Variations in Epidural Steroid Injection Practice Patterns by Pain Medicine Physicians in the United States
Bingham, Nishan; Dhall, Raymon; Montuori, Michael; Padjen, Kristoffer; Gharibo, Christopher; Doan, Lisa
BACKGROUND:Epidural steroid injections (ESI) are one of the most commonly performed pain procedures; however, there has been variation in techniques and approaches amongst pain physicians in the United States. The formation of a multidisciplinary working group was made with considerations to help guide ESI practice. OBJECTIVE:Pain medicine physicians in the United States were surveyed in order to provide an update on current practices for both transforaminal and interlaminar ESI. STUDY DESIGN AND SETTING/METHODS:This was a cross-sectional survey of pain medicine physicians in the United States. METHODS:This study was approved by the institutional review board of our institution. Based on the American Society of Interventional Pain Physicians membership database, an email list was generated, and a web-based survey was sent to interventional pain physicians at academic centers, private practices, government hospitals, and community settings across the United States. Cervical, lumbar, and caudal ESI sections were divided into questions regarding preferences for fluoroscopic views, injectates, and techniques. RESULTS:A total of 261 responses were analyzed. All but one used fluoroscopy for lumbar ESI. There were variations in methods to detect intravascular uptake, choice of injectate, and the use of particulate steroids for lumbar transforaminal epidural steroid injection (TFESI). LIMITATIONS/CONCLUSIONS:The response rate is a limitation, and thus the results may not be representative of all pain medicine physicians in the United States. CONCLUSIONS:Since the 2015 multidisciplinary pain workgroup recommendations were made for ESI, there appears to be a trend towards following these guidelines compared to prior surveys looking at ESI practices. However, our survey shows there continues to be variations in ESI practice that deviates from these guidelines.
Relation between preoperative benzodiazepines and opioids on outcomes after total joint arthroplasty
Doan, Lisa V; Padjen, Kristoffer; Ok, Deborah; Gover, Adam; Rashid, Jawad; Osmani, Bijan; Avraham, Shirley; Wang, Jing; Kendale, Samir
To examine the association of preoperative opioids and/or benzodiazepines on postoperative outcomes in total knee and hip arthroplasty, we retrospectively compared postoperative outcomes in those prescribed preoperative opioids and/or benzodiazepines versus those who were not who underwent elective total knee and hip arthroplasty at a single urban academic institution. Multivariable logistic regression was performed for readmission rate, respiratory failure, infection, and adverse cardiac events. Multivariable zero-truncated negative binomial regression was used for length of stay. After exclusions, there were 4307 adult patients in the study population, 2009 of whom underwent total knee arthroplasty and 2298 of whom underwent total hip arthroplasty. After adjusting for potential confounders, preoperative benzodiazepine use was associated with increased odds of readmission (pâ€‰<â€‰0.01). Preoperative benzodiazepines were not associated with increased odds of respiratory failure nor increased length of stay. Preoperative opioids were not associated with increased odds of the examined outcomes. There were insufficient numbers of infection and cardiac events for analysis. In this study population, preoperative benzodiazepines were associated with increased odds of readmission. Preoperative opioids were not associated with increased odds of the examined outcomes. Studies are needed to further examine risks associated with preoperative benzodiazepine use.
Preoperative Long-Acting Opioid Use Is Associated with Increased Length of Stay and Readmission Rates After Elective Surgeries
Doan, Lisa V; Wang, Jing; Padjen, Kristoffer; Gover, Adam; Rashid, Jawad; Osmani, Bijan; Avraham, Shirley; Kendale, Samir
OBJECTIVES/OBJECTIVE:To compare postoperative outcomes in patients prescribed long-acting opioids vs opioid-naÃ¯ve patients who underwent elective noncardiac surgeries. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Single urban academic institution. METHODS AND SUBJECTS/METHODS:We retrospectively compared postoperative outcomes in long-acting opioid users vs opioid-naÃ¯ve patients who underwent elective noncardiac surgeries. Inpatient and ambulatory surgery cohorts were separately analyzed. Preoperative medication lists were queried for the presence of long-acting opioids or absence of opioids. Multivariable logistic regression was performed to analyze the impact of long-acting opioid use on readmission rate, respiratory failure, and adverse cardiac events. Multivariable zero-truncated negative binomial regression was used to examine length of stay. RESULTS:After exclusions, there were 93,644 adult patients in the study population, 23,605 of whom underwent inpatient surgeries and 70,039 of whom underwent ambulatory surgeries. After adjusting for potential confounders and inpatient surgeries, preoperative long-acting opioid use was associated with increased risk of prolonged length of stay (incidence rate ratioâ€‰=â€‰1.1, 99% confidence interval [CI]â€‰=â€‰1.0-1.2, Pâ€‰<â€‰0.01) but not readmission. For ambulatory surgeries, preoperative long-acting opioid use was associated with increased risk of all-cause as well as pain-related readmission (odds ratio [OR]â€‰=â€‰2.1, 99% CIâ€‰=â€‰1.5-2.9, Pâ€‰<â€‰0.001; ORâ€‰=â€‰2.0, 99% CIâ€‰=â€‰0.85-4.2, Pâ€‰=â€‰0.02, respectively). There were no significant differences for respiratory failure or adverse cardiac events. CONCLUSIONS:The use of preoperative long-acting opioids was associated with prolonged length of stay for inpatient surgeries and increased risk of all-cause and pain-related readmission for ambulatory surgeries. Timely interventions for patients on preoperative long-acting opioids may be needed to improve these outcomes.
Variations of Technique in Transforaminal Epidural Steroid Injections and Periprocedural Practices by Interventional Pain Medicine Physicians in the United States
Doan, Lisa V; Narvaez, Francisco; Fakhry, Michael; Padjen, Kristoffer; Gharibo, Christopher G
BACKGROUND:Interlaminar and transforaminal epidural steroid injections (ILESI and TFESI) are commonly performed procedures. However, the United States Food and Drug Administration has required the addition of drug warning labels for injectable corticosteroids. Updated evidence and scrutiny from regulatory agencies may affect practice patterns. OBJECTIVE:To characterize TFESI practices as well as to provide an update on periprocedural practices for any type of epidural steroid injection (ESI), we surveyed pain medicine physicians in the United States. STUDY DESIGN AND SETTING/METHODS:This was a cross-sectional survey of pain medicine physicians in the United States. METHODS:A web-based survey was distributed to pain medicine physicians in the United States selected from the Accreditation Council for Graduate Medical Education accredited pain medicine fellowship program list as well as the American Society of Interventional Pain Physicians membership database. Physicians were queried about TFESI practices, including needle size, use of image guidance, methods to detect vascular uptake, and preference for injectate. RESULTS:A total of 249 responses were analyzed. Only a minority of respondents reported performing cervical TFESI. There were variations in needle size, methods to detect vascular uptake, and choice of injectate. There were also variations in monitoring practices. LIMITATIONS/CONCLUSIONS:The response rate is a limitation. Thus the results may not be representative of all US pain medicine physicians. CONCLUSIONS:Though all respondents used image guidance for TFESI, variations in other TFESI practices exist. There are also differences in periprocedural practices. Since the closure of this survey, a multisociety pain workgroup published recommendations regarding ESI practices. Our survey findings support the need for more evidence-based guidelines regarding ESI. KEY WORDS/UNASSIGNED:Epidrual steroid injections, transforaminal epidural steroid injection, steroids, local anesthetic, survey, interventional pain.
Chapter by: Padjen, Kristoffer; Maddalo, Scott; Milord, Patrick; Goldfeiz, Chaim; Otterbeck, Robert; Gharibo, Christopher
in: Academic pain medicine : a practical guide to rotations, fellowship, and beyond by Khelemsky, Yury; et al [Eds]
Cham, Switzerland : Springer, 
ASSOCIATION BETWEEN PREOPERATIVE OPIOID AND BENZODIAZEPINE USE AND POSTOPERATIVE OUTCOMES IN JOINT ARTHROPLASTY [Meeting Abstract]
Doan, Lisa; Padjen, Kristoffer; Gover, Adam; Rashid, Jawad; Osmani, Bijan; Avraham, Shirley; Kendale, Samir
"What was that?" mysterious vascular structure during interlaminar epidural steroid injection [Meeting Abstract]
Swallow, N; Choxi, A A; Khan, F; Padjen, K
Background: Epidural steroid injections (ESI) are a common spine intervention. Serious complications such as paralysis, paraplegia, and death have been documented. Mechanisms proposed for these injuries involve vascular structures surrounding the spinal cord . While epidural veins are present throughout the epidural space, arteries supplying the spinal cord enter laterally through the vertebral foramina and are thought to not be present in the epidural space.
Objective(s): To report a case of suspected arterial vascular uptake during interlaminar ESI. Case Description: A 50 year-old female presented for L4-5 interlaminar ESI. The epidural space was identified by loss of resistance to air, and aspiration was negative for CSF or blood. Contrast was injected with good craniocaudal spread, but also with significant suspected vascular uptake. The vasculature was large in caliber, extra-spinal, and with rapid uptake and washout of contrast. The needle was withdrawn and the procedure repeated at L5-S1, with no vascular uptake and dexamethasone was given. The patient reported no complications related to the procedure.
Discussion(s): Fluoroscopy is a common tool used to avoid intravascular injection during ESI . Arterial injection can be disastrous as vascular injury, spasm, or embolus from particulate steroid can lead to spinal cord ischemia . Even though the procedure was repeated at a different level, the decision to use dexamethasone, rather than methylprednisolone, was made to reduce risk of arterial embolic event. The vascular system within the epidural space involves the internal vertebral venous plexi, and in the absence of anatomic pathology or aberrancy, should be devoid of any large arterial structures. Theoretically, an interlaminar approach avoids the arteries that are inherent to the procedural anatomy of transforaminal injections. This case provides an example where potential intraarterial injection is avoided through use of fluoroscopy during an ESI where arterial structures are typically not present
DNA methylation precedes chromatin modifications under the influence of the strain-specific modifier Ssm1
Padjen, Kristoffer; Ratnam, Sarayu; Storb, Ursula
Ssm1 is responsible for the mouse strain-specific DNA methylation of the transgene HRD. In adult mice of the C57BL/6 (B6) strain, the transgene is methylated at essentially all CpGs. However, when the transgene is bred into the DBA/2 (D2) strain, it is almost completely unmethylated. Strain-specific methylation arises during differentiation of embryonic stem (ES) cells. Here we show that Ssm1 causes striking chromatin changes during the development of the early embryo in both strains. In undifferentiated ES cells of both strains, the transgene is in a chromatin state between active and inactive. These states are still observed 1 week after beginning ES cell differentiation. However, 4 weeks after initiating differentiation, in B6, the transgene has become heterochromatic, and in D2, the transgene has become euchromatic. HRD is always expressed in D2, but in B6, it is expressed only in early embryos. The transgene is already more methylated in B6 ES cells than in D2 ES cells and becomes increasingly methylated during development in B6, until essentially all CpGs in the critical guanosine phosphoribosyl transferase core are methylated. Clearly, DNA methylation of HRD precedes chromatin compaction and loss of expression, suggesting that the B6 form of Ssm1 interacts with DNA to cause strain-specific methylation that ultimately results in inactive chromatin.