scholarly journals Diagnosis and Treatment of Sciatica in the Netherlands: A Survey among Neurologists and Anesthesiologists

2021 ◽  
pp. 1-11
Author(s):  
Bastiaan ter Meulen ◽  
Caroliene Overweg ◽  
Thomas Feenstra ◽  
Brigitte Brouwer ◽  
Michel Terheggen ◽  
...  
Keyword(s):  
Nerve Root ◽  
Pain Medication ◽  
Cross Sectional Survey ◽  
Nerve Blocks ◽  
Cross Sectional ◽  
Steroid Injections ◽  
Nerve Root Block ◽  
Epidural Steroid Injections ◽  
Epidural Steroid ◽  
Pulse Radiofrequency

<b><i>Background:</i></b> This study aimed to assess how Dutch neurologists and anesthesiologists diagnose and treat people with sciatica in secondary care and to evaluate their adherence to the newest guidelines. <b><i>Methods:</i></b> We conducted a cross-sectional survey. Respondents were asked about their current clinical practice related to sciatica. Three authors rated the respondents’ adherence to the guidelines on a three-point Likert scale. <b><i>Results:</i></b> Eighty neurologists and 44 anesthesiologists completed the questionnaire. Neurologists diagnose their sciatica patients primarily using a magnetic resonance imaging (89%). Selective diagnostic nerve blocks are considered useful by 81% of the neurologists. Neurologists primarily treat patients with pain medication, and 40% of them think epidural steroid injections are effective in 40–60% of injected patients. Twenty-nine percent of neurologists refer patients to a neurosurgeon after 4 months. Anesthesiologists consider a selective diagnostic nerve root block to have a higher diagnostic value than mapping. The most reported side effect of epidural injections is exacerbation of pain (82%). Pulse radiofrequency is applied in 9–11% of acute cases. The results also indicate that Dutch neurologists and anesthesiologists follow an evidence-based approach that is strictly or broadly in line with the guideline. <b><i>Conclusions:</i></b> Neurologists treat sciatica patients initially with pain medication and physiotherapy, followed by epidural steroid injections and referral for surgery. Anesthesiologists treat sciatica patients with one or more steroid injections or may perform a selective nerve root block. Imaging, selective nerve root blocks, medication, physiotherapy, and pulse radiofrequency are topics of further research.

Trends in steroid agent and diluent choices for epidural steroid injections: a survey of Spine Intervention Society physicians

2019 ◽  
Vol 44 (8) ◽  
pp. 809-813 ◽  
Author(s):  
Nathan Clements ◽  
Darrell Vydra ◽  
Daniel M. Cushman ◽  
Ameet Nagpal ◽  
Jonathan Julia ◽  
...  
Keyword(s):  
Risk Mitigation ◽  
Mitigation Strategies ◽  
Survey Study ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Spine Intervention ◽  
Epidural Steroid

BackgroundEpidural steroid injections (ESIs) are a frequently used treatment for refractory radicular spinal pain. ESIs, particularly transforaminal epidural steroid injections (TFESI), may provide pain relief and delay the need for surgery. Corticosteroid agent and diluent choices are known to impact the safety of ESIs. In particular, the risk of embolization with particulate corticosteroids has led to recommendations for non-particulate steroid use by the Multisociety Pain Workgroup. Additionally, there is in vitro evidence that ropivacaine can crystalize in the presence of dexamethasone, potentially creating a particulate-like injectate. Despite widespread use and known risk mitigation strategies, current practice trends related to steroid and diluent choices are unknown.ObjectiveIdentify the use of particulate versus non-particulate corticosteroids for epidural steroid injections in the cervical and lumbar spine, as well as local anesthetics commonly used as diluents during these procedures.MethodsCross-sectional survey study of 314 physician members of the Spine Interventional Society.Results41% and 9% of providers reported using particulate corticosteroids during lumbar TFESIs and cervical TFESI, respectively. Four per cent of providers reported the use of ropivacaine in cervical TFESIs. Forty-four per cent of respondents reported using anesthetic in cervical interlaminar ESIs. 21% of providers report using high volumes (> 4.5 mL) during cervical interlaminar ESIs.ConclusionCurrent trends, as assessed by this survey study, indicate substantial variability in steroid and diluent choice for ESIs. Patterns were identified that may impact patient safety including the continued use of particulate corticosteroids for TFESIs and the use of ropivacaine during TFESIs by a subset of respondents.

scholarly journals Review of Occupational Medicine Practice Guidelines for Interventional Pain Management and Potential Implications

2008 ◽  
Vol 3;11 (5;3) ◽  
pp. 271-289
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Pain Management ◽  
Workers Compensation ◽  
Nerve Blocks ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Interventional Pain Management ◽  
Epidural Steroid ◽  
The Cost ◽  
Based Medicine

In the modern day environment, workers’ compensation costs continue to be a challenge, with a need to balance costs, benefits, and quality of medical care. The cost of workers’ compensation care affects all stakeholders including workers, employers, providers, regulators, legislators, and insurers. Consequently, a continued commitment to quality, accessibility to care, and cost containment will help ensure that workers are afforded accessible, high quality, and cost-effective care. In 2004, workers’ compensation programs in all 50 states, the District of Columbia, and federal programs in the United States combined received an income of $87.4 billion while paying out only $56 billion in medical and cash benefits with $31.4 billion or 37% in administrative expenses and profit. Occupational diseases represented only 8% of the workers’ compensation claims and 29% of the cost. The American College of Occupational and Environmental Medicine (ACOEM) has published several guidelines; though widely adopted by WCPs, these guidelines evaluate the practice of medicine of multiple specialties without adequate expertise and expert input from the concerned specialties, including interventional pain management. An assessment of the ACOEM guidelines utilizing Appraisal of Guidelines for Research and Evaluation (AGREE) criteria, the criteria developed by the American Medical Association (AMA), the Institute of Medicine (IOM), and other significantly accepted criteria, consistently showed very low scores (< 30%) in most aspects of the these guidelines. The ACOEM recommendations do not appear to have been based on a careful review of the literature, overall quality of evidence, standard of care, or expert consensus. Based on the evaluation utilizing appropriate and current evidence-based medicine (EBM) principles, the evidence ratings for diagnostic techniques of lumbar discography; cervical, thoracic, and lumbar facet joint nerve blocks and sacroiliac joint nerve blocks; therapeutic cervical and lumbar medial branch blocks and radiofrequency neurolysis; cervical interlaminar epidural steroid injections, caudal epidural steroid injections, and lumbar transforaminal epidural injections; caudal percutaneous adhesiolysis; abd spinal cord stimulation were found to be moderate with strong recommendation applying for most patients in most circumstances. The evidence ratings for intradiscal electrothermal therapy (IDET), an automated percutaneous disc decompression and also deserve further scrutiny and analysis. In conclusion, these ACOEM guidelines for interventional pain management have no applicability in modern patient care due to lack of expertise by the developing organization (ACOEM), lack of utilization of appropriate and current EBM principles, and lack of significant involvement of experts in these techniques resulting in a lack of clinical relevance. Thus, they may result in reduced medical quality of care; may severely hinder access to appropriate, medically needed and essential medical care; and finally, they may increase costs for injured workers, third party payors, and the government by transferring the injured worker into a non-productive disability system. Key words: Guidelines, ACOEM, ASIPP, interventional pain management, interventional techniques, evidence-based medicine, systematic reviews, guideline development, AHCPR, AHRQ, IOM, AMA, AGREE, workers’ compensation, chronic pain guidelines, low back pain guidelines

scholarly journals Contrast Flow Selectivity During Transforaminal Lumbosacral Epidural Steroid Injections

2008 ◽  
Vol 6;11 (12;6) ◽  
pp. 855-861
Author(s):  
Michael B. Furman
Keyword(s):  
Epidural Space ◽  
Nerve Root ◽  
Lumbar Disc ◽  
Human Study ◽  
Contralateral Side ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Needle Position ◽  
Epidural Steroid ◽  
Contrast Flow

Background: Lumbosacral transforaminal epidural steroid injections (LS-TFESIs) are an accepted procedure used in the comprehensive, conservative care for lumbar disc pathology and/or spinal stenosis induced low back pain with a radicular component. Historically, the terminology used to describe the transforaminal technique of instilling medications into the epidural space and/or exiting structures has varied. These procedures have also been referred to as either diagnostic or therapeutic selective nerve root blocks (SNRBs). Although this procedure is typically used to “selectively” treat isolated pathology, the “SNRB” terminology suggests that one can selectively diagnose or treat a specific nerve root as a pain generator by anesthetizing or blocking it. It has been recently demonstrated that L4 and L5 SNRBs are often non-“selective” by investigating the extent of epidural contrast flow patterns after injecting 1.0 mL of contrast. Our study attempts to identify the minimum injectate volume at which LS-TFESIs may still be considered “selective” with no injectate extending to either the adjacent (superior and/or inferior) levels or to the contralateral side. Objective: Quantitatively evaluate contrast flow level selectivity noted during fluoroscopically guided lumbosacral transforaminal epidural steroid injections (LS-TFESIs). Study Design: Prospective, nonrandomized, observational human study. Methods: Thirty patients (female = 10, male = 20) undergoing LS-TFESIs were investigated. After confirming appropriate spinal needle position with biplanar imaging, 4.0 mL of nonionic contrast was slowly injected. Fluoroscopic images were recorded at 0.5 mL increments. These biplanar contrast flow images were evaluated to determine which 0.5 mL volume increment was no longer specific for the injected level. In particular, we documented when contrast extended either to a superior or inferior spinal segment or crossed the midline spine to the contralateral side. Results: After injecting 0.5 mL of contrast, 30% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. After injecting 1.0 mL of contrast, 67% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. After injecting 1.5 mL of contrast, 87% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. After injecting 2.5 mL of contrast, 90% of LS-TFESIs performed in this study were no longer “selective” for the specified root level. Conclusions: Diagnostic LS-TFESI or SNRB blocks limiting injectate to a single, ipsilateral segmental level cannot reliably be considered diagnostically selective with volumes exceeding 0.5mL. Injectate volumes greater than 0.5mL are consistently non-selective and cannot be used reliably for diagnostic block procedures in the epidural space. Key words: Epidural steroid injections, selective nerve root block, transforaminal, contrast flow

scholarly journals Complex Regional Pain Syndrome Type II After Cervical Interlaminar Epidural Injection

2021 ◽  
pp. 213-217
Keyword(s):  
Case Report ◽  
Complex Regional Pain Syndrome ◽  
Nerve Root ◽  
Stellate Ganglion ◽  
Stellate Ganglion Block ◽  
Pain Syndrome ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Nerve Root Injury ◽  
Epidural Steroid

BACKGROUND: Complex regional pain syndrome (CRPS) is a pain condition associated with autonomic and inflammatory features and is characterized by pain that is disproportionate in magnitude to the typical pain after similar injuries. The pathophysiology of CRPS is poorly understood, and many events have been implicated as causative factors. CASE REPORT: There are 2 previously documented case reports of CRPS after epidural steroid injections (ESI). This case report details the development of CRPS symptoms in a patient after receiving a cervical ESI. The precipitating event could have been trauma to a nerve root, nerve root irritation from the injectate, or contrast media reaction. Treatment focused on physical therapy and early intervention with a stellate ganglion block. The patient had complete resolution of her symptoms after 10 months. CONCLUSIONS: Although rare, CRPS due to direct nerve root injury or nerve root irritation can develop after an ESI; early diagnosis and treatment may result in a better outcome. KEY WORDS: Complex regional pain syndrome, CRPS, epidural steroid injections, TFESI, ILESI

scholarly journals Caudal epidural steroid injections versus selective nerve root blocks for single-level lumbar spinal stenosis: a study protocol for a randomized controlled trial

Trials ◽  
2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Akram Osman ◽  
Wei Hu ◽  
Jianhua-Sun ◽  
Jing Li ◽  
Xiao Luo ◽  
...  
Keyword(s):  
Randomized Controlled Trial ◽  
Nerve Root ◽  
Controlled Trial ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Randomized Controlled ◽  
Nerve Root Blocks ◽  
Lumbar Spinal ◽  
Epidural Steroid ◽  
Caudal Epidural

Abstract Background Lumbar spinal stenosis (LSS) is a common degenerative condition associated with old age. Its incidence continues to increase with the rapidly aging population in China. Treatment for LSS usually begins with conservative treatments, as some patients refuse surgical procedures or have surgery contraindications. Caudal epidural steroid injections (CESIs) and selective nerve root blocks (SNRBs) are two commonly used conservative treatments for LSS, which have proven to be effective at relieving LSS symptoms in many studies. However, there are no randomized controlled trials comparing these two procedures. We planned the first study to assess which one of these two procedures is more effective in treating LSS. We will compare the efficacy of these two treatment methods in terms of duration of symptom relief and recurrence rate. We hope our findings will help clinicians choose an optimal treatment for LSS patients. Methods/design We plan to conduct a 1-year randomized controlled trial that will include a total of 76 subjects. They will be randomly divided into two groups: group A (patients will receive CESIs) and group B (patients will receive SNRBs). Two days before the procedure, we will assess these patients using the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale, Oswestry Disability Index (ODI), and numeric rating scale (NRS) for pain. One day, 2 weeks, 3 months, 6 months, and 1 year after the procedure, we will assess the condition of these patients again with the NRS and ODI. Discussion We hope our findings will lay the foundation for the design of further comprehensive studies and help clinicians make a choice between CESIs and SNRBs for LSS patients. Trial registration Chinese Clinical Trial Registry ChiCTR1900028038. Registered on 8 December 2019

scholarly journals Interventional Techniques in Managing Persistent Pain After Vertebral Augmentation Procedures: A Retrospective Evaluation

2007 ◽  
Vol 5;10 (9;5) ◽  
pp. 673-676 ◽  
Author(s):  
Bassem Georgy
Keyword(s):  
Facet Joint ◽  
Persistent Pain ◽  
Cement Augmentation ◽  
Vertebral Compression Fractures ◽  
Nerve Blocks ◽  
Steroid Injections ◽  
Compression Fractures ◽  
Epidural Steroid Injections ◽  
Epidural Steroid ◽  
Joint Injections

Background: Based on systematic reviews, it appears that at least 10% of patients may continue to suffer with residual or persistent pain after successful vertebral or sacral augmentation procedures. Objective: To report and evaluate the incidence and prevalence of different spinal injections in patients who received vertebroplasty, kyphoplasty, and sacroplasty procedures for both benign and malignant compression fractures. Design: A retrospective case review. Methods: Retrospective review of all cases of vertebroplasty, sacroplasty, and kyphoplasty performed in a 12-month period in a single outpatient setting of interventional radiology was conducted. Results: In a 12-month period starting from October 2005 to September 2006, 144 patients underwent cement augmentation procedures. Of the 144, 34 patients required a spinal injection procedure for residual or persistent pain within a 1-year period after the augmentation procedure. Twenty-four patients required epidural steroid injections, 6 patients required intercostal nerve blocks, 5 patients required trigger point injections, 5 patients required sacroiliac joint injections, and 1 patient required facet joint injections. Nine patients who required lumbar epidural steroid injections and all patients who required intercostal nerve blocks and had underwent a thoracic cement augmentation procedure. Conclusion: A small proportion of patients undergoing percutaneous cement augmentation for vertebral compression fractures or sacral insufficiency fractures potentially require spinal injections to treat residual pain after the procedure. Key words: Kyphoplasty, vertebroplasty, sacroplasty, residual pain, vertebral compression fractures, epidural steroid injections, facet joint pain, sacroiliac joint injections, facet joint injections.

scholarly journals Comparative study between transforaminal epidural selective nerve root block versus interlaminar epidural in the treatment of lumbar radicular leg pain

2019 ◽  
Vol 5 (4) ◽  
pp. 694
Author(s):  
Mohammed Sadiq ◽  
Syed Azher Hussain ◽  
Mohammed Nayeemuddin
Keyword(s):  
Targeted Delivery ◽  
Nerve Root ◽  
Comparative Trial ◽  
Epidural Injection ◽  
Leg Pain ◽  
Disc Disease ◽  
Nerve Roots ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Epidural Steroid

<p class="abstract"><strong>Background:</strong> Sciatic neuralgia is a result of nerve root oedema because of the inflammatory, immunological and mechanical factors. Steroid injections play an important role in the management of sciatic radiculopathy. Steroids act by reducing the oedema around the nerve roots and decreasing pain. Locally administered steroids have the advantage of reduced dosage and targeted delivery around the nerve roots. This forms the basis of epidural steroid injections. This can be given around the nerve root in the transforaminal space or in the interlaminar space. There is a paucity of literature comparing the two techniques of epidural steroid injections. We have done a randomized comparative trial, to compare the effectiveness of the two modalities of injection in the management of a single level unilateral foraminal disc herniation.</p><p class="abstract"><strong>Methods:</strong> Patients were randomized in two groups Group A: Transforaminal epidural (SNRB) and Group B: interlaminar epidural. Same dose of steroid was used in each group.<strong></strong></p><p class="abstract"><strong>Results:</strong> Immediate post injection, 2 week and 1 month transforaminal epidural (SNRB) was better compare to interlaminar epidural however at the end of 3 months the difference was not significant (p=0.08).</p><p><strong>Conclusions:</strong> Both transforaminal and interlaminar epidural injection are effective form of treatment in mild to moderate grade of disc disease. Both the technique provide short lasting relief in the symptoms associated with disc pathology, however pain management is better in transforaminal group compared to interlaminar group. Thus these techniques can be considered for delaying surgery and providing intermitant relief. </p>

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