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Biomedical subjects

Milan P Stojanovic

Publications and source records attributed to Milan P Stojanovic.

13 recordsLinked to original sources
PubMed2006

Quantitative sensory testing for spinal cord stimulation in patients with chronic neuropathic pain.

OBJECTIVE: A prospective pilot study was conducted, attempting to identify objective tests that would help clinicians to assess the efficacy of spinal cord stimulation (SCS) trial preceding permanent device implantation. SETTING: Four university hospitals in the United States and Israel. PARTICIPANTS: Thirteen patients with radicular leg pain due to failed back surgery syndrome (FBSS) or leg pain due to complex regional pain syndrome (CRPS) who were candidates for SCS. METHODS: PARTICIPANTS underwent a series of quantitative sensory tests prior to, and seven days after the initiation of SCS trial. These tests included: vibration threshold (conducted using the VSA 3000; Medoc Inc., Ramat Ishay, Israel), cold threshold, warm threshold, heat pain threshold, phasic heat pain threshold, tonic heat pain threshold (conducted using the TSA 2001; Medoc Inc.), and electrical pain tolerance at 5, 250 and 2000 Hz (administered using the NerveScan 2000; Neurotron, Inc., Baltimore, MD, USA). RESULTS: Useful data were obtained from 12 patients. The results of the vibration threshold and the tolerance to electrical stimulation at 5 and 250 Hz changed with an SCS trial. These results also correlated with the decision regarding the permanent implantation, which was made independently of them. In contrast, the results of thermal thresholds and tolerance to electrical stimulation at 2000 Hz tests did not change with the SCS trial. CONCLUSIONS: Our findings, which agree with those of a few other studies, suggest that the vibration threshold and the tolerance to electrical stimulation at 5 and 250 Hz tests can assist the clinician to select the right patients for permanent stimulation.

Adolescent↗
PubMed2004

The causes of false-positive medial branch (facet joint) blocks in soldiers and retirees.

OBJECTIVE: The purpose of this study was to determine the factors associated with false-positive medial branch blocks (MBB), the nerve blocks used to diagnose facet arthropathy, in soldiers and retirees. METHODS: The study subjects were 78 patients with chronic low back pain who underwent diagnostic MBB to determine whether or not the facet joints were pain generators. Radiofrequency denervation of these nerves was performed in all patients with positive responses. Patients who failed to obtain pain relief after the blocks (negative blocks) and those who obtained temporary pain relief after MBB but failed radiofrequency denervation (false-positive blocks) then proceeded to undergo discography. Based on patients' responses to diagnostic blocks, discography results, the presence of radicular pain, and previous back surgery, the data were analyzed to determine whether any of these variables correlated with false-positive MBB. RESULTS: The presence of discogenic or radicular pain was not associated with a higher false-positive response rate to MBB. Conversely, the absence of discogenic pain was associated with a higher percentage of false-positive blocks. There was also a trend for patients with previous back surgery to have a higher false-positive rate than those who had not undergone previous surgery. CONCLUSIONS: Although a high incidence of epidural and foraminal spread occurs during the performance of MBB, this is unlikely to be a significant cause of false-positive blocks.

Adult↗
PubMed2003

The predictive value of sympathetic block for the success of spinal cord stimulation.

OBJECTIVE: The purpose of this study was to assess the predictive value of response to sympathetic blockade (SB) on the success rate of spinal cord stimulation (SCS) in patients with complex regional pain syndrome. METHODS: We performed a retrospective study on 23 patients with complex regional pain syndrome who underwent both SB and subsequent SCS trials in the past 3 years at the Massachusetts General Hospital Pain Center, Boston, MA, and Walter Reed Army Medical Center, Washington, DC. Fifteen of these patients underwent permanent placement of an SCS device, and pain relief at 1- and 9-month follow-up was recorded. RESULTS: Among the 23 patients included in the study, those having transient pain relief with SB were more likely to have a positive SCS trial: all 13 with positive SB had good pain relief during the trial, compared with only 3 of the 10 with negative SB (100% versus 30%, P < 0.001). Among the 10 patients with negative SB, 7 noted poor pain relief during the trial despite adequate coverage, and they did not undergo placement of a permanent device. Among the patients who underwent permanent placement of an SCS device, those who received good pain relief with SB were more likely to have greater than 50% pain relief at 1-month follow-up (100% versus 33%, P = 0.029) and 9-month follow-up (87.5% versus 33.3%, P = 0.15). CONCLUSION: We conclude that patients with good response to SB before SCS are more likely to have a positive response during their SCS trial and long-term pain relief after placement of permanent SCS device.

Adult↗
PubMed2002

The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns.

STUDY DESIGN: A multicenter, retrospective analysis of cervical epidurograms. OBJECTIVES: To determine the effectiveness of the loss of resistance (LOR) technique in identifying the cervical epidural space. To delineate the pattern of epidural contrast spread during cervical epidural steroid injections. BACKGROUND: Previous studies have shown that if performed without fluoroscopy, the LOR technique can result in inaccurate needle placement in up to 30% of lumbar epidural steroid injections. To date, no study has examined accuracy of LOR technique and pattern of radiographic contrast spread in cervical epidural levels. METHODS: Epidurograms of 38 cervical epidural steroid injections in 31 patients were reviewed. The number of LOR attempts and pattern of contrast spread was analyzed. The effects of age, gender, MRI results, previous cervical laminectomy, and the physician's level of training were correlated with results. RESULTS: The authors found a 53% rate of false LOR during the first attempt to enter the epidural space. Unilateral epidural contrast spread was found in 51% and ventral epidural spread was found in 28% of cases. The average number of cervical vertebral levels covered with 2 mL of contrast was 3.14, with significantly wider spread noted in those patients who had not undergone previous cervical laminectomy. Other variables did not influence the accuracy of needle placement and pattern of epidural contrast spread. CONCLUSIONS: The loss of resistance technique may not be an adequate method for ensuring accurate needle placement in blindly performed cervical epidural injections. The use of epidurography can improve the accuracy of needle placement and medication delivery to targeted areas of pathology.

Adult↗
PubMed2002

The technical aspects of epidural steroid injections: a national survey.

UNLABELLED: Although epidural steroid injections (ESIs) are a common treatment for chronic pain conditions, it is not clear whether there is consensus on their technical aspects. The current literature suggests that variations in technical aspects may affect ESI outcomes. The goal of the survey was to help establish a standard frame of reference for the performance of ESIs. We analyzed survey results from 68 academic anesthesia programs and 28 private practices in the United States. The main finding in this survey is that there is no clear-cut consensus as to the ideal method to perform ESI. There is a wide variation among individual practices in almost every technical aspect of ESI. Private practices use significantly more fluoroscopy than academic centers. The large difference was found in the cervical region where 73% of private practices and only 39% of academic institutions polled perform the ESIs with fluoroscopic guidance (P = 0.005). A similar discrepancy was found in approaches to the epidural space after laminectomy where 61% of private practices, but only 15% of academic centers, use the transforaminal approach. The study results indicate that there is no consensus, and that there is a wide variation in current practices. IMPLICATIONS: A national survey of practices performing epidural steroid injections was conducted. The purpose was to establish whether consensus exists on technical aspects of this procedure. The study results indicate that there is no consensus, and that there is a wide variation in current practices.

Analgesia, Epidural↗
PubMed2002

Spinal cord stimulation.

Spinal cord stimulation is the most common mode of neuromodulation used in managing chronic low back pain. It is minimally invasive and reversible as opposed to nerve ablation. The basic scientific background of the initial spinal cord stimulation trials was based on the gate control theory of Melzack and Wall. It has been demonstrated in multiple studies that dorsal horn neuronal activity caused by peripheral noxious stimuli could be inhibited by concomitant stimulation of the dorsal columns. Various other mechanisms, which may play a significant role in the mechanism of action of spinal cord stimulation, include the suppressive effect of spinal cord stimulation on tactile allodynia, increased dorsal horn inhibitory action of gamma-aminobutyric acid (GABA), prevention or abolition of peripheral ischemia, and effects on human brain activity. Spinal cord stimulation is indicated in low back pain with radiculopathy, failed back surgery syndrome, complex regional pain syndrome, peripheral vascular disease, and ischemic heart disease. There is substantial scientific evidence on the efficacy of spinal cord stimulation for treatment of low back and lower extremity pain of neuropathic nature. Clinical studies revealed a success rate of from 50% to 70% with spinal cord stimulation, with decreased pain intensity scores, functional improvement and decreased medication usage. This review discusses multiple aspects of spinal cord stimulation, including pathophysiology and mechanism of action, rationale, indications, technique, clinical effectiveness, and controversial aspects.

Journal Article↗
PubMedDate not supplied

Lumbar discography: a comprehensive review of outcome studies, diagnostic accuracy, and principles.

BACKGROUND AND OBJECTIVES: Since its advent more than 50 years ago, the use of discography has been mired in controversy. The purpose of this review is to provide a clinical overview of lumbar discography and discogenic back pain, with special emphasis on determining the accuracy of discography and whether or not the procedure improves outcomes for surgery. METHODS: Material for this review was obtained from a MEDLINE search conducted from 1951 thru September 2004, bibliographic references, book chapters, and conference proceedings. RESULTS: Based on a large number of comparative studies, plain discography is less accurate than magnetic resonance imaging in diagnosing lumbar herniated nucleus pulposus and comparable or slightly more sensitive in detecting degenerative disc disease. For disc degeneration, CT discography remains the gold standard for diagnosis. There are very few studies comparing surgical outcomes between patients who have undergone preoperative provocative discography and those who have not. What little evidence exists is conflicting. Before disc replacement surgery, approximately half the studies have used preoperative discography. A comparison of outcomes did not reveal any significant difference between the 2 groups but none of the studies was controlled, and they used different outcome measures, follow-up periods, and surgical techniques. Because all intradiscal electrothermal therapy (IDET) studies have used discography before surgery, no conclusions can be drawn regarding its effects on outcome. CONCLUSIONS: Although discography, especially combined with CT scanning, may be more accurate than other radiologic studies in detecting degenerative disc disease, its ability to improve surgical outcomes has yet to be proven. In the United States and Europe, there are inconsistencies in the use of lumbar discography such that it is routinely used before IDET, yet only occasionally used before spinal fusion.

Costs and Cost Analysis↗
PubMedDate not supplied

A prospective crossover comparison study of the single-needle and multiple-needle techniques for facet-joint medial branch block.

BACKGROUND AND OBJECTIVES: Medial branch blocks have been widely described in the literature as a diagnostic tool for facet joint pain. Recently, a new "single-needle' technique was described that is purported to be equally accurate, and in some respects, superior to the standard multiple-needle technique. To date, no studies have been performed that compared these 2 techniques. METHODS: In a multicenter setting, 24 subjects underwent 2 separate diagnostic medial-branch blocks in a randomized, single-blind crossover comparison of the single-needle and multiple-needle techniques. Multiple variables were compared between the 2 techniques, including procedure-related discomfort, post-procedure pain relief, volume of local anesthetic required, accuracy as determined by final needle position and contrast-media spread, and time needed to perform the procedure. RESULTS: In this pilot study, the single-needle technique resulted in less procedure-related pain (P = .0003), required less superficial local anesthesia (P =.0006), and took less time to complete (P < .0001) than did the multiple-needle approach. With regard to final needle position, contrast spread, and post-procedure pain relief (P = .8), no differences were noted between the 2 techniques. CONCLUSIONS: Our results indicate that the single-needle technique takes less time to perform and causes less patient discomfort than does the standard technique but provides the same degree of accuracy. More studies with larger sample sizes are needed to corroborate these results and explore the effect the single-needle approach has on the rate of false-positive medial branch blocks.

Anesthesia, Spinal↗
PubMedDate not supplied

Single needle approach for multiple medial branch blocks: a new technique.

BACKGROUND AND OBJECTIVES: Medial branch blocks are an important tool for the diagnosis of facet joint arthropathy. The most commonly used technique involves multiple needle placements, one for each nerve blocked. This multiple needle technique may require a large amount of local anesthetic for anesthetizing the skin, thereby increasing the rate of false-positive blocks. TECHNIQUE: Diagnostic lumbar medial branch blocks are usually performed using multiple needles, one for each branch. The authors describe a different technique using a single needle for all levels. Initially, the needle is directed toward the medial branch located at the level of the affected facet joint in the antero-posterior view. After anesthetizing this nerve with local anesthetic, the same needle is withdrawn to the skin with the tip still in the subcutaneous tissue and repositioned to block the medial branch above, and thereafter below, while continuing to use only the antero-posterior view, thereby using only one entry site. CONCLUSIONS: When performed correctly, the single needle technique provides accuracy similar to the more conventional multiple needle approach during the performance of diagnostic facet joint nerve blocks. Because only one skin entry point is needed, however, this technique may afford several advantages over the multiple needle approach. These may include less patient discomfort, less time required and less radiation exposure since only one C-arm position is used, a smaller volume of local anesthetic, and possibly a lower incidence of false-positive blocks.

Anesthesia, Spinal↗