Background Comprehensive, evidence-based guidelines for interventional techniques in the management of chronic spinal pain are described here to provide recommendations for clinicians. Objective To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain. Design Systematic assessment of the literature. Methods Strength of evidence was assessed by the U.S. Preventive Services Task Force (USPSTF) criteria utilizing 5 levels of evidence ranging from Level I to III with 3 subcategories in Level II. Outcomes Short-term pain relief was defined as relief lasting at least 6 months and long-term relief was defined as longer than 6 months, except for intradiscal therapies, mechanical disc decompression, spinal cord stimulation and intrathecal infusion systems, wherein up to one year relief was considered as short-term. Results The indicated evidence for accuracy of diagnostic facet joint nerve blocks is Level I or II-1 in the diagnosis of lumbar, thoracic, and cervical facet joint pain. The evidence for lumbar and cervical provocation discography and sacroiliac joint injections is Level II-2, whereas it is Level II-3 for thoracic provocation discography. The indicated evidence for therapeutic interventions is Level I for caudal epidural steroid injections in managing disc herniation or radiculitis, and discogenic pain without disc herniation or radiculitis. The evidence is Level I or II-1 for percutaneous adhesiolysis in management of pain secondary to post-lumbar surgery syndrome. The evidence is Level II-1 or II-2 for therapeutic cervical, thoracic, and lumbar facet joint nerve blocks; for caudal epidural injections in managing pain of post-lumbar surgery syndrome, and lumbar spinal stenosis, for cervical interlaminar epidural injections in managing cervical pain (Level II-1); for lumbar transforaminal epidural injections; and spinal cord stimulation for post-lumbar surgery syndrome. The indicated evidence for intradiscal electrothermal therapy (IDET), mechanical disc decompression with automated percutaneous lumbar discectomy (APLD), and percutaneous lumbar laser discectomy (PLDD) is Level II-2. Limitations The limitations of these guidelines include a continued paucity of the literature, lack of updates, and conflicts in preparation of systematic reviews and guidelines by various organizations. Conclusion The indicated evidence for diagnostic and therapeutic interventions is variable from Level I to III. These guidelines include the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. Further, these guidelines also do not represent "standard of care."

/pdf/comprehensive-evidence-based-guidelines-for-interventional-25v98tginx.pdf

Comprehensive Evidence-Based Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain

/pdf/comprehensive-evidence-based-guidelines-forinterventional-42xrrh561x.pdf

Comprehensive Evidence-Based Guidelines forInterventional Techniques in the Managementof Chronic Spinal Pain

Background:Epidural corticosteroid injections are a common treatment for radicular pain caused by intervertebral disc herniations, spinal stenosis, and other disorders Although rare, catastrophic neurologic injuries, including stroke and spinal cord injury, have occurred with these injectionsMetho

Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations.

Corticosteroids and local anesthetics have significant variability in their formulations that may increase their adverse event profile for specific procedures.

https://pubs.rsna.org/doi/pdf/10.1148/radiol.2523081929

Injectable corticosteroid and local anesthetic preparations: a review for radiologists.

STUDY DESIGN A comprehensive literature review. OBJECTIVES To review and critically evaluate the past literature focusing on incidence and clinical presentation of complications associated with transforaminal cervical epidural steroid injection (TFCESI) and techniques employed to avoid them. The overall goal is to guide the direction of future research and improve clinical care by increasing awareness of complications and measures that may be undertaken to increase safety. SUMMARY OF BACKGROUND DATA TFCESI is a component in the diagnosis and management of cervical radicular syndromes in patients who have failed conservative management. There has been much discussion and also controversy in the recent literature. Considerable attention has been paid to reports of catastrophic complications and proposed measures to avoid them. METHODS Medical databases were searched for studies of TFCESI. The bibliographies of these articles were then searched as well. Thoracic and lumbar articles were discarded as were any non-transforaminal cervical procedures or those that did not involve injection into the epidural space. Particular attention was paid to serious neurologic sequelae after TFCESI and its mechanism, as well as techniques being employed to avoid complications. RESULTS There are a limited number of studies looking at complications of TFCESI. One retrospective study reported an overall rate of complications of 1.64%. There are reports of serious neurologic sequelae in the literature including brain and spinal cord infarction due to embolic phenomenon of particulate steroids. Cadaveric dissection revealed ascending and deep cervical arterial branches entering the external opening of the posterior intervertebral foramen, the classic target site for TFCESI. Measures to avoid complications mentioned in the literature include the use of nonparticulate steroids, test dose of local anesthetic before injection of steroids, live fluoroscopy, digital subtraction, no to light sedation, use of true lateral view to supplement frontal and oblique views in fluoroscopy, use of blunt needles, and computed tomography guidance. CONCLUSION The literature reveals a number of rare, potentially catastrophic neurologic sequelae including brain and spinal cord infarction. Most of these are thought to be due to intravascular uptake of particulate steroids. The true overall incidence remains obscure due to the lack of blinded controlled studies. Injectionists, referring physicians, and patients should be aware of the nature and potential consequences of these complications. Additionally, it is imperative for injectionists to standardize techniques to minimize complications, especially by using a test dose of local anesthetic before injection of preferably nonparticulate corticosteroid.

Complications of transforaminal cervical epidural steroid injections.

A 60-year-old man with a 4-year history of intractable neck pain and radicular pain in the C5 nerve root distribution presented to our department for a CT-guided transforaminal left C5 nerve root block. He had had a similar procedure on the right 2 months previously, and had significant improvement of his symptoms with considerable pain relief. On this occasion he was again accepted for the procedure after the risks and potential complications had been explained. Under CT guidance, a 25G spinal needle was introduced and after confirmation of the position of the needle, steroid was injected. Immediately the patient became unresponsive, and later developed a MR-proven infarct affecting the left vertebral artery (VA) territory. This is the first report of a major complication of a cervical root injection under CT guidance reported in the literature. We present this case report and the literature review of the potential complications of this procedure.

Cerebellar and brainstem infarction as a complication of CT-guided transforaminal cervical nerve root block.

Sarcoidosis is a noncaseating granulomatous disease that involves multiple organs, most commonly the lungs, lymph nodes, skin, and eyes, but may be clinically evident in any organ system. Symptomatic muscular sarcoidosis is very rare and has been reported in only 1.4% of known sarcoidosis cases, while skeletal involvement has been reported in 1-13%. Different types of muscular and osseous sarcoidosis have been described in the literature. We present a case of muscular sarcoidosis, which is unique in its clinical presentation and imaging findings. The presence of the marked periosteal reaction, which has never been described with muscular sarcoidosis, also makes this case unique.

An unusual presentation of muscular sarcoidosis

Introduction: The study aimed to study the impact of the COVID-19 pandemic on surgical practice in a tertiary care setup in India and the future implications of the pandemic. Methodology: This observational cross-sectional study was conducted at a tertiary-care hospital. The case series consisted of a snapshot search of all operating theatre activity at AIIMS, Rishikesh between the 1st of March 2020, and 31st August 2020. Observations: A total of 790 patients were operated on in the first 6 months of the covid era while 5308 patients had undergone surgery in the 6 months preceding the onset of covid-19. In the precovid era, 73.71% of the cases were performed under General Anaesthesia while 62.6% of the cases were performed under general anaesthesia in the covid era. 18.83% of the cases in precovid era were performed under spinal anaesthesia and 3.5% under combined spinal and epidural anaesthesia in the precovid era. Conclusion: This study has shown the extent to which general surgical practice was affected during the covid pandemic. With the lessons learnt during this period, we can implement a more robust plan in the eventuality of another pandemic and be more thoroughly prepared the next time around.

Impact of the COVID-19 pandemic on general surgical practice – An observational cross-sectional study

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Cerebellar and brainstem infarction as a complication of CT-guided transforaminal cervical nerve root block.

An unusual presentation of muscular sarcoidosis

Impact of the COVID-19 pandemic on general surgical practice – An observational cross-sectional study