Cervical Epidural Copy2

Embed Size (px)

Citation preview

  • 8/3/2019 Cervical Epidural Copy2

    1/20

    CERVICAL EPIDURALSTEROIDS FOR CANCERPAIN MANGEMENT

    SHORT TERM EXPERIENCE IN

    TWO PATIENTSDr.Vikas Gogia,Dr.Seema Misra,Dr.Sushma

    Bhatnagar

    Presented by-Dr. Siddharth Sharma

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    2/20

    Introduction

    An epidural steroid injection (ESI) is a minimally

    invasive procedure that can help relieve neck, arm,

    back, and leg pain caused by inflamed spinal nerves.

    ESIs have been recommended to deliver steroids in amore localized fashion to the area of affected nerve

    roots.They can provide diagnostic and therapeutic

    benefits.

    Cervical ESIs is specialized technique requiring

    expertise or else can be associated with serious

    complications.

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    3/20

    CASE 1

    62 year malec/o pain in left upper limb x 3 monthsk/c/o chronic cervical spondylosis

    MRI spine: spondylotic changes with cordcompression at C5-6 and C6-7PET scan : malignant mass involving superiormediastinum left side, left lung upper lobe, left 1strib and first thoracic vertebra, left upper deepcervical and mediastinal lymph nodesCo-morbidities: DM and COPDNature of pain: severe burning and tingling downthe whole left upper limb

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    4/20

    VAS: 8-9/10Medications: Flexon TDS, Lyrica 150 mg BDPatient admitted to PCU (IRCH AIIMS),was

    started on i.v. Morphine 3mg stat followed by 0.5mg/hr infusion which was later increased to 1mg/hr.No adequate pain relief even after 6 hrs ofincreased rate of infusion.

  • 8/3/2019 Cervical Epidural Copy2

    5/20

    CASE 2

    36 yrs maleC/o: pain over left supraclavicular area and leftarm

    k/c/o metastatic medullary carcinoma of thyroid-2 1/2 yrsSurgery: near total thyroidectomy withsupraclavicular lymph node excision in June07Received 2 cycles of CT in July07Received palliative RT in August08CT chest: Multiple enlarged lymph nodes, insupraclavicular, left axillary and superiormediastinal region

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    6/20

    Nature of pain: severe burning pain with tinglingsensation over left supraclavicular area and leftarm

    Pain was not relieved with Morphine 20 mg 4 hrly,Gabapin 800 mg TDS and Flexon TDS.

    VAS-7/10

    Patient was admitted to PCU and was started on

    Morphine 30mg 4 hrlyPatient still had partial pain relief.

    VAS- 5-6/10.

  • 8/3/2019 Cervical Epidural Copy2

    7/20

    WHAT DID WE DO?

    Cervical epidural catheter was placed in bothpatients at C7-T1 interspace and fixed at skin withcatheter length of 5 cm inside the epidural space

    After negative test dose ,8 ml of 0.125%bupivacaine was given

    Noted 100% pain relief within 5 minutes ofinjection

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    8/20

    First Patient-a 62 yr old male

    pain was relieved for 4 hrs after 1st injectionThen 8 ml of 0.0625% bupivacaine with 80mgmethylprednisolone was given

    Pain was relieved for 8 hrs.Topped up with 8 ml of 0.125% bupivacaine twiceduring the night(12 hrs)Patient was started on morphine 5mg 4 hrly with

    flexon tds, lyrica 75mg BD.(VAS 3/10)Morphinewas titrated upwards to 10mg 4 hrly.Patient was satisfied at discharge. VAS(1/10)

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    9/20

    Second patient- 36 yr old male

    pain was relieved for 2 hrs after initial bolus

    Then 8 ml of 0.0625% bupivacaine with 80 mgmethylprednisolone was given

    Complained of pain after 2 hrsOvernight three top up shots of 8ml of 0.125%bupivacaine was given.(12 hrs).Morphine was started at 20 mg 4 hrly,Gabapentin

    400mg tds and Flexon tds was resumedPatient had adequate pain relief and wasdischarged with above mentioned drugs & doses.(VAS 2/10).

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    10/20

    DISCUSSION

    Both patients had neuropathic pain

    Origin of pain in first patient was

    neuraxialIn Second patient it was plexopathy

    Duration of pain relief was greater in

    first patient

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    11/20

    Reasons:

    1.First patient had radiculopathy andcord compression, both conditions in

    which epidural steroids have a provenrole

    2. First Patient was more educated and

    was able to assess and explain aboutpain relief in better way.

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    12/20

    Epidural steroids

    An epidural steroid injection was first used in 1957for the treatment of sciatica.Lievre, et al. Bull Soc. Med Paris,1957.

    Proposed mechanism of action:Steroids decrease neuropeptides such as calcitoningene related peptide (CGRP) and substance P (sP) thatare involved in neurogenic inflammation.

    Hong D, et al. Pain 1993; 55:171

    It also induces the production of kynurenic acid, apostsynaptic NMDA antagonist

    Marek P, et al Brain Research 1991; 558:163

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    13/20

    Indications

    Severe neuropathic pain associated

    with cancerPost-herpetic neuralgiaRadiculopathy, radicular pain, orradiculitisAxial painLumbar stenosis

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    14/20

    Steroids Used

    Methylprednisolone 40 mg-80 mg

    Triamcinolone 40 mg

    Betamethasone 6 mgTechniques:

    Interlaminar

    transforaminal

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    15/20

  • 8/3/2019 Cervical Epidural Copy2

    16/20

    CONTROVERSIES:1,2 OR 3 ESI?

    Evaluate response after each ESI. Instudies, patients who did not respond to aninitial injection still showed improvement

    after 1 or 2 more ESIs. Total dose for methylprednisolone should

    be approximately 3 mg/kg of body weight

    to prevent excessive salt and waterretention .

    In general, up to 3-4 epidural injectionsmay be performed if clinically indicated.

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    17/20

    Gap between ESI?

    The interval between injections varies withthe steroid preparations used.

    Injected methylprednisolone hasbeen reported to remain in situ forapproximately 2 weeks. The clinician shouldexpect to wait 2 weeks after the injection

    to administer a repeat injection.

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    18/20

    COMPLICATIONS ANDADVERSE EFFECTS

    Direct Spinal Cord injury

    Headache

    Infection Bleeding Paraplegia

    Nerve root injury Increased blood sugar Hypertension

    Pedal edema, CHF

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    19/20

    What need to be done?

    Regarding efficacy of ESIs for the cervical spine,and treatment of upper extremity radicular pain,no randomized, controlled trials have beenperformed to date. eMedicine Specialities,Physical medicine andRehabilitation Therapeutic Modalities Sept2007.Although Retrospective study by Kwon et al sept2007 and prospective study by Sturb et al sept2007 showed effective pain relief in radicularpain of neck. Kwon et al Skeletal Radiol. 2007 May;36(5):431-6, Sturb etal J Vasc Interv Radiol. 2007 Sep;18(9):1151-5

    Recently,Systematic review of the effectivenessof cervical epidurals in the management of chronicneck pain by Benyamin et al Jan 2009showedsignificant effect in relieving chronic intractable

    pain of cervical origin. Benyamin etalPain Physician. 2009 Jan-

    Feb;12(1):137-57.

    http://images.google.co.in/imgres?imgurl=http://services.epnet.com/GetImage.aspx/getImage.aspx%3FImageIID%3D6894&imgrefurl=http://www.ridgeviewmedical.org/HealthInformation/EbscoDetails.aspx%3Ftoken%3D51afbb05-f9d1-4202-819b-75fb766b22f2%26chunkiid%3D217146&usg=__-mQkA33N5Ty2V7I7KrS1qQnWD6s=&h=334&w=394&sz=73&hl=en&start=2&tbnid=CJNVUyZOnoTkCM:&tbnh=105&tbnw=124&prev=/images%3Fq%3Dcervical%2Bepidural%26gbv%3D2%26hl%3Den%26sa%3DG
  • 8/3/2019 Cervical Epidural Copy2

    20/20

    Thank

    You