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  1. Article ; Online: Percutaneous Adhesiolysis Is an Effective, Safe Procedure.

    Helm, Standiford

    Pain medicine (Malden, Mass.)

    2019  Volume 21, Issue 1, Page(s) 206–207

    MeSH term(s) Cost-Benefit Analysis ; Epidural Space ; Failed Back Surgery Syndrome ; Humans ; Low Back Pain
    Language English
    Publishing date 2019-08-27
    Publishing country England
    Document type Journal Article ; Comment
    ZDB-ID 2015903-1
    ISSN 1526-4637 ; 1526-2375
    ISSN (online) 1526-4637
    ISSN 1526-2375
    DOI 10.1093/pm/pnz181
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  2. Article ; Online: Response to "cervical radicular pain".

    Helm, Standiford / Noe, Carl / Racz, Gabor

    Pain practice : the official journal of World Institute of Pain

    2023  Volume 24, Issue 3, Page(s) 573–574

    MeSH term(s) Humans ; Radiculopathy ; Neck Pain
    Language English
    Publishing date 2023-11-04
    Publishing country United States
    Document type Letter
    ZDB-ID 2151272-3
    ISSN 1533-2500 ; 1530-7085
    ISSN (online) 1533-2500
    ISSN 1530-7085
    DOI 10.1111/papr.13316
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  3. Article ; Online: Inconsistencies in the consensus facet joint guidelines.

    Helm, Standiford / Benyamin, Ramsin

    Regional anesthesia and pain medicine

    2020  Volume 46, Issue 3, Page(s) 286

    MeSH term(s) Consensus ; Humans ; Low Back Pain ; Pain Management ; Zygapophyseal Joint
    Language English
    Publishing date 2020-05-31
    Publishing country England
    Document type Letter ; Comment
    ZDB-ID 1425299-5
    ISSN 1532-8651 ; 1098-7339 ; 0146-521X
    ISSN (online) 1532-8651
    ISSN 1098-7339 ; 0146-521X
    DOI 10.1136/rapm-2020-101590
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  4. Article ; Online: Cervical Nerve Root Block Using a Curved Blunt Needle and Posterior Approach.

    Noe, Carl / van Hal, Michael / Helm Ii, Standiford / Racz, Gabor B

    Pain physician

    2024  Volume 27, Issue 3, Page(s) 161–168

    Abstract: Background: Cervical transforaminal epidural steroid injections have become less popular due to the risk of catastrophic complications they pose. However, cervical nerve root blocks are useful for surgical planning in patients with cervical radicular ... ...

    Abstract Background: Cervical transforaminal epidural steroid injections have become less popular due to the risk of catastrophic complications they pose. However, cervical nerve root blocks are useful for surgical planning in patients with cervical radicular pain syndromes.
    Objectives: Our aim was to find a method of performing cervical selective nerve root blocks that removed the risk of catastrophic complications.
    Study design: Retrospective case review.
    Setting: Academic multidisciplinary spine center.
    Methods: Among patients, 50 consecutive cases were retrospectively reviewed for immediate pain scores and follow-up results. In the intervention, a posterior approach using a curved blunt needle was employed for cervical selective nerve root blocks to minimize the risk of arterial injection. To measure the outcomes, we used quantitative pain severity scores and qualitative responses.
    Results: This technique detailed in this study has a high immediate analgesic effect that can be used for diagnostic purposes. It is not known if this technique has prognostic value with respect to surgery. The prolonged response rate is about 50%, which is in line with other techniques.
    Limitations: This study had no control group.
    Conclusion(s): Cervical selective nerve root blocks using a curved blunt needle and a posterior approach are effective in selectively identifying nerves that cause clinical symptoms. This technique minimizes the risk of arterial or spinal cord impingement and therefore may be safer than transforaminal selective nerve root blocks.
    MeSH term(s) Humans ; Retrospective Studies ; Spinal Nerve Roots/surgery ; Spinal Cord ; Radiculopathy/surgery ; Pain
    Language English
    Publishing date 2024-03-08
    Publishing country United States
    Document type Journal Article
    ZDB-ID 2146393-1
    ISSN 2150-1149 ; 1533-3159
    ISSN (online) 2150-1149
    ISSN 1533-3159
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  5. Article ; Online: Fulminant Cervical Epidural Hematomas: Why Do They Happen, How Can We Minimize Their Occurrence, and What Can We Do When They Do Occur? A Perspective.

    Helm, Standiford / Sanapati, Mahendra R / Noe, Carl / Racz, Gabor

    Pain physician

    2023  Volume 26, Issue 5, Page(s) 449–456

    Abstract: Background: Epidural hematomas after appropriately performed cervicothoracic interlaminar epidural injections have been associated with the rapid onset of neurological symptoms and devastating outcomes, despite prompt identification and treatment. ... ...

    Abstract Background: Epidural hematomas after appropriately performed cervicothoracic interlaminar epidural injections have been associated with the rapid onset of neurological symptoms and devastating outcomes, despite prompt identification and treatment. Anticoagulation issues were initially felt to be the problem, but the occurrence of fulminant hematomas in patients without coagulation forced a reassessment of the causes and responses to this problem.
    Objectives: To evaluate why fulminant epidural hematomas occur after cervicothoracic epidural injections, with a literature review to survey knowledge about them in the surgical literature, and to offer comments as to what the interventional pain physician can do to minimize their occurrence.
    Study design: A perspective piece with a literature review.
    Settings: Interventional pain management practices.
    Methods: A perspective on the issue of fulminant cervical hematomas and an associated literature review.
    Results: Anatomical studies show that there are no meaningful arteries in the posterior epidural spaces which would explain hematomas. There is a dense posterior intravertebral epidural venous plexus at C1 and also at C6-C7 extending caudally to the upper thoracic region. A venous origin has been questioned because venous pressure was felt to be too low to explain the bleeding. The surgical literature, going back 80 years, contains numerous reports of engorged epidural veins causing radiculopathy and myelopathy. These engorged veins can occur in the presence or absence of spinal pathology. There is no known means of reliably identifying these engorged veins; they have been mistaken for disc protrusions. At least one report documents massive bleeding from these veins. Studies done on a feline model of cervical stenosis suggest that the epidural pressure can reach arterial levels.
    Limitations: No direct documentation of arterialized posterior intravertebral epidural venous pressures has been made. While anatomical anomalies and degeneration contribute to epidural scarring, we do not have a full understanding as to the cause of arterialization of veins, particularly in younger patients with no obvious intraspinal pathology.
    Conclusion: Fulminant cervicothoracic epidural hematomas after an epidural injection appear to arise from the unintentional and unavoidable puncture of arterialized veins with sharp needles. A technique to open a path out from the foramen so that the blood can escape is described. Alternatively, providers should consider injecting more cephalad, between C2-C3 and C6-C7 in the cervical spine, or an alternative procedure, such as a selective nerve root injection. A cervical transforaminal approach should only be attempted with a blunt needle, which cannot enter an artery. Should symptoms occur, cervical flexion rotation maneuvers should be implemented while awaiting prompt transfer to a facility where an appropriate diagnosis and treatment can be provided.
    Key words: Cervical epidural hematoma, cervical epidural injection, posterior intravertebral venous plexus, arterialized epidural veins, pressurized epidural veins.
    Language English
    Publishing date 2023-09-29
    Publishing country United States
    Document type Journal Article
    ZDB-ID 2146393-1
    ISSN 2150-1149 ; 1533-3159
    ISSN (online) 2150-1149
    ISSN 1533-3159
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    Zs.A 5930: Show issues Location:
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  6. Article ; Online: Superior and Middle Cluneal Nerve Entrapment: A Cause of Low Back and Radicular Pain.

    Karl, Helen W / Helm, Standiford / Trescot, Andrea M

    Pain physician

    2022  Volume 25, Issue 4, Page(s) E503–E521

    Abstract: Background: The superior and middle cluneal nerves are sources of low back, buttock, and leg pain. These nerves are cutaneous branches of the lateral branches of the dorsal rami of T11- S4. Pain arising from entrapment or dysfunction of one or more of ... ...

    Abstract Background: The superior and middle cluneal nerves are sources of low back, buttock, and leg pain. These nerves are cutaneous branches of the lateral branches of the dorsal rami of T11- S4. Pain arising from entrapment or dysfunction of one or more of these nerves is called "cluneal nerve syndrome." A clear understanding of the anatomy underlying cluneal nerve syndrome and its treatment has been hampered by the very small size of the cluneal nerves and their complex, varying anatomy. Because of differing methods and foci of investigation, the literature regarding cluneal nerves has been confusing and even contradictory.
    Objectives: This paper provides a thorough critical literature review of cluneal nerve anatomy and implications for therapy.
    Study design: A modified scoping review.
    Methods: The bibliographic trail of English language papers on the anatomy and treatment of cluneal nerve syndrome was used to resolve the contradictions that have appeared in some of the anatomic descriptions and, where applicable, to examine their implications for therapy.
    Results: Recent anatomic and surgical investigations confirm a wider than previously realized range of central nervous system origins of these peripheral nerves, explaining why cluneal nerve dysfunction can cause a wide array of symptoms, including low back, buttock, and/or leg pain or "pseudosciatica."
    Conclusions: Cluneal nerve syndrome is characterized by a triad of pain, tender points, and relief with local anesthetic injections. The pain is a deep, aching, poorly localized low back pain with variable involvement of the buttocks and/or legs. Tender points are localized at the iliac crest or caudal to the posterior superior iliac spine. Muscle weakness and dermatomal sensory changes are absent in cluneal nerve syndrome. If the pain returns after injections, neuroablation, nerve stimulation, or surgical release may be needed.
    MeSH term(s) Buttocks/innervation ; Humans ; Ilium/innervation ; Low Back Pain/surgery ; Low Back Pain/therapy ; Nerve Compression Syndromes/complications ; Nerve Compression Syndromes/surgery ; Spinal Nerves/anatomy & histology
    Language English
    Publishing date 2022-07-06
    Publishing country United States
    Document type Journal Article ; Review
    ZDB-ID 2146393-1
    ISSN 2150-1149 ; 1533-3159
    ISSN (online) 2150-1149
    ISSN 1533-3159
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  7. Article ; Online: Cervicothoracic Epidural Venous Anatomy Explains Fulminant Hematomas.

    Helm, Standiford / Noe, Carl E / Racz, Gabor

    Pain medicine (Malden, Mass.)

    2020  Volume 21, Issue 10, Page(s) 2613–2615

    MeSH term(s) Catheters ; Hematoma, Epidural, Cranial ; Hematoma, Epidural, Spinal/diagnostic imaging ; Hematoma, Epidural, Spinal/surgery ; Humans ; Injections ; Steroids
    Chemical Substances Steroids
    Language English
    Publishing date 2020-02-07
    Publishing country England
    Document type Letter ; Comment
    ZDB-ID 2015903-1
    ISSN 1526-4637 ; 1526-2375
    ISSN (online) 1526-4637
    ISSN 1526-2375
    DOI 10.1093/pm/pnz368
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  8. Article ; Online: Hyaluronidase in Neuroplasty: A Review.

    Helm Ii, Standiford / Racz, Gabor

    Pain physician

    2019  Volume 22, Issue 6, Page(s) 555–560

    Abstract: Background: Neuroplasty, also known as percutaneous adhesiolysis, is an effective treatment for persistent axial and radicular pain.: Objectives: One issue of concern is whether hyaluronidase should be used when performing neuroplasty. The objective ... ...

    Abstract Background: Neuroplasty, also known as percutaneous adhesiolysis, is an effective treatment for persistent axial and radicular pain.
    Objectives: One issue of concern is whether hyaluronidase should be used when performing neuroplasty. The objective of this narrative review is to evaluate the current literature relating to hyaluronidase and its role in neuroplasty.
    Methods: The literature relating to hyaluronidase was examined via a search of PubMed and Google Scholar until April 2019, review of the citations of relevant literature, and the authors' knowledge of the literature and activity in the field. The literature was reviewed in light of hyaluronidase's physiologic role, allergenicity, medical uses, and evaluation specifically for neuroplasty.
    Results: Hyaluronidase facilitates the spread of medications in the extracellular matrix by breaking down polysaccharides in the interstitial space. While allergic reactions to hyaluronidase have been reported, these reactions occurred with animal-derived preparations. The current human recombinant hyaluronidase does not have any reports of allergic reactions. Laboratory studies show that it does not evoke an immune response. Hyaluronidase has been extensively used in a variety of medical applications, including intrathecal treatment of arachnoiditis.There have been multiple studies reporting benefit from the use of hyaluronidase in interventional procedures. One randomized trial specifically looking at the use of hyaluronidase in neuroplasty found that the addition of hyaluronidase improved pain ratings at 12 months compared to other techniques and decreased the number of procedures needed to gain effect.
    Limitations: There have been limited studies examining the enhanced efficacy of neuroplasty when hyaluronidase is added.
    Conclusions: Because of enhanced efficacy and safety, and because of the decrease in the number of procedures needed to be performed, hyaluronidase should be considered when deciding which medications to use when performing neuroplasty.
    Key words: Neuroplasty, adhesiolysis, hyaluronidase, spinal stenosis, failed back surgery synderome, post lumbar surgery syndrome.
    MeSH term(s) Humans ; Hyaluronoglucosaminidase/therapeutic use ; Lumbosacral Region ; Neurosurgical Procedures ; Pain/drug therapy ; Pain Management/methods ; Spinal Stenosis ; Treatment Outcome
    Chemical Substances Hyaluronoglucosaminidase (EC 3.2.1.35)
    Language English
    Publishing date 2019-11-27
    Publishing country United States
    Document type Journal Article ; Review
    ZDB-ID 2146393-1
    ISSN 2150-1149 ; 1533-3159
    ISSN (online) 2150-1149
    ISSN 1533-3159
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  9. Article ; Online: A review of the role of epidural percutaneous neuroplasty.

    Helm, Standiford / Knezevic, Nebojsa Nick

    Pain management

    2018  Volume 9, Issue 1, Page(s) 53–62

    Abstract: Degeneration, whether from age or postsurgical, in the ventral and lateral epidural space can lead to irritation of both the nerve roots and of the nerves present in the epidural space, the peridural membrane and the posterior longitudinal ligament. This ...

    Abstract Degeneration, whether from age or postsurgical, in the ventral and lateral epidural space can lead to irritation of both the nerve roots and of the nerves present in the epidural space, the peridural membrane and the posterior longitudinal ligament. This irritation is often accompanied by mild scarring. Neuroplasty is a specific procedure designed to relieve this irritation. The effectiveness of neuroplasty is not affected by the extent of spinal stenosis. Neuroplasty can be performed in the lumbar, thoracic and cervical spine, and using caudal, transforaminal and interlaminar approaches. Postprocedural home exercises are an integral part of the procedure. There are multiple high-grade studies positive for the effectiveness and safety of neuroplasty. Neuroplasty should be offered prior to surgery in patients with persistent back and/or extremity pain.
    MeSH term(s) Epidural Space/surgery ; Humans ; Low Back Pain/surgery ; Nerve Degeneration/surgery ; Neurosurgical Procedures ; Spinal Cord/surgery
    Language English
    Publishing date 2018-12-03
    Publishing country England
    Document type Journal Article
    ISSN 1758-1877
    ISSN (online) 1758-1877
    DOI 10.2217/pmt-2018-0042
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  10. Article ; Online: Neuroplasty Is a Safe, Effective Procedure.

    Racz, Gabor / Candido, Kenneth / Helm, Standiford

    Anesthesia and analgesia

    2017  

    Language English
    Publishing date 2017-11-10
    Publishing country United States
    Document type Journal Article
    ZDB-ID 80032-6
    ISSN 1526-7598 ; 0003-2999
    ISSN (online) 1526-7598
    ISSN 0003-2999
    DOI 10.1213/ANE.0000000000002546
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