Abstract
Objective: To investigate the effect of progressive resistance training using resistance (elastic) bands on subacromial bursitis following triamcinolone acetonide injection.
Design: Randomized clinical trial.
Patients: A total of 68 patients with subacromial bursitis were randomized to a triamcinolone acetonide group or a triamcinolone acetonide plus resistance band training group.
Methods: Visual analogue scale, Constant scores, range of motion, proprioception, and muscle strength were evaluated at pretreatment and at 3, 12 and 24 weeks’ follow-up. Re-treatment ratio was calculated at one-year follow-up.
Results: At 3 and 12 weeks, both the triamcinolone acetonide group and triamcinolone acetonide plus resistance band training group showed a significant improvement in Visual analogue scale score, Constant score, range of motion, proprioception and muscle strength. Although the scores in the triamcinolone acetonide group had not increased at 24 weeks compared with baseline, the scores in the triamcinolone acetonide plus resistance band training group showed continued improvement at 24 weeks. A lower proportion of patients in the triamcinolone acetonide plus resistance band training bands group than in the triamcinolone acetonide group had received re-treatment at one-year follow-up (12.1% vs 82.9%).
Conclusion: Progressive resistance training with resistance (elastic) bands has the advantages of extending the benefits of corticosteroid injection and maintaining long-term effects on shoulder function in patients with subacromial bursitis.
neuralgia.
Abstract
Hemiplegic shoulder pain (HSP), which occurs in most patients with hemiplegia, causes considerable distress and worsens outcomes in rehabilitation. Although they have received the treatments such as anti-inflammatory drugs or physical therapy, many of the individuals remain suffering from shoulder pain 6 months after acute stroke event. In this retrospective study, we evaluated the effectiveness of ultrasound guided subacromial-subdeltoid (SASD) bursa injections with botulinum toxin type A (BoNT/A) compared to steroids for refractory HSP.The data were collected retrospectively by reviewing the patient’s medical records and pain questionnaires in our rehabilitation center. In total, 38 patients who received ultrasound guided SASD bursa injection (BoNT/A group, n = 18; corticosteroid group, n = 20) were included. The pain visual analog scale (VAS) score at rest and during arm passive abduction, Fugl-Meyer score of upper limbs (F-M score) were evaluated before, 2, 4, 8, and 12 weeks after injection.Both 2 groups obtained a significant improvement of VAS score at rest or during arms passive abduction compared to baseline score (within group compare, P < .05). There were no significant differences of pain score improvement between two groups at week 2, 4, 8, and 12 after injection either at rest or during passive arm abduction (between 2 groups compare, P > .05). There were also no differences in results of the post treatment F-M score between 2 groups (between 2 groups compare, P > .05). Similarly, during the follow-up period no collateral effects were reported after BoNT/A injection.SASD bursa BoNT/A injection can substantially reduce the pain as corticosteroid in patients with HSP. BoNT/A injection could be a useful strategy for replacing steroids as a treatment for refractory HSP especially in the patients who cannot tolerate the steroids injection.
Abstract
Objective: To analyse the effectiveness of corticosteroid (CS) and hyaluronic acid (HA) subacromial – subdeltoid (SASD) injection compared with normal saline (NS) in patients with chronic subacromial bursitis (CSB).
Design: A prospective three-arm double-blinded randomised controlled trial.
Setting: Rehabilitation department of two teaching hospitals.
Subjects: Patients with CSB (N = 186) divided into CS (N = 68), HA (N = 60), and NS (N = 58) groups.
Interventions: Three SASD injections under ultrasound guidance: group A, 20 mg of triamcinolone; group B, 2.5 mL of HA; and group C, 2.5 mL of NS.
Outcome measures: The primary outcome measures were the pain visual analogue scale (VAS) score at eight weeks. The secondary outcomes were scores on the Shoulder Pain and Disability Index (SPADI) and Shoulder Disability Questionnaire.
Results: At eight weeks, the pain VAS scores during activity were 2.56 ± 2.29, 3.65 ± 2.50, and 4.71 ± 2.83 in the CS, HA, and NS groups, respectively (CS vs NS, P < 0.001; HA vs NS, P = 0.013; CS vs HA, P = 0.010). SPADI scores were 40.83 ± 21.75, 36.92 ± 22.78, and 33.35 ± 23.38 in the CS, HA, and NS groups, respectively (CS vs NS, P < 0.001; HA vs NS, P = 0.197; CS vs HA, P = 0.004).
Conclusion: Ultrasound-guided corticosteroid injection into the subacromial – subdeltoid bursa was proven to be effective and superior to hyaluronic acid and normal saline injection for treating CSB. Hyaluronic acid injection was only marginally more effective than normal saline injection.
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Abstract
Introduction: Subacromial bursitis is caused by inflammation of the bursa that separates the superior surface of the supraspinatus tendon from the overlying coraco-acromial ligament and acromion. While multiple cytokines are implicated, interleukin-1 beta appears to play a prominent role. Rilonacept, an interleukin-1 trap, may be an alternative to corticosteroid injection for the management of this condition.
Methods: This single center, randomized, non-inferiority, unblinded study recruited 33 subjects over 9 months. Twenty subjects received 160mg intrabursal injection of rilonacept and 13 received a 6mL mixture of lidocaine, bupivacaine, and 80mg triamcinolone acetonide. QuickDASH, subject reported pain, and adverse events were recorded at time of injection, 2 days later, 2 weeks later, and 4 weeks later. Primary outcome was improvement in QuickDASH 4 weeks post-injection. Secondary outcomes were improvement in subject reported pain and occurrence of adverse events at 4 weeks.
Results: Both study groups were equally matched for age, gender, ethnicity, and site of bursa injection. Both medications demonstrated a statistically significant improvement in QuickDASH 4 weeks post-injection, but triamcinolone acetonide injection offered greater improvement (P=0.004). Both medications demonstrated improvement in subject reported pain but between group comparison at 4 weeks showed that triamcinolone was superior (P=0.044). No statistically significant differences in adverse events were noted between groups, but subjects who received rilonacept experienced more episodes of diarrhea and headache.
Conclusions: While improvement in QuickDASH and pain was noted with a single intrabursal injection of rilonacept at 4 weeks, injection with triamcinolone acetonide was more efficacious.
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Abstract
This study is a systematic review of prospective randomised control studies comparing ultrasound-guided steroid injection of the subacromial space with anatomic landmark-guided injection in the treatment of subacromial impingement to determine if there is any difference in pain relief and functional outcome. Mesh terms and free-text words search of electronic databases, reference list of identified studies and grey literature was performed using the PICO format. All identified papers were sifted sequentially by title, abstract and review of full text articles. Four papers qualified and were included in the review and analysis. The total number of patients in the studies was 234 patients with 117 patients randomised to each of landmark-guided and ultrasound-guided injection groups. There was no statistically significant difference in VAS pain scores (P = 0.67), SDQ scores (P = 0.43), SPADI disability score (P = 0.17) and functional outcomes scores (P = 0.09) at 4 to 6 weeks when USS-guided subacromial steroid injection was compared with landmark-guided injection. SPADI pain scores (P = 0.02) demonstrates significant reduction in favour of landmark-guided injection. There was low to moderate risk of bias. In conclusion, ultrasound-guided subacromial steroid injection does not offer any statistically significant clinical improvement over landmark-guided injection in adults with subacromial impingement.
Abstract
Background
Subacromial pain syndrome (SAPS) is a common complaint in orthopaedics. Subacromial corticosteroid injections (CSI) can relieve pain in the short term. Anodal transcranial direct current stimulation (a-tDCS) has been used for symptomatic pain relief in a variety of chronic pain conditions. The aim of this pilot study was to assess whether the application a-tDCS could enhance the symptomatic relief provided by CSI in patients affected by SAPS.
Methods
Thirty-eight participants (18 to 65-year-old) suffering from SAPS were recruited to have a CSI and randomly allocated to receive, 1 weeks post CSI, real a-tDCS (r-tDCS), sham tDCS (s-tDCS) or no intervention (Control). Upper limb function was measured 1 week prior to the CSI, at the 2- and 4-week follow-ups using self-administered questionnaires and physical measures. Self-reported pain and activity during each day were logged by the participants using visual analog scales (VAS). Differences between groups were tested using repeated-measures ANOVAs.
Results
Pain VAS and the Single Assessment Numeric Evaluation scale (SANE) showed significant improvement from baseline 2 weeks and 4 weeks after CSI in all groups (p < 0.05). There were no significant group X time interaction 2 weeks following tDCS treatment in any of the variables.
Conclusion
All groups showed significant improvement in pain VAS and SANE scores following the CSI. One session of a-tDCS treatment 2 weeks following CSI did not result in any additive or potentializing effects when compared to a s-tDCS or a control group.
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Abstract
Background
subacromial-subdeltoid chronic bursitis is one of the main causes of shoulder pain syndrome. There are various causes of shoulder pain syndrome including chronic bursitis. The sonographic appearances of chronic bursitis vary from patient to patient, depending upon the underlying cause. However, rice bodies are the rare sonographic presentation among them. Rice bodies can be associated with atypical mycobacterial tenosynovitis, bursitis, mycobacterium tuberculosis and infections, but very rarely occur in the chronic subacromial-subdeltoid bursitis. Its unique sonographic presentation makes it easy to be diagnosed confidently, but it is difficult to be recognized, interpret and distinguish from other pathologies due to its rare occurrence. It is therefore intended to present this rare and interesting sonographic presentation of chronic subacromial-subdeltoid bursitis as a case report.
Case-presentation
A 36-year-old male suffering from swelling and pain on his left shoulder for 6 months came to the clinic with Grade-3 impingement syndrome. Free-floating echogenic rice bodies were identified in the subacromial-subdeltoid bursa during ultrasound examination, which was also confirmed with Magnetic resonance imaging (MRI) and serological tests of the specimen after surgery.
Conclusion
The unique sonographic presentation of rice bodies in the chronic subacromial-subdeltoid bursitis makes it easy to be diagnosed confidently, but it is difficult to be recognized, due to its rare occurrence.
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Abstract
Background: Postherpetic neuralgia, a persistent pain condition often characterized by allodynia and hyperalgesia, is a deleterious consequence experienced by patients after an acute herpes zoster vesicular eruption has healed. The pain associated with postherpetic neuralgia can severely affect a patient’s quality of life, quality of sleep, and ability to participate in activities of daily living. Currently, first-line treatments for this condition include the administration of medication therapies such as tricyclic antidepressants, pregabalin, gabapentin, and lidocaine patches, followed by the application of tramadol and capsaicin creams and patches as second- or third-line therapies. As not all patients respond to such conservative options, however, interventional therapies are valuable for those who continue to experience pain.
Methods: Search of PubMed database for all randomized controlled trials regarding postherpetic neuralgia that were published before the end of May 2017.
Results: The current evidence is insufficient for determining the single best interventional treatment. Considering invasiveness, price, and safety, the subcutaneous injection of botulinum toxin A or triamcinolone, transcutaneous electrical nerve stimulation, peripheral nerve stimulation, and stellate ganglion block are recommended first, followed by paravertebral block and pulsed radiofrequency. If severe pain persists, spinal cord stimulation could be considered. Given the destructiveness of the dorsal root ganglion and adverse events of intrathecal methylprednisolone injection, these interventions should be carried out with great care and only following comprehensive discussion.
Conclusion: With the exception of intrathecal methylprednisolone injection for postherpetic neuralgia, the evidence for most interventional procedures used to treat postherpetic neuralgia is Level 2, according to “The Oxford Levels of Evidence 2”. Therefore, these modalities have received only grade B recommendations. Despite the lack of a high level of evidence, spinal cord stimulation and peripheral nerve stimulation are possibly useful for the treatment of postherpetic neuralgia.
Abstract
Postherpetic neuralgia (PHN) is the most troublesome side effect of Herpes Zoster (HZ), which mainly affects the elderly and immunocompromised populations. Despite the current advancement of treatments, PHN persists in many individuals influencing their daily activities and reducing their quality of life. Anticonvulsants, antidepressants, topical therapies including lidocaine and capsaicin, and opioids, are the most widely used therapies for the treatment of PHN. These medications come with their adverse effects, so they should be used carefully with the elderly or with patients with significant comorbidities. Other measures like botulinum toxin, nerve blocks, spinal cord stimulation, and radiofrequency have also contributed significantly to the management of PHN. However, the efficacy, safety, and tolerability of these invasive methods need to be carefully monitored when administering them. Early diagnosis and early initiation of treatment can reduce the burden associated with PHN. The zoster vaccine has effectively reduced the incidence of HZ and PHN. In this article, we discuss the treatment options available for the management of PHN, mainly focusing on the efficacy and safety of different therapeutic modalities.
Abstract
This study investigated the safety and efficacy of mirogabalin, a novel, potent, selective ligand of the a2d subunit of voltage- dependent Ca21 channels, for the treatment of postherpetic neuralgia (PHN). In this multicenter, double-blind, placebo-controlled phase 3 study, Asian patients $20 years with PHN were randomized 2:1:1:1 to placebo or mirogabalin 15, 20, or 30 mg/day for up to 14 weeks (NCT02318719). The primary efficacy endpoint was the change from baseline in average daily pain score at week 14, defined as a weekly average of daily pain (0 5 “no pain” to 10 5 “worst possible pain,” for the last 24 hours). Of 765 patients randomized, 763 received $ 1 dose of the study drug and were included in the analysis; 303, 152, 153, and 155 received placebo, mirogabalin 15, 20, or 30 mg/day, respectively. A total of 671 (87.7%) patients completed the study. At week 14, the difference in average daily pain score least squares mean vs placebo was 20.41, 20.47, and 20.77, respectively; all mirogabalin groups showed statistical significance. The most common treatment-emergent adverse events were somnolence, nasopharyngitis, dizziness, weight increase, and edema, and all of them were mild or moderate in severity. Mirogabalin was superior to placebo in all groups for relieving PHN and appeared well tolerated.
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Abstract
BACKGROUND: Postherpetic neuralgia (PHN) is a chronic, painful condition characterized by persistent pain following resolution of a herpes zoster (HZ) infection. Epidemiologic data demonstrate that the risks for HZ infections and the development of PHN increase with age.
OBJECTIVE: To characterize prescribing patterns, health care utilization, and treatment costs for adults with PHN based on real-world data.
METHODS: This study analyzed medical and pharmacy claims from 2010 to 2014 in the MarketScan Commercial and Medicare Supplemental databases. PHN patients were identified based on criteria from a published algorithm. PHN treatment patterns were analyzed by age and reported descriptively for patients aged < 65 or ≥ 65 years. Excess incremental health care costs were calculated for PHN patients by comparing expenditures for a cohort of PHN patients to expenditures of a propensity score-matched control group of patients with HZ alone.
RESULTS: Approximately 0.4% of patients aged < 65 years were diagnosed with HZ versus 1.3% of patients aged ≥ 65 years; approximately 15.3% of HZ patients aged < 65 years and 26.4% of patients aged ≥ 65 years were diagnosed with PHN. Overall, opioids remained the most frequently prescribed initial treatment. Approximately 21.6% of PHN patients received an opioid as an initial treatment for PHN, 15.1% received gabapentin; 8.9% received a prescription nonsteroidal anti-inflammatory drug (NSAID); 8.3% received a lidocaine patch; 3.3% received pregabalin; 2.5% received a tricyclic antidepressants (TCAs); 0.8% received other topical lidocaine; and < 1% received capsaicin. Observed first-line use of the lidocaine patch and gabapentin was higher in patients aged ≥ 65 years relative to patients aged < 65 years. When separated by age group, only 24.6% of patients aged < 65 years and 38.5% of patients aged ≥ 65 years were prescribed a recommended first-line treatment for initial PHN therapy (gabapentin, lidocaine patch, pregabalin, and TCAs). Comparisons of treatment costs of PHN patients to matched HZ patients without PHN indicated that PHN patients initiated on opioids had the highest mean additional health care expenditure compared with PHN patients initiated on other medications. On average, PHN patients initiated on opioids had $7,601 additional health care expenditure compared with HZ patients with no PHN; additional expenditures were $6,428 for pregabalin, $4,213 for lidocaine patches, $3,478 for gabapentin, $3,304 for NSAIDs, and $2,797 for TCAs, respectively.
CONCLUSIONS: Management of PHN is associated with substantial utilization of opioid-based therapies across all ages. Medications supported by evidence either as first-line therapies or as part of a multimodal regimen for the management of PHN are underused relative to opioid-based PHN therapies. Improving adherence to evidence-based PHN treatment regimens offers the potential to reduce opioid prescribing first line and reduce overall treatment costs. Given the emphasis to reduce opioid prescribing to minimize the risk of dependence, abuse, and diversion, multimodal analgesic treatments that can avoid or reduce opioid use should be considered
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Abstract
Background: Postherpetic neuralgia (PHN) is a neuropathic pain that causes a reduction in patients’ quality of life. There are many topical drugs for PHN, including topical lidocaine patch, topical application of capsaicin, and others.
Objectives: This study aims to compare the efficacy and safety of topical drugs for PHN.
Study design: Relevant studies were found by systemically searching for terms including “topical” and “Postherpetic neuralgia” in PubMed, Cochrane library, MEDLINE, and EMBASE databases (inception through June 12, 2019). The primary outcome was the percentage of change in the Numeric Rating Scale or the Visual Analog Scale scores from baseline. The secondary outcome was the number of adverse events.
Methods: The efficacy and safety of topical drugs for PHN was investigated by the pairwise meta-analysis and Bayesian network meta-analysis, applying Revman 5.3, the Stata 14.0 software, and GeMTC 0.14.3.
Results: Twelve studies met the inclusion criteria, and eligible studies were selected for the ultimate meta-analysis. Our meta-analysis displayed 6 topical drugs for PHN. Lidocaine, high-concentration capsaicin, and aspirin/diethyl ether (ADE) had a higher possibility of bringing pain relief than placebo. Among them, lidocaine had the highest possibility of being the most effective drug for PHN and had the statistical significances compared with diclofenac, high-concentration capsaicin, indomethacin, low-concentration capsaicin, and placebo, and lidocaine was significantly preferable than other effective drugs in the aspect of safety.
Conclusions: Compared with other topical drugs, lidocaine was the most effective and most tolerable drug to be recommended for PHN.
Abstract
Objectives: Trigeminal postherpetic neuralgia (TPHN) often presents with moderate to severe pain, hyperalgesia, and allodynia. Conventional analgesic treatments are poorly effective, which seriously affects the quality of life. This retrospective study aimed to evaluate the efficacy of pulsed radiofrequency (PRF) for the treatment of TPHN.
Methods: A total of 90 TPHN patients were selected between January 2014 and December 2016 in the Department of Pain Management, Shengjing Hospital, China Medical University. Patients were randomly divided into two groups according to the order of enrollment (n = 45 per group): group A, peripheral nerve (supraorbital nerve, infraorbital nerve and mental nerve) PRF; group B, gasserian ganglion PRF. Follow-up assessments of visual analogue scale (VAS) pain assessment, SF-36 health status questionnaire, total efficiency rate, and drug dosage of anticonvulsants and opioid analgesics were performed at time points of 1 week, 1 month, 3 months, 6 months, and 1 year after surgery.
Results: At each postsurgery time point, the VAS decreased, SF-36 (physical and mental components) increased, and drug dosage of anticonvulsants and opioids analgesics decreased in both treatment groups; values at each time point were significantly different from presurgery values (P < 0.05). Compared with group A, VAS decreased, SF-36 increased, and dosage of anticonvulsants and opioids analgesics decreased significantly in group B (P< 0.05). The total efficiency rates one year after surgery in group A and group B were 68.9 and 86.7%, respectively. The total efficiency rate of group B was statistically higher than that of group A (P < 0.05).
Conclusion: PRF relieved TPHN, and gasserian ganglion PRF was more effective than peripheral nerve PRF. The method was effective and improved the quality of life of the patients. PRF is recommended as a treatment for TPHN.
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Abstract
Objective: Postherpetic neuralgia (PHN) is the most common complication of herpes zoster, manifesting as a persistent, spontaneous, knife-like pain or paroxysmal burning that seriously affects a patient’s quality of life. An effective treatment of PHN is lacking. This retrospective study examined the efficacy and safety of stellate ganglion (SG) pulsed radiofrequency (PRF) on facial and upper limb PHN.
Methods: Eighty-four patients with PHN on the face or upper limbs were enrolled for the study. Patients were randomly divided into two surgical groups according to the order of enrollment; one group underwent SG block (SG-B group, n = 42) and the other underwent SG pulsed radiofrequency (SG-P group, n = 42). After surgery, patients were followed at 1 week, 2 weeks, 1 month, 3 months, and 6 months. Observation at each follow-up included basic patient characteristics, visual analog scale (VAS), quality of life (QOL) using Physical Component Summary (PCS), and Mental Component Summary (MCS) to assess, total effective rate, complications and side effects.
Results: Compared with preoperative values, VAS decreased in both groups after surgery (P < 0.05). In the SG-B group, VAS increased after 1 month, while in the SG-P group, VAS gradually decreased at later follow-up time points. VAS decreased more significantly in the SG-P group after 1 month (P< 0.05). PCS and MCS increased in both groups after the operation, and the difference was significant compared with preoperative values (P < 0.05). The total effective rates of the SG-B and SG-P groups were 64.3 and 83.3%, respectively. The total effective rate of the SG-P group was higher than that of the SG-B group (P < 0.05). The incidence of complications and side effects in the SG-B group was higher than that in the SG-P group (P < 0.05).
Conclusion: SG pulsed radiofrequency treatment of facial and upper limb PHN is safe and effective. It is a treatment method worth promoting.
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Abstract
The present meta‑analysis study aimed to investigate the safety and efficacy of local administration of botulinum toxin (BTX‑A) vs. lidocaine in the treatment of post‑herpetic neuralgia. A systematic search of the Cochrane Library, PubMed, Embase, Chinese National Knowledge Infrastructure, Wanfang, Chongqing VIP Information Co. and Chinese Biomedical Literature Database was performed to identify randomized controlled trials (RCTs) comparing BTX‑A and lidocaine in the treatment of post‑herpetic neuralgia. The primary outcomes were Visual Analogue Scale (VAS) pain scores at 1, 2 and 3 months after treatment and the effective rate. Secondary outcomes were scores on the McGill pain questionnaire and adverse event rate. A total of 7 RCTs comprising 752 patients were included. The VAS pain score was significantly lower at 1 month [mean difference (MD)=‑2.31; 95% CI: ‑3.06, ‑1.56; P<0.00001)], 2 months (MD=‑2.18; 95% CI: ‑2.24, ‑2.11; P<0.00001) and 3 months (MD=‑1.93; 95% CI: ‑3.05, ‑0.82; P=0.0007) after treatment, the effective rate was significantly higher (odds ratio=2.9; 95% CI: 1.71, 4.13; P<0.0001) and scores on the McGill pain questionnaire were significantly lower (MD=‑10.93; 95% CI: ‑21.02, ‑0.83; Z=2.12; P=0.03) in patients who received BTX‑A for post‑herpetic neuralgia compared to those who received lidocaine. There was no difference in the adverse event rate between treatments. In conclusion, BTX‑A has potential as a safe and effective treatment option for post‑herpetic neuralgia. Further large and well‑designed RCTs are required to confirm this conclusion.
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Abstract
Background: The usefulness of early sympathetic blockade in the prevention of postherpetic neuralgia (PHN) has been reported. However, the optimal duration and frequency of paravertebral blocks that prevent or maximally reduce the incidence of PHN need to be clarified.
Methods: Eighty patients suffering from acute thoracic herpes zoster eruption were randomly allocated into 2 groups. Group I received paravertebral block using 25 mg bupivacaine plus 8 mg dexamethasone in a total volume of 10 mL twice one week apart. Group II received paravertebral block using 25 mg bupivacaine plus 8 mg dexamethasone in a total volume of 10 mL 3 times one week apart. All patients received daily 300 mg pregabalin in divided doses (150 mg/12 hours). Pain scores were evaluated during each visit. Once the patient reported mild pain, the trial for reducing the pregabalin dose was done. Acetaminophen was available as a rescue analgesia. At each assessment visit, the total analgesic consumption was recorded. The times of the complete resolution of the pain and the skin eruption were recorded. The incidence of PHN after 3, 6, and 12 months was also reported.
Results: Pre-eruptive pain severity and duration were comparable between both groups. There was no statistically significant difference between both groups with respect to the day of the block, the total duration of pain until the first block, and eruptive and herpetic pain duration parameters. The severity of skin lesions was comparable among both groups. Four patients (10.5%) had PHN in group I versus 3 patients (8.1%) in group II after 3 months of follow-up. Meanwhile, these numbers were 3 patients (7.9%) and 2 patients (5.4%) at 6 and 12 months in both groups, respectively. Compared with basal parameters, effective pain control was noticed in both groups with no significant difference between groups.
Limitations: Small size, lack of complete blindness, and the use of fluoroscopy in block performance in the era of performing this block under ultrasound.
Conclusions: Repeated paravertebral blocks using local anesthetic and steroids weekly over 2 or 3 weeks in the management of acute thoracic herpes zoster can provide safe and effective pain relief and minimize the incidence of PHN. However, no added benefit was detected from repeated blocks more than twice.
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Abstract
Introduction
We investigated the effect and safety of ozone autohemotherapy combined with pharmacological therapy in postherpetic neuralgia (PHN).
Methods
Ninety-eight patients with PHN were enrolled in this study and randomly divided into a pharmacological therapy group and ozone autohemotherapy group (49 patients in each group). The PHN patients in the pharmacological therapy group were administered pharmacological therapy for 2 weeks, whereas PHN patients in the ozone autohemotherapy group were given ozone autohemotherapy (200 mL blood from patients, the concentration of medical ozone was set as 30 μg/mL using an ozone medical apparatus, 40 mL medical ozone was incubated in 200 mL autologous blood for 3–5 minutes) combined with pharmacological therapy for 2 weeks. The Visual Analog Scale (VAS), the 50% VAS reduction in the initial value, McGill Pain Questionnaire (MPQ), the Patients’ Global Impression of Change (PGIC) scale, and the World Health Organization Quality of Life (WHOQOL-BREF) instrument were used to evaluate the outcomes of all PHN patients before therapy and at 1 week, 1 month, and 3 months after therapy.
Results
Forty-five patients in the pharmacological therapy group and 47 patients in the ozone autohemotherapy group completed the study. Compared with before therapy, the two groups showed significant improvements in VAS, MPQ, PGIC, and WHOQOL-BREF scores after therapy (P<0.05). Moreover, compared with the scores of the pharmacological therapy group, the ozone autohemotherapy group’s scores were significantly improved in the VAS, MPQ, PGIC, and WHOQOL-BREF as well as the 50% VAS reduction of the initial value after therapy (P<0.05). Finally, there were no statistically significant differences in adverse effects between groups after therapy (P>0.05).
Conclusion
The results of this study demonstrated that ozone autohemotherapy combined with pharmacological therapy was superior to isolated pharmacological therapy in patients with PHN and was an effective and safe way to relieve PHN.
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Abstract
Background: The efficacy of particulate and non-particulate steroids in patients receiving epidural steroid injections remains unclear.
Objective: The purpose of this meta-analysis was to compare the efficacy of particulate and non-particulate steroids in patients receiving epidural injections for radicular pain over 3 months.
Study design: Systematic review and meta-analysis.
Methods: We reviewed PubMed, PubMed Central, Scopus, Central Register of Clinical Trials of the Cochrane Collaboration, Google Scholar, and Directory of open access journals for trials that compared efficacy of particulate steroid with non-particulate. A meta-analysis was performed on treatment related to mean change in visual analogue score (VAS) between the particulate and non-particulate steroids. Two authors independently reviewed the data for inclusion.
Results: Seven studies comprising 3,542 patients in the particulate group and 856 patients in the non-particulate group were included. Pooled mean maximum change of VAS was higher by 0.53 (95% CI: 0.14 to 0.92; P = 0.007; I2 = 50.2%) in the particulate group compared to the non-particulate group. The non-particulate group had a larger proportion of patients with more than 50% pain relief than the particulate group [OR 0.81 (95% CI: 0.68 to 0.97, P = 0.024).
Limitations: Limited number of trials that fit the inclusion criteria and were available for analysis.
Conclusions: As the use of particulate steroids seems to be associated with slightly better VAS scores only, clinicians need to weigh their clinical relevance in the light of complications and recent FDA recommendations on the use of particulate steroids.
Abstract
Background:
Administration of steroids in the lumbar transforaminal block for lumbar radicular pain is considered one of the preferred treatment methods though it is associated with some complications.Objectives:
The effects and side effects of triamcinolone and dexmedetomidine in the lumbar transforaminal block were investigated in the present study.Methods:
In this study, 30 patients, aged 40 – 70 years, suffering from lumbar radicular pain arising from the lumbar disc protrusion were equally divided into two groups of triamcinolone (T) and dexmedetomidine (D). They all underwent lumbar transforaminal blocks. An injection solution of triamcinolone (20 mg) plus ropivacaine (0.2%) and another one containing dexmedetomidine (50 μg) plus ropivacaine (0.2%) were administered in the triamcinolone and dexmedetomidine groups, respectively. Visual Analog Scale (VAS), Oswestry Disability Index (ODI), Straight Leg Raise (SLR or lasègue’s test), and Fasting Blood Sugar (FBS) were measured at 0, 2 weeks, 1, 3, and 6 months post-procedure. The levels of calcium, magnesium, and vitamin D, as well as potential complications, were also evaluated.Results:
Significant differences were found in the VAS and ODI during the measurement times within each group. The VAS and ODI were remarkably different between the dexmedetomidine group and the triamcinolone group. In addition, there were considerable differences in the increased FBS and reduced calcium and vitamin D levels in the triamcinolone group from changes in the dexmedetomidine group.Conclusions:
Abstract
Objective
Methods
Results
Conclusion
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Abstract
Background: Transforaminal epidural injections have been used since the late 1990s to treat lumbar radicular pain. They have been the subject of considerable attention, with varying conclusions from systematic reviews as to their efficacy. Transforaminal injections have been associated with rare but major complications. Further, the use of transforaminal injections has increased since the passage of the Affordable Care Act. Finally, with the SARS-CoV-2 pandemic, there has been heightened concern regarding the risk associated with steroid injections.
Objectives: To evaluate and update the effectiveness of transforaminal injections for 4 indications: radicular pain; from spinal stenosis; from failed back surgery syndrome; and for axial low back pain; and to evaluate the safety of the procedure.
Study design: A systematic review and meta-analysis of the efficacy of transforaminal injections.
Methods: The available literature on transforaminal injections was reviewed and the quality assessed. The level of evidence was classified on a 5-point scale based on the quality of evidence developed by the US Preventive Services Task Force (USPSTF) and modified by the American Society of Interventional Pain Physicians (ASIPP). Data sources included relevant literature from 1966 to April 2020, and manual searches of the bibliographies of known primary and review articles. Pain relief and functional improvement were the primary outcome measures. A minimum of 6 months pain relief follow-up was required.
Results: For this systematic review, 66 studies were identified. Eighteen randomized controlled trials met the inclusion criteria. No observational studies were included. Eleven randomized controlled trials dealt with various aspects of transforaminal injections for radicular pain owing to disc herniation. Based on these studies, there is Level 1 evidence supporting the use of transforaminal injections for radicular pain owing to disc herniation. A meta-analysis showed that at both 3 and 6 months, there was highly statistically significant improvement in both pain and function with both particulate and nonparticulate steroids. For radicular pain from central stenosis there is one moderate quality study, with Level IV evidence. For radicular pain caused by failed back surgery syndrome there is one moderate quality study, with Level IV evidence. For radicular pain from foraminal stenosis and for axial pain there is Level V evidence, opinion-based/consensus, supporting the use of transforaminal injections. Transforaminal injections are generally safe. However, they have been associated with major neurologic complications related to cord infarct. Causes other than intraluminal injection of particulates appear to be at play. The use of an infraneural approach and of blunt needles appear to offer the greatest patient safety. Because of concern over the role of particulate steroids, multiple other injectates have been evaluated, including nonparticulate steroids, tumor necrosis factor alpha (TNF-a) inhibitors, and local anesthetics without steroids. No injectate has been proven superior. If there is concern about immunosuppression because of risk of COVID-19 infection, either the lowest possible dose of steroid or no steroid should be used.
Limitations: The study was limited by the paucity of literature for some indications.
Conclusions: There is Level I evidence for the use of transforaminal injections for radicular pain from disc herniations.
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Abstract
Introduction: This study is to compare advantages, safety and mid-term effects of fluoroscopy (FL)-guided transforaminal (TF) to caudal (CA) epidural steroid injection (ESI) for chronic pain after spinal surgery (CPSS) by assessing pain relief and improvement of functionality.
Methods: Patients with radicular pain in CPSS who received FL-guided CA (n = 21) or TF (n = 28) ESI were included in this retrospective study. Complication frequencies, adverse events, treatment effects, and functional improvements for each procedure were compared at 1, 3, and 6 months following the last injection.
Results: Both the Oswestry Disability Index (ODI) and verbal numeric pain scale scores (VNS) demonstrated improvement in both groups at all 1, 3, and 6 months following the last injection, without meaningful difference between groups (p < 0.05). Moreover, no meaningful difference was present between groups in terms of treatment success rate at every time point. The amount of time used for the injection procedure was shorter in CA group than in TF group (410.32 ± 25.73 seconds vs 640.65 ± 18.03 seconds, p < 0.05). Within 2 weeks of the injection treatment, the patient satisfactory scores were evaluated, with excellent being rated 85.7% (n = 18) among CA-ESI patients and 55.7% (n = 16) among TF-ESI patients (p < 0.05). Logistic regression analysis revealed that variables such as method of injection (CA or TF approach), sex, use of analgesics, pain duration, number of injections, and age were not significant variables for successful treatment results. There were no adverse complications after the procedure in both groups.
Conclusion: The outcomes of FL-guided CA-ESI and TF-ESI for CPSS are similar in terms of pain reduction and functional improvements. CA-ESI is associated with lesser procedure time. In addition, compared with the TF-ESI, the patient experiences less discomfort during the injection, and the satisfaction with the injection treatment is confirmed to be better. Accordingly, both methods are effective; however, in the CA approach, patient satisfaction is higher and the procedure time is shorter.
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Abstract
Background: Transforaminal epidural steroid injection (TFESI) is an interventional technique used to relieve disc herniation related back and radicular pain. Although few studies have investigated the factors predicting positive outcomes after TFESI, there is no data concerning the possible relationship between pre-procedure serum 25-hydroxyvitamin D (25(OH)D) levels and the response to TFESI.
Objectives: To investigate the effect of vitamin D deficiency to treatment success of fluoroscopy-guided transforaminal epidural steroid injection.
Study design: A retrospective assessment.
Setting: A university hospital interventional pain management center.
Methods: Nine hundred forty-eight patients received lumbosacral TFESI between January 2018 and December 2019 in a university hospital pain management center and were examined retrospectively for eligibility. Clinical and demographic data; magnetic resonance imaging (MRI); pre-procedure laboratory tests, including serum 25(OH)D; pain scores at baseline, third week, and third month follow-ups were collected.
Results: A total of 83 patients were recruited and divided into 2 groups with respect to vitamin D status. The number of patients with serum 25(OH)D level below 20 ng/mL was 57 and the number of patients with serum 25(OH)D level above 20 ng/mL was 26. Treatment success rates were significantly lower in vitamin D deficient group at third week and third month (P: 0.006, P: 0.01).
Limitations: Retrospective nature and the absence of functional outcomes.
Conclusion: Vitamin D deficiency is associated with a lower probability of meaningful pain relief following TFESI. It may worth assessing serum vitamin D level prior to this intervention, although prospective investigation is necessary.
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Abstract
Transforaminal epidural block (TEB) is a widely accepted technique and minimally invasive procedure for the treatment of lumbosacral radicular pain. This study aimed to evaluate the accuracy, efficacy, and safety of ultrasound and nerve stimulator guidance lumbar transforaminal epidural block (UNTEB) for the patients with unilateral lower lumbar radicular pain. The accuracy of this method was evaluated by fluoroscopy. Using UNTEB via axial and the in-plane approach technique was performed in 42 segments of 25 patients who presented with lumbosacral radicular pain to lower extremities. The contrast medium was injected to evaluate the needle tip at the intervertebral foramen under fluoroscopic guidance. The numerical rating scale was used to assess pain before and after treatment. The success ratio of UNTEB in L3/L4 level was 100%, in L4/L5 was 95.4% and in L5/S1 was 100%. The numerical rating scale (NRS) for lumbosacral radicular pain improved from a mean from 7.8 to 2.8 1 day after procedure (p = 0.01) and from a mean from 7.8 to 2.4 1 week after UNTEB (p = 0.01). None of our subjects experienced any complications during and after the procedure. UNTEB with fluoroscopic validation is an accurate, effective, and safe method for short-term pain relief of the patients with unilateral lumbosacral radicular pain.
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Abstract
Lumbar transforaminal epidural block (TFEB) is an effective treatment modality for radicular pain due to lumbar disc herniation (LDH). The addition of steroids is more effective than local anesthetic alone in TFEBs for patients with LDH. Moreover, the efficacy of TFEBs has been reported to be positively correlated with the volume of injectate. We hypothesized that high-volume TFEBs without steroids effectively alleviate axial back and radicular pain associated with LDH. This study compared the efficacy of high-volume TFEBs with vs. without steroids for the management of the axial and radicular pain caused by LDH.
A total of 54 patients were randomly assigned to either group L or group D. Patients in group L received 8-mL injections of 0.33% lidocaine only. Patients in group D received 8-mL injections of 0.33% lidocaine with 5 mg of dexamethasone. The primary outcomes were pain intensity at baseline and 4 weeks after the procedure. The secondary outcomes included the change of functional disability between baseline and 4 weeks after the procedure, pain scores during injection, and adverse effects.
Both groups showed a significant reduction in axial and radicular pain and improvement in the functional status at the outpatient visit 4 weeks after TFEB. However, there were no significant differences between the groups in terms of changes in back pain (10.00 [20.00] vs. 10.00 [22.50]; P = 0.896) or radicular pain (5.00 [20.00] vs. 10.00 [12.50]; P = 0.871).
High-volume TFEBs with and without steroid administration yielded similar significant pain reductions and functional improvements among LDH patients 4 weeks after the procedure.
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Abstract
Objective: Lumbar radiculopathy is a major health problem, which often treated by neurosurgery or guided lumbar epidural steroids for pain relief. We used autologous Platelet Rich Plasma (PRP) as a novel pharmaceutical agent that has strongly emerged in recent years to treat patients of lumbar disc herniation. From that, we evaluated the efficacy of PRP via transforaminal route in treatment of radicular pain in patients with lumbar disc herniation.
Methods: Twenty-five patients were enrolled and injected with 4 ml of autologous platelet rich plasma under fluoroscopic guidance via transforaminal epidural injection into area of affected nerve root. They were followed using Visual Analogue Scale (VAS), Modified Oswestry Disability Index (ODI) and Straight Leg Raising Test (SLRT) for clinical assessment.
Results: Patients who received transforaminal injections with autologous PRP showed statistically significant improvements on all three evaluation tools (VAS, ODI, SLRT). The improvements were sustained over twelve-month follow-up and there were no associated complications.
Conclusion: Transforaminal injection with autologous PRP helps patients relieve chronic pains and be able return to work. Besides, autologous PRP can be considered as a good alternative to epidural steroids in management of lumbar disc herniation.
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Background: The U.S. Food and Drug Administration has prohibited epidural steroid injection (ESI) with particulate steroids. Thus, this study aimed to compare the efficacy and safety of ESI with two nonparticulate steroids, dexamethasone and betamethasone.
Methods: The eligible patients (n = 600) who received ESI (0 week) with dexamethasone (ESI-dexa) or betamethasone (ESI-beta) had follow-up visits at 2, 4, and 8 weeks with a phone interview at 12 weeks. The primary endpoint was the proportion of effective responders without pain or who were much improved at 2 weeks. The secondary endpoints were the proportion of crossover injections at 2 weeks; changes in the visual analog scale (VAS) and disability index scores at 2, 4, and 8 weeks; the number of additional ESIs in 12 weeks; the number of participants having spinal surgery, as well as the incidence of adverse events over the 12 weeks.
Results: The proportion of effective responders at 2 weeks was not different between ESI-beta (72/216, 33.3%) and ESI-dexa (63/200, 31.5%; P = 0.670). Adverse events were more common with ESI-dexa (40/200, 20.0%) than with ESI-beta (24/216, 11.1%; P = 0.012). VAS scores decreased more with ESI-beta than with ESI-dexa at 2 weeks (difference, 0.35; P = 0.023) and 4 weeks (difference, 0.42; P = 0.011). The disability score improved significantly more with ESI-beta compared with ESI-dexa at 2 weeks (difference, 3.37; P = 0.009), 4 weeks (difference, 4.01; P = 0.002), and 8 weeks (difference, 3.54; P = 0.007).
Conclusions: Betamethasone would be more appropriate for ESI.
