cervical epidural copy2
TRANSCRIPT
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CERVICAL EPIDURALSTEROIDS FOR CANCERPAIN MANGEMENT
SHORT TERM EXPERIENCE IN
TWO PATIENTSDr.Vikas Gogia,Dr.Seema Misra,Dr.Sushma
Bhatnagar
Presented by-Dr. Siddharth Sharma
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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.
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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
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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.
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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
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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.
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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
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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)
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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).
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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
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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.
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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
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Indications
Severe neuropathic pain associated
with cancerPost-herpetic neuralgiaRadiculopathy, radicular pain, orradiculitisAxial painLumbar stenosis
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Steroids Used
Methylprednisolone 40 mg-80 mg
Triamcinolone 40 mg
Betamethasone 6 mgTechniques:
Interlaminar
transforaminal
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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.
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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.
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COMPLICATIONS ANDADVERSE EFFECTS
Direct Spinal Cord injury
Headache
Infection Bleeding Paraplegia
Nerve root injury Increased blood sugar Hypertension
Pedal edema, CHF
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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.
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Thank
You