作者：Allison Gandey
出處：WebMD醫學新聞
October 16, 2008 — 研究者指出，醫師必須停止使用盲目技術進行腰椎硬膜外類固醇注射；一篇發表於美國疼痛控制學會第19屆年度臨床會議上的海報，研究者強烈建議醫師，在考慮為病患進行脊椎手術之前，使用腰椎硬膜外類固醇注射，但並不是所有的專科醫師都適合這個正確方法。
作者建議，醫師使用阻力消失法和影像加強劑與lopamidol顯影劑作為神經根病變病患的黃金標準，他們建議應以這個方法取代結果比較不好的盲目技術。
資深作者、賓州費城Hahnemann大學醫院與Drexel醫學院的Saeid Alemo醫師在訪問中表示，不應再使用盲目技術，它會失敗且無法接受。
Alemo醫師與該大學神經外科疼痛門診的Amirali Sayadipour醫師合作，研究371名臨床影像證實為神經根病變的患者。
在這篇回溯研究中，病患年紀為18至89歲，曾經接受過類固醇注射，在監控麻醉照護下進行手術。
放置針頭時使用螢光鏡和阻力消失法；為了確認硬膜外注射，研究者使用0.5 mL的lopamidol顯影劑；每位病患接受5 mL的0.25% bupivacaine混合80 mg 的methylprednisolone。
研究者發現有10.7%的病患不符阻力消失，研究中的整體發病率為5.1%，包括腦脊髓液洩漏引起暫時性頭痛、偶發腦脊髓膜內bupivacaine引起暫時性半身不遂、在6至8小時內恢復、類固醇過敏與高血糖血症。
研究中並未觀察到其他的罕見併發症，包括：
* 腦膜炎
* 硬腦膜上血腫
* 硬腦膜上膿瘍
* 硬腦膜上脂瘤病
* 硬腦膜下血腫
* 對lopamidol過敏。
* 體重增加
* 類固醇肌肉病變
* 對類固醇過敏(高血壓與心搏過速)
* 骨骼無血管壞死
* 骨質疏鬆
* 液體滯留
* Cushing症候群
* 腎上腺皮質高能症
* 類固醇引起的化學性腦膜炎
* 神經根損傷
* 蛛網膜炎
* 視網膜出血
* 急性視網膜壞死
* 氣腦
* 暫時性眼盲
* 死亡或者腦損傷
Alemo醫師向Medscape Neurology & Neurosurgery表示，這不是一個無風險的手術，我們要確保醫師對此有瞭解。
【不是一個無風險的手術】
開業醫師David Glick在被要求提出評論時表示，他擔心的是作者沒有把足夠的新資訊攤在檯面上。
他表示，我們已經在文獻中一再的看到這個，我不確定為何還需要其他的研究來評估腰椎硬膜外類固醇注射的安全性和準確性。
目前服務於美國疼痛處理學會多個委員會的Glick醫師表示，他希望看到醫師花更多時間關心病患，而不是只有影像檢查結果。
我們得把手從病患身上縮回來，停止評估可以怎樣處理疼痛，開始釐清如何一次解決問題；什麼引起疼痛？就是我們要花時間精力聚焦的部份。
對於這些建議，Alemo 醫師回應表示，就像許多海報，我們的海報不是最新的，但我們試著對此技術提供綜合看法，其中有一些資訊的確是新的。
研究者宣稱沒有相關資金上的往來。
美國疼痛控制學會第19屆年度臨床會議：海報9。發表於2008年9月8-11日。
Blind Technique Fails in Lumbar Epidural Steroid Injection
By Allison Gandey
Medscape Medical News
October 16, 2008 — Clinicians should stop using the blind technique for lumbar epidural steroid injections, report researchers. In a poster presented at the American Academy of Pain Management 19th Annual Clinical Meeting, in Nashville, Tennessee, investigators strongly recommended that doctors treat patients with lumbar epidural steroid injection before considering spinal surgery, and they suggested that not all specialists are adopting the correct approach.
The authors recommend that clinicians use the loss-of-resistance technique with an image intensifier and lopamidol injection as a gold standard for patients with radiculopathy. They suggest this should be in place of the blind technique, which has shown suboptimal outcomes.
The blind technique should not be used anymore.
"The blind technique should not be used anymore," senior author Saeid Alemo, MD, from Hahnemann University Hospital and Drexel College of Medicine, in Philadelphia, Pennsylvania, said during an interview. "It fails and is not acceptable."
Working with Amirali Sayadipour, MD, from University Neurosurgical Pain Clinic, in Philadelphia, Dr. Alemo looked at 371 patients with clinical and imaging evidence of radiculopathy.
In this retrospective study, patients ranged in age from 18 to 89 years and had been treated with a steroid injection. The procedure was carried out under monitored anesthesia care.
Fluoroscopy and loss of resistance were used for locating the needle. To confirm epidural injection, the investigators used 0.5 mL of lopamidol contrast medium. Each patient received 5 mL of 0.25% bupivacaine mixed with 80 mg of methylprednisolone.
The researchers detected false loss of resistance in 10.7% of the patients. The total morbidity observed in the study was 5.1% and included cerebrospinal fluid leak that caused transient headache, transient paraplegia due to incidental intrathecal bupivacaine with full recovery in 6 to 8 hours, steroid allergy, and hyperglycemia.
Other rare potential complications were not observed in the study. These include:
Meningitis.
Epidural hematoma.
Epidural abscess.
Epidural lipomatosis.
Subdural hematoma.
Allergic reaction to lopamidol,
Weight gain.
Steroid myopathy.
Hypersensitivity to steroid (hypertension and tachycardia).
Avascular necrosis of bone.
Osteoporosis.
Fluid retention.
Cushing syndrome.
Hypercorticism.
Chemical meningitis due to steroid.
Nerve root injury.
Arachnoiditis.
Retinal hemorrhage.
Acute retinal necrosis.
Pneumocephalus.
Transient blindness.
Death or brain injury.
"This is not a risk-free procedure, and we want to make sure clinicians understand that," Dr. Alemo told Medscape Neurology & Neurosurgery.
Not a Risk-Free Procedure
Asked to comment on these findings, David Glick, DC, who has a practice in Richmond, Virginia, said he is concerned that the authors are not bringing enough new information to the table.
"We've seen this over and over again in the literature, and I'm not sure why we needed another study evaluating the safety and accuracy of lumbar epidural steroid injection," he said.
Dr. Glick, who currently serves on several committees for the American Academy of Pain Management, said he would like to see doctors spend more time reading patients than imaging results.
"We need to get our hands back on the patient and stop evaluating how we can manage pain and start figuring out how we can eliminate it altogether. What is causing the pain? That is where our time and energy should be focused."
Responding to the comments, Dr. Alemo said, "Like every poster, not every aspect of our work is new. But what we have tried to do is offer a comprehensive review of the technique. Some of this is new, and some of it is not."
The researchers have disclosed no relevant financial relationships.
American Academy of Pain Management 19th Annual Clinical Meeting: Poster 9. September 8-11, 2008.
[ 本帖最後由 goodcat1111 於 2008-10-26 09:40 編輯 ] |
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