Pain - Clinical, Chronic Pain - Clinical, Chronic
S-193 S-194 ABSTRACTS ANESTH ANALG 2004; 98; S-1–S-282 S-193 EFFECTIVE DISCOGENIC PAIN RELIEF IN PATIENTS WITH PULSED RADIOFREQUENCY OF THE DORSAL ROOT GANGLIA (DRG’S) AUTHORS: D. K. Cope, M. Loomba, H. K. Dhadha, N. N. Rizk; AFFILIATION: University of Pittsburgh, Pittsburgh, PA. INTRODUCTION: Past studies describing pulsed radiofrequency in the lumbar dorsal root ganglia to treat patients with radicular pain have not demonstrated significant long term benefits(1). However the pulsed modality radiofrequency preferentially affects small pain fibers, such as the sinoverterbral nerve which innervates the dorsal lumbar discs, rather than large motor or sensory fibers implicated in radicular pain. Therefore we conducted this study in patients with degenerative lumbar disc disease in which the main pain pattern was non-radicular to determine the effects of pulsed radiofrequency at bilateral L2, L3 and L4 DRG’s. METHODS: Six patients seen at our clinic from June 2002 through December 2002 were selected based on the following criteria: 1. Chronic low-back pain on weight bearing for at least six months, not attributable to radiculopathy or sacroilitis. 2. Unsuccessful physical therapy. 3. Unsuccessful series of either epidural or selective nerve injections. 4. Failed relief from NSAIDs and adjuvants. 5. Continued pain despite high opioid doses. Patients gave informed consent, were given IV sedation and MAC.Procedure was done sterilely in the prone position under fluoroscopic guidance. At the DRG’s sensory and motor stimulation confirmed needle positioning. Pulsed RF for 42° c for 120 sec. RESULTS: Table I summarizes the results. Improvement in function at six mos. ranged from 50% improvement to 90%. Activity level improved with 3/6 requiring no ambulation assistance device. Opioid use decreased (4/6) and nonsteroidal and adjuvant medication use either remained stable (4/6) or decreased (2/6). No patient reported increased medication use. The only reported side effect was transient neuritis (1/ 6) that resolved in 15 days. Pain decreased for all patients (Mean: baseline 7.5/10, post-procedure S-194 EPIDURAL STEROID INJECTION FOR POST LAMINECTOMY SYNDROME: TRANSFORAMINAL VERSUS CAUDAL AUTHORS: J. J. Huang; AFFILIATION: Anesthesiologists of Greater Orlando, Orlando, FL. INTRODUCTION: Pain treatment for post laminectomy syndrome patients is a challenge. It remained questionable whether scar tissue can explain the post laminectomy pain syndrome. Epidural steroid injection is a well accepted therapeutic modality used in the management of lumbar radicular pain. Transluminar, transforaminal, and caudal approach had been widely applied for post laminectomy syndrome patients. It is unknown whether different injection techniques have different outcome. We performed this observations and cross-over study to compare transforaminal epidural injection with caudal injection for patients with post laminectomy syndrome. METHODS:The patients with recurrent low back pain after having had one or two lumbar laminectomies and having diagnosed by either neurosurgeon or an orthopedic surgeon as having postlaminectomy syndrome were included in the study. The pain duration was at least 6 months, the pain intensity (VAS) was > 7, and the pain was unilateral radicular pain. The pain did not response to physical therapy, antiinflammatories, or analgesics. All epidural injections were performed at an ambulatory surgery center by one anesthesiologist. All patient initially received caudal epidural steroid injection after evaluation. Two weeks later, patient was reevaluated. If patient had significant pain relief from caudal injection, then caudal epidural steroid injection was repeated. If patient had no significant pain relief from caudal injection, then transforaminal epidural injection was performed. Caudal epidural injection: a 22-gauge spinal needle was radiographically guided to the caudal spinal canal. The needle position was verified by contrast spread into the caudal spinal canal. Then 80 mg triamcinolone with 15 mg lidocaine (15ml in total) was injected into the caudal spinal canal. Transforaminal epidural injection: a 25-gauge 10cm spinal needle was radiographically guided to the dorsal/ventral 5.0/10, one mo 2.0/10, four mo 2.2/10, six mo 3.0/10) but returned to baseline in one patient after six months. DISCUSSION: Discogenic low back pain is a very common condition with limited treatment options. Previously it was thought that the disc annulus was not innervated, but recent neuroanatomical studies have shown rich innervation by the sinovertebral nerves, branches of the lumbar ventral rami, the gray rami communicans and even the sympathetic chain. By pulsed RF at the DRG's we have shown improvement in pain scores, function in daily activities, ability to ambulate without assistant devises, opioid, NSAID and adjuvant medication requirement that this therapy can provide sustained relief at six months follow up with minimal risk or side effects. These patients had failed physical therapy, other neuroaxial injections, medical management, and even sustained opioid therapy. We have demonstrated a safe and efficacious procedure to treat disc pain and are currently collecting outcome data on a much larger patient population to see if indeed this is a therapy that offers significant patient benefit. REFERENCES: 1. The Lancet, 361, 2003. Patients Pain Score (1-10) Function Opioids Medications Side Effects (motor, sensory, sympathetic NSAIDs Adjuvantssymptoms and function, neuritis, infection, and systemic effects) BL 7; Post 4; Able to climb stairs; Able 1 1 mo 2; 4 mo to do household activity; N/A Decreased Decreased None 2; 6 mo 2 Overall 60% better Able to walk and climb 2 BL 9; Post 7; steps; Discontinued assist Decreased 1 mo 5; 4 mo device; Overall 80% bet- methadone 5; 6 mo 2 ter; Sleep and mood improved N/A Same None 3 No longer using cane; BL 6; Post 5; Able to do yard work; 1 mo 0; 4 mo Decreased Decreased Decreased Transient neuritis Able to return to hunting; 0; 6 mo 0 Greater than 80% better BL 8; Post 6; 4 1 mo 0; 4 mo Overall 90% better 0; 6 mo 1 Decreased N/A Same None 5 No use of assist device; BL 7; Post 4; Able to stand and walk 1 mo 1; 4 mo Decreased for longer periods; Mood 2; 6 mo 2 and sleep 80% better Same Same None 6 BL 8; Post 4; Function initial improve- 1 mo 4; 4 mo ment 50% 4; 6 mo 8 Same Same Same None aspect of the neural foramina at the suspected symptomatic radicular level. Once an epiduralgram was obtained, 40 mg triamcinolone with 15 mg lidocaine (2ml in total) was injected into the epidural space. A quality of pain relief of 50% or greater was considered as significant. Data was analyzed with Fisher’s exact test. A P value of < 0.05 was considered significant. RESULTS: There were total 12 patients in the study. Three patients had significant pain relief from caudal epidural injection. Eight patients had no pain relief from initial caudal epidural injection, however, they subsequently had 50% pain relief from transforaminal epidural injection. One patient had no relief from either caudal or transforaminal epidural injections. The difference in pain relief effect between transforaminal epidural injection and caudal epidural injection was statistically significant (8/1 vs. 3/9) (P < 0.05). CONCLUSION: Transforaminal epidural steroid injections had better pain relief for post laminectomy syndrome patients than caudal epidural injection.