Minimally Invasive Inferior Intra-Articular Sacroiliac Joint Fusion: Successful Application of Osseous Stabilization Using Allograft Bone.

Minimally invasive sacroiliac joint (SIJ) fusion is the preferred surgical method for managing patients with recalcitrant, chronically severe SIJ pain and dysfunction refractory to conservative medical measures. The primary surgical objective of all minimally invasive SIJ fusion procedures is to provide immediate stabilization within the joint space to support osseous consolidation and the development of a mechanically solid arthrodesis. The intra-articular surgical approach to the SIJ with allograft bone placement utilizes a trajectory and easily identifiable landmarks that allow the surgeon to control the risk of violating important neuro-vascular structures. The intra-articular approach can employ a superior or inferior operative trajectory, with the former restricted to allograft placement in the ligamentous portion of the SIJ. The inferior approach utilizes decortication to surgically create a channel originating in the purely articular portion of the joint space allowing for truly intra-articular implant placement within the osseous confines of the ilium and sacrum. Positioning the implant along the natural joint line and securing it within the underlying sub-chondral bone, mortise and tenon fashion provides stabilization and large surface area contact at the bone implant interface. The inferior, intra-articular approach also places the implant perpendicular to the S1 endplate, near the sacral axis of rotation, which addresses the most significant biomechanical forces across the joint. Short-term, post-surgical observational data from a 57 patient multi-center registry using the inferior, intra-articular approach show uniform and statistically significant improvement in all clinical outcomes (p < 0.001 for all comparisons), including an average 3-point improvement in back pain severity from 6.8 preoperatively to 3.8 at 6 months. Further clinical evaluation with longer-term follow-up of the inferior, intra-articular SIJ fusion procedure is encouraged.

Understanding whether chronic lower back pain patients with lumbar spinal stenosis benefit from multiple epidural steroid injections prior to the mild® Procedure.

Originally published in Pain Management, this article is a summary of a study performed to look at the benefit, if any, of more than one epidural steroid injection in the spine before the mild® Procedure. Minimally invasive lumbar decompression (commonly known as the mild Procedure) and epidural steroid injections are both common treatment options for lumbar spinal stenosis (commonly referred to as LSS), a condition that causes chronic lower back pain in older adults. To determine how to best treat LSS patients, healthcare professionals use a guide to help with the decision-making process (called an algorithm) to pass through non-medical to more invasive therapies that often includes one or more epidural steroid injections. An epidural steroid injection is medication inserted in the lower back to reduce swelling and provide relief from pain. Researchers wanted to look at a change to when in the treatment process the mild Procedure is carried out. In the study, researchers compared the medical records of participants who had received either just one or no steroid injection prior to the mild Procedure, to participants who received two or more epidural steroid injections prior to the mild Procedure. Similar outcomes in both treatment groups in this study proved that giving more than one epidural steroid injection prior to the mild Procedure did not improve how well patients did and may have delayed patient care. Based on the results of the study, it is recommended that the standard treatment process for LSS patients be changed to give the mild Procedure either as soon as LSS is diagnosed or after the failure of the first epidural steroid injection.

Minimally invasive direct decompression for lumbar spinal stenosis: impact of multiple prior epidural steroid injections.

Background: A modified algorithm for the treatment of lumbar spinal stenosis with hypertrophic ligamentum flavum using minimally-invasive lumbar decompression (mild®)was assessed, with a focus on earlier intervention. Patients & methods: Records of 145 patients treated with mild after receiving 0-1 epidural steroid injections (ESIs) or 2+ ESIs were retrospectively reviewed. Pain assessments as measured by visual analog scale (VAS) scores were recorded at baseline and 1-week and 3-month follow-ups. Results: Improvements in VAS scores at follow-ups compared with baseline were significant in both groups. No statistically significant differences were found between the two groups. Conclusion: Multiple ESIs prior to mild showed no benefit. A modified algorithm to perform mild immediately upon diagnosis or after the failure of the first ESI is recommended.

Lay abstract Physicians use a structured decision-making process (an algorithm) to decide how best to treat lumbar spinal stenosis (LSS) that results from abnormal thickening of the spinal ligaments that run the length of the spinal cord. Early treatments can include one or more epidural steroid injections (ESIs). This study evaluated a change to the algorithm that involves earlier intervention with a minimally invasive, short outpatient procedure that removes a major root cause of the abnormal thickening (lumbar decompression) and leaves no implants behind. Records of patients treated with minimally-invasive lumbar decompression (mild^®) after receiving either a single ESI procedure or none at all, were compared with the records of patients who underwent the mild procedure after receiving two or more ESIs (145 total patients). The patients' pain scores before surgery, at 1 week postsurgery and at 3 months postsurgery were reviewed. The improvements in pain scores following the mild procedure were compared within each group and between the two groups. The improvements in pain scores at both the 1-week and 3-month follow-up visits indicated that the mild procedure had a positive effect for both groups. Further, there were no significant differences in how much pain scores improved when the two groups were compared. Since neither group experienced significantly more pain relief than the other, there appears to be no benefit to having multiple ESI procedures before undergoing the mild procedure. The authors recommend that the algorithm be modified to perform the mild procedure either as soon as LSS is diagnosed or after the failure of the first ESI procedure.

Ketamine-A Narrative Review of Its Uses in Medicine.

One of the most fascinating drugs in the anesthesiologist's armament is ketamine, an N-methyl-D-aspartate receptor antagonist with a myriad of uses. The drug is a dissociative anesthetic and has been used more often as an analgesic in numerous hospital units, outpatient pain clinics, and in the prehospital realm. It has been used to treat postoperative pain, chronic pain, complex regional pain syndrome, phantom limb pain, and other neuropathic conditions requiring analgesia. Research has also demonstrated its efficacy as an adjunct in psychotherapy, as a treatment for both depression and posttraumatic stress disorder, as a procedural sedative, and as a treatment for respiratory and neurologic conditions. Ketamine is not without its adverse effects, some of which can be mitigated with certain efforts. Such effects make it necessary for the clinician to use the drug only in situations where it will provide the greatest benefit with the fewest adverse effects. To the best of our knowledge, none of the reviews regarding ketamine have taken a comprehensive look at the drug's uses in all territories of medicine. This review will serve to touch on its chemical data, pharmacokinetics and pharmacodynamics, medical uses, and adverse effects while focusing specifically on the drugs usage in anesthesia and analgesia.