September 14, 2022
2 minutes to read
Source / Disclosures
Christo BJ. A Landscape of Wonders: Injections, Neuronal Blocks, Pumps, and Neuromodulation. Filed At: PAINWeek; Las vigas; September 9-12, 2022.
Christo reports financial relationships with Eli Lilly, Exicure, GlaxoSmithKline Consumer Healthcare, Neurana, Neumentum, and Y mAbs.
LAS VEGAS – CDC guidelines issued in response to the opioid crisis have led many healthcare providers to reduce or eliminate pain control with opioids, Paul J. Christo, MD, MBAhe said at PAINWeek 2022.
“The guidelines suggested non-drug therapies and non-opioid treatments,” said Christo, MD, assistant professor of anesthesiology and critical care medicine at Johns Hopkins Medicine. “We’ve seen interest in procedural interventions and the number of procedural interventions being performed.”
The Centers for Disease Control (CDC) recommendations for non-pharmacological measures include exercise, weight loss, psychological, and sleep interventionsand procedures, he said.
“The injections can be helpful,” Christo said. “We do it for the therapeutic value, the diagnostic value, the predictive value and the outlook.”
Christo suggested an epidural steroid injection (ESI) as an alternative pain management option.
He indicated the use of ESI in cases of neck, back, leg, arm or chest pain. The source is nerve root irritation, compression, or spinal stenosis from herniated discs or spinal stenosis.
Candidates for ESI include, “Patients with radicular pain due to herniated nucleus pulposus, patients with pain of shorter duration, more leg pain than back pain, intermittent pain, and young [age]Christo said.
Those with pain lasting longer than 6 months, degenerative disc disease or spinal stenosisback pain more than leg pain, poor imaging correlation, failure of interventions, persistent pain, unemployment due to pain and psychological overlap have unfavorable prognosis.
“Guidelines for when to give ESI suggest using conservative treatments first, such as acetaminophen and exercise,” Christo said.
Acute pain is considered pain that lasts from 4 to 6 weeks; He said that after 12 weeks the illness is chronic.
Christo said that sixty percent of more than 40 clinical trials indicate that ESI has short-term benefits.
He said, “For acute pain, engage with conservative treatments, but, personally, if I had radicular pain, I would have these treatments earlier. Leg pain that lasts for a month is not easy to deal with.”
Side effects tend to be minimal and include a headache after the injection and some nausea.
“The risk of a postdural hole is very low,” he said. People with diabetes may see elevated blood sugar levels. Based on retrospective studies, there is a slightly increased risk of vertebral fractures.”
Christo said he is not aware of any consistent guidelines or randomized clinical trials that address recurrence.
“Some will say no more than three injections in the same place in a 12-month period,” he said. This is due to the risk of hypothalamic-pituitary-adrenal axis suppression, which can lead to complications. There is no consensus. I’d keep it at four a year if I could.
“Also with ESI, we don’t have guidelines on the dosage of steroids and which ones,” he continued. “It’s a combination. We don’t have randomized clinical trials on how to do these ideal doses.”
Christo also discussed facial blocks, radiofrequency denervation, sacroiliac joint injections, neuromodulation, spinal cord stimulation, dorsal root ganglion stimulation, peripheral nerve stimulation, and intrathecal drug delivery as other alternatives to opiates.