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BACKGROUND: Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE: To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS: The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and recommendations were provided. RESULTS: In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives. The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness. The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness. Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness. The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS: The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS: These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations. KEY WORDS: Chronic spinal pain, interventional techniques, epidural procedures, caudal epidural, lumbar interlaminar epidural, cervical interlaminar epidural, thoracic interlaminar epidural, lumbar transforaminal epidural, percutaneous adhesiolysis DISCLAIMER: These guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a “standard of care.” There was no external funding in the preparation of this manuscript.

Background and AimsHorner’s syndrome is characterized by miosis, partial ptosis, anhidrosis and apparent enophthalmos. After epidural analgesia, it is the result of the stellar ganglion blockade, suggesting a high level (C8–T4) of anaesthetic effects.MethodsWe report a full-term parturient submitted to labor analgesia under epidural technique. We administered ropivacaine and sufentanil, which produced a relatively symmetric sensitive block at T6/T7. Fifteen minutes later we noticed the patient developed Horner syndrome. Upon detection of the symptoms, a dilemma arose on whether to keep the catheter, which was resolved through discussions with the patient. Together we decided to keep it in place for the following boluses. Two additional fractioned boluses were administered. The patient maintained an adequate sensitive block at T6/T7, had no additional neurological findings and kept hemodynamic stability throughout the entire period. The condition was reversed completely three hours later with no additional interventions.ResultsHorner’s syndrome is associated with epidural anesthesia and pregnancy: due to reduced epidural volume from uterine pressure and increased local anesthetic sensitivity. Symptoms tend to be mild, but cardiorespiratory arrest is a possible complication due to high sympathetic block and close vigilance should occur. In this case, the decision to administer further boluses was based on the cardiorespiratory stability, the relatively mild presentation and the patient’s understanding of the situation.ConclusionsThis case highlights the importance of careful technique and vigilant monitoring during epidural analgesia, as well as the necessity of considering patient comfort and autonomy in the decision-making process.

Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)Background and Aims Pain management for Vertical Rectus Abdominis Musculocutaneous (VRAM) Flap can be challenging due to a large surgical incision. We present a case of a 65-year-old female admitted for correction of recidivate complex uterovaginal prolapse and VRAM Flap. We aim to demonstrate the benefits of combined anesthesia for this type of surgery.MethodsAn epidural catheter was placed at L3/L4 level with an initial bolus of 10ml of 0.75% ropivacaine administered without relevant hemodynamic instability. After induction of total intravenous anesthesia (propofol and remifentanil), 2mg of epidural morphine was administered to spread the analgesia. Another bolus of 7 ml of 0.2% ropivacaine was administered only 5h after. The maintenance dose of remifentanil was low (up to less than 0,05-0,10 mcg/kg/min). Analgesia was complemented with cetorolac 30mg, paracetamol 1g and metamizol 2g. The procedure lasted for 7 hours and at the end, a patient-controlled epidural infusion (PCEA) was connected with 0,1% ropivacaine with a continuous infusion of 5ml/h and 4ml patient-controlled bolus with a lockout of 20min.ResultsPost-operative pain was well controlled, 2 out of 10 (numerical rating scale pain) at rest and movement at 0h and 12h without bolus attempts in the PCEA nor opioid rescue analgesia.ConclusionsPatient-controlled epidural infusion limited postoperative opioids necessities and their associated side effects while providing controlled analgesia in VRAM flap surgeries.

To the Editor, Identification of bony landmarks by palpation can be difficult in obese pregnant women, and obesity is associated with higher epidural catheter failure rates [1]. Ultrasound may help offset the challenges of epidural catheter placement in obese patients [2], but few studies have compared it to landmark palpation in morbidly obese (body mass index, BMI ≥40) patients. In the palpation group, there were two cases of paresthesia during epidural needle placement, one unilateral block requiring catheter adjustment (epidural catheter pulled back 1 cm, no reinsertion required), and one unintentional dural puncture resulting post-dural puncture headache (declined epidural blood patch).

Cervical transforaminal epidural block (CTEB) is a useful option in the diagnosis and treatment of cervical radicular pain. However, inadvertent intravascular injection can lead to severe neurologic complications. Blunt needles are considered to displace instead of penetrate vessels because of their dull needle tip. To investigate whether there is a difference between blunt and sharp needles in intravascular injection rates during CTEB. Prospective, randomized, clinical trial. A tertiary hospital in South Korea. After institutional review board approval, 108 patients undergoing CTEB for treatment of radicular pain resulting from spinal stenosis and herniated nucleus pulposus were randomly assigned to one of 2 needle groups (blunt needle or sharp needle). The needle position was confirmed using biplanar fluoroscopy, and 2 mL of nonionic contrast medium was injected to detect intravascular injection. Intravascular injection was defined as the contrast medium spreading out through the vascular channel during injection under real-time fluoroscopy. This study was registered in ClinicalTrials.gov. The intravascular injection rate was not significantly different between the blunt needle and sharp needle groups (35.2% vs. 33.3%, P > 0.05). The procedure time was longer in the blunt needle group than in the sharp needle group (101.00 ± 12.4 seconds vs. 56.67 ± 8.3 seconds, P < 0.001). This was a single-center study. Additionally, the physicians could not be blinded to the type of needle used. In the present study, use of a blunt needle did not reduce the rate of intravascular injection during CTEB compared to use of a sharp needle. In addition, procedure time significantly increased with blunt needle use compared to sharp needle use. Analgesia, bleeding, blunt needle, cervical spine, clinical trials, complications, intravascular injection, radiculopathy, sharp needle, transforaminal epidural block.

We developed an innovative method for ultrasound-assisted thoracic epidural catheter placement and assessed its potential to reduce procedural duration for trainees. A cadaveric observational study and a clinical randomized controlled trial. Sapporo Medical University Hospital. A total of 52 adult patients scheduled for thoracic or abdominal surgery and four cadavers. Patients were randomly assigned to either group receiving conventional palpation (conventional group) or combination of the ultrasound examination and conventional palpation (ultrasound group). The primary outcome was total procedure time (sum of skin marking time and needling time) by trainees. The secondary outcomes were (1) skin marking time, (2) needling time, (3) multiple skin punctures, (4) needle redirection, (5) complications, and (6) failed cases. Through dissection of four cadavers, the most dorsal site of the transverse process root was identifiable by ultrasound and the reliable indicator of the interlaminar space. We devised ultrasound-assisted middle thoracic epidural catheter placement utilizing the most dorsal sites of bilateral transverse process roots as anatomical landmarks. Trainees in the ultrasound group had significantly longer skin marking time and significantly shorter needling time than those in the conventional group (107 [87–158] vs 46 s [34–54] s, p < 0.001 and 197 [156–328] vs 341 [303–488] s, p = 0.003). Consequently, there was no significant difference between the two groups in total procedure time (326 [263–467] s vs 391 [354–533] s, p = 0.167). Moreover, the probability of trainee failure in epidural anesthesia was significantly lower in the ultrasound group (2/26 [17.7 %] vs 10/26 [38.5 %], p = 0.019). Our novel technique for thoracic epidural catheter placement resulted in expedited needling and enhanced success rates among trainees, although there was no significant difference between total procedure time when using ultrasound guidance and that when using conventional palpation. •The most dorsal site of the transverse process root was identifiable by ultrasound.•The transverse process root was a reliable landmark of the interlaminar space.•We developed an innovative method for thoracic epidural catheter placement.•Our novel technique expedited needling among trainees.•Our novel technique enhanced success rates among trainees.

Background and aimsAccidental dural puncture (ADP) is often associated with post-dural puncture headache (PDPH) in parturients. Although conventional treatment versus epidural blood patch (EBP) has been extensively reviewed, there is no consensus on the overall patient management.MethodsWe report a retrospective analysis of 116 parturients posted for caesarean section (CS) (108) or vaginal birth (VB) (8) who experienced ADP during combined spinal epidural (CSE) or epidural anaesthesia, while attending at a tertiary referral obstetric unit between January 2010 and December 2018. Patient records were reviewed for interventions, timing of EBP and outcome.ResultsDuring that period, we performed 5936 epidurals for VB, 12036 CSEs and 83 epidurals for CS. The overall rate of ADP was 0.64%, (0.89% CS and 0.13% VB). The majority of ADPs (93) were reported during the identification of epidural space (80.2%), whilst 20 (17.2%) were recognized only after the withdrawal of the pencil-point needle or during the epidural catheter threading (1–0.9%). In 2 cases, ADP was reported during local infiltration with the blue-hub (23G) needle. Among 34 parturients who experienced PDPH (29.3%), 13 were classified as having experienced severe PDPH, whereas 20 as having mild. Only 11 patients consented to active treatment with an EBP. All EBPs were performed 48 hrs after ADP. In 2 cases, a second EBP is reported due to an unresolved headache. The mean dose of blood injected was 21.72 ml (min 11 ml, max 40 ml). Follow-up was arranged in 100% of EBP patients.ConclusionsEBP could be the most effective treatment for PDPH.

Background and aimsIn an area of the UK covered by a busy district general hospital 6.4% of households have no adult who has English as their main language [1]. This can pose a problem for the consent of procedures, such as caesareans and epidurals. In view of the medico-legal requirement to communicate effectively with our patients [2], and the time-consuming nature of using telephone translation services, we evaluated the effectiveness of the online translation service Google Translate (GT).MethodsEight phrases commonly used during epidural consenting and placement were typed into GT. the audio translation of six languages was then listened to by a non-medical native speaker. Their understanding of the audio was then recorded in English. This was compared to the original English statement and assessed for meaning. the accuracy of the translation was ranked: correct; minor errors with no effect on understanding; and major errors with significant effect on understanding or factually incorrect.ResultsBoth Asian languages had major error rate of 50%, Romanian 25%, Spanish and French 12.5% and Polish 0%.Abstract ESRA19-0324 Table 1Abstract ESRA19-0324 Table 2ConclusionsGT is a statistical machine translation service; therefore, some of the major errors in translation were completely nonsensical. In Tamil ‘paralysis’ was translated to ‘possessed’ and in Spanish ‘ventouse’ to ‘ventricular’, rendering it inappropriate for medical consent. There could be scope for its use in procedural instructions if no specialist terms are used. However, care is needed to maintain a patient’s confidence particularly during this vulnerable period. In future a precompiled set of accurate audio translations could be evaluated.

IntroductionThe Microsoft HoloLens is a head-mounted mixed reality device, which allows for overlaying hologram-like computer-generated elements onto the real world. This technology can be combined with preprocedural ultrasound during thoracic epidural placement to create a visual of the ideal needle angulation and trajectory in the users’ field of view. This could result in a technically easier and potentially safer alternative to traditional blind landmark techniques.MethodsPatients were randomly assigned to one of two groups: (1) HoloLens-assisted thoracic epidural technique (intervention—group H) or (2) traditional thoracic epidural technique (control—group C). The primary outcome was needling time (defined as skin puncture to insertion of epidural catheter) during the procedure. The secondary outcomes were number of needle punctures, number of needle movements, number of bone contacts, and epidural failure. Procedural pain and recovery room pain levels were also evaluated.ResultsEighty-three patients were included in this study. The primary outcome of procedure time was reduced in the HoloLens group compared with control (4.5 min vs 7.3 min, p=0.02, 95% CI), as was the number of needle movements required (7.2 vs 14.4, p=0.01), respectively. There was no difference in intraprocedure or postprocedure pain, bone contacts, or total number of needle punctures. Three patients in the control group experienced epidural failure versus one patient in the HoloLens group.ConclusionsThis study shows that thoracic epidural placement may be facilitated by using a guidance hologram and may be more technically efficient.Trial registration number NCT04028284.

BACKGROUND: Despite epidurals being one of the most common interventional pain procedures for managing chronic spinal pain in the United States, expenditure analysis lacks assessment in correlation with utilization patterns. OBJECTIVES: This investigation was undertaken to assess expenditures for epidural procedures in the fee-for-service (FFS) Medicare population from 2009 to 2018. STUDY DESIGN: The present study was designed to assess expenditures in all settings, for all providers in the FFS Medicare population from 2009 to 2018 in the United States. In this manuscript: • A patient was described as receiving epidural procedures throughout the year. • A visit was considered to include all regions treated during the visit. • An episode was considered as one treatment per region utilizing primary codes only. • Services or procedures were considered as all procedures including bilateral and multiple levels. A standard 5% national sample of the Centers for Medicare and Medicaid Services (CMS) physician outpatient billing claims data for those enrolled in the FFS Medicare program from 2009 to 2018 was utilized. All the expenditures were presented with allowed costs and adjusted to inflation to 2018 US dollars. RESULTS: Total expenditures were$723,981,594 in 2009, whereas expenditures of 2018 were $ 829,987,636, with an overall 14.6% increase, or an annual increase of 1.5%. However, the inflation-adjusted rate was$847,058,465 in 2009, compared to $ 829,987,636 in 2018, a reduction overall of 2% and an annual reduction of 0.2%. Inflation-adjusted per patient annual costs decreased from$988.93 in 2009 to $ 819.27 in 2018 with a decrease of 17.2% or an annual decline of 2.1%. In addition, inflation-adjusted costs per procedure decreased from$399.77 to $ 377.94, or 5.5% overall and 0.6% annually. Per procedure, episode, visit, and patient expenses were higher for transforaminal epidural procedures than lumbar interlaminar/caudal epidural procedures. Overall, costs of transforaminal epidurals increased 27.6% or 2.7% annually, whereas lumbar interlaminar and caudal epidural injections cost were reduced 2.7%, or 0.3% annually. Inflation-adjusted costs for transforaminal epidurals increased 9.1% or 1.0% annually and declined 16.9 or 2.0% annually for lumbar interlaminar and caudal epidural injections. LIMITATIONS: Expenditures for epidural procedures in chronic spinal pain were assessed only in the FFS Medicare population. This excluded over 30% of the Medicare population, which is enrolled in Medicare Advantage plans. CONCLUSIONS: After adjusting for inflation, there was a decrease of expenditures for epidural procedures of 2%, or 0.2% annually, from 2009 to 2018. However, prior to inflation, the increases were noted at 14.6% and 1.5%. Inflation-adjusted costs per patient, per visit, and per procedure also declined. The proportion of Medicare patients per 100,000 receiving epidural procedures decreased 9.1%, or 1.1% annually. However, assessment of individual procedures showed higher costs for transforaminal epidural procedures compared to lumbar interlaminar and caudal epidural procedures. KEY WORDS: Chronic spinal pain, epidural procedures, caudal epidural, lumbar interlaminar epidural, cervical interlaminar epidural, thoracic interlaminar epidural, lumbar transforaminal epidural procedures, Medicare expenditures