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      Inyección epidural interlaminar ecoguiada de esteroides: evaluación de rendimiento mediante el método de la suma acumulativa (CUSUM) Translated title: Ultrasound guided interlaminar epidural steroid injection: the cumulative sum method (cusum) for performance evaluation

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          Abstract

          RESUMEN Introducción: El uso de la ecografía para asistir o guiar la realización de procedimientos intervencionistas para tratamiento del dolor crónico se encuentra en crecimiento permanente. La inyección epidural de esteroides utilizando la ecografía en plano y en tiempo real es técnicamente más dificultosa, con curvas de aprendizaje más prolongadas aun en manos experimentadas. El lugar de la ecografía en este tipo de inyecciones aún no se encuentra establecido, debido en parte a la dificultad de detectar una inyección intravascular de la solución. Objetivo: El objetivo de este estudio fue la descripción de la inyección epidural de esteroides interlaminar ecoguiada, en plano y en tiempo real, en pacientes con dolor radicular lumbar. El aprendizaje de la técnica por el investigador principal fue evaluado estadísticamente utilizando el Método de la Suma Acumulativa (CUSUM). Pacientes y métodos: Un total de 25 pacientes con dolor radicular lumbosacro fueron seleccionados para recibir inyecciones epidurales interlaminares de esteroides en posición decúbito dorsal, utilizando la técnica ecoguiada en plano, en tiempo real, en eje corto o transversal. En todos los casos, un epidurograma de control fue realizado previo a la inyección de la solución de esteroides. El rendimiento de la técnica fue estudiado mediante la tasa de éxito de la misma, entendido como éxito a la obtención de un epidurograma sin necesidad de abandonar la técnica ecográfica en un tiempo menor a 10 minutos. El rendimiento del procedimiento fue estadísticamente evaluado por el método de la suma acumulativa (CUSUM), y la curva de aprendizaje aplicando este método fue construida. Resultados: La distancia promedio desde la piel al complejo posterior evaluada por el escaneo ecográfico previo al procedimiento fue de 6,7 ± 1,8 cm. De los 25 procedimientos realizados, en 21 se alcanzó el espacio epidural sin ayuda de la fluoroscopia, en un tiempo promedio de 4,8 ± 1,2 minutos. Esto constituye una tasa de éxito del 84 %. En los cuatro procedimientos restantes el espacio epidural fue alcanzado con éxito mediante el uso complementario de la fluoroscopia. Se alcanzó la tasa de éxito mínima aceptable de 80 % propuesta aplicando el CUSUM después de 12 procedimientos, con un error α igual o menor a 0,1, manteniéndose así hasta el final del estudio. Conclusiones: Hemos demostrado la utilidad de la inyección epidural de esteroides por vía interlaminar ecoguiada, en plano, en tiempo real, en un abordaje paramediano en eje transversal. En un primer intento, el éxito de la misma fue de 84 %. Utilizando el método de la suma acumulativa, un índice de éxito de 80 % con significación estadística fue obtenido luego de 12 procedimientos, manteniéndose el mismo hasta el final del estudio. El lugar de la técnica ecoguiada en plano para la inyección epidural de esteroides como único medio de asistencia requiere de mayor evaluación, así como su papel en la disminución de la irradiación en conjunto con la fluoroscopia.

          Translated abstract

          ABSTRACT Background: Real time ultrasound-guided epidural injections are considered technically more difficult than flouroscopy-guided procedures, with longer learning curves, even in experienced physicians. The cumulative sum (Cusum) method has been shown to be a useful tool to evaluate skill acquisition. The goal of our study was to assess the feasibility of real time, ultrasound guided, paramedian interlaminar epidural steroid injections, in patients with lumbosacral radicular pain. The evaluation of an experienced interventional pain physician´s learning curve of the technique is proposed, utilizing the CUSUM method Patients and methods: The feasibility of the technique was studied by the success rate, which was considered the obtaining of an epidurogram exclusively using the ultrasound guide. For Cusum calculations, 20 % was taken as an acceptable failure rate and 40 % unacceptable failure rate. Results: Between August and December 2020, 25 patients were recruited, 15 females and 10 males. The average age of was 52 ± 12 years. In 21 procedures the epidural space was reached exclusively by ultrasound guide, in an average time of 5 ± 1.6 minutes. This implies a success rate of 84 %. In four procedures the epidural space was successfully achieved with the complementary use of fluroscopy. Using the Cumulative Sum method, the learning curve of the technique could be described on an experienced physician in ultrasound guided procedures. A 80 % success rate with statistical significance was obtained after performing 12 procedures. Conclusion: The "real time" ultrasound guided interlaminar epidural steroid injection in the transverse scan, is a feasibly and relatively easy to learn technique. The Cusum method could be a useful tool to assess skill acquisition in interventional pain medicine.

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          An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations.

          To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain. Systematic assessment of the literature. I. Lumbar Spine • The evidence for accuracy of diagnostic selective nerve root blocks is limited; whereas for lumbar provocation discography, it is fair. • The evidence for diagnostic lumbar facet joint nerve blocks and diagnostic sacroiliac intraarticular injections is good with 75% to 100% pain relief as criterion standard with controlled local anesthetic or placebo blocks. • The evidence is good in managing disc herniation or radiculitis for caudal, interlaminar, and transforaminal epidural injections; fair for axial or discogenic pain without disc herniation, radiculitis or facet joint pain with caudal, and interlaminar epidural injections, and limited for transforaminal epidural injections; fair for spinal stenosis with caudal, interlaminar, and transforaminal epidural injections; and fair for post surgery syndrome with caudal epidural injections and limited with transforaminal epidural injections. • The evidence for therapeutic facet joint interventions is good for conventional radiofrequency, limited for pulsed radiofrequency, fair to good for lumbar facet joint nerve blocks, and limited for intraarticular injections. • For sacroiliac joint interventions, the evidence for cooled radiofrequency neurotomy is fair; limited for intraarticular injections and periarticular injections; and limited for both pulsed radiofrequency and conventional radiofrequency neurotomy. • For lumbar percutaneous adhesiolysis, the evidence is fair in managing chronic low back and lower extremity pain secondary to post surgery syndrome and spinal stenosis. • For intradiscal procedures, the evidence for intradiscal electrothermal therapy (IDET) and biaculoplasty is limited to fair and is limited for discTRODE. • For percutaneous disc decompression, the evidence is limited for automated percutaneous lumbar discectomy (APLD), percutaneous lumbar laser disc decompression, and Dekompressor; and limited to fair for nucleoplasty for which the Centers for Medicare and Medicaid Services (CMS) has issued a noncoverage decision. II. Cervical Spine • The evidence for cervical provocation discography is limited; whereas the evidence for diagnostic cervical facet joint nerve blocks is good with a criterion standard of 75% or greater relief with controlled diagnostic blocks. • The evidence is good for cervical interlaminar epidural injections for cervical disc herniation or radiculitis; fair for axial or discogenic pain, spinal stenosis, and post cervical surgery syndrome. • The evidence for therapeutic cervical facet joint interventions is fair for conventional cervical radiofrequency neurotomy and cervical medial branch blocks, and limited for cervical intraarticular injections. III. Thoracic Spine • The evidence is limited for thoracic provocation discography and is good for diagnostic accuracy of thoracic facet joint nerve blocks with a criterion standard of at least 75% pain relief with controlled diagnostic blocks. • The evidence is fair for thoracic epidural injections in managing thoracic pain. • The evidence for therapeutic thoracic facet joint nerve blocks is fair, limited for radiofrequency neurotomy, and not available for thoracic intraarticular injections. IV. Implantables • The evidence is fair for spinal cord stimulation (SCS) in managing patients with failed back surgery syndrome (FBSS) and limited for implantable intrathecal drug administration systems. V. ANTICOAGULATION • There is good evidence for risk of thromboembolic phenomenon in patients with antithrombotic therapy if discontinued, spontaneous epidural hematomas with or without traumatic injury in patients with or without anticoagulant therapy to discontinue or normalize INR with warfarin therapy, and the lack of necessity of discontinuation of nonsteroidal anti-inflammatory drugs (NSAIDs), including low dose aspirin prior to performing interventional techniques. • There is fair evidence with excessive bleeding, including epidural hematoma formation with interventional techniques when antithrombotic therapy is continued, the risk of higher thromboembolic phenomenon than epidural hematomas with discontinuation of antiplatelet therapy prior to interventional techniques and to continue phosphodiesterase inhibitors (dipyridamole, cilostazol, and Aggrenox). • There is limited evidence to discontinue antiplatelet therapy with platelet aggregation inhibitors to avoid bleeding and epidural hematomas and/or to continue antiplatelet therapy (clopidogrel, ticlopidine, prasugrel) during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic fatalities. • There is limited evidence in reference to newer antithrombotic agents dabigatran (Pradaxa) and rivaroxan (Xarelto) to discontinue to avoid bleeding and epidural hematomas and are continued during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic events. Evidence is fair to good for 62% of diagnostic and 52% of therapeutic interventions assessed. The authors are solely responsible for the content of this article. No statement on this article should be construed as an official position of ASIPP. The guidelines do not represent "standard of care."
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            The construction of learning curves for basic skills in anesthetic procedures: an application for the cumulative sum method.

            This study aimed at constructing learning curves for basic procedural skills in anesthesiology using the cumulative sum method. We recorded 1234 peripheral venous cannulations, 895 orotracheal intubations, 688 spinals, and 344 epidurals performed by residents during the first 10 mo of training. Learning curves for each procedure were constructed by using the cusum method. The number of procedures performed until attainment of acceptable failure rates was calculated. All residents mastered peripheral venous cannulation after 79 +/- 47 procedures. Four of 7 residents attained acceptable failure rates at orotracheal intubation after 43 +/- 33 proce- dures. Seven of 11 residents attained acceptable failure rates at spinal anesthesia after 36 +/- 20 procedures. At epidural anesthesia, 5 of 11 residents attained acceptable failure rates after 21 +/- 11 procedures. The cusum method is a useful tool for objectively measuring performance during the learning phase of basic procedures. The wide interindividual variability in the number of procedures required to be performed before attaining acceptable failure rates suggests that performance should be followed on an individual basis. Learning curves for peripheral venous cannulation, tracheal intubation, and spinal and epidural anesthesia were constructed using the cumulative sum (cusum) method. There was a wide variability in the number of procedures performed until attainment of acceptable failure rates. The cusum method may improve our means of evaluating residents' technical skills.
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              Real-time ultrasound-guided paramedian epidural access: evaluation of a novel in-plane technique.

              Current methods of locating the epidural space rely on surface anatomical landmarks and loss-of-resistance (LOR). We are not aware of any data describing real-time ultrasound (US)-guided epidural access in adults. We evaluated the feasibility of performing real-time US-guided paramedian epidural access with the epidural needle inserted in the plane of the US beam in 15 adults who were undergoing groin or lower limb surgery under an epidural or combined spinal-epidural anaesthesia. The epidural space was successfully identified in 14 of 15 (93.3%) patients in 1 (1-3) attempt using the technique described. There was a failure to locate the epidural space in one elderly man. In 8 of 15 (53.3%) patients, studied neuraxial changes, that is, anterior displacement of the posterior dura and widening of the posterior epidural space, were seen immediately after entry of the Tuohy needle and expulsion of the pressurized saline from the LOR syringe into the epidural space at the level of needle insertion. Compression of the thecal sac was also seen in two of these patients. There were no inadvertent dural punctures or complications directly related to the technique described. Anaesthesia adequate for surgery developed in all patients after the initial spinal or epidural injection and recovery from the epidural or spinal anaesthesia was also uneventful. We have demonstrated the successful use of real-time US guidance in combination with LOR to saline for paramedian epidural access with the epidural needle inserted in the plane of the US beam.
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                Author and article information

                Journal
                dolor
                Revista de la Sociedad Española del Dolor
                Rev. Soc. Esp. Dolor
                Inspira Network Group, S.L (Madrid, Madrid, Spain )
                1134-8046
                February 2022
                : 29
                : 1
                : 21-27
                Affiliations
                [1] Montevideo orgnameFacultad de Medicina. UDELAR orgdiv1Hospital de Clínicas orgdiv2Departamento y Cátedra de Anestesiología Uruguay
                Article
                S1134-80462022000100021 S1134-8046(22)02900100021
                10.20986/resed.2022.3988/2022
                52fa02c2-99d9-4f86-9088-d402cb0e4024

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

                History
                : 07 July 2022
                : 24 April 2022
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 14, Pages: 7
                Product

                SciELO Spain

                Categories
                Originales

                CUSUM,Esteroides epidurales,inyecciones ecoguiadas,ultrasound guide injections,Epidural steroid injections

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