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Epidural Injections (epidural + injection)

Distribution by Scientific Domains

Medical Sciences	100%

Distribution within Medical Sciences

Anesthesia & Pain Management	45%
2 Other Subdomains	10%

Selected Abstracts

Size and Aggregation of Corticosteroids Used for Epidural Injections

PAIN MEDICINE, Issue 2 2008
Richard Derby MD
ABSTRACT Objective., The purpose of this study was to document particulate size in commonly used corticosteroid preparations. Inadvertent injection of particulate corticosteroids into a vertebral or foraminal artery can cause brain and spinal cord embolic infarcts and the size of the particles could be directly related to the chance that a clinically significant infarct would occur. One might assume that corticosteroids with particles significantly smaller than red blood cells might be safer. Design., The following four types of corticosteroid preparations were used in various solutions and evaluated under light microscopy: dexamethasone sodium phosphate injection, triamcinolone acetonide injectable suspension, betamethasone sodium phosphate and betamethasone acetate injectable suspension, and methylprednisolone acetate injectable suspension. Results., Dexamethasone sodium phosphate particle size was approximately 10 times smaller than red blood cells and the particles did not appear to aggregate; even mixed with 1% lidocaine HCl solution and with contrast dye, the size of the particles were unchanged. Triamcinolone acetonide and betamethasone sodium phosphate showed variable sizes; some particles were larger than red blood cells, and aggregation of particles was evident. Methylprednisolone acetate showed uniformity in size and the majority were smaller than red blood cells which were not aggregated, but the particles were densely packed. Conclusions., Compared with the particulate steroid solutions, dexamethasone sodium phosphate had particles that were significantly smaller than red blood cells, had the least tendency to aggregation, and had the lowest density. These characteristics should significantly reduce the risk of embolic infarcts or prevent them from occurring after intra-arterial injection. Until shown otherwise in clinical studies, interventionalists might consider using dexamethasone or another corticosteroid preparation with similar high solubility and negligible particle size when performing epidural injections. [source]

MULTIDISCIPLINARY PAIN ABSTRACTS: 5

PAIN PRACTICE, Issue 1 2004
Article first published online: 15 MAR 200
In this study, the authors prospectively evaluated whether abnormalities at the lumbar level as diagnosed by magnetic resonance imaging (MRI) are confirmed by epiduroscopy, and assessed if targeted epidural injection of medication alleviates sciatic pain. A flexible, 0.9-mm fiberoptic endoscope was introduced through a disposable steering shaft into the caudal epidural space and advanced until the targeted spinal nerve was identified. Adhesions were mechanically mobilized under direct vision, and a mixture of 120 mg methylprednisolone acetate, 600 IU hyaluronidase, and 150 ,g clonidine was applied locally. Pain scores were measured by the visual analog scale (VAS) and global subjective efficacy rating. Nineteen of 20 patients studied showed adhesions via epiduroscopy. Six patients showed concomitant signs of active root inflammation. Of 20 patients treated with a targeted epidural injection, 11 patients experienced significant pain relief at 3 months. This was maintained at 6 months for eight of the patients, at 9 months for seven of the patients, and at 12 months for seven of the patients. Mean VAS at 3 months was significantly reduced and this persisted at 12 months Epiduroscopy is of value in the diagnosis of spinal root pathology. In sciatica, adhesions unreported by MRI can be identified. Targeted epidural medication administered near the compromised spinal nerve results in substantial and prolonged pain relief. [source]

ORIGINAL ARTICLE: Risk of intravascular injection in transforaminal epidural injections

ANAESTHESIA, Issue 9 2010
F. S. Nahm
Summary Transforaminal epidural injection is an effective method for treating spinal pain but can cause devastating complications that result from accidental vascular uptake of the injectate or a direct vascular injury. We prospectively evaluated the patient factors that might be associated with intravascular uptake during transforaminal epidural injections. A total of 2145 injections were performed on 1088 patients under contrast-enhanced real-time fluoroscopic guidance. The collected data included the patient's age, sex, body mass index, diagnosis, injection level, side of injection, history of spinal surgery at the targeted level, and the number of injections at the targeted site. The overall incidence of intravascular injection was 10.5% (224/2145). The highest incidence was at the cervical level (28/136; 20.6%), followed by the sacral level (111/673; 16.5%), the thoracic level (23/280; 8.2%) and the lumbar level (64/1056; 6.1%). The difference was significant for the cervical and sacral level compared with the lumbar and thoracic levels (p < 0.001). Intravascular injection was not associated with the other patient characteristics studied. [source]

Checks before bolus epidural injection

ANAESTHESIA, Issue 6 2010
J. A. W. Wildsmith
No abstract is available for this article. [source]

Size and Aggregation of Corticosteroids Used for Epidural Injections

EPIDUROGRAPHY: CHARACTERISTICS OF EPIDURALGRAMS PERFORMED DURING LESI

PAIN MEDICINE, Issue 2 2002
Article first published online: 4 JUL 200
David C. Miller MD, DABPM Woodland Pain Center, Michigan City, IN Fluoroscopically guided, contrast enhanced lumbar epidural steroid injections are commonly performed for persistent or sever lumbar radicular pain. An epiduralgram is a real-time fluoroscopic image of contrast injected into the epidural space prior to the injection of local anesthetic and steroid. This report details the results of one hundred consecutive epiduralgrams. The epidural needle was placed under continuous multiplainer fluoroscopic guidance using ISIS protocol. Three ml. of Omnipaque 300 were injected after initial insertion to obtain the epiduralgram. This was followed by injection of 3 ml. of Celestone diluted with 4 ml. of preservative-free 1% lidocaine to obtain the epiduralgram. The epidural needle was placed at the predetermined spinal level and appropriate side 100% of the time. Needles were successfully placed into the epidural space on the first attempt in 95%. One needle was subarachnoid, one was intra vascular, three were in tissue plains superficial to the epidural space and were apparent only with contrast injection. Three ml. of contrast flowed unilaterally in 74% of lumbar epidural injections. The contrast flowed cephalad only in 20%, caudad only in 28%, and bidirectional in 52%. Contrast spread less than three spinal levels 64% of the time. The desired nerve root was visualized in 62%. Contrast was seen in the ventral epidural space on lateral views 88% of the time. Ventral spread was always fewer levels than the dorsal spread. Epidurography provides essential information for the accurate performance of lumbar epidural steroid injections. One out of every twenty presumed epidural injections were inaccurately placed even by an experienced operator. One out of every fifty was dangerously positioned and identified only by performance of an epiduralgram. [source]

Transient loss of motor-evoked responses associated with caudal injection of morphine in a patient with spondylolisthesis undergoing spinal fusion

PEDIATRIC ANESTHESIA, Issue 5 2006
PETER R.J. GIBSON MBBS FANZCA
Summary A 7-year-old girl having posterior spinal fusion for Grade 3 anterior spondylolisthesis at the L5/S1 level was administered 2.5 mg of morphine in 10 ml saline via the caudal epidural route before surgery. Motor-evoked responses were markedly diminished in her lower limbs for 1 h following this but returned spontaneously. She suffered no neurological injury. The cause for this is postulated to be transient cauda equina compression from the volume of injectate. This complication of caudal injection has not been reported before. The possible mechanisms for this are discussed. We believe that significant L5/S1 spondylolisthesis should be considered a contraindication to the use of caudal epidural injections. [source]

Latest news and product developments

PRESCRIBER, Issue 8 2007
Article first published online: 23 JUL 200
Lamotrigine for partial, valproate for generalised A large UK trial has shown that lamotrigine is the most effective choice in the treatment of partial epilepsy (Lancet 2007;369: 1000-15). The SANAD trial, commissioned by the National Institute for Health Research's Health Technology Assessment programme, randomised 1721 patients (for whom carbamazepine monotherapy would have been the treatment of choice) to treatment with carbamazepine, gabapentin, lamotrigine, oxcarbazepine (Trileptal) or topiramate (Topamax). Lamotrigine was associated with a longer time to treatment failure, though time to 12-month remission favoured carbamazepine. Over four years' follow-up, lamotrigine was numerically but not significantly superior. The authors concluded lamotrigine is clinically superior to carbamazepine for partial epilepsy A second arm of the trial, yet to be published, evaluated the treatment of generalised epilepsy and found valproate to be clinically most effective, though topiramate was cost effective for some patients. Chronic pain common in nursing homes Most residents in nursing homes say they have long- term pain but only one in seven say a health professional has ever discussed its treatment with them, according to a report by the Patients' Association (www.patients-association.org.uk). Pain in Older People ,A Hidden Problem was a qualitative study of 77 older residents in care homes in England. Most were frail and suffered long-term illness. The study found that 85 per cent of residents said they were often troubled by aches or pains and these lasted over a year in 74 per cent. Most described their pain as moderate (33 per cent) or severe (38 per cent) but 8 per cent said it was excruciating. Many reported limitations on mobility and social activities despite a high level of stoicism. All but one were taking medication to relive pain; one-third experienced adverse effects but 78 per cent believed drugs offered the most effective treatment. One-quarter said a doctor or nurse had discussed how to stop their pain worsening, and 15 per cent said they had discussed how to treat their pain. Visits from GPs appeared to be uncommon. Atherothrombotic events despite treatment Between one in five and one in seven of high-risk patients experience atherothrombotic events despite evidence-based treatment, the REACH study has shown (J Am Med Assoc 2007;297:1197-1206). REACH (REduction of Atherothrombosis for Continued Health) is an international observational study involving 68 236 patients with atherothrombotic disease or at least three risk factors. Most were taking conventional evidence-based medication. After one year, the incidence of the combined endpoint of cardiovascular death, myocardial infarction, stroke or hospitalisation for atherothrombotic events was approximately 15 per cent for patients with coronary artery disease or cardiovascular disease, and 21 per cent in patients with peripheral artery disease and established coronary disease. Event rates increased with the number of vascular beds affected, rising to 26 per cent in patients with three symptomatic arterial disease locations. Extended CD prescribing by nurses and pharmacists The Medicines and Healthcare products Regulatory Agency (MHRA) is consulting on expanding the prescribing of controlled drugs (CDs) by nonmedical prescribers. Currently, nurse independent prescribers can prescribe 12 CDs, including diamorphine and morphine, but pharmacist independent prescribers may not prescribe any CDs. The proposal is to allow both professions to prescribe any CDs within their competence, with the exception of cocaine, diamorphine or dipipanone for the management of addiction. The closing date for consultation is 15 June. Consultation is also underway on expanding the range of CDs nurses and pharmacists can prescribe under a patient group direction (PGD), and their use for pain relief. The closing date for consultation is 20 April. Intrinsa: transdermal testosterone for women A transdermal formulation of testosterone has been introduced for the treatment of low sexual desire associated with distress in women who have experienced an early menopause following hysterectomy involving a bilateral oophorectomy and are receiving concomitant oestrogen therapy. Manufacturer Procter & Gamble says that Intrinsa, a twice-weekly patch, delivers testosterone 300µg every 24 hours, achieving premenopausal serum testosterone levels. Clinical trials showed that Intrinsa reduced distress in 65-68 per cent and increased satisfying sexual activity in 51-74 per cent of women. A month's treatment (eight patches) costs £28.00. Fish oil for secondary ,not primary ,prevention of CHD Supplementing statin therapy with eicosapentaenoic acid (EPA) reduces the risk of major coronary events in patients with coronary heart disease (CHD) ,but not in patients with no history of CHD Lancet 2007;369:1090-8). The five-year study in 18 645 patients with total cholesterol levels of 6.5mmol per litre or greater found that the incidence of sudden cardiac death, fatal and nonfatal myocardial infarction in CHD patients treated with EPA plus a statin was 8.7 per cent compared with 10.7 per cent with a statin alone (relative risk reduction 19 per cent). A similar relative risk reduction in patients with no CHD was not statistically significant. There was no difference in mortality between the groups but EPA did reduce unstable angina and nonfatal coronary events. Department pilots information prescriptions The Department of Health has announced 20 sites to pilot information prescriptions prior to a nationwide roll-out in 2008. The prescriptions will guide people with long-term conditions such as diabetes and cancer to sources of support and information about their condition. The Department hopes the project will increase patients' understanding of their discussions with health professionals, empower them to locate the information they need, and provide long-term support. NPSA guidelines for safer prescribing The National Patient Safety Agency (www.npsa.nhs.uk) has published five guidelines to improve medication safety in the NHS. Targeting ,high-risk issues', the guidance covers anticoagulant prescribing, liquid medicines for oral or enteral administration, injectable medicines, epidural injections and infusions, and paediatric intravenous infusions. The implementation of each guide is supported by additional tools and resources. Better adherence not matched to outcomes A systematic review has found that interventions can increase adherence to prescribed medication but there is no evidence that clinical outcomes also improve (Arch Intern Med 2007;167:540-9). The review of 37 trials identified 20 reporting increased adherence. The most effective interventions were behavioural changes to reduce dose demands and those involving monitoring and feedback. Improvements in clinical outcomes were variable and did not correspond to changes in adherence. Antidepressant plus mood stabiliser no better US investigators have found that combining a mood stabiliser with an antidepressant is no more effective than a mood stabiliser alone in preventing mood changes (N Engl J Med 2007; published online 28 March, doi.10.1056/NEJMoa064135). The study found durable recovery occurred in 23.5 per cent of patients treated with a mood stabiliser and adjunctive antidepressant therapy for six months compared with 27.3 per cent of those taking a mood stabiliser plus placebo. [source]