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20 Articles in Volume 20, Issue #2
20/20 with Peter Staats, MD: The Future of Pain Medicine
Ask the APP: How useful and practical are pain assessment tools?
Ask the PharmD: What are the recommendations for preventing and treating pediatric migraine?
Axial Spondyloarthritis: Updated Medication and Imaging Recommendations
CGRP Monoclonal Antibodies for Chronic Migraine Prevention: Evaluation of Adverse Effects Using A Checklist
Chronic Low Back Pain: Can We Find a Treatment Consensus?
Chronic Pain and Coronavirus
Correspondence: Are ESIs Still Worth It? Benzocaine for Orofacial Pain.
Could Pulsed RF Provide Lasting Chronic Headache Relief in Refractory Patients?
Diagnosis Is Everything: Low Back Pain As a Symptom of an Underlying Condition or Conditions
Editorial: From Just Say No, to Say Now and Say Know
Erenumab and Onabotulinumtoxin A Show Additive Effect in Refractory Chronic Migraine
Experts Roundtable: Finding a Bottom Line in Back Pain Care
Inside the Potential of RNAi to Target the Etiology of hATTR Neuropathy
Muscle Dysfunction in Head and Neck: Pain Causes, Osteopathic Options
New Migraine Medications: Oral Gepants, Ditan Tablet, and More
Root Cause of Sacroiliac Joint Dysfunction: Four-Step Exercise Protocol
The Emotional Impact of Chronic Low Back Pain
The Rise in Tianeptine Abuse: Our Next Kratom Problem?
The Sensory Component of Pain: Modifying Its Emotional and Cognitive Meaning

Correspondence: Are ESIs Still Worth It? Benzocaine for Orofacial Pain.

March/April 2020 Letters to the Editor, including a discussion on the risks of epidural steroid injections and how one clinician found an unexpected benefit of benzocaine.
Page 11

Are ESIs Still Worth It?

Dear PPM,

Regarding “Epidural Steroid Injections: Are the Risks Worth the Benefits?” (July 2019), most pain management providers, let alone referring providers and patients, may not be aware of the background surrounding the FDA stance and the initial request to ban the use of epidural steroid injections (ESIs). In July 2018, the New York Times’ Sheila Kaplan reported that, in 2013, Pfizer Pharmaceuticals requested that the FDA ban the use of Depo-Medrol in the epidural space. Neither organization made this public at the time. The article cited a review of FDA records between 2004 and March 2018 showing 2,442 serious injuries (including 154 deaths) reported with the injection of steroids into the epidural space. It may be reasonable to assume more injuries occurred but were not reported or attributed to ESIs.

While the FDA has not banned the use of steroids in the epidural space, many other countries have done so. Pain management societies, practitioners, and patients should be better informed about safety communications regarding ESIs, as well as warnings contained in steroid package inserts. Depo-Medrol has labeling stating: “Serious neurologic events, some resulting in death, have been reported with epidural injection of corticosteroids. Specific events reported include, but are not limited to, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, and stroke.... The safety and effectiveness of epidural administration of corticosteroids have not been established, and corticosteroids are not approved for this use.”

Multiple articles in the literature demonstrate a lack of long-term benefit from such injections beyond a few weeks, compared to less expensive, more conservative, and safer options. Match this with the costs of these procedures, and I don’t understand why these injections continue to be done. There have been catastrophic outcomes from ESIs. In my own practice, I had a patient with no prior history of low back injury nor surgery who had 7 ESIs done by another provider. Her most recent MRI showed adhesive arachnoiditis with no other injury as the likely cause. She is in constant pain.

I believe the primary motivators for doing these procedures lie in habit and financial gain. In fact, I have heard from some hospital administrators that, “even though we know they don’t work, as long as we have a fee for service mode and can make money, we will allow providers to do them.” One VP from a major insurance company told me that they keep paying for ESIs “because no one wants to be the first to say no and deal with the backlash.” There are many reasonable and less risky pain management procedures that help to manage pain, but an ESI is not one of them.

– Terence K. Gray, DO

 

Response: In his Letter to the Editor (appearing above, and in the PPM March/April 2020 issue), Dr. Gray questions the continued utility of ESIs in the treatment of spinal pain. He asserts that an ESI is an extremely risky procedure, there is little evidence of benefit, and there are other safer more conservative treatments. 

There are millions of ESIs performed each year in the US and undoubtedly Dr. Gray is correct that there may be too many of these procedures done. Yet his reported number of serious complications and deaths (over what timeframe?) is a very low rate and most of these complications could have been avoided by avoiding high risk procedures such as cervical transforaminal ESI and attention to concomitant anticoagulant therapy. 

While Dr. Gray also asserts that ESIs only are effective for "a few weeks," well designed studies have shown a beneficial effect for up to 3 months with radiculopathy. While the benefit in spinal stenosis is less clear, recent studies have shown significant benefit when the ESI is carefully placed at the stenotic level.

I wonder what the "more conservative,  less expensive and safer options" are? Gabapentin is less expensive but has a high failure rate, physical therapy is almost as expensive and has a high failure rate (especially in the elderly), opioids are cheap but have considerable side effects and risk (especially in the elderly) and surgery is quite expensive with a very high failure rate. While there are newer minimally invasive procedures that offer significant improvement, many patients are not candidates. And what about those patients who have failed all the above? Spinal cord stimulation or an intrathecal pump is very expensive and very invasive. 

I agree with Dr. Gray that ESIs are overused. Many are performed with little attention to the underlying pathology. But don't throw out the baby with the bath water. ESIs are still valuable for patients with acute or chronic radicular pain and those patients with spinal stenosis for which there is no good surgical option,  especially those patients who have failed to improve with the more conservative options.

– Kenneth Lister, MD

OTC Benzocaine for Head and Facial Pain: A Self-Case

Dear PPM,

Local anesthetics, including benzocaine, have been used for years topically and in regional nerve blocks for procedures involving the upper airways.1 However, an online literature review and informal survey of medical colleagues failed to yield findings that use of OTC topical oral benzocaine may be effective in the management of symptoms of altered sensation following rhino-neurosurgery. The author presents himself as such a case:

A 62-year-old Caucasian male who, during evaluation for an apparent transient ischemic attack, underwent brain imaging that revealed the presence of a pituitary macroadenoma measuring 1.7 cm at its longest axis. Subsequently, he underwent successful resection of the tumor via a trans-sphenoidal approach, with septoplasty also undertaken to address a deviated septum and facilitate this surgical approach. Loss of sensation over the distal hard palate behind the upper incisors, in the distribution of the naso-palatine nerve, was noted post-operatively. At 7 weeks follow-up, activity and intra-
nasal medication restrictions were removed; around this time, paresthesia in the previously numb distal hard palate area was noted; this evolved over the next few weeks to some dysesthesic sensation in the area which persisted along with some dull frontal head and facial aching. Empirical management approaches were pursued, and it was found that OTC topical oral benzocaine 20% gel applied gently in small amounts bilaterally intranasally on the septal mucus membranes, conceptually similar to topical blockade of the greater and lesser palatine nerves,
3 and orally on the distal upper palate using a finger or swab once or twice daily significantly aided in the management of this pain. This approach has continued to be effective for symptoms over 8 months post-operative.

The naso-palatine nerve is present bilaterally in the face, going through the spheno-
palatine foramen and along the roof of the nose medially to the upper posterior septal boarder and then going anteriorly and inferiorly in the septal mucus membrane to go through the incisive canal to the hard palate, supplying the posterior-inferior nasal septum and the anterior palate behind the incisor teeth.2 Rhino-neurosurgery complications may include disorders of sensation involving the palate or teeth. In the self-presented case, the sensory abnormality appeared to be in the distribution of the naso-palatine nerve. Use of OTC oral benzocaine 20% gel intranasally on the nasal septum bilaterally as well as orally on the distal upper palate may be helpful in the management of neuropathic symptoms following rhino-neurosurgery for pituitary macroadenoma removal.

While medical procedures, such as sphenopalatine ganglion blocks, have been used in the management of various headaches and facial neuralgias,3 the case presented indicates that clinically simple approaches using non-prescription medication may be effective in managing certain head and facial pain as well.

– Robert L. Harmon, MD

Last updated on: May 14, 2020
Continue Reading:
Correspondence: Opioid-Induced Hyperalgesia; Pain Care in Older Adults
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