ABSTRACT
BACKGROUND: Suprascapular nerve blockade (SSNB) through injection (SSNBi) and/or pulsed radiofrequency (PRF) provide options for the management of painful shoulder pathology. Multiple techniques for delivery of SSNB are described but no consensus on optimal symptom control is available. This systematic review and meta-analysis aims to assess patient-focussed outcomes in SSNB and explore the impact of variation in the technical application of this treatment modality. METHODS: MEDLINE, Embase and CINAHL were searched for case series, cohort studies and randomised control trials published from database inception until 28 January 2021. Articles reporting use of SSNBi or PRF for treatment of shoulder pain with a minimum 3 months follow-up were included. Patient-reported outcome measures (PROMs) were extracted and the pooled standardised mean difference (SMD), weighted by study size, was reported. Quality of methodology was assessed using Wylde's nonsummative four-point system. FINDINGS: Of 758 references, 18 studies were included, totalling 704 SSNB. Average pain improvement at 3 months was 52.3%, with meta-analysis demonstrating a SMD of 2.37. Whereas SSNBi combined with PRF shows the greatest SMD of 2.75, this did not differ significantly from SSNBi or PRF when used as monotherapy. Location of treatment and the guidance technique used did not influence outcome. CONCLUSION: SSNBi and PRF provide safe and effective treatment for shoulder pain, as judged by PROMs. This may be of particular value in aging or comorbid patients and with surgical restrictions during the Covid-19 pandemic. Regardless of technique, patients experience a marked improvement in pain that is maintained beyond 3 months.
ABSTRACT
Introduction: Residency training has faced substantial challenges during the COVID-19 pandemic. Understandably, interventional pain procedures have seen an associated reduction in case volume due to global healthcare recommendations, especially due to many interventional spine procedures being categorized as elective. For PM&R residents, the ACGME recommends observation or performance of 10 total epidural, facet, or SI joint injections and no requirement of exposure to neuromodulatory procedures during their training. This quality improvement project utilizes a 3D printed spine, medical instruments, and virtually simulated fluoroscopic images to create a hybrid training platform. The goal of the study was to enhance resident exposure to neuromodulation while improving technical proficiency, efficiency, and confidence of trainees with spinal cord stimulator placement. Methods: Current PM&R residents of all PGY levels were recruited to this study (n=10). A pre-test survey to determine baseline levels of comfort and experience with neuraxial procedures was taken by all participants. They were then taken through two standardized attempts of accessing the epidural space via interlaminar approach followed by placement of spinal cord stimulator leads. After the first attempt, a brief teaching session to correct significant deficiencies or mistakes was allotted. After the second attempt, a post-test survey to evaluate confidence levels and self-perception of procedural skill was completed. Performance during each attempt was objectively assessed via a modified Operative Performance Rating System (OPRS) evaluation. Results: During pre-test survey, participants of the study had extremely limited exposure to percutaneous lead placement (4 total cases observed, 0 performed) with correlated low confidence levels. Between first and second attempts, participants had significant improvements in their ability to safely access the epidural space (40% failure rate on first attempt, improved to 0%). Ability to effectively drive percutaneous leads was also demonstrated, with less incidence of anterior migration requiring leads to be withdrawn (53% improvement of average lead travel distance between attempts). Procedural efficiency also substantially improved (34% average decrease of total fluoroscopy time between attempts). Finally, objective OPRS evaluations and subjective participant procedural confidence levels improved proportionately with performance. Conclusion: Virtually simulated fluoroscopic training is a viable and effective method of initiating or augmenting neuromodulatory procedure education. The device provides a safe, radiation-free setting for learning procedures prior to performing them on real patients and improves the confidence, efficiency, and objective performance of participants. Ultimately, this is an even more important didactic option given ongoing events surrounding the global pandemic. Disclosure: William White, DO: None, Michael Jung, MD, MBA: None [Formula presented] [Formula presented] [Formula presented]