Complications and pitfalls of lumbar interlaminar and transforaminal epidural injections

Lumbar interlaminar and transforaminal epidural injections are used in the treatment of lumbar radicular pain and other lumbar spinal pain syndromes. Complications from these procedures arise from needle placement and the administration of medication. Potential risks include infection, hematoma, intravascular injection of medication, direct nerve trauma, subdural injection of medication, air embolism, disc entry, urinary retention, radiation exposure, and hypersensitivity reactions. The objective of this article is to review the complications of lumbar interlaminar and transforaminal epidural injections and discuss the potential pitfalls related to these procedures. We performed a comprehensive literature review through a Medline search for relevant case reports, clinical trials, and review articles. Complications from lumbar epidural injections are extremely rare. Most if not all complications can be avoided by careful technique with accurate needle placement, sterile precautions, and a thorough understanding of the relevant anatomy and contrast patterns on fluoroscopic imaging

Cervical epidural steroid injections in the management of cervical radiculitis: interlaminar versus transforaminal. A review

There has been recent concern regarding the safety of cervical epidural steroid injections. The decision to proceed with treatment requires balancing the risk and benefits. This article is an in depth review of the efficacy, complications, and technique of both interlaminar and transforaminal cervical epidural steroid injections in the management of cervical radiculitis

Nitric Oxide Synthase Inhibitors into the Clinic at Last

The 1998 nobel prize in medicine and physiology for the discovery of nitric oxide, a nitrogen containing reactive oxygen species (also termed reactive nitrogen or reactive nitrogen/oxygen species) stirred great hopes. Clinical applications, however, have so far pertained exclusively to the downstream signaling of cgmp enhancing drugs such as phosphodiesterase inhibitors and soluble guanylate cyclase stimulators. All clinical attempts, so far, to inhibit nos have failed even though preclinical models were strikingly positive and clinical biomarkers correlated perfectly. This rather casts doubt on our current way of target identification in drug discovery in general and our way of patient stratification based on correlating but not causal biomarkers or symptoms. The opposite, no donors, nitrite and enhancing no synthesis by enos/nos3 recoupling in situations of no deficiency, are rapidly declining in clinical relevance or hold promise but need yet to enter formal therapeutic guidelines, respectively. Nevertheless, nos inhibition in situations of no overproduction often jointly with enhanced superoxide (or hydrogen peroxide production) still holds promise, but most likely only in acute conditions such as neurotrauma (stover et al., j neurotrauma 31(19):1599–1606, 2014) and stroke (kleinschnitz et al., j cereb blood flow metab 1508–1512, 2016; casas et al., proc natl acad sci u s a 116(14):7129–7136, 2019). Conversely, in chronic conditions, long-term inhibition of nos might be too risky because of off-target effects on enos/nos3 in particular for patients with cardiovascular risks or metabolic and renal diseases.graphical abstractnitric oxide synthases (nos) and their role in health (green) and disease (red). Only neuronal/type 1 nos (nos1) has a high degree of clinical validation and is in late stage development for traumatic brain injury, followed by a phase ii safety/efficacy trial in ischemic stroke. The pathophysiology of nos1 (kleinschnitz et al., j cereb blood flow metab 1508–1512, 2016) is likely to be related to parallel superoxide or hydrogen peroxide formation (kleinschnitz et al., j cereb blood flow metab 1508–1512, 2016; casas et al., proc natl acad sci u s a 114(46):12315–12320, 2017; casas et al., proc natl acad sci u s a 116(14):7129–7136, 2019) leading to peroxynitrite and protein nitration, etc. Endothelial/type 3 nos (nos3) is considered protective only and its inhibition should be avoided. The preclinical evidence for a role of high-output inducible/type 2 nos (nos2) isoform in sepsis, asthma, rheumatic arthritis, etc. Was high, but all clinical development trials in these indications were neutral despite target engagement being validated. This casts doubt on the role of nos2 in humans in health and disease (hence the neutral, black coloring).keywordsnitric oxidenitric oxide synthasenosnos inhibitor nos isoforms

Efficacy and tolerability of a new ibuprofen 200mg plaster in patients with acute sports-related traumatic blunt soft tissue injury/contusion

Background: Ibuprofen is used for the treatment of non-serious pain. This study assessed the efficacy and safety of a new ibuprofen plaster for the treatment of pain associated with acute sports impact injuries/contusions. Methods: In this randomised, double-blind, multi-centre, placebo controlled, parallel group study, adults (n = 130; 18-58 years of age) diagnosed with acute sports-related blunt soft tissue injury/contusion were randomized to receive either ibuprofen 200 mg plaster or placebo plaster. Plasters were administered once daily for five consecutive days. The primary assessment was area under the visual analogue scale (VAS) of pain on movement (POM) over 0 to three days (VAS AUC(0-3d)). Other endpoints included algometry AUC from 0 to three days (AUC(0-3d)) and 0 to five days (AUC(0-5d)), to evaluate improvement of sensitivity at the injured site, and patient and investigator global assessment of efficacy. Safety was monitored throughout the study. Results: The ibuprofen plaster resulted in superior reduction in AUC(0-3d) compared with placebo; the Least Squares (LS) mean difference was 662.82 mm*h in favour of the ibuprofen 200mg plaster (P = 0.0011). The greater improvement in VAS AUC of POM was also observed after 12 h, 24 h, and five days of therapy. Tenderness also significantly improved with the ibuprofen plaster compared with placebo; LS mean difference in algometry/tenderness AUC(0-3d) was 1.87 N/cm(2)*d and AUC(0-5d) was 1.87 N/cm(2)*d (P values Conclusions: The results of this study indicate 200 mg plaster is effective and safe for the treatment of pain due to acute sports-related traumatic blunt soft tissue injury/contusion in adults