Procedural Pain During Lumbar Medial Branch Blocks With and Without Skin Wheal Anesthesia: A Prospective Comparative Observational Study.

OBJECTIVE: To determine if skin wheals reduce procedural pain associated with lumbar medial branch blocks (MBBs) performed with 25-gauge needles. DESIGN: Prospective comparative observational study. SETTING: Outpatient Physical Medicine & Rehabilitation and interventional pain practice within an academic tertiary care center. SUBJECTS: Ninety-nine consecutive patients who underwent lumbar MBBs for facet pain were included. Patients who were obese or required larger-diameter needles were excluded. METHODS: One to three facet joints were targeted per side, with some patients receiving bilateral procedures. All injections were performed with 25-gauge, 3.5-inch Quincke tip needles under fluoroscopic guidance. A total of 306 needle sticks were recorded. MBBs were performed without skin wheals or any other type of local anesthesia (35 patients, 108 needle sticks), with skin wheals (30 patients, 94 needle sticks), and in mixed groups (34 patients, 47 needle sticks with skin wheals, 57 needle sticks without skin wheals or other type of local anesthesia). Patients rated the pain of each needle placement immediately after the multilevel MBB procedure. RESULTS: Considering all 306 needle sticks, needles that were placed using skin wheals caused slightly more pain than those placed without skin wheals or any other type of local anesthesia (P = 0.007). CONCLUSIONS: Skin wheals do not reduce and may increase procedural pain associated with lumbar MBBs performed with 25-gauge needles.

The Clinical Efficacy for Two-Level Transforaminal Epidural Steroid Injections.

BACKGROUND: Epidural steroid injections have been used in combination with other modalities for the treatment of lumbar radicular pain. The literature has shown that 1-level lumbar fluoroscopically guided transforaminal epidural steroid injections (TFESIs) are effective in decreasing pain and morbidity; however, the efficacy of 2-level TFESIs has not been investigated, although they are performed by many practitioners in the treatment of lumbar radicular pain. OBJECTIVES: To assess the clinical effectiveness of 2-level TFESIs in patients with unilateral, single-level lumbar radicular pain. In addition, a subgroup analysis was performed based on disk herniation location. STUDY DESIGN: Retrospective cohort. SETTING: Outpatient physiatry pain practice. PATIENTS: A total of 721 patients were included in this study having undergone a two-level transforaminal epidural steroid injection. METHODS: The study group included patients who underwent a 2-level lumbar TFESI. Patients presented for lumbar radicular pain as the result of disk herniation with or without radiculopathy and were scheduled to receive a lumbar TFESI at L3 or below. Of this group, only those that underwent a 2-level TFESIs were included in the study, and data analysis was carried out on this group. MAIN OUTCOME MEASURES: Subjects were assessed with a pain numerical rating scale (NRS 0-10) and Oswestry Disability Index (ODI) before TFESI and at 2-week and 2-month follow-up. Responders were defined as greater that 50% reduction in NRS or greater than 40% reduction in ODI. RESULTS: A total of 57.7% of patients were responders in terms of NRS (P < .05, confidence interval 53.6%-61.9%) and 51.7% responded in ODI at 2-month follow-up (P < .05 [confidence interval 47.5%-55.9%]). In addition, patients with complete pain relief (defined as 0/10 on NRS) were noted at both 2-week (n = 239, 33%) and 2-month (n = 130, 18%) follow-up. In subgroup analysis, the paracentral/subarticular disk group had an increased number of responders, 66.0% in NRS and 64.0% in ODI at 2-month follow-up (P < .05). CONCLUSIONS: Two-level TFESIs are effective in the management of radicular pain, but more research is needed to evaluate the utility of this treatment compared with single-level TFESI. Our study showed a greater improvement in pain and function as a result of 2-level TFESIs in the setting of paracentral/subarticular disk herniations. LEVEL OF EVIDENCE: IV.