Sacrococcygeal epidural injection for chronic pain management in dogs with lumbosacral stenosis: a retrospective study

Degenerative lumbosacral stenosis in dogs is thought to be a multifactorial disease, with both mechanical and inflammatory underlying causes. Because of the decreased quality of life of the dogs affected by this condition, an accurate diagnosis and a directed and effective treatment should always be put in action. It is also important to keep investigating the pathogenesis of degenerative lumbosacral stenosis, since with better understanding of the disease, better and more accurate treatment options can be put in practice in the veterinary clinical routine. This dissertation is composed of a literature review about canine degenerative lumbosacral stenosis, as well as a retrospective study to assess the outcome of a sacrococcygeal epidural injection of triamcinolone, lidocaine, and morphine for chronic pain management in six dogs affected with this condition, which was evaluated at one and three months after the treatment. Although it was not possible to prove an improvement of most clinical signs after the treatment, the results of this study are encouraging since the efficacy of the sacrococcygeal injection was demonstrated and the overall quality of life seemed to improve in all six dogs; RESUMO: Injeção epidural sacrococcígea para controlo de dor crónica em cães com estenose lombossagrada: um estudo retrospetivo A estenose lombossagrada em cães é considerada uma doença degenerativa de origem multifatorial, em que existem fatores mecânicos e inflamatórios na sua génese. Devido ao impacto na qualidade de vida dos cães afetados por esta condição, é importante estabelecer um diagnóstico correto, assim como um tratamento eficaz e bem direcionado. É também importante que se aprofunde a investigação acerca da patogénese da estenose lombossagrada, uma vez que dispondo de um melhor conhecimento da doença, melhores tratamentos com maior eficácia poderão ser aplicados à prática clínica veterinária. Esta dissertação é composta por uma revisão de literatura acerca da estenose lombossagrada canina degenerativa, assim como por um estudo retrospetivo para averiguar o efeito após um e três meses da administração de uma injeção epidural sacrococcígea de triamcinolona, lidocaína e morfina para controlo de dor crónica em seis cães afetados por esta condição. Embora não tenha sido possível provar a melhoria de todos os sinais clínicos após o tratamento, os resultados deste estudo mostraram-se encorajadores, uma vez que a injeção sacrococcígea se demonstrou eficaz e, numa perspetiva geral, a qualidade de vida de todos os cães melhorou após o tratamento

Outcomes of Fluoroscopically Guided Lumbar Transforaminal Epidural Steroid Injections in Degenerative Lumbar Spondylolisthesis Patients

Study DesignA prospective cohort.PurposeTo report the short and long term outcomes of fluoroscopically guided lumbar transforaminal epidural steroid injection (TFESI) in degenerative lumbar spondylolisthesis (DLS) patients.Overview of LiteratureTFESI has been widely used for the treatment of lumbosacral radicular pains. However, to our knowledge, there has been no study which has evaluated the outcomes of TFESI in patients with DLS.MethodsThe DLS patients received fluoroscopically guided lumbar TFESI with 80 mg of methylprednisolone and 2 mL of 1% lidocaine hydrochloride. Patients were evaluated by an independent observer before the initial injection, at 2 weeks, at 6 weeks, at 3 months, and at 12 months after the injections. Visual analog scale (VAS), Roland 5-point pain scale, standing tolerance, walking tolerance, and patient satisfaction scale were evaluated for outcomes.ResultsThirty three DLS patients treated with TFESI, who were completely followed up, were included in this study. The average number of injections per patient was 1.9 (range from 1 to 3 injections per patient). Significant improvements in VAS and Roland 5-point pain scale were observed over the follow up period from 2 weeks to 12 months. However, the standing and walking tolerance were not significantly improved after 2 weeks. At 2 weeks, the patient satisfaction scale was highest, although, these outcomes declined with time. The DLS patients with one level of spinal stenosis showed significantly better outcome than the DLS patients with two levels of spinal stenosis. Five patients (13%) underwent surgical treatment during the 3 to 12 months follow up.ConclusionsTFESI provides short term improvements in VAS and Roland 5-point pain scale, standing tolerance, walking tolerance and patient satisfaction scale in DLS patients. In the long term, it improves VAS but limits the improvements in Roland 5-point pain scale, standing tolerance, walking tolerance and patient satisfaction scale

Perianesthesia analgesia, recovery efficacy, and financial impact of ultrasound-guided lumbar plexus and sciatic nerve analgesia in dogs undergoing tibial plateau leveling osteotomy

Includes bibliographical references.2022 Fall.Perioperative analgesia is critical for patients undergoing surgery because uncontrolled pain can result in deleterious consequences and predispose chronic pain. Therefore, developing an appropriate analgesia technique is crucial, and in this study, an analgesia protocol was investigated in dogs undergoing tibial plateau leveling osteotomy (TPLO). The TPLO is a surgical technique used to stabilize the stifle joint for treating cranial cruciate ligament disease. This surgical procedure is invasive and painful. Therefore, multimodal analgesia is often required for controlling pain associated with TPLO surgery. This study used ultrasound-guided regional anesthesia of the lumbar plexus and sciatic nerve as a component of multimodal analgesia to control perioperative pain compared to patients only receiving a standard systemic analgesia. The study was designed to evaluate the efficacy of regional anesthesia and to determine the financial impact of this additional multimodal procedure. We hypothesized that ultrasound-guided lumbar plexus and sciatic nerve blocks would provide a better analgesic effect intraoperative and postoperatively. The second part of the study we hypothesized that ultrasound-guided lumbar plexus and sciatic nerve blocks would increase the anesthesia cost. It would then be possible to determine a cost – benefit of the procedure. The study was designed as a prospective, randomized, blinded clinical trial. Twenty dogs underwent TPLO surgery were enrolled in the study and randomly assigned to regional analgesia (RA) or control (CON) group. Dogs in the RA group received 0.5% ropivacaine for ultrasound-guided lumbar plexus and sciatic nerve blocks. The total dose of ropivacaine for both blocks was 0.15 mg/kg. Dogs in the CON group received sterile 0.9% saline for the blocks. All dogs received 0.2 mg/kg of hydromorphone and 0.02 mg/kg of atropine for anesthesia premedication. Propofol was administered for anesthesia induction to perform endotracheal tube intubation. Isoflurane in oxygen was delivered using a circle rebreathing system to maintain anesthesia. The ultrasound-guided lumbar plexus and sciatic nerve blocks were performed prior to TPLO surgery. Fentanyl was used for intraoperative as rescue analgesia to reduce the response from surgical stimulation or with an increase in heart rate, respiratory rate, or mean arterial blood pressure. Isoflurane was adjusted to maintain the appropriate anesthesia plane. Hypotension was treated following a stepwise protocol, in a sequencing fashion. The treatment protocol was added until the complications was resolved. The treatment protocol started from decreased isoflurane vaporizer setting, lactate Ringer's solution bolus, hetastarch bolus, and dopamine administration. At extubation, the recovery quality and pain were evaluated. Dexmedetomidine was used to treat poor recovery quality and pain. During the postoperative 12 hours period, pain and recovery quality were assessed by Colorado State University acute pain scale, visual analog pain scale, and modified University of Melbourne pain scale. Fentanyl or methadone was used for postoperative rescue analgesia. Dexmedetomidine or acepromazine was administered to calm the patient. The amount of every drug used, complications management, and extra nursing care were recorded to evaluate the blocks' efficacy. The micro-costing technique was used to collect the financial data and was analyzed to determine the financial impact. In the clinical study, there was a statistically significant difference in the amount of intraoperative fentanyl administered for rescue analgesia between the groups (p = 0.02), with lesser doses given to the RA group. Hypotension was found in 40% of dogs in the RA group and 80% of the dogs in the CON group (p = 0.16). Dogs in the RA group required less intensive treatment than in the CON group. There was a statistically significant difference in the recovery scores between the groups, with those in the RA group having lower recovery scores (p = 0.04). In the postoperative period, the time to receive the first dose of rescue analgesia for dogs in the RA group was longer than dogs in the CON group (p=0.04). Micro-costing method was used for collecting the monetary information. The cost analysis was performed for evaluating the costs of dogs that received ultrasound-guided regional anesthesia with 0.5% ropivacaine and 0.5% sterile saline. The anesthesia fixed cost for the surgery was US$354. There was a statistically significant difference between the variable costs, with the RA group (US$82.65 (69.15-94.56); median (min-max)) having less anesthesia variable costs than dogs in the CON group (US$125.8 (55.23 to 156.35); p = 0.02). The additional cost for a charge per service of the use of ultrasound and electro-nerve stimulator machines (US$26.62) affects the total anesthesia cost for the RA group into both direction, it can enhance and save the total anesthesia cost. It can increases the total anesthesia cost by $US40.54 per dog and it can save the total anesthesia cost by$US35.17 per dog. From the clinical perspective, the number of dogs receiving TPLO surgery at the study hospital is approximately 160 cases per year. This number was used for estimating cost benefit per year performing nerve blocks for TPLO surgery and found that the nerve blocks would potentially increase the total cost for 160 dogs to US$6,486.40 per year but would decrease the total anesthesia cost by US$5,627.20 per year. Ultrasound-guided lumbar plexus and sciatic nerve regional analgesia was found to be an effective multimodal analgesia for TPLO surgery. The technique provided effective intraoperative analgesia that decreased rescue analgesia during surgery and led to better recovery from anesthesia for the dogs in this study. The ultrasound-guided analgesia technique would increase anesthesia costs but better analgesia, anesthesia, and decreased complications provided significant cost-saving benefits when performing regional analgesia for TPLO surgery

Pain Management

Pain Management - Current Issues and Opinions is written by international experts who cover a number of topics about current pain management problems, and gives the reader a glimpse into the future of pain treatment. Several chapters report original research, while others summarize clinical information with specific treatment options. The international mix of authors reflects the "casting of a broad net" to recruit authors on the cutting edge of their area of interest. Pain Management - Current Issues and Opinions is a must read for the up-to-date pain clinician

Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines.

BACKGROUND: Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE: To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS: The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and recommendations were provided. RESULTS: In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives.The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness.Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness.The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS: The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS: These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations

Pain Management

This book has seven chapters, from more than 15 authors from different countries (Korea, Poland, Saudi Arabia, Taiwan, Turkey and USA) edited by Professor Milica Prostran MD, PhD. The potential reader is shown the modern approach to pain management because the chapters deal at length and clearly with their topics. I believe that this book that I edited with great pleasure and dedication will capture the attention of many readers, from medical students to practicing doctors. All of them need to deal with this extremely important field of medicine: pain treatment. I do believe that the answers they may find in Pain Management will make their practice easier. Also, the life of their patients will be considerably more pleasant, or at least more bearable

Topics in Neuromodulation Treatment

"Topics in Neuromodulation Treatment" is a book that invites to the reader to make an update in this important and well-defined area involved in the Neuroscience world. The book pays attention in some aspects of the electrical therapy and also in the drug delivery management of several neurological illnesses including the classic ones like epilepsy, Parkinson's disease, pain, and other indications more recently incorporated to this important tool like bladder incontinency, heart ischemia and stroke. The manuscript is dedicated not only to the expert, but also to the scientist that begins in this amazing field. The authors are physicians of different specialties and they guarantee the clinical expertise to provide to the reader the best guide to treat the patient