The double MBB protocol better correlated with favorable MBN outcomes compared with a single MBB protocol. Using a double MBB protocol, a 70% cutoff value for reported subjective pain relief post-MBB best predicted overall outcome following MBN. Without a confirmatory MBB, an 80% cutoff value was the optimal value.
The recent death of a famous football player raised public awareness of the fatal nature of heat stroke, which is actually the third leading cause of death among American athletes. We present a typical case of heat stroke to illustrate its clinical manifestation and recovery process; risk factors, treatment options, and the importance of prevention are also discussed. Although heat stroke is not a common admission diagnosis for inpatient rehabilitation, physiatrists need to be aware of its pathophysiology, rehabilitation management, and prevention.
Diagnostic MBB using progressively stringent MBB cutoff values incrementally excluded patients without posterior element pain as evidenced by incremental increase in positive outcomes following MBN. The exclusion of patients from MBN due to failure to report 70% or greater pain relief following MBB resulted in cost savings in favor of performing diagnostic MBB.
No studies have directly measured the false negative rate of medial branch block (MBB) with correlation to medial branch neurotomy (MBN) outcome. We investigated the potential false negative MBB rate and the subsequent MBN outcome on a consecutive audit of all patients undergoing a double MBB protocol. We prospectively collected audit data and retrospectively collected data by phone on 229 consecutive patients undergoing diagnostic MBB. One-hundred-twenty-two patients reporting greater than 50% of subjective pain relief subsequently underwent either MBN or a confirmatory block followed by MBN. A total of 55 patients underwent a second confirmatory MBB and within that group 27.3% (15/55) reported less than 50% relief post initial MBB and 30.9% (17/55) between 50% and 69% relief. We performed an in-depth analysis of these 2 subgroups focusing on the reason a second MBB was performed despite a “negative” or “indeterminant” first MBB. We divided the “negative” responders to the first MBB into those reporting < 50% relief (Group 1) and those reporting between 50% and 69% relief (Group 2). We calculated a potential 46.7% false negative rate in Group 1 and 47.1% false negative in Group 2; however, the false negative results in Group 1 were predominately in those patients reporting delayed relief of pain and those re-blocked greater than 2 years after the first MBB. The success rate in all patients undergoing MBN was 87% compared to the 75% relief in the false negative groups with no statistically significant difference. In summary, the false negative rate for patients reporting less than 50% relief post MBB is probably less than 20% although there is a high “apparent negative” responds in patients reporting delayed relief or in those who had a second block 2 or more years post initial MBB. Patients reporting between 50 and 69% pain relief have a false negative response rate of 47.1% and should be considered for a confirmatory block. Key words: Facet rhizotomy, zygapophyseal joint, low back pain, chronic pain, facet joint, radiofrequency neurotomy, medial branch block, medial branch neurotomy
Cord trauma is a risk with a cervical and thoracic interlaminar epidural approach to the epidural space. Intermittent lateral fluoroscopic imaging to detect needle depth is often cumbersome and may be difficult to interpret. In comparison, the contra-lateral oblique (CLO) fluoroscopic view is efficient and easy to interpret. However, the in vivo reliability and safety of this technique has not been formally investigated. The senior author collected fluoroscopic images on 278 consecutive patients undergoing an interlaminar epidural block at the T1-T2 level performed using a 17 gauge Tuohy needle. Before catheter placement, anterior-posterior (AP) and CLO fluoroscopic images were saved with the needle at the ligamentum flavum and the needle just through the ligamentum flavum. We randomly selected the images of 40 cases that included the paired CLO images (total 80 images) documenting the views at and through the ligamentum flavum. Three interventionalists were asked to review, in a blinded fashion, the randomly selected, paired CLO images and to score each image, recording whether the 17 gauge needle was in or out of the epidural space to determine the accuracy and reliability of this technique. There was a 97.5%, 95%, and 93.8% agreement between each reviewing physician and the senior author resulting in a correlation using the Kappa statistic value of 0.950, 0.875, and 0.874, respectively (P < 0.001). The 3 reviewing physicians disagreed with the senior author’s correct answer in 2.5%, 5%, and 6.2%, respectively, however, the disagreement occurred primarily because of poor image quality. Agreement between the 3 reviewing physicians was 93.8%, 96.3%, and 90%, with a Kappa value of 0.875, 0.924, and 0.799, respectively (P < 0.001). There was 100% technical success in the 278 case series without “wet taps,” provocation of pain during entry, or any other immediate post procedural complication. We conclude the CLO view provides an efficient and reliable method to visualize needle tip depth in relation to the epidural space. The close inter-observer agreement was possible with minimal physician instruction. Key words: Cervical interlaminar, cervical epidural, contra-lateral oblique, fluoroscopic imaging
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