The Influnce of Epidural Steroids Injections with Transforaminal and Interlaminal Approaches on Quality of Sleeping, Anxiety, and Depression in Patients With Chronic Lumbal Radicular Pain - Prospective, Randomized Research

Chronic lumbar radicular pain is connected with the anxiety, depression and sleep disorders. The aims of this study are to compare the effect of pain on sleep quality, anxiety and depression in patients receiving interlaminar and transforaminal epidural steroids injections. The study is an original scientific-research work, a prospective randomized controlled clinical trial that included 70 patients with lumbar radicular pain at the Clinical Hospital Centre Osijek. The selected patients were divided into two groups considering the approach of administration of epidural steroids, the interlaminar (IL) and transforaminal group (TF). The anxiety, depression and sleep disorders were evaluated with questionnaires "Hospital Anxiety and Depression Scale (HADS)" and "Questions for assessing sleep in chronic pain". In the end 64 patients completed the study, 41 women (64.1%) and 23 men (35.9%). Significantly lower values were recorded during the assessment of the sleep quality in the group with the interlaminar injection of steroids (ANOVA, p = 0.030), compared to the group with the transforaminal injection of steroids (ANOVA, p = 0.002), but there is no difference between the groups. In both groups, there is an improvement in anxiety and depression, but only in the sixth measurement a significantly lower evaluation value of the HADS questionnaire was obtained in transforaminal (TF) group (Mann Whitney test, p = 0.025). Within the TF group, the values of anxiety (Friedman\u27s test, p <0.001) and depression (Friedman\u27s test, p = 0.007) are significantly reduced. In patients who received epidural steroids injection with a transforaminal approach, lower levels of depression and anxiety were observed as there was a greater reduction in pain, compared to an interlaminar group. Sleep quality was higher in patients who received steroids via transforaminal compared to the interlaminar approach

TREATMENT OF TRIGEMINAL NEURALGIA BY RADIOFREQUENCY NEUROMODULATION

Trigeminalna neuralgija (TN) jedan je od najčešćih uzroka boli lica. Medikamentno liječenje katkada nije dovoljno učinkovitoi može imati neprihvatljive nuspojave. Ostale mogućnosti liječenja obuhvaćaju kiruški zahvat, te minimalno invazivne tehnike poput perkutane rizotomije glicerolom, perkutane mikrokompresije balonom, te kontinuirane radiofrekventne termokoagulacije (CRF). CRF se široko rabi u liječenju TN, no visoke temperature >70° C mogu dovesti do ozbiljnih komplikacija, dok suniže temperature nedovoljno učinkovite. Pulsna radiofrekventna neuromodulacija (PRF) rabi struju u kratkim, visokovoltažnim impulsima, dok “tiha” faza omogućava eliminaciju topline te temperatura tkiva u pravilu ne prelazi 42° C. Mehanizam kojim se PRF dovodi do smanjenja boli bez termičkog oštećenja tkiva nije potpuno razjašnjen, no pretpostavlja se da brze promjene električnog polja dovode do promijenjenog prijenosa bolnih impulsa. Prema dostupnoj literaturi, u odnosu na CRF učinkovitost je nešto niža, no sa značajno manje komplikacija. Ipak, produljenje vremena izvođenja PRF sa 2 na 6 do 8 minuta može značajno povećati učinkovitost navedene metode.Trigeminal neuralgia (TN) is one of the most common causes of facial pain. Sometimes medical treatment is not effective enough and may have unacceptable side effects. Other treatment options include surgical interventions and minimally invasive techniques such as percutaneous rhizotomy with glycerol, percutaneous balloon decompression, and percutaneous radiofrequency thermocoagulation (CRF). CRF is widely used for TN treatment, but high temperatures >70 °C can cause serious complications, while lower temperatures are inefficient. Pulsed radiofrequency (PRF) uses the current in short, high-power pulses, while the ‘silent’ phase allows heat elimination and temperature of the tissue generally does not exceed 42 °C. The mechanism by which PRF leads to pain reduction without thermal damage to the tissue is not fully understood, but rapid changes in the electrical fi eld are assumed to result in altered transmission of pain signals. According to available literature, compared to CRF, effi cacy is lower, but with signifi cantly less complications. However, the prolongation of PRF time from 2 to 6 to 8 minutes can signifi cantly increase the effi ciency of this method

SPINAL CORD STIMULATION FOR THE TREATMENT OF CHRONIC PAIN – THE INITIAL OSIJEK EXPERIENCE

Stimulacija kralježnične moždine (engl. spinal cord stimulation - SCS) je postupak kojim se ugrađuju jedna ili dvije elektrode u epiduralni prostor torakalne i lumbalne kralježnice te se elektrode spoje na bateriju koja isporučuje stimulaciju programiranu za tog bolesnika. SCS je indiciran kod bolesnika s jakom kroničnom boli koja se ne smanjuje primjenom ostalih oblika liječenja. Ovaj zahvat se radi kod bolesnika koji imaju bolove u lumbalnom dijelu kralježnice nakon neurokirurških zahvata na lumbalnoj kralježnici s posljedičnim stvaranjem priraslica, sa širenjem boli u donje ekstremitete ili bez širenja boli, kod bolesnika s bolovima nakon amputacije donjih ekstremiteta, te boli koja je posljedica kompleksnih regionalnih bolnih sindroma. U KBC-u Osijek tijekom 2017. g. postupak perkutane ugradnje elektroda za stimulator kralježnične moždine učinjen je kod 5 bolesnika. Prema našim saznanjima sve dosadašnje ugradnje stimulatora kralježnične moždine u Republici Hrvatskoj učinjene su kirurškim, a ne perkutanim pristupom. Bolesnike se procjenjivalo putem numeričke ljestvice za procjenu boli, Oswestry upitnika za procjenu stupnja invalidnosti, SF-36 upitnika za procjenu kvalitete života. Upitnici su ispunjavani prije zahvata, na kontrolnom pregledu prije ugradnje trajne stimulacije, te mjesec i tri mjeseca nakon ugradnje trajnog stimulatora. U ukupnim vrijednostima opaženo je značajno poboljšanje ocjene tjelesnog zdravlja, smanjenje stupnja invalidnosti kao i trenutni, prosječni i najjači intenzitet boli proteklih četiri tjedana u odnosu na prvu vizitu.Spinal cord stimulation (SCS) is a procedure of incorporating one or two electrodes into the epidural space of the thoracic and lumbar spine. The epidural space is located above the dura that covers the spinal cord. This procedure is performed in patients with pain in the lumbar spine with or without pain spreading to lower extremities, in patients with lower extremity amputation, and pain resulting from complex regional pain syndromes. SCS is indicated in patients with severe chronic pain that cannot be alleviated by other modes of treatment. Total SCS was performed in fi ve patients. Patients fi lled out a numerical scale assessing the intensity of pain, the Oswestry questionnaire assessing the degree of disability, and the SF36 questionnaire assessing the quality of life. The above-mentioned questionnaires were completed by the patients before implantation of permanent SCS, then one month after permanent SCS and 3 months of permanent SCS. The results showed signifi cant improvement in the quality of life at the 4th visit in almost all SF-36 items except for limiting the activity for physical health, emotional problems, and mental health. In the overall values, the improvement in physical health assessment with a median 33 (interquartile range from 30 to 59) was signifi cantly better as compared to the 15 (interquartile range from 11 to 16) on the fi rst visit (Friedman’s test, p=0.007). There was also a signifi cant reduction in the degree of disability, as well as in the current, average and most severe pain intensity lasting for four weeks compared to the fi rst visit

Utjecaj različitih minimalno invazivnih metoda na ishod liječenja lumbalne radikularne boli

Lumbar radicular pain is a major public health, social and economic problem and is often the cause of professional disability. The aim of this study was to compare pain intensity, disability and neuropatic pain depending on the method of treatment (epidural steroid injection or percutaneous laser disc decompression) in the treatment of lumbar radicular pain caused by intervertebral disc herniation with or without discoradicular contact. Data were collected from 28 patients at 3 measurement points (before the procedure and at examinations on the 15th and 30th day after the procedure) using the Numeric Rating Scale (NRS), Oswestry Disabilitiy Indeks (ODI) and Pain Detect. The reduction of the pain after the procedure was statistically significant only in the group of patients with discoradicular contact in whom PLDD was performed (P=0.04). From the obtained results, it can be concluded that percutaneous laser disc decompression (PLDD) led to a greater reduction in disability (P=0.009) in patients with discorradicular contact, whereas lumbar transforaminal epidural steroid injection (ESI TF) led to greater reduction in patients without discorradicular contact (P=0.02). The results indicate that there was a significant (P=0.01) reduction in neuropathic pain in patients without discorradicular contact who were treated with ESI TF and in patients with discoradicular contact who were treated with PLDD (P=0.04).Lumbalna radikularna bol je veliki javnozdravstveni, društveni i ekonomski problem i često je uzrok profesionalne nesposobnosti. Cilj ovog istraživanja bio je usporediti intenzitet boli, onesposobljenost i neuropatsku bol ovisno o načinu liječenja (epiduralna injekcija steroida ili perkutana laserska dekompresija diska) u liječenju lumbalne radikularne boli uzrokovane hernijom intervertebralnog diska sa ili bez diskoradikularnog kontakta. Podaci su prikupljeni od 28 pacijenata u 3 točke mjerenja (prije zahvata i na pregledima 15. i 30. dana nakon zahvata) pomoću Numeric Rating Scale (NRS), Oswestry Disabilitiy Indeks (ODI) i Pain Detect. Smanjenje boli nakon zahvata bilo je statistički značajno samo u skupini bolesnika s diskoradikularnim kontaktom kod kojih je učinjen PLDD (p = 0,04). Iz dobivenih rezultata može se zaključiti da je PLDD doveo do većeg smanjenja onesposobljenosti (p = 0,009 ) u bolesnika s diskoradikularnim kontaktom a ESI u bolesnika bez diskoradikularnog kontakta (p = 0,02 ). Rezultati pokazuju da je došlo do značajnog (p = 0,01) smanjenja neuropatske boli u bolesnika bez diskoradikularnog kontakta koji su liječeni ESI i u bolesnika s diskoradikularnim kontaktom koji su liječeni PLDD (p = 0,04)

PATIENT SELECTION FOR SPINAL CORD STIMULATION

Stimulacija kralježnične moždine (SCS) je neuromodulacijski postupak koji ne dovodi samo do smanjenja boli, već i do poboljšanja funkcije i kvalitete života pacijenata s kroničnom boli. No, SCS je skupi, invazivni postupak s mogućim komplikacijama.bRani pokušaji primjene SCS doveli su razočaravajućih rezultata zbog, između ostalog, lošeg odabira pacijenata. Pravilan odabir pacijenata za ugradnju SCS je ključni čimbenik za postizanje dobrih kratkoročnih i dugoročnih rezultata. Proces odabira obuhvaća dva glavna područja – osnovnu bolest i stanje pacijenta, poput njegovog zdravstvenog statusa, pridruženih bolesti i mentalnog statusa. Multidisciplinski pristup procjeni pacijenta je neophodan za postizanje najboljih rezultata.Spinal cord stimulation (SCS) as a neuromodulation procedure not only reduces pain but also improves function and quality of life in patients with chronic pain. However, SCS is an expensive and invasive procedure with possible complications. Early treatment with SCS led to disappointing results due to, among other factors, poor patient selection. Proper selection of patients for SCS implantation is a critical factor for good short-term and long-term outcomes. The selection process includes two main areas, underlying medical condition and patient characteristics, such as their health status, comorbidities and psychological status. A multidisciplinary approach in patient evaluation is essential for achieving the best results

SAFETY OF THE RADIOFREQUENCY DENERVATION FOR CHRONIC PAIN TREATMENT - SINGLE CENTRE EXPERIENCE FROM OSIJEK UNIVERSITY HOSPITAL CENTRE

Liječenje bolesnika koji pate od kronične boli bilo kojeg uzroka vrlo je zahtjevno i zahtijeva više modalitetni pristup analgeticima, nefarmakološkim metodama (fi zikalna terapija i akupunktura), injekcijama lokalnog anestetika i kortikosteroida unutar zglobnih prostora ili u okolinu živaca, a svaki dio ovog pristupa nosi određeni rizik povezan s nuspojavama i komplikacijama. Oralni protuupalni lijekovi pomažu smanjiti bol i upalu, no u određenim skupinama bolesnika su kontraindicirani ili nose veći rizik od nuspojava i komplikacija. Opioidni analgetici mogu biti teško podnošljivi, zbog mučnine ili, u težim slučajevima, povraćanja i opstipacije te bolesnici nerijetko odustaju od tih analgetika. Koanalgetici (antidepresivi i antikonvulzivi) su također lijekovi sa značajnim nuspojavama i većina ih bolesnika teško podnosi i nerado uzima. Nefarmakološke metode liječenja kronične boli su uglavnom vezane uz minimalne ili nikakve komplikacije, no ograničenog su analgetskog učinka. Injekcije lokalnog anestetika i kortikosteroida u zglobne prostore ili epiduralno nose također određene rizike od komplikacija. RF (radiofrekvencijska denervacija, neurotomija, ablacija) u literaturi se opisuje kao minimalno invazivni postupak kojim se u svrhu prekida bolnog signala u mozak na živčanom tkivu stvara toplinska lezija. RF najčešće primjenjujemo u sljedećim kroničnim bolnim stanjima: neuralgija trigeminalnog živca, bolovi u kralježnici uzrokovani degenerativnim upalnim promjenama fasetnih zglobova te artroza zgloba kuka i koljena. Tijekom ovog postupka, kao i tijekom svake druge medicinske intervencije, moguće su komplikacije koje su u literaturi vrlo rijetko opisane. U ovom članku donosimo pregled literature i naša iskustva vezana uz komplikacije RF živaca za najčešće bolne sindrome.Treatment of patients suffering from chronic pain of any cause is very demanding and often involves multimodal approach. Analgesics, non-pharmacological methods (physical therapy and acupuncture), local anesthetics and corticosteroids as intraarticular injection or near the nerves are parts of this multimodal approach. Each part of this approach carries a certain risk of side effects and complications. Oral anti-infl ammatory drugs reduce pain and infl ammation, but in certain groups of patients they are contraindicated or represent a greater risk for side effects and complications. Opioid analgesics could be less tolerable for some patients during the treatment due to nausea or, in severe cases, vomiting and constipation, and patients often abandon these analgesics. Co-analgesics (antidepressants and anticonvulsants) are also medicines with signifi cant side effects, most of them are diffi cult to tolerate and patients are reluctant to take them. Non-pharmacological methods for treating chronic pain are mostly associated with minimal or no complications, but with limited analgesic effect. Intraarticular injections of local anesthetics and corticosteroids or injections in the epidural space also represent certain risks for complications. Radiofrequency denervation (neurotomy, ablation) is described in the literature as a minimal invasive procedure in order to induce thermal lesions on the nerves to stop the pain signals to the brain. Radiofrequency denervation is most commonly used in the following chronic pain conditions: trigeminal nerve neuralgia, cervical or back pain caused by degenerative infl ammatory changes in facet joints and osteoarthritis of hip and knee joints. During this procedure, as well as during any other medical intervention, complications are possible, but rarely described in the literature. In this article, we provide an overview of the literature and our experiences associated with the complications of radiofrequency denervation of the nerves most commonly used

Factors associated with difficult neuraxial blockade

Spinal and epidural blocks are common practice in anesthesia and are usually used for various surgical or endoscopic procedures. Correct identification and puncture of the epidural or subarachnoid space determine the success or failure of the technique. Multiple attempts and difficult access to the epidural or subarachnoid space is a frequent problem in operating theaters and may be hazardous due to a number of possible acute or long-term complications. In addition, multiple punctures are associated with increased pain and patient discomfort. The aim of this study was to determine the factors associated with a difficult spinal or epidural block, dependent on the patient (age, gender, height, weight, body mass index, and quality of anatomical landmarks), the technique (type of blockade, needle gauge, and patient positioning), and the provider (level of experience). The study was conducted at the Department of Anesthesiology, Resuscitation, and Intensive Care Unit of University Hospital Osijek (Osijek, Croatia) and it included 316 patients who underwent a range of different surgical procedures in neuraxial blocks. There were 219 cases of first puncture success, while the overall success of neuraxial blocks was 97.5%. Five patients (1.6%) were submitted to the alternative technique, ie, general anesthesia. In three patients (0.9%), neuraxial block was partial so they required supplementation of intravenous anesthetics and analgesics. Furthermore, it was found that first puncture success was associated with younger age (P=0.007), lower weight (P=0.032), and body mass index (P=0.020). Spine deformity (P=0.015), poor identification of interspinous space (P=0.005), recumbent patient position during the puncture (P=0.001), and use of a paramedian approach were associated with first puncture failure. Adequate preoperative prediction of difficulties can help to reduce the incidence of multiple attempts, rendering the technique more acceptable and less risky to the patient, and consequently leading to improvement of medical care quality. The attending anesthesiologist should consider an alternative technique (general anesthesia or peripheral nerve block) for a patient if certain difficulties can be predicted