ABSTRACT
Selective nerve root blocks (SNRB) have been used for many years as a diagnostic tool in patients with low back pain with radicular symptoms. However the accuracy, specificity, and sensitivity of these blocks has been questioned as a screening tool for spine surgery. The utility of current SNRB techniques relies primarily on the relief of pain when local anesthetic is injected. However, patient responses are often non specific, and pain relief after injecting local anesthetic is often difficult to interpret. A new technique for performing SNRB using electrical stimulation is described in this article. The technique has been developed in order to reproduce radicular pain by stimulation with electrical current rather than to rely on a response to local anesthetic injection. The technique decreases the reliance on spread of local anesthetic for interpretation, and can therefore reduce false positive results from too much anesthetic (epidural spread affecting more than one nerve root) or not enough anesthetic (block peripheral to the area of inflammation or the "pain generator"). By stimulating several nerve roots in random order in a blind fashion to the patient, the technique can also eliminate placebo responders.
ABSTRACT
Despite the popularity of epidural steroid injections for low back pain, there still remains a lack of consensus on which type of steroid to inject. Most comparison studies regarding epidural steroids are based on an assumption that different types of steroids are equal as long as equipotent doses are utilized. In the spring of 2002, a national shortage of all depo steroids allowed the authors to compare epidural methylprednisolone (Depo-Medrol) to a non depo form of betamethasone in patients with low back pain. Patients who received epidural methylprednisolone (Depo-Medrol) reported significant reduction in pain ratings as well as disability scores after 4 weeks, while patients receiving betamethasone showed no significant difference in pain or disability scores. This study shows that the aqueous steroid betamethasone is not an effective alternative to the commonly used depo-steroid methylprednisolone (Depo-Medrol) when injected epidurally in patients with lumbar pain. The study also shows that the anti-inflammatory effect of a depo-steroid can be greater than a non-depo steroid, even at equipotent doses. This should be an important factor to consider when reviewing epidural steroid outcome studies, where the type of steroid might affect results as much as other variables such as route of administration, volume of injectate, or use of fluoroscopy.
ABSTRACT
Baylor University Medical Center established a pain initiative group in 1996 to research the effectiveness of pain management throughout the hospital. After analyzing 300 patient surveys, the group undertook an intensive program to educate physicians, nurses, and patients regarding newer pain management techniques. The outcome of this educational initiative was reassessed in 2001 based on surveys completed by 100 patients after discharge. Results showed marked improvement in patient education regarding pain management. In 2001, 93% of patients were offered education and choices regarding pain management vs only 36% in 1996. Fewer patients were afraid to "bother" their nurses to ask for pain medication (3% in 2001 vs 14% in 1996). Waiting time for administration of analgesics decreased considerably. The number of patients reporting moderate to severe pain decreased significantly since 1996, yet the overall satisfaction with pain relief remained high and did not change significantly. The overall incidence of patients reporting moderate to severe pain was significantly less at Baylor than the national average. In conclusion, attitudes, misconceptions, and fears about pain management can be changed with intensive educational programs.
ABSTRACT
The purpose of this study was to determine whether an exaggerated response to a mildly painful stimulus would reflect abnormal levels of psychological distress in patients and, conversely, whether patients who show abnormal levels of psychological distress would have a low tolerance for a mildly painful stimulus. A total of 101 patients were given a mildly painful stimulus (30-gauge needle stick) and asked to record the amount of pain they felt on a scale of 0 to 10 (0 = no pain, 10 = severe pain). The mean response to the needle stick was a 1.9 on this scale. There was no gender difference, and the average did not change with increasing age. Psychological testing showed that 18% of the 101 patients had psychological distress prior to the needle stick. The pain ratings to needle stick of these 18 patients were not significantly different than those of patients without psychological distress (2.3 vs 1.9 on the scale). Seven percent of patients had a very low tolerance for pain (pain score of > or = 7). Evaluation of the psychological testing results on these patients showed no significant difference compared with known normal psychological values. Therefore, the assumption that patients who over-respond to a mildly painful stimulus have psychological distress is not valid. The results of this study suggest only that patients who over-respond to a needle stick have a low tolerance for pain. Furthermore, it is not valid to assume that patients who have psychological distress, poor coping abilities, or marked stress will respond in an exaggerated fashion to a mildly painful stimulus.
