral plexuses, (2) discuss the optimal approaches and techniques for lower limb regional anesthesia, (3) present evidence to guide the selection of pharmacological agents and adjuvants, (4) describe potential complications associated with lower extremity nerve blocks, and (5) identify informational gaps pertaining to outcomes, which warrant further investigation.

[...]significantly lower DASH scores (lower level of disability) in the CS group were noted at 4 and 8 weeks with comparable findings at 12 weeks, and lower DASH scores in the PRP group at 24 weeks. Intra-articular saline injection is as effective as corticosteroids, platelet-rich plasma and hyaluronic acid for hip osteoarthritis pain: a systematic review and network meta-analysis of randomised controlled trials. Comparing Intra-articular Platelet-Rich Plasma With Hyaluronic Acid for the Treatment of Hip Osteoarthritis: A Systematic Review and Meta-Analysis.

BackgroundThe risk of spinal epidural hematoma (SEH) has been described in the literature but the impact in various patient populations has not been assessed in the same study. We identified the risk factors for SEH and calculated the OR for recovery in the pediatric, adult and obstetric (OB) patients based on the degree of neurological deficit before surgery.MethodsAdult non-OB cases were categorized whether they were on anticoagulants or not; SEH was related to neuraxial or pain procedure; or whether there was adherence to the American Society of Regional Anesthesia (ASRA) guidelines. Eligible cases were identified through PubMed and Embase searches in the English literature from 1954 to July 2022.ResultsA total of 940 cases were evaluated. In the pediatric cases, SEH was typically spontaneous, related to coagulopathy or athletic trauma. OB cases were spontaneous or related to neuraxial injections. Among adults on anticoagulant(s), SEH was mostly spontaneous with no related etiology or related to neuraxial procedure. SEH occurred despite adherence to the ASRA guidelines. Among non-OB adults not on anticoagulants, SEH was due to trauma, neuraxial injections, surgery or other causes. Neurological recovery was related to the degree of neurological deficit before surgery.ConclusionsOur data show a preponderance of spontaneous SEH in all patient populations. SEH developed even though the ASRA guidelines were followed, especially in patients on multiple anticoagulants. Patients with less impairment prior to surgery had a higher likelihood of complete recovery, regardless of the interval between surgery and onset of symptoms.

The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with neuraxial blockade is unknown. Although the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics, recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient populations. Overall, the risk of clinically significant bleeding increase with age, associated abnormalities of the spinal cord or vertebral column, the presence of an underlying coagulopathy, difficulty during needle placement, and an indwelling neuraxial catheter during sustained anticoagulation (particularly with standard heparin or low-molecular weight heparin). The need for prompt diagnosis and intervention to optimize is also consistently reported.In response to these patient safety issues, the American Society of Regional Anesthesia and Pain Medicine (ASRA) convened its Third Consensus Conference on Regional Anesthesia and Anticoagulation. Practice guidelines or recommendations summarize evidence-based reviews. However, the rarity of spinal hematoma defies a prospective randomized study, and there is no current laboratory model. As a result, the ASRA consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation. These are based on case reports, clinical series, pharmacology, hematology, and risk factors for surgical bleeding. An understanding of the complexity of this issue is essential to patient management.

The medical field has been experiencing numerous drug shortages in recent years. The most recent shortage to impact the field of interventional pain medicine is that of iodinated contrast medium. Pain physicians must adapt to these changes while maintaining quality of care. This position statement offers guidance on adapting to the shortage.

The latest American Society of Regional Anesthesia and Pain Medicine guideline recommended that PNBs be performed in patients on anticoagulants, based on compressibility, body habitus, comorbidities, and degree of anticoagulation.1 A practice advisory defined the risks of bleeding and suggested alterations in the anticoagulation regimens based on the specific PNB.2 The decision to stop anticoagulation needs to be weighed against the possibility of increasing risks related to thromboembolic events. The type of surgeries and blocks are noted in table 2.Table 1 Patientdemographics, perioperative variables, and complications in patients receiving peripheral nerve blocks on antiplatelet or anticoagulation medications Antiplatetet continued Antiplatelet discontinued Antiplatelet continued, anticoagulant discontinued Antiplatelet discontinued, anticoagulant discontinued Antiplatelet continued, anticoagulant continued Anticoagulant discontinued Number of patients, n 166 37 26 19 8 26 Median age (IQR) in years 63 (54–71) 66 (55–71) 72 (60–77) 69 (60–76) 64.5 (56, 71) 63 (46–67) Sex, n (%)  Male 117 (70.5) 22 (59.5) 16 (61.5) 11 (57.9) 5 (62.5) 19 (73.1)  Female 49 (29.5) 15 (40.5) 10 (38.5) 8 (42.1) 3 (37.5) 7 (26.9) Median BMI (IQR) in kg/m2 27 (23–31) 30 (25–36) 27 (25–36) 30 (25–33) 29 (24–38) 27 (23–34) ASA classification, n (%)  2 3 (1.8) 0 (0) 2 (7.7) 1 (5.3) 0 (0) 0 (0)  3 135 (81.3) 28 (75.7) 18 (69.2) 14 (73.7) 6 (75) 23 (88.5)  4 27 (16.3) 9 (24.3) 6 (23.1) 4 (21.1) 2 (25) 2 (7.7) Median CHA2DS2-VASc* (IQR) score 3 (2–4) 4 (3–4) 4 (2–5) 3 (2–5) 2 (1–5) 2 (1–4) CHA2DS2VASc risk classification, n (%)  Low 13 (7.8) 1 (2.7) 0 (0) 0 (0) 0 (0) 1 (3.8)  Moderate 61 (36.7) 3 (8.1) 8 (30.8) 5 (26.3) 4 (50) 14 (53.8)  High 92 (55.4) 33 (89.2) 18 (69.2) 14 (73.7) 4 (50) 11 (42.3) Tsui risk classification,† n (%)  Low 50 (30.1) 18 (48.6) 11 (42.3) 5 (26.3) 1 (12.5) 5 (19.2)  Intermediate 115 (69.3) 19 (51.4) 15 (57.7) 14 (73.7) 7 (87.5) 21 (80.8) Median hemoglobin (IQR) in g/dL  Preoperative 9.7 (8.8–11.1) 9.9 (8.9–11) 9.5 (8.3–10.7) 10.2 (9.3–11.5) 9.5 (8.4–10.9) 9.7 (8.9–11.2)  Postoperative 9.2 (8.3–10.6) 9.9 (8.4–10.9) 8.3 (7.7–9.8) 9.9 (8.3–11.1) 9.8 (8.4–10.3) 10.1 (9.2–11.1) Median platelet (IQR) count (*103 /mm)  Preoperative 279 (202–363) 294 (210–341) 301 (132–363) 248 (184–490) 196 (174–384) 224 (187–293)  Postoperative 246 (185–345) 305 (197–366) 244 (136–339) 270 (189–337) 197 (184–269) 255 (162–277) Median INR (IQR) ratio  Preoperative 1.1 (1.1–1.3) 1.1 (1–1.2) 1.3 (1.1–1.5) 1.3 (1.1–1.4) 1.5 (0.98–1.6) 1.4 (1.2–1.6)  Postoperative 1.2 (1.1–1.3) 1.1 (1–1.2) 1.2 (1.1–1.5) 1.3 (1.1–1.7) 1.2 (1.2–2.1) 1.4 (1.1–1.6) Complications, n Hematoma requiring surgical evacuation 1 1 Bruising/hematoma not requiring surgery 3 AV fistula clot requiring thrombectomy 4 1 Antiplatelet agents include aspirin and P2Y12 inhibitors. Anticoagulant agents include Coumadin, heparin, low-molecular-weight heparin, fondaparinux, and the novel oral anticoagulants. *CHA2DS2VASc score: A risk assessment tool for thromboembolic events in patients with atrial fibrillation: categories: 0=low risk; 1=intermediate risk; 2=high risk.5 †Based on Tsui et al risk assessment of peripheral and interfascial plane blocks.2 AV, arteriovenous; BMI, body mass index; INR, internal normalized ratio; ASA, American Society of Anesthesiologists.Table 2 Case distribution by surgery type and block type Antiplatetet continued Antiplatetet discontinued Antiplatetet continued, anticoagulant discontinued Antiplatetet discontinued, anticoagulant discontinued Antiplatetet continued, anticoagulant continued Anticoagulant discontinued No of patients, n 166 37 26 19 8 26 Surgery type  Arteriovenous fistula 51 8 8 4 4 14  Toe amputation 40 10 8 5 1 5  Below knee amputation 23 9 2 4 0 3  Transmetatarsal amputation 20 4 4 1 0 2  Arteriovenous fistula staging or revision 19 4 1 0 1 0  Toe or transmetatarsal amputation closure 7 2 0 3 0 0  Above knee amputation 1 0 1 1 0 1  Ankle disarticulation 2 0 0 1 1 0  Knee amputation revision 1 0 1 0 0 1  Digit amputation 2 0 0 0 0 0  Through knee amputation 0 0 1 0 0 0 Upper extremity mass excision 0 0 0 0 1 0 Block type  Interscalene 2 0 0 0 0 1  Supraclavicular 62 11 8 4 6 12  Infraclavicular 2 1 0 0 0 0  Axillary 3 0 1 0 0 1  Femoral 14 7 5 5 1 4  Sciatic 33 7 7 7 0 6  Lateral femoral cutaneous 0 1 1 1 0 1  Adductor canal 23 3 3 1 1 1  Popliteal 9 2 0 2 1 0  Obturator 1 1 1 1 0 1  Posterior cutaneous nerve of thigh 2 1 1 0 0 0  Ankle 50 14 10 7 1 6 Total number of patients: 284, total number of blocks: 357, total number of surgeries: 284. For atrial fibrillation, CHADS2 or CHA2DVS2VASc scores help to quantify risks associate with TIA/stroke.4 5 For interventional pain procedures, it has been recommended that the anticoagulant be continued, or a low-molecular-weight heparin bridge instituted, in patients with CHADS2 scores of ≥3.6 However, it is unclear if this recommendation applies to other reasons for anticoagulation.

BackgroundDisease-modifying anti-rheumatic drugs (DMARDs) are used in the management of rheumatoid arthritis (RA) and are classified as conventional DMARDs and biologic agents. A concern with DMARDs is the increased risk of infection after surgery. A practice advisory from the American Society of Anesthesiologists recommend alternatives to neuraxial injections in patients who are immunocompromized. We describe a patient who was on several DMARDs and developed inflammatory reactions in her bilateral paraspinal muscles and lumbar spine after an epidural steroid injection (ESI).Case presentationThe patient was a 79-year-old woman; she was taking methotrexate, adalimumab and prednisone for her RA. She had a left L5-S1 paramedian ESI for her L5 radiculitis. After relief of her back and radicular pain for 5 weeks, she had an acute exacerbation of her back pain. MRI showed bilateral paraspinal fluid accumulations and enhancement in her ligamentum flavum. Cultures of the aspirated fluid and biopsy specimens were negative for fungal, aerobic and anaerobic organisms. A repeat MRI 2 months later showed diminution of the fluid collection but with a new fluid accumulation near the left L4-5 facet and left L4 pedicle. Repeat cultures and gram stain of the specimens taken from the pedicle and the paraspinal muscles were negative. The patient was followed by her rheumatologist and in the pain clinic until resolution of her symptoms.ConclusionsSeveral society guidelines recommend the continuation of methotrexate but stoppage of the biologic DMARDS before surgery. The occurrence of an intense inflammatory reaction after an ESI in our patient calls for additional research on the subject and shared decision-making between the pain physician, patient and rheumatologist especially in patients on several DMARDs.