Two different interventional approaches in the conservative care of radiculopathic low back pain were presented in a poster today at the 28th Annual Meeting of the American Academy of Pain Medicine.

Results from a small study showed that patients receiving interlaminar lumbar epidural steroid injections (LESI), by either the midline (MIL) approach or the parasagittal (PIL) approach had significant improvement in pain relief, quality of life and everyday functionality.

However, the PIL approach was more effective in targeting low back pain with radicular pain that was secondary to lumbar disk disease, compared to the MIL approach. Kenneth D. Candido, Chairman, Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, and Professor of Clinical Anesthesiology at the University of Illinois Hospitals in Chicago reported these results.

A lumbar epidural steroid injection (LESI) is an elective procedure for pain control. “Despite limited evidence for efficacy and long-term improvement in pain and functionality of LESI, this is one of the most commonly performed interventional pain management procedures in the U.S.,” comments Dr. Candido.

The purpose of this study was to evaluate the effect of interlaminar LESI on the quality of life and everyday functionality and to compare the two different approaches, the midline (MIL) approach and the parasagittal interlaminar (PIL) approach.

The two most accepted types of treatments in the conservative care of low back pain with radiculopathy secondary to lumbar disk disease have been the midline approach and the transforminal technique, with the transforminal technique thought to be superior in terms of providing more effective pain relief and more superior analgesia.

However, beginning in 2004, Dr. Candido indicated that they began to hear of several cases where permanent paraplegia and paralysis were associated with the transforminal technique. “This technique does not rely on approaching the interlaminar space but approaches the spine from a lateral aspect where the nerve root foramen is found.

Paralysis occurs because the nerve root has a radicular artery, and if that artery is violated, the medication that is typically injected into the artery can cause an infarction of the spinal cord,” Dr. Candido stated. The parasagittal interlaminar approach was developed to maintain the safety of the midline approach, but enhance the analgesic efficacy of using interlaminar LESI.

In the parasagittal interlaminar approach, the needle is inserted towards the angled corner of the interlaminar space, unlike the midline approach in which the injection is made in the center of the space. If a patient is having right-sided pain, the needle will be inserted into the right corner, and in the left corner for left-sided pain.

After Institutional Review Board approval and written informed consent, 44 adult patients scheduled to undergo LESI for radicular low back pain were randomly assigned to one of two groups. The first group (22 patients) received LESI using the midline (MIL) approach, and the second group (22 patients) received LESI using the parasagittal interlaminar (PIL).

The patients ranged in age from 18 to 80 and had a history of unilateral lumbosacral radiculopathic pain and lumbar disk disease including disk herniations, bulging discs and degenerated discs, where at least 50 percent of the disk height was preserved respective to contiguous levels (based on MRI findings). All patients completed the Oswestry Low Back Pain Questionnaire before injection and on days 1, 7, and 28 after injections.

The Oswestry Questionnaire is designed to give information about how the patients’ back pain affects their ability to manage everyday life. Sections on impairments, such as pain, and abilities that include personal care, lifting, walking, sitting, standing, sleeping, social life, sex life and traveling are included as well.

The injections included 120 mg (2mL) of MPA (Methylprednisolone Acetate) + 1 mL of NSS (normal saline solution, sterile, no preservatives) + 1mL of Lidocaine 1%. The NRS (Numeric Pain Rating Scale) was recorded at rest and during movement 20 minutes before, and on days 1, 7, and 28 after the injection.

The results showed no difference in the basal Oswestry Low Back Pain Score between the PIL and MIL group (21.25+/-7.60 vs. 19.50+/-5.13). Both groups of patients had significant improvement in pain relief, quality of life and everyday functionality. The results showed that the PIL approach was more effective than the MIL approach in targeting low back pain with radicular pain secondary to lumbar disk disease. At day 28, the PIL group had an 11 on the Oswestry Scale, from a starting point of 22 (on a scale from 1 to 50, with 50 being severe pain).

This was not only a statistically significant result but also a clinically significant result. “If we can improve a patient’s overall daily function by about 50 percent and if this improvement can be persistent as it was in this study following a single injection for up to one month’s time, the parasagittal interlaminar approach is a viable alternative to midline injection techniques, and a potentially safer alternative to the transforminal approach,” Dr. Candido concludes.

More information is available at www.painmed.org.

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Ameritox (SM), the nation’s leader in pain medication monitoring, will sponsor a safe opioid prescribing symposium highlighting emerging trends and technologies in medication monitoring at the American Academy of Pain Medicine’s (AAPM) 28th Annual Meeting in Palm Springs, California.

“For clinicians treating the tens of millions of people suffering from chronic pain, helping patients find safe, effective relief is the ultimate priority,” said Dr. Harry Leider, Chief Medical Officer at Ameritox.

The symposium will focus on a new set of expert consensus recommendations, to be presented during a poster session at the meeting, which answer critical questions in pain monitoring. These recommendations are intended to add specifics to previous clinical guidelines, with the goal of providing physicians guidance on how to use urine drug monitoring to improve patient outcomes.

The symposium will also provide attendees with the latest data on the emerging use of urine opioid levels in helping physicians assess patients for adherence to a chronic opioid regimen. This segment will highlight Ameritox research, which resulted in a proprietary monitoring tool, Rx Guardian CD (SM), being made available to clinicians who prescribe opioids to patients with chronic pain to help reduce the risk of opioid misuse, abuse and diversion.

Rx Guardian CD(SM) consists of a reference database of more than 1,000 pain patients who were clinically assessed as adherent to their prescription regimens. It then displays the results to allow physicians to see, at a glance, how a specific patient’s drug monitoring results compare to patients in the database.

“Physicians are on the front lines of both patient care and drug abuse prevention,” Leider said. “Providing tools, supported by quality research, to help physicians evaluate whether their patients take the proper medications as directed should improve patient care and help keep prescription painkillers out of the hands of those who abuse these medications.”

Topics and Faculty include:

New Expert Consensus Recommendations on the Use of Pain Medication Monitoring (Urine Drug Testing)
Steven Passik, PhD and John Peppin, DO, FACP

Use of Urine Opioid Levels to Assist Physician Assessment of Adherence
Harry Leider, MD, FACPE

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