Interlaminar versus transforaminal epidural steroids for the treatment of lumbar radicular pain: a randomized, blinded, prospective outcome study

(358) Interlaminar versus transforaminal epidural steroids for the treatment of lumbar radicular pain: A randomized, (356) Evaluation of multi-modal preemptive analgesia on post- operative opioid requirements in total joint arthroplasty M Perloff, G Varlotta, and C Gharibo; NYU-Hospital for Joint Diseases, New R Rome, A Kipp, D Colquhoun, A Judd, W Novicoff, G Syverud, and R Hamill- Ruth; University of Virginia Health Science System, Charlottesville, VA Argument in the literature exists over lumbar epidural interlaminar steroid in- Traditional treatment of pain following total joint arthroplasty (TJA) involves jection (LESI) verses transforminal (TF) technique as the most effective therapy oral and intravenous narcotics, which can result in significant postoperative in lumbar radiculopathy. However, all studies to date have been retrospective.
morbidity. Multi-modal analgesia may be effective in reducing postoperative After IRB approval, 42 age matched patients with similar lower back pain and opioid requirements and result in fewer associated complications. Further- unilateral radicular symptoms were enrolled and randomized in a double blind more, preemptive analgesia has been shown to reduce postoperative pain trial to LESI or TF from 2007 to 2009. Prior to intervention and 10-16 days after and may reduce the incidence of neuropathic pain. This study compared the injection, each patient was evaluated by patient questionnaire and physical impact of multi-modal preemptive analgesia (MA) versus standard analgesia exam by an independent physician. 38 patients completed the study, 18 in (SA) on postoperative opioid requirements for 48 hours and analgesic-related the LESI and 20 in the TF group. In both groups, 2 patients required repeat in- complications following TJA. A retrospective review compared 33 TJA patients jection, and 1 patient crossed over to the alternative injection type. Overall, after implementation of MA protocol and 33 control matched TJA patients. MA physical exam, diagnostic testing, disability, activity and depression measures, consisted of oxycodone-CR, gabapentin, acetaminophen, and celecoxib. MA and opioid pill use, were similar between the 2 groups, both pre-injection base- doses were adjusted for age, ASA classification, hepatic and renal function, line and post-injection improvement. The Oswestry Disability Index (ODI%) prior narcotic exposure, and history of obstructive sleep apnea. Postopera- was reduced from 37.5612.6 (mean values +/- standard deviation) to tively, both groups received patient controlled analgesia containing morphine, 19.0616.7 (49.3%639.2%) in the LESI group and 38.366.4 to 21.6616.8 hydromorphone, or fentanyl while the study patients continued to receive MA (43.7%634.8%) in the TF group. Depression scale was reduced from daily. 15 SA and 18 MA total hip arthroplasty (THA) patients, and 17 SA and 16 4.3963.22 to 2.2863.20 (48.1%652.0%) in the LESI group and 4.1061.94 to MA total knee arthroplasty (TKA) patients were compared. Analysis was limited 1.6561.63 (61.0%639.1) in the TF group. Walking tolerance was increased to patients with complete records. Statistically, there was no difference be- from 8.164.6 blocks to 10.664.4 (30.8%6133.2%) in the LESI group and tween SA and MA patients’ morphine equivalent use or complications postop- 8.965.3 blocks to 11.864.2 (32.8%6318.7%) in the TF group. The follow-up pa- eratively using parametric and nonparametric analysis. On day 1, there was tient numerical rating scale (NRS) was more greatly reduced in the TF group.
a trend toward more opioid use in the SA groups. This was more pronounced NRS decreased from 7.061.9 to 3.963.1 (44.4%637.6) in the LESI group and in THA (mean 48+31 v. 34+25 mg; median 36 v 31 mg) than TKR (mean 42+36 6.462.1 to 1.761.4 in the TF group (73.2%621.3%). Overall, results suggest v. 35+20mg, median 28 v. 32 mg). On day 2, this trend reversed. The median that patients may experience greater subjective relief, as least initially, from was lower in the SA than MA (THA 19 v 26 mg; TKA 19 v. 33 mg). Limitations TF epidural steroid injections over LESI. However, more objective, and likely of this study included small sample size and inability to clearly identify preop- subacute, therapeutic effects are similar.
erative medication use. In this study, multi-modal preemptive analgesia did notdecrease postoperative opioid requirements.
(359) Effect sizes of diclofenac sodium 1% gel in randomized R Petruschke, J Peniston, M Gold, M Wieman, and R Altman; Multiple studysites n/a, n/a Acetaminophen, oral nonsteroidal anti-inflammatory drugs (NSAIDs), and top-ical NSAIDs are pharmacological options for patients with osteoarthritis (OA) ina few superficial joints. Topical NSAIDs permit treatment of the affected jointwith low systemic NSAID exposure compared with oral NSAIDs. In a post hocanalysis of 2 randomized controlled trials, effect sizes (ES) for diclofenac so-dium 1% gel (DSG) in patients with knee OA were compared with ES for acet-aminophen and oral NSAIDs as presented in current OA guidelines. Adults(n=1426) applied DSG or vehicle gel (4 g/knee 4 times daily) to 1 or 2 kneesfor 12 weeks. ES for Western Ontario and McMaster Universities OA Index (WO-MAC) pain, function, and stiffness subindices and pain on movement (POM)were calculated as the mean difference between active treatment and controlfor each outcome divided by the standard deviation of the outcome. ESs foracetaminophen (WOMAC pain, function, and stiffness) and oral NSAIDs (WO-MAC pain) were published in the 2010 OA Research Society Internationalknee OA treatment guidelines. In the 2 trials, effects sizes for WOMAC pain(0.29 and 0.26), WOMAC function (0.28 and 0.39), WOMAC stiffness (0.30and 0.50), and POM (0.27 and 0.40) corresponded to clinically meaningful ef-fects. ESs for acetaminophen were 0.14 for pain, 0.09 for function, and 0.16for stiffness. For oral NSAIDs, the ES for pain was 0.29. These results suggestthat, where comparisons were possible, ES for topical DSG were greater thanES for acetaminophen and similar to oral NSAIDs. Funded by Endo Pharmaceu-ticals Inc. (Baraf et al, Physician Sports Med, 2010; Barthel et al, Sem ArthritisRheum, 2009; Zhang et al, Osteoarthr Cartilage, 2010).

Source: http://pain-medicine.med.nyu.edu/files/pain-medicine/u7/900_S1526590011X00068_S1526590011003129_main.pdf