Critical items to consider before adopting advocacy of digital subtraction angiography.

Critical items to consider before adopting advocacy of digital subtraction angiography

Perineural dexamethasone added to local anesthesia for brachial plexus block improves pain but delays block onset and motor blockade recovery

BACKGROUND: Multiple studies have shown that perineural dexamethasone improves postoperative analgesia. However, some studies have shown minimal benefit, and have raised concerns regarding adverse physio-chemical effects of perineural dexamethasone. Furthermore, there is a paucity of studies wherein control (IV) dexamethasone was considered. OBJECTIVE: The purpose of this meta-analysis was to evaluate the effectiveness of different concentrations of perineural dexamethasone injection on postoperative analgesia, as well as complications from its use for brachial plexus blocks. METHODS: A systematic literature search was conducted using the Cochrane Central Registry of Controlled Trials, PubMed, and Scopus. Trials comparing control and local dexamethasone-treated groups, and those which reported duration of analgesia and/or pain scores/opioid consumptions were selected. Meta-analysis was performed using the Review Manager (RevMan) software 5.1. RESULTS: Fourteen studies consisting of a total of 1,022 patients were included. Perineural dexamethasone significantly prolonged the duration of postoperative analgesia in patients receiving both low-dose (4 - 5 mg) [SMD 2.41 (95% CI: 1.47, 3.35 P = 0<0.00001) I² = 82%], and higher-doses (8 - 10 mg) [SMD 4.46 (95% CI 3.54, 5.38 P < 0.00001) I² = 94%]. However, the duration of motor block was also prolonged [SMD 2.52 (95% CI: 1.06, 3.98 P = 0.0007) I² = 97%] and dexamethasone delayed latency of onset of sensory [SMD -0.49 (95% CI: -0.89, -0.09 P = 0.02) I² = 76%] and motor [SMD -0.56 (95% CI: -1.13, 0.00 P = 0.05) I² = 87%] blocks. Postoperative pain scores were improved at both 24 hours [SMD -1.46 (95% CI: -2.43, -0.50 P = 0.003) I² = 95%] and 48 hours [SMD -1.20 (95% CI: -2.26, -0.13 P = 0.03) I² = 95%] in dexamethasone-treated groups, whereas opioid consumption was reduced only at 48 hours [SMD -2.97 (95% CI: -4.17, -1.76 P < 0.00001) I² = 88%]. Complications were comparable between control and dexamethasone-adjuvant groups, except for the excessively prolonged nerve block that was observed predominantly in the dexamethasone-adjuvant group. LIMITATIONS: The limitations include different definitions used for the measurements of certain parameters such as the duration of analgesia and duration of motor block, number of studies assessing certain parameters having high heterogeneity, and varying types of local anesthetics used in various studies. CONCLUSIONS: Perineural dexamethasone addition to local anesthetic solutions significantly improved postoperative pain in brachial plexus block without increasing complications. However, perineural adjuvant dexamethasone delayed the onset of sensory and motor block, and prolonged the duration of motor block. Smaller doses of dexamethasone (4 - 5 mg) were as effective as higher doses (8 - 10 mg)

Do cervical epidural injections provide long-term relief in neck and upper extremity pain? A systematic review.

BACKGROUND: The high prevalence of chronic persistent neck pain not only leads to disability but also has a significant economic, societal, and health impact. Among multiple modalities of treatments prescribed in the management of neck and upper extremity pain, surgical, interventional and conservative modalities have been described. Cervical epidural injections are also common modalities of treatments provided in managing neck and upper extremity pain. They are administered by either an interlaminar approach or transforaminal approach. OBJECTIVES: To determine the long-term efficacy of cervical interlaminar and transforaminal epidural injections in the treatment of cervical disc herniation, spinal stenosis, discogenic pain without facet joint pain, and post surgery syndrome. METHODS: The literature search was performed from 1966 to October 2014 utilizing data from PubMed, Cochrane Library, US National Guideline Clearinghouse, previous systematic reviews, and cross-references. The evidence was assessed based on best evidence synthesis with Level I to Level V. RESULTS: There were 7 manuscripts meeting inclusion criteria. Of these, 4 assessed the role of interlaminar epidural injections for managing disc herniation or radiculitis, and 3 assessed these injections for managing central spinal stenosis, discogenic pain without facet joint pain, and post surgery syndrome. There were 4 high quality manuscripts. A qualitative synthesis of evidence showed there is Level II evidence for each etiology category. The evidence is based on one relevant, high quality trial supporting the efficacy of cervical interlaminar epidural injections for each particular etiology. There were no randomized trials available assessing the efficacy of cervical transforaminal epidural injections. LIMITATIONS: Paucity of available literature, specifically conditions other than disc herniation. CONCLUSION: This systematic review with qualitative best evidence synthesis shows Level II evidence for the efficacy of cervical interlaminar epidural injections with local anesthetic with or without steroids, based on at least one high-quality relevant randomized control trial in each category for disc herniation, discogenic pain without facet joint pain, central spinal stenosis, and post surgery syndrome