Dexamethasone Effectively Reduces the Incidence of Post-neurotomy Neuropathic Pain: A Randomized Controlled Pilot Study.

BACKGROUND: Radiofrequency neurotomy (RFN) of facet or sacroiliac joints is widely used for the treatment of chronic axial pain and can provide long-term pain relief in well-selected patients. The most common side effect is transient neuropathic pain at the paravertebral level of interest. Pain physicians commonly administer corticosteroid post-neurotomy to reduce the risk of post-neurotomy neuropathic pain, yet it remains unclear if this provides a true reduction in incidence. OBJECTIVES: To determine the efficacy of corticosteroid administration post-lesion in preventing the development of post-neurotomy neuropathic pain after cervical, thoracic, lumbar, and sacroiliac joint radiofrequency denervation. STUDY DESIGN: Randomized, placebo-controlled, double-blind prospective study. SETTING: Ambulatory Surgical Center within a Tertiary Hospital System. METHODS: This trial is registered on ClinicalTrials.gov (NCT03247413). Permission to conduct human research was obtained from the Institutional Review Board. Eligible patients included those with cervical, thoracic, or lumbar facet or sacroiliac joint pain who had positive concordant medial branch blocks (thus scheduled for bilateral RFN), at least 18 years of age, and English-speaking. Patients received dexamethasone vs saline (control) at each lesion site, serving as their own control (with laterality). Follow-ups were completed at 4- and 8-weeks post-intervention to evaluate the incidence of post-procedure pain (questionnaire) and function using the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI). RESULTS: At the time of data analysis, 35/63 patients completed the study protocol. There was a statistically significant reduction in the incidence of post-neurotomy pain in the steroid group vs the control group (20/35 control group vs 3/35 steroid group, P < 0.001). ODI/NDI scores changed differently over time depending on the spinal level of neurotomy, showing statistically significant improvement in ODI/NDI in the cervical subgroup and lumbar subgroup at 4-week (P = 0.05) and 8-week time points (P < 0.01), respectively. There was no improvement of ODI scores in the sacral subgroup. The incidence of post-neurotomy neuropathic pain was not significantly different among patients with different spinal levels of neurotomy. Patients who developed post-neurotomy neuropathic pain did not differ in ODI/NDI scores at any time point. LIMITATIONS: This study has several limitations, most notably the number of patients lost to follow-up, the use of a single corticosteroid, and the use of laterality for incidence reporting. Additionally, all procedures were performed by a single interventionalist using one neurotomy system. CONCLUSIONS: A statistically significant reduction in post-neurotomy pain was observed in the steroid group. This protocol can be feasibly conducted in an effective and resource-efficient manner. Additional research is needed to increase the power of the study.

Reopening Interventional Pain Practices during the Early Phase of the COVID-19 Global Pandemic.

OBJECTIVE: Examine how interventional pain physicians navigated the early phase of reopening practices during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: In June/July 2020, Spine Intervention Society members were queried about practice demographics, perception of COVID-19 prevalence, financial impact, and implementation of new tools and procedures when re-opening practices. RESULTS: Of the 2,295 members approached, 195 (8%) completed the survey. A majority (71%) reported using risk stratification tools and changing scheduling patterns. Nearly 70% performed initial assessments via telehealth and 87% for follow-up encounters. More than 80% performed symptom/temperature checks upon in-person clinic/facility entrance, and 63% screened patients via phone. Most (58%) did not test patients for COVID-19 for office visits, while 38% tested only if symptomatic. For epidural injections, intra-articular injections, and radiofrequency neurotomy procedures, 43% reported not testing patients, while 36% tested patients only if symptomatic. Most (70%) required patients to wear a mask upon entering the clinic/facility. For nonprocedure encounters, respondents used surgical masks (85%), gloves (35%), face shields/goggles (24%), N95 respirators (15%), and gowns (6%). Some (66%) discussed unique COVID-19 risks/complications and 26% provided written information. Most did not make changes to steroid dosage (67%) or peri-procedural anticoagulation management (97%). The vast majority (81%) estimated that COVID-19 will have a moderate-severe financial impact on their practice. CONCLUSIONS: COVID-19 has dramatically affected interventional pain practices with regard to telehealth, in-clinic precautions, screening/testing protocols, and patient counseling. Practice patterns will continue to evolve as we learn more about the disease and improve methods to provide safe and effective care.

Bilateral Intra-Articular Radiofrequency Ablation for Cervicogenic Headache.

Introduction. Cervicogenic headache is characterized by unilateral neck or face pain referred from various structures such as the cervical joints and intervertebral disks. A recent study of patients with cervical pain showed significant pain relief after cervical medial branch neurotomy but excluded patients with C1-2 joint pain. It remains unclear whether targeting this joint has potential for symptomatic relief. To address this issue, we present a case report of C1-2 joint ablation with positive outcomes. Case Presentation. A 27-year-old female presented with worsening cervicogenic headache. Her pain was 9/10 by visual analog scale (VAS) and described as cramping and aching. Pain was localized suboccipitally with radiation to her jaw and posterior neck, worse on the right. Associated symptoms included clicking of her temporomandibular joint, neck stiffness, bilateral headaches with periorbital pain, numbness, and tingling. History, physical exam, and diagnostic studies indicated localization to the C1-2 joint with 80% decrease in pain after C1-2 diagnostic blocks. She underwent bilateral intra-articular radiofrequency ablation of the C1-C2 joint. Follow-up at 2, 4, 8, and 12 weeks showed improved function and pain relief with peak results at 12 weeks. Conclusion. Clinicians may consider C1-C2 joint ablation as a viable long-term treatment option for cervicogenic headaches.

Persistent Singultus Associated with Lumbar Epidural Steroid Injections in a Septuagenarian: A Case Report and Review.

Singultus are rare but notable adverse effect of epidural steroid injections (ESIs). To date, reports of persistent hiccups associated with ESIs have been reported mostly in adults aged 65 years or older. We present the first case of persistent hiccups in a septuagenarian who underwent repeated transforaminal ESIs for chronic lumbar radiculopathy. Under fluoroscopic guidance, 1.5 mL of 1% lidocaine (preservative free) and 0.8 mL of dexamethasone solution (10 mg/mL) was injected into the bilateral L4-L5 neural foramen and epidural space.After the first epidural injection, episodes of singultus occurred at a frequency of 5 to 7 episodes per minute and lasted for 36 hours. One month later, he was treated with the second epidural injection after which he immediately developed singultus, occurring at 2- to 3-hour intervals. Interventions for the singultus included drinking small sips of water, vagal maneuvers, and oropharyngeal stimulation with ice chips. The singultus eventually resolved without medical intervention within 5 days of onset. A major take-home point is that preprocedure informed consent should include singultus as one of the potential adverse effects of ESIs. Increased awareness and appropriate planning may help curb the incidence of adverse outcomes in older adults undergoing ESI.

Water-Cooled Radiofrequency Provides Pain Relief, Decreases Disability, and Improves Quality of Life in Chronic Knee Osteoarthritis.

Chronic osteoarthritis (OA) is a widespread source of pain and disability and represents a growing economic burden across aging populations. Representing a major focus of arthritis care, OA of the knee is especially concerning as it has the potential to restrict mobility and significantly impair quality of life. Chronic OA is often poorly managed both pharmacologically and nonpharmacologically, with surgical management representing the definitive treatment. Those who are not surgical candidates or simply opt for minimally invasive treatments are usually faced with a lack of alternatives. An additional treatment presents itself in the form of water-cooled radiofrequency ablation, which involves the use of thermal lesions to interrupt the active pain pathways. An 81-year-old woman with bilateral severe knee OA was initially seen and evaluated in an outpatient physiatry clinic after multiple previous workups of her ongoing knee pain. With a known diagnosis of end-stage knee OA, the patient chose to proceed with bilateral water-cooled radiofrequency ablation. At 6 weeks and 3 months after the procedure, the patient maintained adequate levels of pain relief, markedly improved function, and enhanced quality of life. Water-cooled radiofrequency ablation has the potential to create lasting pain relief and with minimal adverse effects in patients with chronic knee OA.

What's Tramadol Got to Do with It? A Case Report of Rebound Hypoglycemia, a Reappraisal and Review of Potential Mechanisms.

BACKGROUND: Tramadol has gained traction as an analgesic of choice among pain practicing physicians. However some concerns regarding a previously unlabeled adverse reaction - hypoglycemia - have cast it in a dim light. Prior reports have noted an associated risk of hospitalization for hypoglycemia after tramadol use, but whether tramadol is the main causal agent is poorly understood and the underlying mechanisms are not well delineated. We present a unique case of rebound hypoglycemia as a variation of the theme of tramadol's adverse effect profile in a patient with type 1 diabetes mellitus, and reappraise potential mechanisms underlying this underappreciated phenomenon. CASE PRESENTATION: A 71-year-old woman presented with right buttock pain and right lateral leg discomfort of 9-month duration. Her physical exam suggested sacroiliac joint (SIJ) etiology, confirmed by magnetic resonance imaging (MRI). She was scheduled for an SIJ-diagnostic and therapeutic block and started on tramadol 50 mg 3 times daily on as needed basis. The patient subsequently developed severe hypoglycemia initially resistant to euglycemia restorative interventions with a rebound episode. Hypoglycemia resolved with oral ingestion of high levels of glucose and the patient was taken off tramadol. Fortunately, she did not require hospitalization. DISCUSSION: The clinical scenario described is a case of rebound hypoglycemia after tramadol use in a patient with type-1 diabetes naïve to opioid analgesics. The episodes of hypoglycemia aligned perfectly with the anticipated pharmacodynamic and pharmacokinetic properties of tramadol. The specificity and temporality of events after tramadol use in this patient fulfilled causality criteria. Tramadol may cause rebound hypoglycemia in patients via interference of the intrinsic euglycemia-restoration pathways and a blunted autonomic counter-regulatory response to antecedent hypoglycemia. Its use must be tempered by this underappreciated adverse effect profile.Key words: Tramadol, hypoglycemia, sacroiliac joint arthritis, type 1 diabetes mellitus, serotonin uptake inhibitors, glutamate receptor 4.

Percutaneous Lumbar Disc Decompression Using the Dekompressor: A Prospective Long-Term Outcome Study.

BACKGROUND DATA: Few studies have investigated the long-term efficacy of percutaneous lumbar disc decompression (PLDD) with Dekompressor (Stryker, Kalamazoo, MI) for discogenic radicular pain that has failed conservative management. OBJECTIVE: Determine long-term outcomes of Dekompressor PLDD for discogenic radicular pain. METHODS: Prospective cohort study at a tertiary academic spine center of consecutive patients (12/2004-11/2005) with discogenic lumbosacral radicular pain who underwent PLDD with Dekompressor. Numerical Rating Scale (NRS) leg pain score and Oswestry Disability Index (ODI) score data were collected at 6 months and 1 year. These two measures, 5-point Likert scale patient satisfaction, and surgical rate data were collected at 8 years. RESULTS: Seventy patients underwent PLDD. Forty and 25 patients were successfully contacted at 1-year and 8-year follow-up, respectively. Using intention to treat analysis, at 1 year and 8 years, NRS leg pain scores were reduced >50% in 47% (95% confidence interval [CI] 35%, 59%) and 29% (95% confidence interval [CI] 18%, 40%) of patients, respectively; ODI score improved >30% in 43% (CI 32%, 55%) and 26% (CI 19%, 41%) of patients, respectively. Of the patients who followed up at 8 years, 36% (CI 17%, 55%) had undergone surgery and the median satisfaction was "4" (interquartile range 2,5). CONCLUSIONS: While limited by loss-to-follow-up, this study suggests that treatment of discogenic lumbosacral radicular pain with Dekompressor results in decreased leg pain and disability and favorable satisfaction at long-term follow-up. Further study with adequate follow-up retention is needed to confirm that Dekompressor spares open spinal surgery.

Cooled radiofrequency ablation for bilateral greater occipital neuralgia.

This report describes a case of bilateral greater occipital neuralgia treated with cooled radiofrequency ablation. The case is considered in relation to a review of greater occipital neuralgia, continuous thermal and pulsed radiofrequency ablation, and current medical literature on cooled radiofrequency ablation. In this case, a 35-year-old female with a 2.5-year history of chronic suboccipital bilateral headaches, described as constant, burning, and pulsating pain that started at the suboccipital region and radiated into her vertex. She was diagnosed with bilateral greater occipital neuralgia. She underwent cooled radiofrequency ablation of bilateral greater occipital nerves with minimal side effects and 75% pain reduction. Cooled radiofrequency ablation of the greater occipital nerve in challenging cases is an alternative to pulsed and continuous RFA to alleviate pain with less side effects and potential for long-term efficacy.

Perioperative upper extremity peripheral nerve traction injuries.

Peripheral nerve traction injuries may occur after surgical care and can involve any of the upper extremity large peripheral nerves. In this review, injuries after shoulder or elbow surgical intervention are discussed. Understanding the varying mechanisms of injury as well as classification is imperative for preoperative risk stratification as well as management.

Perioperative lower extremity peripheral nerve traction injuries.

Peripheral nerve traction injuries may occur after surgical care and can involve any of the lower extremity large peripheral nerves. In this review, the authors discuss injuries after knee or hip surgical intervention. The diagnosis, including electrodiagnostic studies, is time sensitive and also relies on a detailed history and physical examination. Successful prevention and treatment involve familiarity with risk and predisposing factors as well as prophylactic measures.