Clonidine in spinal and epidural blocks prolongs anesthesia, but can cause hypotension and bradycardia. The aim of our study was to compare hemodynamic and analgesic effects of spinal versus epidural clonidine alone and after repetitive dosing. In a prospective, randomized, double-blind study, we evaluated 40 patients scheduled for lower extremity orthopedic surgery under continuous spinal or epidural anesthesia with bupivacaine 0.5% (initial dose 5 mg and 50 mg, respectively). In either spinal or epidural technique one-half of patients received clonidine (150 micrograms) in addition to bupivacaine. Repeat doses of the same anesthetic mixture were allowed in cases of subsequent pain. Mean arterial pressure (MAP) and heart rate were recorded for 6 h after each injection. Duration of clinically useful anesthesia was defined as the time from drug administration to first sensation of pain. Intrathecal, but not epidural, clonidine decreased MAP significantly compared with bupivacaine alone. MAP after intrathecal clonidine with bupivacaine was lower than epidural clonidine with bupivacaine 5 and 6 h after injection. Repetitive administration caused no further decrease in MAP. Onset time required to surgical anesthesia (sensory block of T11) did not differ among the four groups. Duration of spinal and epidural anesthesia was increased more than two fold by clonidine. In summary, the addition of clonidine prolongs analgesia by either route. These results may be explained by clonidine's sites of action in hemodynamic control and the density of bupivacaine-induced block.

Objective To determine the effectiveness of lumbar medial branch thermal radiofrequency neurotomy based on different selection criteria and procedural techniques. Design Comprehensive systematic review. Methods A comprehensive literature search was conducted, and all authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies. Outcome Measures The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief, as well as procedural technique with perpendicular or parallel placement of electrodes. Results Results varied by selection criteria and procedural technique. At six months, 26% of patients selected via single medial branch block with 50% pain relief and treated via perpendicular technique achieved at least 50% pain relief; 49% of patients selected via dual medial branch blocks with 50% pain relief and treated via parallel technique achieved at least 50% pain relief. The most rigorous patient selection and technique—two diagnostic medial branch blocks with 100% pain relief and parallel electrode placement—resulted in 56% of patients experiencing 100% relief of pain at six months. Conclusions This comprehensive systematic review found differences in the effectiveness of lumbar medial branch radiofrequency neurotomy when studies were stratified by patient selection criteria and procedural technique. The best outcomes are achieved when patients are selected based on high degrees of pain relief from dual medial branch blocks with a technique employing parallel electrode placement.

Objective To determine the rate of vasovagal (vv) complications in fluoroscopically guided interventional procedures. Design Retrospective case series analysis of prospectively collected data from March 8, 2004 to January 30, 2009. Setting A single academic medical center. Subjects Four thousand one hundred eighty-three subjects undergoing 8,010 consecutive injections. Outcome Measures Pearson's chi-square test was used to determine the relationship between categorical variables. Results A total of 8,010 injections, including epidural steroid injections, radiofrequency nerve ablations, medial branch blocks, hip injections, knee injections, and glenohumeral injections were performed. Overall vv reaction rate was 2.6%, with 0.8% of procedures resulting in early terminated due to vv reaction. Peripheral joint injections had a vv rate of 0.2%, all occurring in hip injections. Transforaminal epidural steroid injections had a vv rate of 3.5%. Diagnostic blocks of the medial branches had the highest rate of vv (5.1%). Other predictors of vv reactions were identified including preprocedure pain score visual analog scale <5 (P = 0.004), male gender (P < 0.001), and age less than 65 years old (P < 0.001). Conclusions vv reactions have an overall low occurrence rate (2.6%) in interventional procedures ranging from 0% in peripheral knee and shoulder injections to 5.1% in medial branch blocks. Conservative treatment of vv reaction and willingness to terminate procedures resulted in no serious adverse events related to vv reaction in 8,010 procedures.

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Other than for interlaminar procedures, the evidence does not support the view that anticoagulant and antiplatelet medication must be ceased before image-guided spine pain procedures. Meanwhile, the evidence shows that ceasing anticoagulants carries a risk of serious consequences, including death. Guidelines on the use of anticoagulants should reflect these opposing bodies of evidence.

Objective To determine the effectiveness of cervical medial branch thermal radiofrequency neurotomy in the treatment of neck pain or cervicogenic headache based on different selection criteria. Design Comprehensive systematic review. Methods A comprehensive literature search was conducted, and the authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies. Outcome Measures The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief. Results Results varied by selection criteria, which included triple placebo-controlled medial branch blocks, dual comparative medial branch blocks, single medial branch blocks, intra-articular blocks, physical examination findings, and symptoms alone. Outcome data showed a greater degree of pain relief more often when patients were selected by triple placebo-controlled medial branch blocks or dual comparative medial branch blocks, producing 100% relief of the index pain. The degree of pain relief was similar when triple or dual comparative blocks were used. Conclusions Higher degrees of relief from cervical medial branch thermal radiofrequency neurotomy are more often achieved, to a statistically significant extent, if patients are selected on the basis of complete relief of index pain following comparative diagnostic blocks. If selected based on lesser degrees of relief, patients are less likely to obtain complete relief.

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