Fluoroscopic Guidance Increases the Incidence of Thoracic Epidural Catheter Placement Within the Epidural Space: A Randomized Trial.

Background and Objectives: Thoracic epidural analgesia can reduce postoperative pain and cardiopulmonary morbidity, but it is associated with a high rate of clinical failure. Up to 50% of clinical failure is thought to be related to technical insertion. In this study, patients undergoing thoracic surgery were randomized to one of two catheter insertion techniques: fluoroscopically guided or conventional loss of resistance with saline/air. Our primary aim was to examine whether fluoroscopic guidance could increase the incidence of correct catheter placement and improve postoperative analgesia. Our secondary aim was to assess the potential impact of correct epidural catheter positioning on length of stay in the postanesthesia care unit and total hospital length of stay. Methods: This randomized clinical trial was conducted at Dartmouth-Hitchcock Medical Center over 25 months (January 2012 to February 2014). Patients (N = 100) undergoing thoracic surgery were randomized to fluoroscopic guidance (n = 47) or to loss of resistance with saline/air (n = 53). Patients were followed for the primary outcomes of 24-hour morphine use, 24-hour numeric pain scores, and the incidence of epidural catheter positioning within the epidural space. Postanesthesia care unit and total hospital lengths of stay were evaluated as secondary outcome measurements and compared for patients with correct epidural catheter positioning and those without correct epidural catheter positioning. Results: One hundred patients were included in an intention-to-treat analysis. Numeric pain scores and 24-hour morphine consumption were no different between groups. Fluoroscopic guidance was associated with an increased incidence of epidural catheter placement within the epidural space compared with loss of resistance with air/saline [fluoroscopic guidance, epidural in 98% (46/47) versus loss of resistance with saline/air, epidural in 74% (39/53)]. There was a significant increase in correct catheter positioning with (odds ratio, 21.07; 95% confidence interval, 2.07-214.38; P = 0.010) or without (odds ratio, 16.15; 95% confidence interval, 2.03-128.47; P = 0.009) adjustment for potentially confounding variables. In an adjusted analysis, correctly positioned thoracic epidural catheters were associated with shorter postanesthesia care unit (5.87 +/- 5.39 hours vs 4.30 +/- 1.171 hours; P = 0.044) and total hospital length of stay (5.77 +/- 4.94 days vs 4.93 +/- 2.79 days; P = 0.031). Conclusions: Fluoroscopic guidance increases the incidence of epidural catheter positioning within the epidural space and may reduce postanesthesia care unit and hospital lengths of stay. Future work should validate the effectiveness of this approach. This clinical trial is registered with ClinicalTrials.gov (NCT02678039). Copyright (C) 2016 by American Society of Regional Anesthesia and Pain Medicine.

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The Neurological Safety of an Epidurally Administered Lipo-PGE1 Agonist in Rats.

Background and Objective: Liposomal prostaglandin E1 (Lipo-PGE1) can inhibit platelet aggregation and vasodilatation and has been found to be therapeutic in ischemia and spinal diseases including stenosis. However, the neurologic safety of epidural administration of lipo-PGE1 requires further study. We investigated the neurotoxicity of epidurally administered lipo-PGE1 agonist in rats. Methods: Twenty-seven rats were randomly divided into three groups: Epidural isotonic sodium chloride solution administration (negative control, group N, n = 9); epidural lipo-PGE1 agonist (group L, n = 9); and epidural alcohol (positive control, group A, n = 9). A single 3-mL injection of lipo-PGE1 agonist (0.3 mL, 0.15 [mu]g/kg), 40% ethanol, or isotonic sodium chloride solution was administered. Neurologic assessments were performed 3, 7, and 21 days after the injection. Histopathologic data were evaluated by one pathologist via light microscopy. Results: All rats in groups N and L, except one rat in group L, demonstrated normal response to neurologic assessments. Histopathologic findings showed no evidence of degenerative myelopathy, chromatolysis, or myelin loss in group N or L at any time point. However, all rats in group A revealed sensory and motor deficits as well as histopathologic abnormalities. Conclusion: Liposomal prostaglandin E1 agonist did not cause any apparent neurologic abnormalities in the spinal cord or dorsal root ganglion, suggesting it is neurologically safe for epidural injection in this species. Additional mammalian study is warranted. Copyright (C) 2016 by American Society of Regional Anesthesia and Pain Medicine.

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A Prospective Randomized Comparative Trial of Targeted Steroid Injection Via Epidural Catheter Versus Standard C7-T1 Interlaminar Approach for the Treatment of Unilateral Cervical Radicular Pain.

Background and Objectives: No study has compared cervical interlaminar epidural steroid injection (CIESI) with epidural catheter advancement to the side and level of pathology versus standard C7-T1 CIESI. This study investigated whether cervical radicular pain is more effectively treated by CIESI with a targeted epidural catheter versus a standard C7-T1 approach. Methods: Prospective, randomized, single-blinded trial. Primary outcome: Numerical Rating Scale (NRS) pain at 1 month. Secondary outcomes: Oswestry Neck Disability Index (ONDI), Pain Disability Index (PDI), McGill Pain Questionnaire (MPQ), Patient Global Impression of Change (PGIC), daily morphine equivalents (DME), and Medication Quantification Scale (MQS) III scores. Results: Seventy-six participants with a median age of 48 years (IQR, 40-56 years), 59% female, with C4 (n = 2), C5 (n = 27), or C6 (n = 47) radicular pain were enrolled. At 1 month in the catheter and no catheter groups, respectively: 26 (72%, 95% confidence interval [CI], 57%-87%) and 23 (60%; 95% CI, 45%-75%) participants reported 50% or greater NRS reduction; 24 (67%; 95% CI, 52%-84%) and 23 (58%; 95% CI, 42%-73%) participants reported 30% or greater ONDI reduction. There were no group differences in median NRS, ONDI, PDI, MPQ, PGIC, DME, or MQSIII scores (P > 0.05). Intergroup differences were not observed at any follow-up interval. Conclusions: This trial showed no significant difference in clinical outcomes with CIESI using a targeted epidural catheter compared to a standard C7-T1 approach for the treatment of unilateral cervical radicular pain at the C5 or C6 level. Both techniques were associated with clinically meaningful improvement across outcome domains of pain, function, disability, and medication use. These effects persisted to 6-month follow-up. The study was registered at Clinical Trials.gov (NCT02095197). Copyright (C) 2016 by American Society of Regional Anesthesia and Pain Medicine.

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Anatomic and Ultrasonographic Evaluation of the Knee Sensory Innervation: A Cadaveric Study to Determine Anatomic Targets in the Treatment of Chronic Knee Pain.

Background and Objectives: Osteoarthrosis is a main cause of knee pain in the elderly. Pain associated with this condition is often refractory to conservative treatment. Total knee replacement may be the best option for severe pathologies; however, the occurrence of a chronic pain state after knee replacement has been well documented in the literature. The previous descriptions of the genicular nerves have been considered somewhat inaccurate. This innervation is complex and exhibits significant interindividual variability. A precise description of these nerves will increase our knowledge on different patterns and targets, to guide treatment and improve outcomes. The objective of this study was to determine sensory innervation patterns of the knee joint and correlate them with dynamic visualization via ultrasound imaging. Methods: Systematic cadaveric dissections were performed to determine different patterns of sensory innervation of the knee followed by ultrasonographic correlation. A short-axis ultrasound view of the nerves was used to inject India ink at several points along their course to facilitate the anatomic dissection and confirm their location among adjacent structures. Results: The visualized structures were the following: infrapatellar branch of the saphenous nerve, the branches to vastus medialis, intermedius, and lateralis muscles; obturator nerve; and lateral retinacular and recurrent peroneal nerves. Conclusions: We conclude that reproducible correlations showing the sensory innervations for the knee are linked to muscular structures. However, high variability among individuals makes it difficult to predict their paths. Our systematic approach, using direct visualization via ultrasound, allows a more accurate placement of the needle for therapeutic purposes. Copyright (C) 2016 by American Society of Regional Anesthesia and Pain Medicine.

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Lung regeneration: steps toward clinical implementation and use.

Purpose of review: Whole lung tissue engineering is a relatively new area of investigation. In a short time, however, the field has advanced quickly beyond proof of concept studies in rodents and now stands on the cusp of wide-spread scale up to large animal studies. Therefore, this technology is ever closer to being directly clinically relevant. Recent findings: The main themes in the literature include refinement of the fundamental components of whole lung engineering and increasing effort to direct induced pluripotent stem cells and lung progenitor cells toward use in lung regeneration. There is also increasing need for and emphasis on functional evaluation in the lab and in vivo, and the use of all of these tools to construct and evaluate forthcoming clinically scaled engineered lung. Summary: Ultimately, the goal of the research described herein is to create a useful clinical product. In the intermediate time, however, the tools described here may be employed to advance our knowledge of lung biology and the organ-specific regenerative capacity of lung stem and progenitor cells. Copyright (C) 2016 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Sacral Stress Fracture following the Bone Union of Lumbar Spondylolysis

While 22 articles have reported on sacral stress fractures, it is a rare injury and its etiology is not well known. We present the case of a 16-year-old male who presented with low back pain in 2015. He was a high school soccer player with a previous history of a bilateral L5 lumbar spondylolysis in 2014. The patient refrained from soccer and wore a brace for six months. Two months after restarting soccer, he again complained of low back pain. After 1 year, a lumbar spine computed tomography revealed the bone union of the spondylolysis. At his first visit to our hospital, his general and neurological conditions were normal and laboratory data were within the normal range. Sacral coronal magnetic resonance imaging (MRI) of the left sacral ala revealed an oblique lineal signal void surrounding bone marrow edema. Based on his symptoms, sports history, and MRI, he was diagnosed with a sacral stress fracture. He again refrained from soccer; his low back pain soon improved, and, after 1 year, the abnormal signal change had disappeared on sacral MRI. Recurrent low back pain case caused by a sacral stress fracture occurring after the bone union of lumbar spondylolysis is uncommon.

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