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Laxmaiah Manchikanti - One of the best experts on this subject based on the ideXlab platform.

  • methodology for evidence synthesis and development of comprehensive evidence based guidelines for interventional techniques in chronic spinal pain
    Pain Physician, 2021
    Co-Authors: Laxmaiah Manchikanti, Mark V. Boswell, Sudhir Diwan, Alan D Kaye, Sairam Atluri, Nebojsa Nick Knezevic, Aaron K Calodney, Kenneth D Candido, Sanjeeva Gupta, Alaa Abdelsayed
    Abstract:

    Background Despite Epidurals being one of the most common interventional pain procedures for managing chronic spinal pain in the United States, expenditure analysis lacks assessment in correlation with utilization patterns. Objectives This investigation was undertaken to assess expenditures for Epidural procedures in the fee-for-service (FFS) Medicare population from 2009 to 2018. Study design The present study was designed to assess expenditures in all settings, for all providers in the FFS Medicare population from 2009 to 2018 in the United States. In this manuscript: • A patient was described as receiving Epidural procedures throughout the year.• A visit was considered to include all regions treated during the visit. • An episode was considered as one treatment per region utilizing primary codes only.• Services or procedures were considered as all procedures including bilateral and multiple levels. A standard 5% national sample of the Centers for Medicare and Medicaid Services (CMS) physician outpatient billing claims data for those enrolled in the FFS Medicare program from 2009 to 2018 was utilized. All the expenditures were presented with allowed costs and adjusted to inflation to 2018 US dollars. Results Total expenditures were $723,981,594 in 2009, whereas expenditures of 2018 were $829,987,636, with an overall 14.6% increase, or an annual increase of 1.5%. However, the inflation-adjusted rate was $847,058,465 in 2009, compared to $829,987,636 in 2018, a reduction overall of 2% and an annual reduction of 0.2%. Inflation-adjusted per patient annual costs decreased from $988.93 in 2009 to $819.27 in 2018 with a decrease of 17.2% or an annual decline of 2.1%. In addition, inflation-adjusted costs per procedure decreased from $399.77 to $377.94, or 5.5% overall and 0.6% annually. Per procedure, episode, visit, and patient expenses were higher for transforaminal Epidural procedures than lumbar interlaminar/caudal Epidural procedures. Overall, costs of transforaminal Epidurals increased 27.6% or 2.7% annually, whereas lumbar interlaminar and caudal Epidural injections cost were reduced 2.7%, or 0.3% annually. Inflation-adjusted costs for transforaminal Epidurals increased 9.1% or 1.0% annually and declined 16.9 or 2.0% annually for lumbar interlaminar and caudal Epidural injections. Limitations Expenditures for Epidural procedures in chronic spinal pain were assessed only in the FFS Medicare population. This excluded over 30% of the Medicare population, which is enrolled in Medicare Advantage plans. Conclusions After adjusting for inflation, there was a decrease of expenditures for Epidural procedures of 2%, or 0.2% annually, from 2009 to 2018. However, prior to inflation, the increases were noted at 14.6% and 1.5%. Inflation-adjusted costs per patient, per visit, and per procedure also declined. The proportion of Medicare patients per 100,000 receiving Epidural procedures decreased 9.1%, or 1.1% annually. However, assessment of individual procedures showed higher costs for transforaminal Epidural procedures compared to lumbar interlaminar and caudal Epidural procedures.

  • analysis of the growth of Epidural injections and costs in the medicare population a comparative evaluation of 1997 2002 and 2006 data
    Pain Physician, 2010
    Co-Authors: Laxmaiah Manchikanti, Mark V. Boswell, Howard S Smith, Vidyasagar Pampati, Joshua A Hirsch
    Abstract:

    Background Interventional techniques for the treatment of spinal techniques are commonly used and are increasing exponentially. Epidural injections and facet joint interventions are the 2 most commonly utilized procedures in interventional pain management. The current literature regarding the effectiveness of Epidural injections is sparse with highly variable outcomes based on the technique, outcome measures, patient selection, and methodology. Multiple reports have illustrated the exponential growth of lumbosacral injections with significant geographic variations in the administration of Epidural injections in Medicare patients. However, an analysis of the growth of Epidural injections and costs in the Medicare population has not been performed with recent data and has not been looked at from an interventional pain management perspective. Study design Analysis of Epidural injection growth and costs in Medicare's population 1997, 2002, and 2006. Objectives The primary purpose of this study was to evaluate the use of all types of Epidural injections (i.e. caudal, interlaminar, and transforaminal in lumbar, cervical and thoracic regions), and other Epidural procedures, including Epidural adhesiolysis. In addition, the purpose was to identify trends in the number of procedures, reimbursement, specialty involvement, fluoroscopy use, and indications from 1997 to 2006. Methods The Centers for Medicare and Medicaid Services (CMS) 5% national sample carrier claim record data from 1997, 2002, and 2006 was utilized. Outcomes assessment Outcome measures included Medicare beneficiaries' characteristics receiving Epidural injections, Epidural injections by place of service, type of specialty, reimbursement characteristics, and other variables. Results Epidural injections increased significantly in Medicare beneficiaries from 1997 to 2006. Patients receiving Epidurals increased by 106.3%; visits per 100,000 population increased 102.7%. Hospital outpatient department (HOPD) payments increased significantly; ASC average payments decreased; overall payments increased. The increase in procedures performed by general physicians outpaced that of interventional pain management (IPM) physicians. Limitations Study limitations include no Medicare Advantage patients; potential documentation, coding, and billing errors. Conclusions Epidural injections grew significantly. This growth appears to coincide with chronic low back pain growth and other treatments for low back pain. Since many procedures are performed without fluoroscopy, continued growth and inappropriate provision of services might reduce access.

  • Epidural steroids in the management of chronic spinal pain a systematic review
    Pain Physician, 2007
    Co-Authors: Salahadin Abdi, Sukdeb Datta, Sairam Atluri, Andrea M Trescot, David M Schultz, Rajive Adlaka, Howard S Smith, Laxmaiah Manchikanti
    Abstract:

    Background: Epidural injection of corticosteroids is one of the most commonly used interventions in managing chronic spinal pain. However, there has been a lack of well-designed randomized, controlled studies to determine the effectiveness of Epidural injections. Consequently, debate continues as to the value of Epidural steroid injections in managing spinal pain. Objective: To evaluate the effect of various types of Epidural steroid injections (interlaminar, transforaminal, and caudal), in managing various types of chronic spinal pain (axial and radicular) in the neck and low back regions. Study Design: A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials, and criteria of Cochrane Musculoskeletal Review Group for randomized trials were used. Methods: Data sources included relevant English literature performed by a librarian experienced in Evidence Based Medicine (EBM), as well as manual searches of bibliographies of known primary and review articles and abstracts from scientific meetings within the last 2 years. Three reviewers independently assessed the trials for the quality of their methods. Subgroup analyses were performed among trials with different control groups, with different techniques of Epidural injections (interlaminar, transforaminal, and caudal), with different injection sites (cervical/thoracic, lumbar/sacral), and with timing of outcome measurement (short- and long-term). Outcome Measures: The primary outcome measure is pain relief. Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term improvement is defined as 6 weeks or less, and long-term relief is defined as 6 weeks or longer. Results: In managing lumbar radicular pain with interlaminar lumbar Epidural steroid injections, the evidence is strong for short-term relief and limited for long-term relief. In managing cervical radiculopathy with cervical interlaminar Epidural steroid injections, the evidence is moderate. The evidence for lumbar transforaminal Epidural steroid injections in managing lumbar radicular pain is strong for short-term and moderate for long-term relief. The evidence for cervical transforaminal Epidural steroid injections in managing cervical nerve root pain is moderate. The evidence is moderate in managing lumbar radicular pain in post lumbar laminectomy syndrome. The evidence for caudal Epidural steroid injections is strong for short-term relief and moderate for long-term relief, in managing chronic pain of lumbar radiculopathy and postlumbar laminectomy syndrome. Conclusion: There is moderate evidence for interlaminar Epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. The evidence for cervical and lumbar transforaminal Epidural steroid injections is moderate for long-term improvement in managing nerve root pain. The evidence for caudal Epidural steroid injections is moderate for long-term relief in managing nerve root pain and chronic low back pain.

  • cpt 2000 interventional pain management coding in the new millennium
    Pain Physician, 2000
    Co-Authors: Laxmaiah Manchikanti
    Abstract:

    UNLABELLED: Current Procedural Terminology is a systematic listing and coding of procedures and services performed by physicians and other providers. The CPT is the most widely accepted nomenclature for the reporting of procedures by physicians and other providers for health-care services provided by the government, and private health-insurance programs. It is most widely accepted for claim processing, and for the development of guidelines for medical care review, and it provides the uniform language applicable to medical education, research, and utilization. The CPT 2000 includes a multitude of changes. Those of most important interest to interventional pain management specialists include neural blockade where the codes used in pain management have been totally revamped. The entire section of neural blockade codes has been substantially altered, either by deletion, modification, or addition of a new code. Various deleted codes include 62274 to 62279, 62288, 62289, 62298, and 64440 to 64445. The definitions for CPT codes 62273, 62280, 62281, 62282, 62287, 62291, 62350, 64622, 64623, and 72285 have been modified and changed. Multiple new codes not only include replacement codes for Epidurals, but also creation of codes for sacroiliac-joint injection, sacroiliac-joint arthrography, percutaneous lysis of Epidural adhesions, facet-joint injections at the cervical and thoracic levels, neurolytic facet-joint neural blockade for cervical and thoracic levels, transforaminal injection codes for cervical/thoracic and lumbar/sacral, epidurography and radiological examination. The several advantages and disadvantages of new codes and future directions in CPT coding are described. KEYWORDS: Interventional pain management, CPT 1999, CPT 2000, Epidural injections, facet-joint.

Salahadin Abdi - One of the best experts on this subject based on the ideXlab platform.

  • lumbar interlaminar Epidural injections in managing chronic low back and lower extremity pain a systematic review
    Pain Physician, 2009
    Co-Authors: Allan T Parr, Sudhir Diwan, Salahadin Abdi
    Abstract:

    BACKGROUND Low back pain with or without lower extremity pain is the most common problem among chronic pain disorders with significant economic, societal, and health impact. Epidural injections are one of the most commonly performed interventions in the United States in managing chronic low back pain. However the evidence is highly variable among different techniques utilized - namely interlaminar, caudal, transforaminal - and for various conditions, namely - intervertebral disc herniation, spinal stenosis, and discogenic pain without disc herniation or radiculitis. STUDY DESIGN A systematic review of lumbar interlaminar Epidural injections with or without steroids. OBJECTIVE To evaluate the effect of lumbar interlaminar Epidural injections with or without steroids in managing various types of chronic low back and lower extremity pain emanating as a result of disc herniation or radiculitis, spinal stenosis, and chronic discogenic pain. METHODS Review of the literature and methodologic quality assessment were performed according to the Cochrane Musculoskeletal Review Group Criteria as utilized for interventional techniques for randomized trials and the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF) for therapeutic interventions. Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to November 2008, and manual searches of bibliographies of known primary and review articles. Results of analysis were performed for multiple conditions separately. OUTCOME MEASURES The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. RESULTS The available literature included only blind Epidural injections without fluoroscopy. The indicated evidence is positive (Level II-2) for short-term relief of pain of disc herniation or radiculitis utilizing blind interlaminar Epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis. The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind Epidural injections. LIMITATIONS The limitations of this study include paucity of literature, lack of quality evidence, lack of fluoroscopic procedures, and lack of applicable evidence in contemporary interventional pain management practices. CONCLUSION The evidence based on this systematic review is limited for blind interlaminar Epidurals in managing all types of pain except for short-term relief of pain secondary to disc herniation and radiculitis. This evidence does not represent contemporary interventional pain management practices and also the evidence may not be extrapolated to fluoroscopically directed lumbar interlaminar Epidural injections.

  • systematic review of the effectiveness of cervical Epidurals in the management of chronic neck pain
    Pain Physician, 2009
    Co-Authors: Ramsin M Benyamin, Sudhir Diwan, Allan T Parr, Vijay Singh, Ann Conn, Salahadin Abdi
    Abstract:

    Background Chronic neck pain is a common problem in the adult population with a typical 12-month prevalence of 30% to 50%, and 14% of the patients reporting grade II to IV neck pain with high pain intensity and disability that has a substantial impact on health care and society. Cervical Epidural injections for managing chronic neck pain are one of the commonly performed interventions in the United States. However, the literature supporting cervical Epidural steroids in managing chronic pain problems has been scant and no systematic review dedicated to the evaluation of cervical interlaminar Epidurals has been performed in the past. Study design A systematic review of cervical interlaminar Epidural injections. Objective To evaluate the effect of cervical interlaminar Epidural injections in managing various types of chronic neck and upper extremity pain emanating as a result of cervical spine pathology. Methods The available literature of cervical interlaminar Epidural injections in managing chronic neck and upper extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF) for therapeutic interventions. Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to November 2008, and manual searches of bibliographies of known primary and review articles. Outcome measures The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results The indicated evidence is Level II-1 in managing chronic neck and upper extremity pain with 1C/strong recommendation. Limitations The limitations of this systematic review include the paucity of literature and lack of randomized trials performed under fluoroscopy. Conclusion The results of this systematic evaluation of cervical interlaminar Epidural injection showed significant effect in relieving chronic intractable pain of cervical origin and also providing long-term relief with an indicated evidence level of Level II-1.

  • Epidural steroids in the management of chronic spinal pain a systematic review
    Pain Physician, 2007
    Co-Authors: Salahadin Abdi, Sukdeb Datta, Sairam Atluri, Andrea M Trescot, David M Schultz, Rajive Adlaka, Howard S Smith, Laxmaiah Manchikanti
    Abstract:

    Background: Epidural injection of corticosteroids is one of the most commonly used interventions in managing chronic spinal pain. However, there has been a lack of well-designed randomized, controlled studies to determine the effectiveness of Epidural injections. Consequently, debate continues as to the value of Epidural steroid injections in managing spinal pain. Objective: To evaluate the effect of various types of Epidural steroid injections (interlaminar, transforaminal, and caudal), in managing various types of chronic spinal pain (axial and radicular) in the neck and low back regions. Study Design: A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials, and criteria of Cochrane Musculoskeletal Review Group for randomized trials were used. Methods: Data sources included relevant English literature performed by a librarian experienced in Evidence Based Medicine (EBM), as well as manual searches of bibliographies of known primary and review articles and abstracts from scientific meetings within the last 2 years. Three reviewers independently assessed the trials for the quality of their methods. Subgroup analyses were performed among trials with different control groups, with different techniques of Epidural injections (interlaminar, transforaminal, and caudal), with different injection sites (cervical/thoracic, lumbar/sacral), and with timing of outcome measurement (short- and long-term). Outcome Measures: The primary outcome measure is pain relief. Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term improvement is defined as 6 weeks or less, and long-term relief is defined as 6 weeks or longer. Results: In managing lumbar radicular pain with interlaminar lumbar Epidural steroid injections, the evidence is strong for short-term relief and limited for long-term relief. In managing cervical radiculopathy with cervical interlaminar Epidural steroid injections, the evidence is moderate. The evidence for lumbar transforaminal Epidural steroid injections in managing lumbar radicular pain is strong for short-term and moderate for long-term relief. The evidence for cervical transforaminal Epidural steroid injections in managing cervical nerve root pain is moderate. The evidence is moderate in managing lumbar radicular pain in post lumbar laminectomy syndrome. The evidence for caudal Epidural steroid injections is strong for short-term relief and moderate for long-term relief, in managing chronic pain of lumbar radiculopathy and postlumbar laminectomy syndrome. Conclusion: There is moderate evidence for interlaminar Epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. The evidence for cervical and lumbar transforaminal Epidural steroid injections is moderate for long-term improvement in managing nerve root pain. The evidence for caudal Epidural steroid injections is moderate for long-term relief in managing nerve root pain and chronic low back pain.

  • role of Epidural steroids in the management of chronic spinal pain a systematic review of effectiveness and complications
    Pain Physician, 2006
    Co-Authors: Salahadin Abdi, Sukdeb Datta, Linda F Lucas
    Abstract:

    BACKGROUND Epidural steroid injections are commonly used for chronic spinal pain. However, there is no conclusive evidence regarding their effectiveness, and debate continues as to their value in managing chronic spinal pain. OBJECTIVE To evaluate various types of Epidural injections (interlaminar, transforaminal, and caudal) for managing chronic spinal pain (axial and radicular). STUDY DESIGN A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials, and criteria of the Cochrane Musculoskeletal Review Group for randomized trials. METHODS Data sources included relevant English literature identified through searches of MEDLINE and EMBASE (January 1966 to November 2004), manual searches of bibliographies of known primary and review articles and abstracts from scientific meetings within the last 2 years. Three reviewers independently assessed the trials for the quality of their methods. Subgroup analyses were performed for trials with different control groups, with different modes of Epidurals (interlaminar, transforaminal, and caudal), with different injection sites (cervical/thoracic, lumbar/sacral), and with timing of outcome measurement (short- and long-term). OUTCOME MEASURES The primary outcome measure was pain relief. Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term improvement was defined as less than 6 weeks, and long-term improvement was defined as 6 weeks or longer. RESULTS For lumbar radicular pain with interlaminar lumbar Epidural steroid injections, the level of evidence was strong for short-term relief and limited for long-term relief. For cervical radicular pain with cervical interlaminar Epidural steroid injections, the evidence was moderate. The evidence for lumbar transforaminal Epidural steroid injections for lumbar nerve root pain was strong for short-term and moderate for long term improvement. The evidence for cervical transforaminal Epidural steroid injections for cervical nerve root pain was moderate. The evidence was limited for lumbar radicular pain in post lumbar laminectomy syndrome. The evidence for caudal Epidural steroid injections was strong for short-term relief and moderate for long-term relief. For managing chronic postlumbar laminectomy syndrome and spinal stenosis the evidence was limited for low back and radicular pain. The evidence was moderate for chronic low back pain. CONCLUSION The evidence for effectiveness of Epidural injections in managing chronic spinal pain ranged from limited to strong.

Robina Matyal - One of the best experts on this subject based on the ideXlab platform.

  • improving clinical proficiency using a 3 dimensionally printed and patient specific thoracic spine model as a haptic task trainer
    Regional Anesthesia and Pain Medicine, 2018
    Co-Authors: Jeffrey Bortman, Yanick Baribeau, Jelliffe Jeganathan, Yannis Amador, Faraz Mahmood, Marc Shnider, Muneeb Ahmed, Philip E Hess, Robina Matyal
    Abstract:

    Background and Objectives Advanced haptic simulators for neuraxial training are expensive, have a finite life, and are not patient specific. We sought to demonstrate the feasibility of developing a custom-made, low-cost, 3-dimensionally printed thoracic spine simulator model from patient computed tomographic scan data. This study assessed the model’s practicality, efficiency as a teaching tool, and the transfer of skill set into patient care. Methods A high-fidelity, patient-specific thoracic spine model was used for the study. Thirteen residents underwent a 1-hour 30-minute training session prior to performing thoracic Epidural analgesia (TEA) on patients. We observed another group of 14 residents who were exposed to the traditional method of training during their regional anesthesia rotation for thoracic Epidural placement. The TEA was placed for patients under the supervision of attending anesthesiologists, who were blinded to the composition of the study and control groups. As a primary outcome, data were collected on successful TEAs, which was defined as a TEA that provided full relief of sensation across the entire surgical area as assessed by both a pinprick and temperature test. Secondary outcomes included whether any assistance from the attending physician was required and failed Epidurals. Results A total of 27 residents completed the study (14 in the traditional training, 13 in the study group). We found that the residents who underwent training with the simulator had a significantly higher success rate (11 vs 4 successful Epidural attempts, P = 0.002) as compared with the traditional training group. The control group also required significantly more assistance from the supervising anesthesiologist compared with the study group (5 vs 1 attempt requiring guidance). The number needed to treat (NNT) for the traditional training group was 1.58 patients over the study period with a 95% confidence interval of 1.55 to 1.61. Conclusions By using patient-specific, 3-dimensionally printed, thoracic spine models, we demonstrated a significant improvement in clinical proficiency as compared with traditional teaching models.

  • use of 3 dimensional printing to create patient specific thoracic spine models as task trainers
    Regional Anesthesia and Pain Medicine, 2017
    Co-Authors: Jelliffe Jeganathan, Jeffrey Bortman, Yanick Baribeau, Yannis Amador, Marc Shnider, Muneeb Ahmed, Feroze Mahmood, Azad Mashari, Rabia Amir, Robina Matyal
    Abstract:

    Background and Objectives Thoracic Epidural anesthesia is a technically challenging procedure with a high failure rate of 24% to 32% nationwide. Residents in anesthesiology have limited opportunities to practice this technique adequately, and there are no training tools available for this purpose. Our objective was to build a low-cost patient-specific thoracic Epidural training model. Methods We obtained thoracic computed tomography scan data from patients with normal and kyphotic spine. The thoracic spine was segmented from the scan, and a 3-dimensional model of the spine was generated and printed. It was then placed in a customized wooden box and filled with different types of silicone to mimic human tissues. Attending physicians in our institution then tested the final model. They were asked to fill out a brief questionnaire after the identification of the landmarks and Epidural space using ultrasound and real-time performance for a thoracic Epidural on the model (Supplemental Digital Content 1, http://links.lww.com/AAP/A197). Likert scoring system was used for scoring. Results The time to develop this simulator model took less than 4 days, and the materials cost approximately $400. Fourteen physicians tested the model for determining the realistic sensation while palpating the spinous process, needle entry through the silicone, the “pop” sensation and ultrasound fidelity of the model. Whereas the tactile fidelity scores were “neutral” (3.08, 3.06, and 3.0, respectively), the ultrasound guidance and overall suitability for residents were highly rated as being the most realistic (4.85 and 4.0, respectively). Conclusions It is possible to develop homemade, low-cost, patient-specific, and high-fidelity ultrasound guidance simulators for resident training in thoracic Epidurals using 3-dimensional printing technology.

Katherine L Kahn - One of the best experts on this subject based on the ideXlab platform.

  • effect of Epidural analgesia for labor on the cesarean delivery rate
    Obstetrics & Gynecology, 1994
    Co-Authors: Sally C Morton, Mark E Williams, Emmett B Keeler, Joseph C Gambone, Katherine L Kahn
    Abstract:

    OBJECTIVE To use meta-analysis to evaluate the effect of Epidural analgesia on the cesarean delivery rate. DATA SOURCES The MEDLINE data base was searched for articles published in English between January 1981 and April 1992. We also interviewed experts and conducted a bibliographic follow-up and manual review of recent journals published from April to July 1992. METHODS OF STUDY SELECTION We excluded articles with irrelevant titles, and those case studies, book chapters, or articles that did not provide primary and relevant data. Two hundred thirty articles were read, including articles that reported on women of standard obstetric risk and on cesarean delivery rates for an Epidural group and for a concurrent no-Epidural group. These criteria yielded six studies for a primary analysis and two others for a secondary analysis. DATA EXTRACTION AND SYNTHESIS The sample size of the Epidural and no-Epidural groups and the number of cesareans within each group were extracted. Tests of homogeneity were conducted. The pooled cesarean delivery risk difference as a result of Epidural analgesia was estimated. The cesarean rate for women undergoing Epidural analgesia was ten percentage points greater than for no-Epidural women (P < .05). More than a nine percentage point increase was shown for cesarean deliveries for dystocia (P < .05), when pooling either all studies or only randomized studies. CONCLUSIONS The results of this meta-analysis strongly support an increase in cesarean delivery associated with Epidural analgesia. Further research should evaluate the balance between analgesia associated with the use of Epidurals, and postpartum morbidity and costs associated with cesarean deliveries.

Andrew Shennan - One of the best experts on this subject based on the ideXlab platform.

  • Epidural analgesia and breastfeeding a randomised controlled trial of Epidural techniques with and without fentanyl and a non Epidural comparison group
    Anaesthesia, 2010
    Co-Authors: Matthew Wilson, Debra Bick, Christine Macarthur, G M Cooper, P Moore, Andrew Shennan
    Abstract:

    We compared breastfeeding initiation and duration in 1054 nulliaparae randomised to bupivacaine Control Epidural, Combined Spinal Epidural or Low Dose Infusion and 351 matched non-Epidural comparisons. Women were interviewed after delivery and completed a postal questionnaire at 12 months. Regression analysis determined factors which independently predicted breastfeeding initiation. Breastfeeding duration was subjected to Kaplan-Meier analysis. A similar proportion of women in each Epidural group initiated breastfeeding. Women with no Epidural did not report a higher initiation rate relative to Epidural groups and those who received pethidine reported a lower initiation rate than control Epidural (p = 0.002). Older age groups (p < 0.001) and non-white ethnicity (p < 0.026) were predictive of breastfeeding. Epidural fentanyl dose, delivery mode and trial group were not predictive. Mean duration for breastfeeding was similar across Epidural groups (Control 13.3, Combined Spinal Epidural 15.5, Low Dose Infusion 15.0 weeks). Our data do not support an effect of Epidural fentanyl on breastfeeding initiation.

  • urinary catheterization in labour with high dose vs mobile Epidural analgesia a randomized controlled trial
    BJA: British Journal of Anaesthesia, 2009
    Co-Authors: M Wilson, Christine Macarthur, Andrew Shennan
    Abstract:

    Abstract Background Dense perineal block from Epidural analgesia increases the risk of urinary catheterization in labour. Mobile Epidurals using low-dose local anaesthetic in combination with opioid preserve maternal mobility and may reduce the risk of bladder dysfunction. We conducted a three-arm randomized controlled trial to compare high-dose Epidural pain relief with two mobile Epidural techniques. Methods A total of 1054 primparous women were randomized to receive high-dose bupivacaine, Epidural analgesia (Control), combined spinal Epidural (CSE), or low-dose infusion (LDI). The requirement for urinary catheterization during labour and postpartum was recorded. Both end points were pre-specified secondary trial outcomes. Women were evaluated by postnatal interview, when their bladder function had returned to normal. Results Relative to Control, more women who received mobile Epidural techniques maintained the ability to void urine spontaneously at any time (Control 11%, CSE 31% and LDI 32%) and throughout labour (Control 3.7%, CSE 13% and LDI 14%), for both mobile techniques P P =0.02). Conclusions Relative to conventional high-dose block, mobile Epidural techniques encourage the retention of normal bladder function and reduce the risk of urinary catheterization in labour.

  • effect of low dose mobile versus traditional Epidural techniques on mode of delivery a randomised controlled trial
    The Lancet, 2001
    Co-Authors: Debra Bick, Andrew Shennan
    Abstract:

    BACKGROUND: Epidural analgesia is the most effective labour pain relief but is associated with increased rates of instrumental vaginal delivery and other effects, which might be related to the poor motor function associated with traditional Epidural. New techniques that preserve motor function could reduce obstetric intervention. We did a randomised controlled trial to compare low-dose combined spinal Epidural and low-dose infusion (mobile) techniques with traditional Epidural technique. METHODS: Between Feb 1, 1999, and April 30, 2000, we randomly assigned 1054 nulliparous women requesting Epidural pain relief to traditional (n=353), low-dose combined spinal Epidural (n=351), or low-dose infusion Epidural (n=350). Primary outcome was mode of delivery, and secondary outcomes were progress of labour, efficacy of procedure, and effect on neonates. We obtained data during labour and interviewed women postnatally. FINDINGS: The normal vaginal delivery rate was 35·1% in the traditional Epidural group, 42·7% in the low-dose combined spinal group (odds ratio 1·38 [95% CI 1·01–1·89]; p=0·04); and 42·9% in the low-dose infusion group (1·39 [1·01–1·90]; p=0·04). These differences were accounted for by a reduction in instrumental vaginal delivery. Overall, 5 min APGAR scores of 7 or less were more frequent with low-dose technique. High-level resuscitation was more frequent in the low-dose infusion group. INTERPRETATION: The use of low-dose Epidural techniques for labour analgesia has benefits for delivery outcome. Continued routine use of traditional Epidurals might not be justified.