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PubMed2006

Injection studies in spinal disorders.

UNLABELLED: Spinal injections have an important role in many centers in the diagnostic assessment and treatment of patient with various spinal disorders. In the literature, many studies describe the application, techniques, and potential benefit of spinal infections. It is well accepted morphologic alterations and pain correlate weakly because many imaging findings in patients with spinal symptoms can be found in asymptomatic individuals. Accordingly, one rationale for spinal injections is to provoke or eliminate pain presumably caused by the target spinal structure; this ostensibly allows a physician to make a better assessment of whether a particular morphologic alteration does or does not cause symptoms. Another rationale is to use spinal injections to support conservative treatment in patients who have from nerve root compromise, spinal stenosis, or facet joint osteoarthritis. Despite the widespread use of these spinal injections, their application is based widely on anecdotal experience and evidence that is not evidence based. We highlight the need for prospective randomized trials on the clinical efficiency of spinal injections and stress the importance for future considerations of cost effectiveness to justify their further application. LEVEL OF EVIDENCE: Level V (expert opinion). See the Guidelines for Authors for a complete description of the levels of evidence.

Analgesics↗
PubMed2003

Interventions in chronic pain management. 2. New frontiers: invasive nonsurgical interventions.

UNLABELLED: Invasive nonsurgical techniques have a central role in the management of patients suffering from acute and chronic pain. This article surveys common percutaneous pain procedures: trigger point injections, intra-articular injections, spinal injections, nerve blocks, radiofrequency lesioning (thermocoagulation and pulsed-mode), epidural adhesiolysis and decompressive neuroplasty, neural mapping, intradiskal and intra-annular procedures, neuromodulation, continuous intrathecal analgesia, and deep brain stimulation. Physiatrists must understand the guiding principles behind these procedures before practicing interventional pain management. OVERALL ARTICLE OBJECTIVE: To review invasive, nonsurgical pain management procedures.

Adjuvants, Immunologic↗
PubMed1979

Anterior spinal artery syndrome--a complication of cervical intrathecal phenol injection.

Spinal nerve block by intrathecal phenol-glycerine infusion is commonly employed for relief of severe pain in terminal carcinomatosis and, frequently, a dramatic regional anesthetic effect is achieved. However, nerve block by this procedure may in very rare instances give rise to serious complications. We have seen a case of terminal malignant melanoma in which clinical manifestations, indicative of anterior spinal artery syndrome, developed following the injection of 0.3 ml of 10% phenol-glycerine into the cervical subarachnoid space at the C4--C5 level for the control of severe right arm pain. This report describes the clinical course of the patient over a period of 4 months after the nerve block and the post-mortem findings along with a brief review of the literature.

Adult↗
PubMed2002

Beneficial effects of information leaflets before spinal steroid injection.

UNLABELLED: How beneficial is the provision of information leaflets to low back pain patients before steroid injection under fluoroscopy? OBJECTIVES: To compare the value of information leaflets with verbal information on steroid injection under fluoroscopy. METHODS: Alternate month design. One hundred and twenty-three low back pain patients hospitalized for steroid injection under fluoroscopy were enrolled in the trial. Fifty-two patients received both written standardized information and non-standardized verbal information (intervention group), seventy one patients received only non-standardized verbal information (control group). Anxiety assessed at baseline evaluation and just before the injection; satisfaction related to the information received assessed on discharge day; knowledge about steroid injection assessed 4 hours and 1 month after the injection. RESULTS: Patients had a high anxiety level at baseline evaluation. Written standardized information did not decrease significantly anxiety (P = 0.068) before the injection, had no effect on pain during the injection, but increased patients' knowledge about the adverse effects on the day of injection and 1 month later (P = 0.040 and P = 0.084 respectively), and improve satisfaction with information received about potential complications of the steroid injections (P = 0.018). CONCLUSIONS: Providing an information leaflet to low back pain patents undergoing steroid injection under fluoroscopy tends to reduce state anxiety, and increases patients' knowledge and satisfaction with information about the risks of the injection.

Adult↗
PubMedDate not supplied

The effect of spinal steroid injections for degenerative disc disease.

BACKGROUND: No conclusive evidence exists to determine that spinal steroid injections give lasting improvement in patients with predominantly axial low back pain resulting from lumbar degenerative disc disease (DDD). PURPOSE: The objectives of the study were to determine the effect of epidural steroid injections (ESIs) and intradiscal steroid injections (ISIs) in patients who exhibit DDD symptoms for more than 1 year and to determine whether patients with inflammatory end-plate changes are a unique subgroup of DDD patients in terms of treatment response. STUDY DESIGN: Pain and function in patients with DDD were prospectively assessed by an outcomes questionnaire before and after various spinal injections. Further correlation was made with end-plate inflammatory (Modic Type 1) changes identified on magnetic resonance imaging (MRI). PATIENT SAMPLE: ESI was performed in 232 patients who were referred for treatment of DDD, and discography with or without intradiscal steroid was performed in 171 patients who were possible spinal arthrodesis candidates. OUTCOME MEASURES: Pain and function were determined by a self-administered outcomes questionnaire that consisted of a visual analog pain scale, pain drawing, Oswestry Disability Index, use of pain medication and opinion of treatment success. METHODS: ESI was performed in 93 patients with DDD and inflammatory end-plate changes and in 139 patients without inflammatory end-plate changes. Patients with inflammatory end-plate changes (n=78) or without inflammatory end-plate changes (n=93), all of whom were considered fusion candidates, underwent discography with or without intradiscal steroid in a randomized fashion. Pain and function were prospectively determined by a self-administered outcomes survey (VAS pain, Oswestry Disability index [ODI], pain diagram [PD] and opinion of success) before and after the patients' injection for a 2-year follow-up period. MRI and discography results were correlated with patient outcomes scores. RESULTS: ESI was effective in improving pain and function, as assessed by outcomes scores at short-term follow-up. However, at 2 years, less than one-third had not had additional invasive treatment. Patients with inflammatory end-plate changes had greater improvement in ODI and PD scores in the first 6 months than did those patients without the end-plate changes. Intradiscal steroid injections into discs with concordant pain at the time of discography led to significant improvement in patients with inflammatory end-plate changes in all outcomes scales, but only minimal temporary improvement in patients without the end-plate changes. Disc pressure manometry at the time of discography found that discs with adjacent inflammatory end-plate changes reproduced symptoms at pressures significantly lower than those in other types of discs. CONCLUSIONS: Spinal steroid injections, both ESI and ISI, are beneficial for a small number of patients with advanced DDD and chronic low back pain. For those patients in whom a beneficial effect is found, spinal steroid injection is a low-risk and rapid treatment option. Spinal steroid injections are more effective in patients with MRI findings of discogenic inflammation, specifically adjacent inflammatory end-plate changes.

Adult↗
PubMed2003

Phosphorylation of CREB and mechanical hyperalgesia is reversed by blockade of the cAMP pathway in a time-dependent manner after repeated intramuscular acid injections.

Spinal activation of the cAMP pathway produces mechanical hyperalgesia, sensitizes nociceptive spinal neurons, and phosphorylates the transcription factor cAMP-responsive element binding protein (CREB), which initiates gene transcription. This study examined the role of the cAMP pathway in a model of chronic muscle pain by assessing associated behavioral changes and phosphorylation of CREB. Bilateral mechanical hyperalgesia of the paw was induced by administering two injections of acidic saline, 5 d apart, into the gastrocnemius muscle of male Sprague Dawley rats. Interestingly, the increases in immunoreactivity for CREB and phosphorylated CREB (p-CREB) in the spinal dorsal horn occur 24 hr, but not 1 week, after the second injection of acidic saline compared with pH 7.2 intramuscular injections. Spinal blockade of adenylate cyclase prevents the expected increase in p-CREB that occurs after intramuscular acid injection. The reversal of mechanical hyperalgesia by adenylate cyclase or protein kinase A inhibitors spinally follows a similar pattern with reversal at 24 hr, but not 1 week, compared with the vehicle controls. The p-CREB immunoreactivity in the superficial dorsal horn correlates with the mechanical withdrawal threshold such that increases in p-CREB are associated with decreases in threshold. Therefore, activation of the cAMP pathway in the spinal cord phosphorylates CREB and produces mechanical hyperalgesia associated with intramuscular acid injections. The mechanical hyperalgesia and phosphorylation of CREB depend on early activation of the cAMP pathway during the first 24 hr but are independent of the cAMP pathway by 1 week after intramuscular injection of acid.

Acids↗
PubMedDate not supplied

Distribution of [3H]colchicine in brain and spinal cord areas following its intracerebroventricular or intra-spinal cord injection in rats.

Intracerebroventricular or intra-spinal cord (at lumbar level) injection of low doses of colchicine leads to irreversible urine retention. To learn whether colchicine induces this effect by diffusing from the sites of injection, we studied, using the above-mentioned routes of administration, the distribution of [3H]colchicine in brain and spinal cord areas as a function of time. The release of [3H]colchicine into the blood and its elimination via the renal route was studied as well. The results of these experiments show that after its intracerebroventricular injection, [3H]colchicine diffuses to brain areas that normally exert a facilitatory or inhibitory action on urine excretion but reaches the lumbar region in only modest amounts (0.02%). On the other hand, after its intra-spinal cord injection, [3H]colchicine remains at the site of injection, where the sacral micturition center is located. This suggests that intracerebroventricular or intra-spinal cord injected colchicine induces urine retention by exerting its action at two different levels of the neuronal pathway that regulates micturition, depending on the site of injection.

Animals↗
PubMedDate not supplied

A survey: conscious sedation with epidural and zygapophyseal injections: is it necessary?

BACKGROUND CONTEXT: Substantial variation exists regarding the use of sedation before interventional spine techniques. Patient preference should play an important role in decision making regarding the need for sedation. However, little is known about patients' anxiety levels before spinal injections and their perceptions about the necessity of sedation. PURPOSE: To determine patient perception for need for sedation before epidural steroid injections and zygapophyseal joint injections. STUDY DESIGN/SETTING: Survey of consecutive spinal injection patients in an outpatient spine center. PATIENT SAMPLE: 500 consecutive lumbar, thoracic, and cervical patients receiving spinal injections. OUTCOME MEASURES: A 12-item questionnaire assessing patients' perceived anxiety before to a spinal injection. METHODS: Subjects were given the questionnaire after their spinal injection. Percentages requesting sedation for a first and potential second procedure were assessed. Additionally, anxiety level and pain rating, location of injection, age, sex, and other medication use were analyzed to determine the effect on the request for sedation. RESULTS: 17% of patients questioned requested sedation before an injection, and 28% would request sedation if they were to have a second injection. CONCLUSIONS: Routine sedation before diagnostic and therapeutic injections is not necessary as the majority of patients would not request sedation before the procedure when given the option. However, in some patients sedation is indicated, and all patients would benefit from educational material on sedation before the injection.

Anxiety↗
PubMed1988

Hindlimb paralytic effects of prodynorphin-derived peptides following spinal subarachnoid injection in rats.

Dynorphin A-(1-17) acts through non-opioid mechanisms to produce dose-related neurological deficits following injection into the lumbar spinal subarachnoid space in rats. Hindlimb motor function was examined following subarachnoid injection of dynorphin A fragments and other opioid peptides derived from prodynorphin to establish: (1) which portion(s) of the dynorphin A molecule cause hindlimb motor dysfunction, and (2) whether these paralytic actions are shared by other opioids (dynorphin B, alpha-neo-endorphin, and beta-neo-endorphin) derived from the same promolecule. To minimize the influence of enzymatic inactivation on relative bioactivities, peptides were coinjected with a combination of peptidase inhibitors previously shown to enhance the actions of dynorphin A fragments in vitro. Dynorphin A-(1-17) and -(2-17) produced dose-related neurological deficits with equal potencies and durations. Although without effect when injected alone, dynorphin A-(1-8), -(1-7) and -(3-8) caused transient motor dysfunction when co-injected with peptidase inhibitors. In contrast, dynorphin A-(1-6), -(1-5) and -(6-17) did not disrupt hindlimb motor function with or without peptidase inhibition. Dynorphin B, alpha-neo-endorphin and beta-neo-endorphin also caused hindlimb dysfunction which was potentiated by peptidase inhibition. These deficits appeared to result from non-opioid actions of these three peptides, since they were not blocked by the opioid antagonist naloxone. Thus, the paralytic effects of dynorphin A: (1) result from non-opioid actions involving the 3-7 or 3-8 positions of the molecule, and (2) are shared by other prodynorphin-derived opioid peptides.

Animals↗
PubMed1988

Spinal subarachnoid injection of somatostatin causes neurological deficits and neuronal injury in rats.

The tetradecapeptide somatostatin produced dose-related neurological deficits following subarachnoid injection in the lumbar spinal cords of rats. Lower pharmacological doses (1.6 and 3.1 nmol, i.t.) of somatostatin caused only transient deficits, while higher doses (6.2-25 nmol, i.t.) caused persistent deficits characterized by motor and sensory impairments in hindlimbs and tail, hindlimb edema, priapism, bladder atony with infarction, and urinary incontinence. Pretreatment with 0.3 nmol of the somatostatin receptor antagonist cyclo[7-aminoheptanoyl-Phe-D-Trp-Lys-Thr(Bzl)] blocked the hindlimb paralytic effects of 3.1 and 6.2 nmol of somatostatin, and significantly improved neurological recovery injection of 12.5 nmol of somatostatin. Higher doses of the antagonist produced hindlimb paralysis by itself. Neuroanatomical evaluations revealed extensive cell loss and necrosis in the lumbosacral spinal cords of rats paralyzed by 25 nmol of somatostatin. Collectively, these results suggest that through interactions with a receptor, somatostatin destroys neurons involved in diverse spinal cord functions.

Animals↗
PubMed2000

Precision diagnostic disc injections.

Spinal pain is an important public health problem affecting the population indiscriminately. The structures responsible for pain in the spine include the vertebrae, intervertebral discs, spinal cord, nerve roots, facet joints, ligaments, muscles, atlanto-occipital joints, atlanto-axial joints, and sacroiliac joints. Even though disc herniation, facet joints, strained muscles, and torn ligaments have been attributed to be the cause of most spinal pain, either in the neck and upper extremities, upper and mid back, or low back and lower extremities, disorders of the disc other than disc herniation have been implicated more frequently than any other disorders. Once stifled by misinformation, discography now has applications in a number of clinical settings. While cervical and lumbar discography is well studied and well known, thoracic discography is in its nascent stages of clinical application. The value of discography lies in its ability to produce pain and thereby identify a "pain generator." This allows treatment to be based on the specific cause of pain. The three primary components of diagnostic disc injection are: provocation/analgesia, discometry, and nucleography. Despite the recent exponential growth of noninvasive spinal technology, diagnostic disc injection remains the sole direct method for definitively determining whether a disc is a physiological pain generator. It is clear that discography is a safe and powerful complement to the overall clinical context.

Journal Article↗
PubMedDate not supplied

The minimum effective dose of 0.5% hyperbaric spinal bupivacaine for cesarean section.

BACKGROUND: The aim of this prospective, blind study was to determine the minimum effective dose of hyperbaric bupivacaine required for cesarean section. METHODS: With Ethical Committee approval and written consent, 24 healthy women undergoing elective cesarean section received a combined spinal epidural anesthesia. We sought to determine the minimum effective dose of spinal bupivacaine using a staircase method. In each patient an arbitrary dose of 0.5% hyperbaric bupivacaine in relation to patient height was used. The initial dose was 0.075 mg/cm height, while the outcome of each patient's response determined the dose for the subsequent patient. When successful spinal block (sensory level = or < T4 with complete motor blockade) was achieved within 20 min from spinal injection, the dose of spinal bupivacaine for the next patient was decreased by 0.01 mg/cm height. Conversely, when successful spinal block was not observed, the dose of spinal bupivacaine for the next patient was increased by 0.01 mg/cm height. Sensory and motor blocks were evaluated every 5 min by an independent, blinded observer. If successful spinal block was not achieved within the designed period, a 5-8 ml epidural bolus of 2% lidocaine was given to achieve adequate surgical anesthesia. RESULTS: No complications were reported during the study, and all women delivered their baby uneventfully (APGAR scores 5 min after delivery ranged from 9 to 10) within 5 min from uterus incision. The duration of surgical procedure ranged from 30 to 48 minutes. The dose of hyperbaric bupivacaine providing adequate surgical anesthesia within 20 min from spinal injection in 50% of subjects was 0.036 mg/cm height (95% confidence intervals: 0.031-0.041 mg/cm height). The ED95 calculated from the probit transformation to provide effective spinal anesthesia for cesarean section was 0.06 mg/cm height. CONCLUSIONS: This prospective, blind study demonstrated that a dose as low as 0.06 mg/cm height represents the dose of intrathecal bupivacaine providing effective spinal block in 95% of women undergoing elective cesarean section.

Adult↗
PubMed2004

Spinal anesthesia for cesarean section following inadequate labor epidural analgesia: a retrospective audit.

BACKGROUND: High blocks have been reported when spinal anesthesia is used for cesarean section following inadequate labor epidural analgesia. We have therefore modified the practice at our institution to minimize this risk and conducted a retrospective observational study of outcome following the change of practice. METHOD: The records of 115 women with inadequate epidural labor analgesia who required cesarean section between July 1998 and January 2002 were studied. No epidural boluses were administered in the 30 min preceding spinal anesthesia and a reduced spinal dose, median (range) 9.38 mg (7.5-11.3 mg) of 0.75% hyperbaric bupivacaine and fentanyl 15 microg (10-25 microg) was used. Patients were left sitting for 2 min and then positioned supine with left uterine displacement and were closely monitored for symptoms or signs that would suggest a high block. RESULTS: No parturient developed a high spinal necessitating intubation, and there was no adverse neonatal outcome. CONCLUSION: These findings do not conclusively establish this method as safe, but should spinal anesthesia for cesarean section following suboptimal labor epidural analgesia be considered, avoiding epidural boluses immediately preceding spinal injection, using a lower spinal dose, and delayed supine positioning following spinal injection may be advisable.

Adult↗