Publications by authors named "Ameet Nagpal"

26 Publications

  • Page 1 of 1

Simplicity Radiofrequency Ablation Demonstrates Greater Functional Improvement Than Analgesia: A Prospective Case Series.

Pain Physician 2021 Mar;24(2):E185-E190

Department of Anesthesiology, UT Health San Antonio, San Antonio, TX.

Background: Pain originating from the posterior sacroiliac complex is notoriously difficult to effectively treat due to its complex anatomy and variable innervation. Data on radiofrequency ablation (RFA) is limited. The Abbott Simplicity probe creates 3 monopolar lesions along the medial aspect of the sacroiliac joint and 2 bipolar lesions between the active portions of the probe. This device has been studied previously with improvement of pain-associated disability and pain reduction, but insufficient data is present to determine its utility at this time. Using the most recent literature for the potential innervation of the posterior sacroiliac joint, it is reasonable to explore this novel device and its ability to treat sacroiliac joint pain.

Objectives: Identify the percentage of improved posterior sacroiliac complex pain and improved function in patients who completed posterior sacroiliac complex radiofrequency ablation using the Simplicity probe.

Study Design: Prospective case series.

Setting: A single outpatient pain clinic.

Methods: This prospective case-series occurred at an outpatient pain clinic. Data were analyzed after completion of follow-up appointments. Inclusion criteria included 2 successful lateral branch blocks. Fourteen patients with posterior sacroiliac complex pain were examined and completed sacroiliac ablation with the Simplicity probe. The numeric rating scale and the Modified Oswestry Disability Index were used as outcome measures for pain and function, respectively. The primary outcome measures were improvement in the numeric rating scale score by a reduction of 2.5 points and an improvement in Modified Oswestry Disability Index by 15% based upon previous studies demonstrating these values as the minimal clinical important difference . Patients were followed at a 3 to 6 month interval and 12 month interval (an average of 88 and 352 days, respectively).

Results: In total, 14 patients were examined. At the first follow-up, 29% of patients had analgesia and 38% functionally improved. At the second follow-up, 15% of patients had analgesia and 31% functionally improved.

Limitations: Considering data were collected retrospectively, this study relied on completed charts. Therefore, data points of interest were limited to what was previously documented, which included multiple answers or the absence of numerical data points. In addition, patients were disproportionately female (71.4%). Data were also affected by patients lost to follow-up. Also, this study examined a relatively small number of patients, therefore the results should be carefully considered.

Conclusions: Radiofrequency ablation of the posterior sacroiliac complex with the Simplicity probe resulted in more functional improvement than analgesia. This study provides more data for clinicians to utilize in managing posterior sacroiliac complex pain. IRB: Protocol number 20170342HU. Not registered in clinical trials.
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March 2021

Diabetic Neuropathy: a Critical, Narrative Review of Published Data from 2019.

Curr Pain Headache Rep 2021 Feb 25;25(3):15. Epub 2021 Feb 25.

Department of Anesthesiology, Joe R. & Thereza Lozano Long School of Medicine, UT Health San Antonio, San Antonio, TX, USA.

Purpose Of Review: This manuscript is a systematic, narrative review that compiles and describes all data available from 2019 related to epidemiologic, diagnostic, and therapeutic advances in diabetic neuropathy (DN).

Recent Findings: Epidemiology of DN is discussed. Diagnostic modalities include predictive models, electrodiagnostics, imaging, and biomarkers. A majority of studies on the treatment of diabetic peripheral neuropathy (DPN) involve pharmacotherapy, but complementary and alternative medicine, exercise, modalities, psychological, interventional, and surgical options are also explored. DN is a highly prevalent and debilitating consequence of diabetes that can present challenges to the clinician as the assessment is largely subjective with different phenotypic presentations among patients. Treatment of DN is largely symptomatic as the pathogenesis of DN is not fully understood and is likely multifactorial. It is evident from the broad range of treatments that too often provide unsatisfactory relief that there is no consensus about a single most effective treatment for DN, and monotherapy rarely proves to be successful.
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http://dx.doi.org/10.1007/s11916-020-00928-xDOI Listing
February 2021

Do Corticosteroid Injections for the Treatment of Pain Influence the Efficacy of mRNA COVID-19 Vaccines?

Pain Med 2021 04;22(4):994-1000

University of Utah, Division of Physical Medicine and Rehabilitation, Salt Lake City, Utah, USA.

Myth: Corticosteroid injection for the treatment of pain and inflammation is known to decrease the efficacy of the messenger ribonucleic acid (mRNA) vaccines for coronavirus disease 2019 (COVID-19).

Fact: There is currently no direct evidence to suggest that a corticosteroid injection before or after the administration of an mRNA COVID-19 vaccine decreases the efficacy of the vaccine.However, based on the known timeline of hypothalamic-pituitary-adrenal (HPA) axis suppression following epidural and intraarticular corticosteroid injections, and the timeline of the reported peak efficacy of the Pfizer-BioNTech and Moderna vaccines, physicians should consider timing an elective corticosteroid injection such that it is administered no less than 2 weeks prior to a COVID-19 mRNA vaccine dose and no less than 1 week following a COVID-19 mRNA vaccine dose, whenever possible.
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http://dx.doi.org/10.1093/pm/pnab063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928682PMC
April 2021

Complementary and Alternative (CAM) Treatment Options for Women with Pelvic pain.

Curr Phys Med Rehabil Rep 2020 Sep 23;8(3):240-248. Epub 2020 May 23.

UT Health San Antonio, Department of Anesthesiology, Associate Professor, Department of Anesthesiology, Medical Director, UT Health San Antonio Pain Consultants, Associate Program Director, UT Health San Antonio Pain Medicine Fellowship.

Purpose Of Review: I.To provide an overview of the current complementary and alternative (CAM) treatment options for women with chronic pelvic pain (CPP).

Recent Findings: II.Recent studies on chronic pain at cellular, molecular and network level and their interaction with the immune system has unfolded several mechanisms for pain making it promising to explore the alternative paradigm to manage the incredibly complex chronic pelvic pain condition where multifactorial etiology often limits successful outcomes.

Summary: III.The multifactorial nature and complexity in establishing the underlying diagnosis in CPP limits predictable response to traditional medical and interventional options. Complementary and alternative options have been studied to improve outcomes. Incorporation of exercise-based CAM, pelvic floor physical therapy, acupuncture and cognitive behavioral therapy are suggested to show promising results but well powered randomized studies are needed to draw conclusions on their efficacy. Evidence for non-opioid alternatives such as oral cannabinoids are preliminary and may emerge to be safe and effective.
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http://dx.doi.org/10.1007/s40141-020-00264-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7879565PMC
September 2020

Innervation of the Posterior Hip Capsule: A Cadaveric Study.

Pain Med 2021 Feb 10. Epub 2021 Feb 10.

Department of Anesthesiology, UT Health San Antonio Joe R. & Theresa Lozano Long School of Medicine.

Objective: Recent studies of hip anatomy have turned to the posterior hip capsule to better understand the anatomic location of the posterior capsular sensory branches and identify nerves with potential for neural blockade. Current literature has shown the posterior hip capsule is primarily supplied by branches from the sciatic nerve, nerve to quadratus femoris, and superior gluteal nerve (1, 2). This cadaveric study investigated the gross anatomy of the posterior hip, while also identifying potential targets for hip analgesia, with emphasis on the superior gluteal nerve and nerve to quadratus femoris.

Design: Cadaveric study.

Setting: University of Texas Health San Antonio Anatomy Lab.

Methods: 10 total cadavers (18 hips total), were posteriorly dissected identifying nerve to quadratus femoris, superior gluteal nerve, and sciatic nerve. Nerves were labeled with radio-opaque markers. Following the dissections, fluoroscopic images were obtained as sequential angles to identify neural anatomy and help expand anatomic knowledge for interventional pain procedures.

Results: The posterior hip capsule was supplied by the sciatic nerve in 1/16 hips, the nerve to quadratus femoris in 15/18 hips, and the superior gluteal nerve in 6/18 hips.

Conclusions: The nerve to quadratus femoris reliably innervates the posterior hip joint. Both the sciatic nerve and superior gluteal nerve may have small articular branches that may be involved in posterior hip innervation, but not this is not seen commonly. The results of this study may elucidate novel therapeutic targets for treatment of chronic refractory hip pain (i.e., the nerve to quadratus femoris).
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http://dx.doi.org/10.1093/pm/pnab057DOI Listing
February 2021

Interventional treatment options for women with pelvic pain.

Curr Phys Med Rehabil Rep 2020 Sep 14;8(3):229-239. Epub 2020 May 14.

Attending physician, Rothman Orthopedics Institute, Clinical Assistant Professor/Clinical Educator track, Department of Physical Medicine and Rehabilitation, Sidney Kimmel Medical College at Thomas Jefferson University.

Purpose Of Review: I.To provide an overview of current interventional treatment options for women with chronic pelvic pain (CPP).

Recent Findings: II.Accessibility of CT imaging, ultrasound, and fluoroscopy have assisted the development of novel interventional techniques. Similarly, neuromodulation techniques have improved with the development of novel stimulation patterns and device implants.

Summary: III.Numerous small-scale studies report high success rates with injection intervention therapies in CPP but there are limited well designed large-scale studies that demonstrate superiority of treatment. Female pelvic pain is difficult to diagnose due to the multifactorial etiology and the variable presentation causing delay in accurate diagnosis and lack of response to conventional medical and initial interventional therapies. Despite the shortfalls of current studies, collectively our understanding of chronic pain conditions and helpful injection interventions are improving. Undoubtedly the breadth of current research will provide a rich foundation for future large-scale well-designed studies involving multiple disciplines with more uniform methods and criteria to produce reliable and reproducible results.
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http://dx.doi.org/10.1007/s40141-020-00265-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7863981PMC
September 2020

The role of identity in chronic pain cognitions and pain-related disability within a clinical chronic pain population.

Int J Psychiatry Med 2021 Jan 24:91217421989141. Epub 2021 Jan 24.

Department of Psychiatry, University of Texas - Health Science Center at San Antonio, San Antonio, TX, USA.

Objective: Chronic pain has a significant impact on functioning and results in the disruption of one's assumed life trajectory, potentially altering their self-perceived identity. The present research is designed to determine whether identity-related issues are associated with common chronic pain cognitions and pain-related disability, which may help inform understanding of clinical chronic pain populations.

Method: Ninety-eight adult chronic pain patients were assessed at a local pain clinic during a regularly scheduled appointment focusing on pain management. Multivariate hierarchal regression was used to determine whether issues related to identity and death anxiety were associated with pain catastrophizing, pain acceptance, and pain-related disability, above and beyond pain severity, fear-avoidance, and age.

Results: Self-concept clarity was significantly related to pain catastrophizing and pain acceptance, above and beyond death anxiety, pain severity, fear-avoidance, and age. Death anxiety was associated with pain catastrophizing, pain acceptance, and pain-related disability above and beyond pain severity, fear-avoidance, and age.

Conclusions: To the best of our knowledge, the present study is the first examination of self-concept clarity and death anxiety as they relate to pain catastrophizing, pain acceptance, and pain-related disability. These descriptive results support the inclusion of identity and death anxiety within the pain experience and could serve as a foundation for future directions relevant to clinical applications.
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http://dx.doi.org/10.1177/0091217421989141DOI Listing
January 2021

The Effectiveness of Dorsal Root Ganglion Neurostimulation for the Treatment of Chronic Pelvic Pain and Chronic Neuropathic Pain of the Lower Extremity: A Comprehensive Review of the Published Data.

Pain Med 2021 02;22(1):49-59

Department of Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.

Objective: To evaluate the effectiveness of dorsal root ganglion neurostimulation for the treatment of refractory, focal pain in the pelvis and lower extremities.

Design: Systematic review.

Outcome Measures: The primary outcome was ≥50% pain relief. Secondary outcomes were physical function, mood, quality of life, opioid usage, and complications.

Results: One pragmatic randomized controlled trial, four prospective cohort studies, and eight case series met the inclusion criteria. A worst-case scenario analysis from the randomized controlled trial reported ≥50% pain relief in 74% of patients with dorsal root ganglion neurostimulation vs. 51% of patients who experienced at least 50% relief with spinal cord stimulation at 3 months. Cohort data success rates ranged from 43% to 83% at ≤6 months and 27% to 100% at >6 months. Significant improvements were also reported in the secondary outcomes assessed, including mood, quality of life, opioid usage, and health care utilization, though a lack of available quantitative data limits further statistical analysis. Complication rates vary, though the only randomized controlled trial reported a higher rate of adverse events than that seen with traditional neurostimulation.

Conclusions: In accordance with the Grades of Recommendation, Assessment, Development, and Evaluation system, low-quality evidence supports dorsal root ganglion neurostimulation as a more effective treatment than traditional neurostimulation for pain and dysfunction associated with complex regional pain syndrome or causalgia. Very low-quality evidence supports dorsal root ganglion neurostimulation for the treatment of chronic pelvic pain, chronic neuropathic groin pain, phantom limb pain, chronic neuropathic pain of the trunk and/or limbs, and diabetic neuropathy.
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http://dx.doi.org/10.1093/pm/pnaa369DOI Listing
February 2021

Current Trends in the Use of Sedation During Spine Intervention Procedures: A Survey Study.

Pain Med 2020 05;21(5):1086-1088

Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA.

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http://dx.doi.org/10.1093/pm/pnz194DOI Listing
May 2020

Serious Complications Associated with Interventional Spine Procedures-Results of a Spine Intervention Society Survey.

Pain Med 2020 03;21(3):651-653

Division of Physical Medicine and Rehabilitation, University of Utah Medical Center, Salt Lake City, Utah.

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http://dx.doi.org/10.1093/pm/pnz135DOI Listing
March 2020

Trends in steroid agent and diluent choices for epidural steroid injections: a survey of Spine Intervention Society physicians.

Reg Anesth Pain Med 2019 May 24. Epub 2019 May 24.

Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA.

Background: Epidural steroid injections (ESIs) are a frequently used treatment for refractory radicular spinal pain. ESIs, particularly transforaminal epidural steroid injections (TFESI), may provide pain relief and delay the need for surgery. Corticosteroid agent and diluent choices are known to impact the safety of ESIs. In particular, the risk of embolization with particulate corticosteroids has led to recommendations for non-particulate steroid use by the Multisociety Pain Workgroup. Additionally, there is in vitro evidence that ropivacaine can crystalize in the presence of dexamethasone, potentially creating a particulate-like injectate. Despite widespread use and known risk mitigation strategies, current practice trends related to steroid and diluent choices are unknown.

Objective: Identify the use of particulate versus non-particulate corticosteroids for epidural steroid injections in the cervical and lumbar spine, as well as local anesthetics commonly used as diluents during these procedures.

Methods: Cross-sectional survey study of 314 physician members of the Spine Interventional Society.

Results: 41% and 9% of providers reported using particulate corticosteroids during lumbar TFESIs and cervical TFESI, respectively. Four per cent of providers reported the use of ropivacaine in cervical TFESIs. Forty-four per cent of respondents reported using anesthetic in cervical interlaminar ESIs. 21% of providers report using high volumes (> 4.5 mL) during cervical interlaminar ESIs.

Conclusion: Current trends, as assessed by this survey study, indicate substantial variability in steroid and diluent choice for ESIs. Patterns were identified that may impact patient safety including the continued use of particulate corticosteroids for TFESIs and the use of ropivacaine during TFESIs by a subset of respondents.
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http://dx.doi.org/10.1136/rapm-2018-100366DOI Listing
May 2019

Current Trends in Steroid Dose Choice and Frequency of Administration of Epidural Steroid Injections: A Survey Study.

PM R 2020 01 11;12(1):49-54. Epub 2019 Sep 11.

Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, UT.

Background: Epidural steroid injections (ESI) are commonly used to treat refractory radicular spinal pain. Although evidence suggests that an increasing cumulative dose of exogenous corticosteroid may be harmful, knowledge of current practice patterns is limited regarding the choice of dose and frequency of epidural steroid injections (ESIs).

Objective: Describe current practice trends in the dose selection and frequency of administration of transforaminal ESIs (TFESIs) and interlaminar ESIs (ILESIs).

Design: Cross-sectional survey study.

Setting: Not applicable.

Participants: Three hundred fourteen physician members of the Spine Intervention Society (SIS). From May to June 2018, an online survey was distributed to 5907 physician members of the SIS.

Interventions: Not applicable.

Main Outcome Measures: Corticosteroid dose used by practitioners and the number of annual ESIs administered per patient.

Results: Three hundred fourteen physicians responded to the survey. For single cervical or lumbar injections of dexamethasone, most physicians (56.0%) reported using 10 mg; 17% of physicians reported use of doses greater than 10 mg, with 6% using a dose of 20 mg per injection level. The most common particulate corticosteroid dose used during both cervical and lumbar ILESIs was 80 mg (cervical = 55.4%, lumbar = 54.7%). During cervical and lumbar ILESIs, 17% and 12.7% of physicians reported using doses greater than 80 mg, respectively. Almost 10% of physicians reported performing cervical TFESIs with particulate steroids. Forty percent of physicians reported allowing four ESIs at a given spinal segmental level per year (cervical/thoracic/lumbosacral). A small percentage of physicians reported allowing more than six ESIs annually (6%) and >10 injections annually (1%).

Conclusions: There is considerable variability among this large cohort of interventionists with regard to corticosteroid dose selection and epidural steroid injection frequency. A small proportion of respondents reported Mulitsociety Pain Workgroup guideline-discordant use of particulate steroids during cervical TFESIs. These findings demonstrate a need for additional research regarding both the reasons for such variation in care and the reasons for guideline-discordant practice in a subset of physicians.

Level Of Evidence: IV.
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http://dx.doi.org/10.1002/pmrj.12192DOI Listing
January 2020

Current Practice Trends in Image Guidance During Lumbar and Cervical Transforaminal Epidural Steroid Injections.

Pain Med 2019 11;20(11):2327-2329

Division of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA.

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http://dx.doi.org/10.1093/pm/pnz065DOI Listing
November 2019

American Academy of Physical Medicine and Rehabilitation Position Statement on Opioid Prescribing.

PM R 2018 06 16;10(6):681-683. Epub 2018 May 16.

Pain Management and Opioid Task Force Chair and Shepherd Center Spine and Pain Institute, Atlanta, GA.

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http://dx.doi.org/10.1016/j.pmrj.2018.05.004DOI Listing
June 2018

Maintaining Opioid Prescription for Chronic Back Pain: Pro Versus Con.

PM R 2018 01;10(1):83-89

Departments of Anesthesiology and PM&R, UT Health San Antonio, 7703 Floyd Curl Dr, MC 7838, San Antonio, TX 78209.

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http://dx.doi.org/10.1016/j.pmrj.2017.12.002DOI Listing
January 2018

Cadaveric Study of the Articular Branches of the Shoulder Joint.

Reg Anesth Pain Med 2017 Sep/Oct;42(5):564-570

From the Departments of *Anesthesiology and †Rehabilitation, University of Texas Health Science Center at San Antonio, San Antonio; ‡Department of Anesthesia, Baylor Scott and White Health, Temple; and §Cellular and Structural Biology, University of Texas Health Science Center at San Antonio, San Antonio, TX.

Background And Objectives: This cadaveric study investigated the anatomic relationships of the articular branches of the suprascapular (SN), axillary (AN), and lateral pectoral nerves (LPN), which are potential targets for shoulder analgesia.

Methods: Sixteen embalmed cadavers and 1 unembalmed cadaver, including 33 shoulders total, were dissected. Following dissections, fluoroscopic images were taken to propose an anatomical landmark to be used in shoulder articular branch blockade.

Results: Thirty-three shoulders from 17 total cadavers were studied. In a series of 16 shoulders, 16 (100%) of 16 had an intact SN branch innervating the posterior head of the humerus and shoulder capsule. Suprascapular sensory branches coursed laterally from the spinoglenoid notch then toward the glenohumeral joint capsule posteriorly. Axillary nerve articular branches innervated the posterolateral head of the humerus and shoulder capsule in the same 16 (100%) of 16 shoulders. The AN gave branches ascending circumferentially from the quadrangular space to the posterolateral humerus, deep to the deltoid, and inserting at the inferior portion of the posterior joint capsule. In 4 previously dissected and 17 distinct shoulders, intact LPNs could be identified in 14 (67%) of 21 specimens. Of these, 12 (86%) of 14 had articular branches innervating the anterior shoulder joint, and 14 (100%) of 14 LPN articular branches were adjacent to acromial branches of the thoracoacromial blood vessels over the superior aspect of the coracoid process.

Conclusions: Articular branches from the SN, AN, and LPN were identified. Articular branches of the SN and AN insert into the capsule overlying the glenohumeral joint posteriorly. Articular branches of the LPN exist and innervate a portion of the anterior shoulder joint.
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http://dx.doi.org/10.1097/AAP.0000000000000652DOI Listing
September 2018

Interventional Management for Pelvic Pain.

Phys Med Rehabil Clin N Am 2017 08 27;28(3):621-646. Epub 2017 May 27.

UT Health San Antonio, 7703 Floyd Curl Drive MC 7838, San Antonio, TX 78229, USA.

Interventional procedures can be applied for diagnostic evaluation and treatment of the patient with pelvic pain, often once more conservative measures have failed to provide relief. This article reviews interventional management strategies for pelvic pain. We review superior and inferior hypogastric plexus blocks, ganglion impar blocks, transversus abdominis plane blocks, ilioinguinal, iliohypogastric and genitofemoral blocks, pudendal nerve blocks, and selective nerve root blocks. Additionally, we discuss trigger point injections, sacroiliac joint injections, and neuromodulation approaches.
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http://dx.doi.org/10.1016/j.pmr.2017.03.011DOI Listing
August 2017

Driving Under the Influence of Opioids.

PM R 2016 07;8(7):698-705

Physical Medicine and Rehabilitation, Weill Cornell Medical College, 525 E 68th Street, Baker 16, New York, NY 10065(§). Electronic address:

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http://dx.doi.org/10.1016/j.pmrj.2016.05.010DOI Listing
July 2016

Digital Subtraction Angiography Use During Epidural Steroid Injections Does Not Reliably Distinguish Artery from Vein.

Pain Physician 2016 05;19(4):255-66

Department of Physical Medicine & Rehabilitation, University of Texas Health Science Center San Antonio.

Background: Epidural steroid injections (ESIs) are among the most common procedures performed in an interventional pain management practice. It is well known that tragic complications may arise from ESIs, most commonly those performed using a transforaminal approach. Digital subtraction angiography (DSA) has been hailed as a fluoroscopic technique that can be used to detect arterial placement of the injection needle, and therefore as a safety measure that can decrease the incidence of catastrophic sequelae of these procedures.

Objective: The objective of this article was to review existing scientific pain literature to determine if DSA can distinguish arterial vs. venous uptake.

Study Design: Narrative review.

Methods: The current narrative review of DSA in interventional spine was completed with a PUBMED search using the key words: digital subtraction angiography, epidural, fluoroscopy, intravascular injection, paraplegia, and quadriplegia in accordance with Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines.

Results: After identification of duplicate articles, 383 articles were screened by title, abstract, and/or full article review. Ten of these articles were deemed appropriate, after applying inclusion and exclusion criteria, as they specifically looked at the use of digital subtraction angiography in interventional spine epidural injections. This included 4 case reports, 3 prospective studies, one retrospective analysis, one prospective cohort study, and one meta-analysis. All of the available studies claiming that DSA was capable of detecting vascular spread are likely accurate, but no significant detection of specifically arterial spread has been reported. The known catastrophic complications related to ESIs are purported to be due to arterial injection of insoluble steroids or local anesthetic and detection of arterial spread of contrast during fluoroscopy would be of obvious benefit to the interventionalist.

Limitations: Small study size, non-randomized studies between DSA and real time fluoroscopy.

Conclusion: Existing studies do not support that DSA can predict arterial spread. In fact, DSA exposes the practitioner and the patient to higher levels of radiation without objective evidence of any safety parameters.

Key Words: Digital subtraction angiography, real-time fluoroscopy, transforaminal epidural injection, particulate steroids, cervical radicular artery, lumbar radicular artery, spinal cord injury.
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May 2016

Longitudinal tear of the biceps brachii from peripheral intravenous catheter infiltration.

Muscles Ligaments Tendons J 2015 Apr-Jun;5(2):120-3. Epub 2015 Jul 3.

Department of Physical Medicine & Rehabilitation, Texas Childrens Hospital, Baylor College of Medicine, Houston, USA.

Background: although peripheral intravenous catheter (PIV) infiltration is a frequent hospital occurrence, muscle rupture is a previously unknown complication of line infiltration. We present the case of a 21-year-old male with a history of cystic fibrosis, bilateral lung transplant, and chronic corticosteroid use, with longitudinal tear of the biceps brachii muscle as a complication of PIV infiltration.

Methods: case report describing a unique case of a longitudinal tear of the biceps brachii.

Results: magnetic resonance imaging revealed longitudinal tear of the biceps brachii with sparing of the proximal and distal tendons. Nerve conduction studies and electromyography revealed bicipital denervation, most likely due to mechanical compression.

Conclusion: we hypothesize that the patient's chronic corticosteroid use predisposed him to muscle injury, as did basilic vein thrombosis caused by PIV infiltration, and this combination of factors led to bicipital rupture. To our knowledge, this is also the first case report to document longitudinal tear of the biceps brachii with sparing of the distal and proximal tendinous insertions of the muscle.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4496011PMC
August 2015

A Novel Use of Regional Anesthesia for Spastic Hemiplegia Evaluation and Treatment: A Case Report.

PM R 2016 Feb 4;8(2):180-2. Epub 2015 Aug 4.

Department of Rehabilitation Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr (MC 7843), San Antonio, TX 78229-3900(‡). Electronic address:

Spastic hemiplegia is a common sequela of stroke. Spasticity that is not optimally reduced with systemic therapy is often treated with intramuscular botulinum toxin injections. Spastic tone can increase the difficulty of appropriately positioning the patient for botulinum toxin injections, lengthen procedure duration, and increase periprocedural pain. Our patient, a 53-year-old woman, was unable to be adequately positioned to receive botulinum toxin injections to her left upper extremity because of challenging flexion synergy posturing and related positional pain. A left interscalene brachial plexus local anesthetic block administered under ultrasound guidance was used to produce both temporary dense muscle relaxation and profound anesthesia, facilitating successful and comfortable botulinum toxin injections in this patient.
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http://dx.doi.org/10.1016/j.pmrj.2015.07.010DOI Listing
February 2016

Onset of spontaneous lower extremity pain after lumbar sympathetic block.

Pain Physician 2015 Jan-Feb;18(1):E89-91

University of Texas Health Science Center at San Antonio, San Antonio, TX.

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October 2015

Vascular causes of radiculopathy: a literature review.

Spine J 2011 Jan;11(1):73-85

Physical Medicine & Rehabilitation Alliance Program, Baylor College of Medicine & University of Texas Health Science Center, 1709 Dryden Road, Houston, TX 77030, USA.

Background Context: Vascular etiologies are a significant source of radiculopathy. The entities that are reviewed here include epidural spinal hematoma, subdural spinal hematoma, spinal arteriovenous malformation, vertebral hemangioma, spinal epidural cavernous hemangioma, vertebral artery anomalies (both tortuosity and dissection), aortic aneurysm, hemorrhagic synovial cysts, ligamentum flavum hematoma, and venous varices. The incidence, pathophysiology, typical clinical presentation, appropriate diagnostic workup, and management are summarized.

Purpose: To review and summarize various vascular causes of radiculopathy and how it impacts the management of patients with radicular spinal pain.

Study Design: Literature review.

Methods: An extensive literature review was done on each of the vascular entities and their presentation as radiculopathy.

Results: Vascular etiologies of radiculopathy may be underestimated in the literature. Imaging in addition to the history and physical examination is essential to identifying vascular sources of radiculopathy and establishing correct treatment.

Conclusions: In examining patients with radicular pain, extraspinal causes of radiculopathy including vascular entities should be included in the differential. Knowledge of the incidence, pathophysiology, clinical presentation, and management of the possibly underreported various vascular causes of radiculopathy increase the ability of the physician to provide optimal care for the patient. A key aspect to identifying such vascular lesions is appropriate imaging for documenting the source of radiculopathy. Blind injections, done without appropriate imaging for identifying the cause of radiculopathy, and also performed without fluoroscopic guidance, increase not only the risk of misdiagnosis but also the comorbidities associated with spinal injections.
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http://dx.doi.org/10.1016/j.spinee.2010.09.027DOI Listing
January 2011

Interaction of amphetamines and related compounds at the vesicular monoamine transporter.

J Pharmacol Exp Ther 2006 Oct 11;319(1):237-46. Epub 2006 Jul 11.

Clinical Psychopharmacology Section, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, 5500 Nathan Shock Dr., Baltimore, MD 21224, USA.

Amphetamine-type agents interact with the vesicular monoamine transporter type 2 (VMAT(2)), promoting the release of intravesicular neurotransmitter and an increase in cytoplasmic neurotransmitter. Some compounds, such as reserpine, "release" neurotransmitter by inhibiting the ability of VMAT(2) to accumulate neurotransmitter in the vesicle, whereas other types of compounds can release neurotransmitter via a carrier-mediated exchange mechanism. The purpose of this study was to determine, for 42 mostly amphetamine-related compounds, their mode of interaction with the VMAT(2). We used a crude vesicular fraction prepared from rat caudate to assay VMAT(2) activity. Test compounds were assessed in several assays, including 1) inhibition of [(3)H]dihydrotetrabenazine binding, 2) inhibition of vesicular [(3)H]dopamine uptake, and 3) release of preloaded [(3)H]dopamine and [(3)H]tyramine. Several important findings derive from this comprehensive study. First, our work indicates that most agents are VMAT(2) substrates. Second, our data strongly suggest that amphetamine-type agents deplete vesicular neurotransmitter via a carrier-mediated exchange mechanism rather than via a weak base effect, although this conclusion needs to be confirmed via direct measurement of vesicular pH. Third, our data fail to reveal differential VMAT(2) interactions among agents that do and do not produce long-term 5-hydroxytryptamine depletion. Fourth, the data reported revealed the presence of two pools of [(3)H]amine within the vesicle, one pool that is free and one pool that is tightly associated with the ATP/protein complex that helps store amine. Finally, the VMAT(2) assays we have developed should prove useful for guiding the synthesis and evaluation of novel VMAT(2) agents as possible treatment agents for addictive disorders.
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http://dx.doi.org/10.1124/jpet.106.103622DOI Listing
October 2006