The role of percutaneous neurolysis in lumbar disc herniation: systematic review and meta-analysis

Background@#Recalcitrant disc herniation may result in chronic lumbar radiculopathy or sciatica. Fluoroscopically directed epidural injections and other conservative modalities may provide inadequate improvement in some patients. In these cases, percutaneous neurolysis with targeted delivery of medications is often the next step in pain management. @*Methods@#An evidence-based system of methodologic assessment, namely, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used. Multiple databases were searched from 1966 to January 2021. Principles of the best evidence synthesis were incorporated into qualitative evidence synthesis.The primary outcome measure was the proportion of patients with significant painrelief and functional improvement (≥ 50%). Duration of relief was categorized as short-term (< 6 months) and long-term (≥ 6 months). @*Results@#This assessment identified one high-quality randomized controlled trial (RCT) and 5 moderate-quality non-randomized studies with an application of percutaneous neurolysis in disc herniation. Overall, the results were positive, with level II evidence. @*Conclusions@#Based on the present systematic review, with one RCT and 5 nonrandomized studies, the evidence level is II for percutaneous neurolysis in managing lumbar disc herniation.

The role of percutaneous neurolysis in lumbar disc herniation: systematic review and meta-analysis

Background@#Recalcitrant disc herniation may result in chronic lumbar radiculopathy or sciatica. Fluoroscopically directed epidural injections and other conservative modalities may provide inadequate improvement in some patients. In these cases, percutaneous neurolysis with targeted delivery of medications is often the next step in pain management. @*Methods@#An evidence-based system of methodologic assessment, namely, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used. Multiple databases were searched from 1966 to January 2021. Principles of the best evidence synthesis were incorporated into qualitative evidence synthesis.The primary outcome measure was the proportion of patients with significant painrelief and functional improvement (≥ 50%). Duration of relief was categorized as short-term (< 6 months) and long-term (≥ 6 months). @*Results@#This assessment identified one high-quality randomized controlled trial (RCT) and 5 moderate-quality non-randomized studies with an application of percutaneous neurolysis in disc herniation. Overall, the results were positive, with level II evidence. @*Conclusions@#Based on the present systematic review, with one RCT and 5 nonrandomized studies, the evidence level is II for percutaneous neurolysis in managing lumbar disc herniation.

Therapeutic lumbar facet joint nerve blocks in the treatment of chronic low back pain: cost utility analysis based on a randomized controlled trial

BACKGROUND: Related to escalating health care costs and the questionable effectiveness of multiple interventions including lumbar facet joint interventions, cost effectiveness or cost utility analysis has become the cornerstone of evidence-based medicine influencing coverage decisions. METHODS: Cost utility of therapeutic lumbar facet joint nerve blocks in managing chronic low back pain was performed utilizing data from a randomized, double-blind, controlled trial with a 2-year follow-up, with direct payment data from 2016. Based on the data from surgical interventions, utilizing the lowest proportion of direct procedural costs of 60%, total cost utility per quality adjusted life year (QALY) was determined by multiplying the derived direct cost at 1.67. RESULTS: Patients in this trial on average received 5.6 ± 2.6 procedures over a period of 2 years, with average relief over a period of 2 years of 82.8 ± 29.6 weeks with 19 ± 18.77 weeks of improvement per procedure. Procedural cost for one-year improvement in quality of life showed USD $2,654.08. Estimated total costs, including indirect costs and drugs with multiplication of direct costs at 1.67, showed a cost of USD $4,432 per QALY. CONCLUSIONS: The analysis of therapeutic lumbar facet joint nerve blocks in the treatment of chronic low back pain shows clinical effectiveness and cost utility at USD $2,654.08 for the direct costs of the procedures, and USD $4,432 for the estimated overall cost per one year of QALY, in chronic persistent low back pain non-responsive to conservative management.

Mucopolysaccharidoses: anesthetic considerations and clinical manifestations

Mucopolysaccharidosis [MPS] is a group of genetic disorders that presents challenges during anesthetic care and in particular difficulty with airway management. Patients should be managed by experienced anesthesiologists at centers that are familiar with these types of conditions. Rarely encountered disease states have been identified as important topics in the continuing education of clinical anesthesiologists. This review will define MPS, describe the pathophysiology of MPS, describe how patients with this rare lysosomal storage disorders have dysfunction of tissues, cite the incidence of MPS, list the clinical manifestations and specific problems associated with the administration of anesthesia to patients with MPS, present treatment options for patients with MPS, define appropriate preoperative evaluation and perioperative management of these patients, including, to anticipate potential postoperative airway problems

importance of training for ultrasound guidance in central vein catheterization

To review the complication and success rates associated with CVC placement in patients undergoing cardiovascular surgery depending on the technique utilized and the degree of ultrasound experience of the anesthesia provider. Randomized controlled trial. Operating room and post anesthesia care unit. 325 patients with CAD requiring cardiovascular surgery with an ASA of III or above. The subjects underwent CVC of the Internal Jugular vein with or without ultrasound guidance in preparation for cardiovascular surgery. Utilization of US, carotid artery puncture/cannulation and the presence of post procedure pneumothorax. When comparing the group that had CVC without US versus the group having CVC placement with US, there was significant difference in complication rates based on Z-testing [95% confidence level]. Furthermore, with 90% confidence [based on Z-testing] there was a significant difference in complication rates between the experienced and non experienced US practitioners. With adequate US training, the complications from CVC including carotid artery puncture and pneumothorax can be significantly reduced

Update on anesthesia considerations for electroconvulsive therapy

Depression is diagnosed in 14 million Americans every year, and pharmacotherapy is the standard treatment. However, in approximately 50% of patients, pharmacology intervention does not resolve depression. Electroconvulsive therapy [ECT] has been a mainstay as a treatment option for treatment-resistant major depression since its inception in the 1930s. It has also been shown to be effective in treatment-resistant mania and catatonic schizophrenia. The complication rate of ECT has improved from 50% in the 1960's to almost anecdotal adverse events, similar to the morbidity and mortality seen in minor surgery and childbirth. Although anesthetic agents are administered briefly, many patients experience significant fluctuations in physiologic parameters. The clinical anesthesiologist must be aware of these changes as well as have an understanding of perioperative pharmacological interventions. ECT is a proven therapy for select psychiatric patients, and appropriate anesthesia is a critical part of successful ECT. Careful review of the patient's medical history may reveal pertinent anesthetic considerations

Rheumatoid arthritis: current pharmacologic treatment and anesthetic considerations

A diagnosis of rheumatoid arthritis carries with it a lifelong progressive disease; however twenty percent of patients enjoy periods of partial to total remission. After remission, the disease will frequently plague previously unaffected joints. Life expectancy is reduced by an average of three to seven years. Complications of RA include vasculitis and amyloidosis affecting any vessel, including the aorta. Additionally, complications of therapy such as chronic NSAID use leading to GI bleeding and infections associated with long term steroid use, can add to the difficulties of the disease. The recent discovery and use of anticytokines and DMARDs has lead to greatly reduced symptomology associated with RA and greater patient comfort. Side effects of drugs should be well understood including the risk of bleeding from NSAIDs. Management and surgical intervention of problems that arise from this disease vary dramatically. The anesthesiologist must be aware of airway pathologies, pain management techniques, and available pharmacology parameters

Anesthesia and congestive heart failure: pathology, medical and surgical management

Congestive heart failure [CHF] is increasingly being recognized as a health problem in the United States. It is estimated that the lifetime risk for CHF is 1 in 5. The clinical anesthesiologist can expect to see several cases involving patients suffering from CHF. Because of the danger associated with surgery in a patient with CHF, a thorough knowledge of the disorder and the potential effects on the delivery of anesthetics must be considered. In addition, knowledge of the disease process and its manifestations is required for smooth guidance of the patient through the perioperative period. The understanding of current pharmacotherapies, surgical procedures and their implications related to interactions with anesthetics are all discussed

Autosomal dominant polycystic kidney disease-clinical challenges

While not very common, the clinical anesthesiologist can expect to see between two and three patients per year with autosomal dominant polycystic kidney disease, ADPKD. Careful education and proper planning are essential to assure appropriate care for these patients. In addition, co-morbid conditions associated with the disease, make it especially challenging for the anesthesiologist who must be prepared for all contingencies. Also, decreased renal function and the systemic effects combine to create unique problems in properly anesthetizing these patients. Finally, proper preoperative assessment is essential to protect patients with ADPKD, and special care should be taken to select drugs that rely on non-renal metabolism for excretion. This review summarizes anesthetic considerations regarding epidemiologic, diagnostic, genetic, and perioperative clinical issues related to this disease

Postoperative nausea and vomiting. a review

Post operative nausea and vomiting [PONV] remains an unpleasant and persistent problem for patients undergoing surgery. In fact PONV are among the most important factors contributing to delay in discharge of patients and an increase in unanticipated admissions after ambulatory surgery. Anesthesia providers are most often blamed for PONV, sometimes rightfully so, many times wrongly so. PONV is a multifactorial issue involving many physiological and biological mechanisms. As the trend towards ambulatory surgery increases, PONV continues to pose serious challenges for anesthesia providers because the potential cost savings of performing surgeries on an ambulatory basis may be negated by unanticipated hospital admission. Although PONV may be unavoidable in some patients for reasons we do not fully understand, there are risk factors that can be identified. As anesthesiologists it is essential for us to understand the mechanisms involved in nausea and vomiting and the available perioperative treatment options. We must do whatever we can to prevent and treat PONV and improve patient outcome for both medical and economic reasons