Evaluation of therapeutic thoracic medial branch block effectiveness in chronic thoracic pain: a prospective outcome study with minimum 1-year follow up.

BACKGROUND: The prevalence of persistent upper back and mid back pain due to involvement of thoracic facet joints has been described in controlled studies as varying from 43% to 48% based on IASP criteria. Therapeutic intraventions utilized in managing chronic neck pain and low back pain of facet joint origin include intraarticular injections, medial branch nerve blocks, and neurolysis of medial branch nerves by means of radiofrequency. These interventions have not been evaluated in managing chronic thoracic pain of facet joint origin. OBJECTIVE: To determine the clinical effectiveness of therapeutic thoracic medial branch blocks in managing chronic upper back and mid back pain of facet joint origin. DESIGN: A prospective outcome study. SETTING: Interventional pain management setting in the United States. METHODS: Fifty-five consecutive patients meeting the diagnostic criteria of thoracic facet joint pain by means of comparative, controlled diagnostic blocks were included in this evaluation. All medial branch blocks were performed in a sterile operating room under fluoroscopic visualization with mild sedation with midazolam and/or fentanyl. Statistical methods incorporated intent-to-treat analysis. OUTCOME MEASURES: Numeric pain scores, significant pain relief > or = 50%), Oswestry Disability Index, work status and Pain Patient Profile (P-3). Significant pain relief was defined as an average 50% or greater reduction of numeric pain rating scores. RESULTS: The results showed significant differences in numeric pain scores and significant pain relief (50% or greater) in 71% of the patients at three months and six months, 76% at 12 months, 71% at 24 months, and 69% at 36 months, compared to baseline measurements. Functional improvement was demonstrated at one year, two years, and three years from baseline. There was significant improvement with increase in employment among the patients eligible for employment (employed and unemployed) from baseline to one year, two years, and three years (61% vs 96% to 100%) and improved psychological functioning. CONCLUSION: Therapeutic thoracic medial branch blocks were an effective modality of treatment in managing chronic thoracic pain secondary to facet joint involvement confirmed by controlled, comparative local anesthetic blocks.

Does random urine drug testing reduce illicit drug use in chronic pain patients receiving opioids?

BACKGROUND: Prescription drug abuse and illicit drug use are common in chronic pain patients. Adherence monitoring with screening tests, and urine drug testing, periodic monitoring with prescription monitoring programs, has become a common practice in recent years. Random drug testing for appropriate use of opioids and use of illicit drugs is often used in pain management practices. Thus, it is expected that random urine drug testing will deter use of illicit drugs, and also improve compliance. OBJECTIVES: To study the prevalence of illicit drug use in patients receiving opioids for chronic pain management and to compare the results of illicit drug use with the results from a previous study. DESIGN: A prospective, consecutive study. SETTING: Interventional pain management practice setting in the United States. METHODS: A total of 500 consecutive patients on opioids, considered to be receiving stable doses of opioids supplemental to their interventional techniques, were studied by random drug testing. Testing was performed by rapid drug screen. Results were considered positive if one or more of the monitored illicit drugs including cocaine, marijuana (THC), methamphetamine or amphetamines were present. RESULTS: Illicit drug use was evident in 80 patients, or 16%, with marijuana in 11%, cocaine in 5%, and methamphetamine and/or amphetamines in 2%. When compared with previous data, the overall illicit drug use was significantly less. Illicit drug use in elderly patients was absent. CONCLUSION: The prevalence of illicit drug abuse in patients with chronic pain receiving opioids continues to be a common occurence. This study showed significant reductions in overall illicit drug use with adherence monitoring combined with random urine drug testing.

Evaluation of lumbar transforaminal epidural injections with needle placement and contrast flow patterns: a prospective, descriptive report.

BACKGROUND: Transforaminal epidural steroid injection is one of the commonly employed modalities of treatment in managing nerve root pain. However, there have been no controlled prospective evaluations of epidural and nerve root contrast distribution patterns and other aspects of fluoroscopically directed lumbosacral transforaminal epidural steroid injections. OBJECTIVES: To evaluate contrast flow patterns and intravascular needle placement of fluoroscopically guided lumbosacral transforaminal epidural injections. DESIGN: A prospective, observational study. METHODS: A total of 100 consecutive patients undergoing fluoroscopically guided transforaminal epidural steroid injections were evaluated. The contrast flow patterns, ventral or dorsal epidural filling, nerve root filling, C-arm time, and intravascular needle placement were evaluated. RESULTS: Ventral epidural filling was seen in 88% of the procedures, in contrast to dorsal filling noted in 9% of the procedures. Nerve root filling was seen in 97% of the procedures. Total intravenous placement of the needle was noted in 22% of the procedures, whereas negative flashback and aspiration was noted in 5% of the procedures. CONCLUSION: Lumbosacral transforaminal epidural injections, performed under fluoroscopic visualization, provide excellent nerve root filling and ventral epidural filling patterns. However, unrecognized intravascular needle placement with negative flashback or aspiration was noted in 5% of the procedures.

Evaluation of fluoroscopically guided caudal epidural injections.

OBJECTIVE: To evaluate accuracy of needle placement and flow patterns of fluoroscopically guided caudal epidural injections. DESIGN: A prospective observational study of patients with low back pain undergoing caudal epidural injections under fluoroscopy. BACKGROUND: Epidural administration of corticosteroids is one of the commonly used interventions in managing chronic low back pain. Sacral or caudal epidural placement of the needle is one of the commonly used means to access the lumbar epidural space for administration of various drugs. METHODS: A total of 100 consecutive patients underwent fluoroscopically guided caudal epidural injections. Needle insertion was performed blindly (without the use of fluoroscopic guidance) based on palpable landmarks, palpation of subcutaneous airflow, subjective impression that the needle was in a satisfactory position, and ease of injection of contrast. These clinical criteria were compared with the position of the needle as seen under fluoroscopy and the spread of radiopaque contrast in the epidural space. The contrast flow patterns, ventral or dorsal epidural filling, nerve root filling, and correlation of filling to the side of pain were evaluated. RESULTS: Successful injection placement without fluoroscopic visualization was confirmed on subsequent fluoroscopic visualization in 77% of the patients. Various filling and flow patterns showed that with injection of 10 mL of contrast, filling was noted up to S1 in 70% of the patients, followed by L5 nerve root filling in 12% of the patients. Ventral epidural filling was seen in 69% of the patients, in contrast to dorsal filling in 92% of the patients. Nerve root filling correlated with leg pain in only 43% of the patients. Intravenous placement of the needle was noted in 14% of the patients with positive flashback and aspiration in 50% of the patients. CONCLUSION: Caudal epidural injections are ideally performed with fluoroscopic guidance as the gold standard for accurate needle placement. However, this does not assure either targeted delivery or accurate placement of the drug.

Risk of whole body radiation exposure and protective measures in fluoroscopically guided interventional techniques: a prospective evaluation.

BACKGROUND: Fluoroscopic guidance is frequently utilized in interventional pain management. The major purpose of fluoroscopy is correct needle placement to ensure target specificity and accurate delivery of the injectate. Radiation exposure may be associated with risks to physician, patient and personnel. While there have been many studies evaluating the risk of radiation exposure and techniques to reduce this risk in the upper part of the body, the literature is scant in evaluating the risk of radiation exposure in the lower part of the body. METHODS: Radiation exposure risk to the physician was evaluated in 1156 patients undergoing interventional procedures under fluoroscopy by 3 physicians. Monitoring of scattered radiation exposure in the upper and lower body, inside and outside the lead apron was carried out. RESULTS: The average exposure per procedure was 12.0 PlusMinus; 9.8 seconds, 9.0 PlusMinus; 0.37 seconds, and 7.5 PlusMinus; 1.27 seconds in Groups I, II, and III respectively. Scatter radiation exposure ranged from a low of 3.7 PlusMinus; 0.29 seconds for caudal/interlaminar epidurals to 61.0 PlusMinus; 9.0 seconds for discography. Inside the apron, over the thyroid collar on the neck, the scatter radiation exposure was 68 mREM in Group I consisting of 201 patients who had a total of 330 procedures with an average of 0.2060 mREM per procedure and 25 mREM in Group II consisting of 446 patients who had a total of 662 procedures with average of 0.0378 mREM per procedure. The scatter radiation exposure was 0 mREM in Group III consisting of 509 patients who had a total 827 procedures. Increased levels of exposures were observed in Groups I and II compared to Group III, and Group I compared to Group II.Groin exposure showed 0 mREM exposure in Groups I and II and 15 mREM in Group III. Scatter radiation exposure for groin outside the apron in Group I was 1260 mREM and per procedure was 3.8182 mREM. In Group II the scatter radiation exposure was 400 mREM and with 0.6042 mREM per procedure. In Group III the scatter radiation exposure was 1152 mREM with 1.3930 mREM per procedure. CONCLUSION: Results of this study showed that scatter radiation exposure to both the upper and lower parts of the physician's body is present. Protection was offered by traditional measures to the upper body only.

Effectiveness of protective measures in reducing risk of radiation exposure in interventional pain management: a prospective evaluation.

It is estimated that over 50% of approximately 4 million interventional procedures performed annually in the United States are performed utilizing fluoroscopy. Fluoroscopy offers validity to interventional techniques by providing precise localization of anatomic target areas and facilitating accurate delivery of injectate. Exposure to ionizing radiation is an unavoidable consequence while performing fluoroscopic procedures. The primary source of radiation to the physician during interventional procedures is from scatter reflected back from the patient. Multiple investigators have prospectively evaluated radiation exposure to the physician performing fluoroscopically guided interventional procedures in various settings, with varying results. This prospective controlled study was undertaken to evaluate scatter radiation risk of whole body exposure and protective measures to reduce scatter radiation in the upper and lower parts of the body in fluoroscopically guided interventional techniques. Five hundred consecutive patients, undergoing interventional procedures, in an ambulatory surgery setting were studied. The mode utilized varied from pulsed-imaging to continuous fluoroscopic imaging. All the protective measures were incorporated, including lead shielding from the table to the floor covering the entire area of the beam. Scatter radiation exposure was monitored in 5 areas with 3 badges inside the apron and 2 outside the apron. Results of this study showed an average exposure per patient of 8.9 -/+ 0.4 seconds and per procedure of 4.9 -/+ 0.11 seconds. Scatter radiation exposure was higher outside the lead aprons compared to inside the lead aprons. Scatter radiation exposure at groin level was similar with or without lead shielding from the table to the floor.

Radiation exposure to the physician in interventional pain management.

Fluoroscopy is an integral part of the practice of interventional pain management in present day modern medical practices. The major purpose of fluoroscopy in interventional pain management is correct needle placement to ensure target specificity and accurate delivery of the injectate. Fluoroscopy has become mandatory for multiple procedures based either on the definition of the procedure or the requirement of third parties. The most commonly used fluoroscopy in interventional pain management is with C-arm fluoroscopes with image intensification. Fluoroscopy is associated with risk for patients, clinicians, and the personnel in the operating room unless it is managed with appropriate understanding, skill, and vigilance. A total of 1,000 consecutive patients undergoing interventional procedures with chronic pain performed by one physician were studied. Two fluoroscopy units were utilized and operated by two certified radiological technologists. The procedures performed included caudal and interlaminar epidural injections, facet joint nerve blocks, percutaneous adhesiolysis, intercostal nerve blocks, sympathetic blocks, transforaminal epidural injections, along with other procedures. Results showed that a total of 1,000 patients underwent 1,729 procedures with average radiation exposure of 13.2 +/- 0.33 seconds per patient and 7.7 +/- 0.21 seconds per procedure. Dosimetry measurements showed total exposure of 1,345 mREM outside the apron and 0 mREM inside the apron during this period. The average exposure outside the apron was 1.345 mREM per patient and 0.778 mREM per procedure outside the apron and 0 mREM inside the apron. The levels of exposure are significantly below the annual limits recommended. It is concluded that it is feasible to perform all procedures under fluoroscopy in the described setting safely and effectively in interventional pain management.