References
Addiction rate, article type
Ives et al. (2006)
32%, prospective survey
Adams et al. (2006)
4.9%, prospective registry
Fishbain et al. (1992)
18.9%, systematic review
Portenoy and Foley (1986)
5%, case series
Morphine is the gold standard analgesic used for battlefield pain control, having been first administered orally in the War of 1812 and parenterally in the U.S. Civil War. Intramuscular (IM) morphine can be given on the battlefield or battalion aid station (BAS), ideally by a medical corpsman, or alternatively by a buddy, or the soldier himself. Although IM administration generally provides rapid and reliable analgesia, the liabilities of this delivery mode include variable absorption during shock and with lower extremity wounds, and the risk of infection. Intravenous administration is more reliable than IM use, but is often impractical and requires specialized equipment and trained personnel (Jowitt and Knight 1983). The U.S. military is currently investigating the feasibility of providing transmucosal fentanyl citrate in “wound packs” to small, highly disciplined units that tend to operate independently without the benefit of an organized, medical support system (e.g. Special Forces) (Black and Mcmanus 2009). The pharmacokinetics of transmucosal delivery are comparable to IM administration, with therapeutic blood levels being reached within 10–15 min, and peak plasma concentration occurring about 20 min after administration (Fine and Streisand 1998). Depending on the formulation, between 25 and 50% of transmucosal fentanyl is absorbed via the oral or buccal mucosa, with another 15–25% being slowly absorbed through the gastrointestinal tract. The pharmacokinetics of transmucosal fentanyl also appear to be independent of age, unaffected by multiple dose regimens, and less prone to hemodynamic variations (Egan et al. 2000; Kharasch et al. 2004). This may make it an ideal agent for battlefield analgesia. Kotwal et al. recently reported using high dose (1,600 μg) oral transmucosal fentanyl citrate to treat 27 soldiers with acute orthopedic injuries in an out-of-hospital setting in OIF (Kotwal et al. 2004). Excellent pain relief without the need for additional analgesia was reported in 19 patients, with minor, self-limiting side effects occurring in eight soldiers. In one patient who received a repeat dose of fentanyl followed by subsequent intravenous opioids, hypoventilation requiring reversal with naloxone occurred 4 h postadministration. Other rapidly acting analgesics that may someday be used in lieu of parenteral opioids include intranasal butorphanol, intranasal ketamine, and fentanyl buccal tablets (Davis 2010).
Second echelon medical treatment facilities include mobile field surgical teams and forward surgical teams (FST), whose providers include surgeons, anesthetists, and nurses. The primary functions of FSTs are resuscitation and stabilization. Pain control at this level of care generally involves oral opioids, nonopioid analgesics, and intravenous opioids, which can be safely monitored by nurses and other trained personnel. Patient-controlled analgesia may also be used at these facilities as resources dictate.
Combat support hospitals (CSH), which have fully replaced mobile army surgical hospitals or MASH units in the U.S. military, represent the backbone of forward-deployed medical care. Care at these units generally includes a wide array of medical and surgical specialists some of whom may possess training in pain management. Since the U.S. and allied militaries do not currently classify anesthesiologists and most other physicians by subspecialty training, having a pain management specialist serving downrange in a forward-deployed area is a serendipitous endeavor. However, this may soon change, as both the U.S. Army and Navy have appointed pain management consultants to their respective Surgeon Generals. Recommendations from the Army Surgeon General’s (2010) pain medicine task force stated that a provider trained in pain management should be assigned to each CSHs. However, at the present time, these recommendations have not been adopted.
Care at third echelon military treatment facilities includes intensive care units and medical wards, which may administer continuous infusions of opioid and nonopioid (e.g. ketamine and epidural infusions of local anesthetics) analgesics for acute and subacute injuries. When pain management-trained anesthesiologists are deployed to CSH, more advanced interventions such as sympathetic and paravertebral blocks may be performed. Recently, anesthesiologists have also begun to employ peripheral nerve catheters for intermediate-term pain control (Buckenmaier et al. 2005, 2006). In addition to providing safe and titratable pain relief, peripheral nerve catheters also can be used for anesthesia in patients requiring repeat surgery or wound debridement (Table 14.2). With proper maintenance and monitoring, tunneled peripheral nerve catheters can be reliably used for up to 3 weeks or longer postplacement. The main factors limiting the routine use of peripheral nerve block catheters are the speed of evacuation, variability in training levels of medical personnel, and theoretical concerns about masking compartment syndrome. Compartment syndrome may result in permanent nerve and muscle damage (Wall et al. 2010).
Table 14.2
Advantages of peripheral nerve catheters for war injuries
Can provide anesthesia for repeat surgery or wound debridement |
Can provide excellent, limb-specific analgesia |
Stable hemodynamics |
Minimal side effects |
Reduced need for opioid and other analgesics |
Improved alertness |
Requires only simple, easily transportable equipment |
To a lesser degree, care at this level focuses on reducing the long-term sequelae of acute injury. Recently, the U.S. military has attempted to reduce the incidence of chronic pain following trauma or surgery by the preventive use of neuropathic pain medications such as gabapentin. When used preemptively before surgical procedures associated with a high incidence of severe acute and chronic postsurgical pain, gabapentin, pregabalin, and similar drugs used to treat neuropathic pain have been shown to reduce perioperative pain and opioid requirements, and decrease the incidence of chronic postsurgical pain (Fassoulaki et al. 2001, 2002; Hurley et al. 2006). At fourth and fifth echelon treatment centers, acute and chronic pain management is also similar to the care received in civilian trauma centers and pain management clinics, respectively.
Emerging developments in the acute pain management of combat casualties, especially the polytrauma patient, also require additional evaluation (Malchow and Black 2008). There is a lack of randomized, controlled studies with long-term outcomes. That said, there is a growing body of evidence that suggests that early and effective use of analgesia is associated with improved short-term outcomes including a decreased incidence of thromboembolic events (Tuman et al. 1991; Sorenson and Pace 1992), decreased pulmonary complications (Wu et al. 2006), shortened ICU and hospital stays (Liu et al. 1995), and a diminished catabolic stress response marked by absent tachycardia, decreased oxygen consumption, and the avoidance of immunosuppression (Desborough 2000; Schricker et al. 2004). Whether these short-term effects will actually translate into better long-term benefits is yet another area ripe for clinical investigation.
Acute Pain
There is considerable evidence that acute pain intensity is a strong predictor for the development of chronic pain (Kelhet et al. 2006; see also Short and Vetter 2011). Research studies and clinical experience both support the hypothesis that chronic pain develops in association with a hypervigilant state that is initiated by a traumatic event and reinforced by prolonged acute pain (De Kock 2009, see also Vetter 2011). A predisposition toward the development of hypervigilance varies in terms of the type of trauma, the length of exposure, genetic susceptibility, age, gender, and related factors. Thus, the intensity and duration of the inciting traumatic event must overcome an “unknown” threshold such that the hypervigilant state develops, thereby creating the biobehavioral environment where acute pain can become chronic. However, once a hypervigilant state exists, biobehavioral factors including fear, anxiety, and perceptual amplification, which are associated with the patient’s hypervigilance, become barriers to effective pain control and relief. Early and effective pain relief (e.g. pharmacologic) in association with psychological therapies (e.g. cognitive behavioral therapy) have been shown to decrease acute pain, thereby preventing acute pain patient from reaching the hypervigilance threshold, and making that biobehavioral transition from acute pain to chronic pain (De Kock 2009, see also Short and Vetter 2011). Holbrock et al. found an association between morphine use and the decreased development of post-traumatic stress disorder (PTSD) (Holbrook et al. 2010). Aggressive pain management is key to the prevention of the transition from acute pain to long-term chronic pain states and psychological morbidity (De Kock 2009; see also Short and Vetter 2011).
Despite this need, a multidisciplinary team that includes a psychologist or psychiatrist is not included in the military table of organization and equipment (MTOE). The MTOE is the document that regulates staffing for all deployed military units including the CSHs. One psychiatrist is assigned to the CSH, but they are a limited resource. Their primary role as part of the multidisciplinary team is the diagnosis and treatment of psychiatric diseases (e.g. intractable depression, suicidal ideation, generalized anxiety disorder, etc.). The psychiatrist can serve as a consult to assist with pain treatment. However, due to the rapid evacuation from the CSH and operational tempo, they are frequently unable to provide treatment before the patient is evacuated. Training of the multidisciplinary team in the treatment of fear, uncertainty, and anxiety by all clinical staff is a critical component for the combat environment and care (Newcomer et al. 2010). In our practice at Fort Bragg, we found that the nursing staff was able to effectively improve patient’s anxiety and pain levels by teaching them to use and teach guided imagery, distraction, and relaxation techniques in conjunction with prescribed medication or pain relief procedures.
Multidisciplinary pain care includes psychotherapies (e.g. cognitive behavioral therapy; see also Donovan et al. 2011) that focus on the treatment of depression, fear, and anxiety with the goal of improving the patients’ sense of control and is one method that has been shown to lessen the biological pain that the patient experiences. The development of an acute pain treatment regimen that is designed to lessen biological pain often presents a clinical conundrum. Every acute pain management strategy requires a basal analgesic regimen. Currently, only opioids and local anesthetic nerve blockade provide adequate analgesia and can be used as the primary analgesic. Many other classes of medications such as N-methyl-d-aspartate (NMDA) receptor antagonists, alpha-2 receptor agonists, NSAIDs, sodium channel blockers, anticonvulsants, and presynaptic calcium channel blockers can be used as adjunctive pain medications, but none either alone or in combination can provide analgesia comparable to opioids and nerve blocks. Therefore, either opioids or local anesthetic nerve blockade should form the centerpiece of any analgesic plan, with adjunctive medications used to augment the primary analgesic. In the case of local anesthetics, augmentation by adjunctive pain medications provides additional pain relief at the cost of increased medication-related side effects. Conversely, if opioids are the base analgesic, adjunctive medications can actually decrease many opioid-related side effects due to synergy and opioid sparing effects (Pal et al. 1997).
Opioids in the Treatment of Pain in the Battlefield Injured: Pros and Cons
Opioid analgesia is a key pillar to universal effective pain management in the current and future theater of war yet; despite the potential for adverse events, opioid-centered analgesia remains the primary base analgesic for acute pain management. Opioids are effective for all types of pain if used in the appropriate dose regimen, though neuropathic pain syndromes generally require higher doses, and this issue needs to be factored into the short- and long-term treatment plan and communicated to the patient (Ballantyne and Shin 2008). Other advantages of opioid analgesics include physician familiarity and the absence of end-organ toxicity. That said, opioid-centered analgesia has many adverse and well-known side effects including: respiratory depression, sedation, nausea, vomiting, bowel dysfunction, abuse, and addiction (Trescot et al. 2006). Some of the lesser-known side effects of intermediate or long-term opioid use include immunosuppression, hyperalgesia, increased bone mass demineralization, and anabolic hormonal suppression (Daniel 2002; Page 2005; Angst and Clark 2006). Collectively, these adverse effects are likely to have a negative long-term impact on polytrauma patients who are at greater risk for the development of long-term chronic pain syndromes.
The observed discrepancy in addiction rates as described in Table 14.1 is primarily due to variations in definition. The Diagnostic and Statistical Manual for Mental Disorders (DSM IV) does not have a definition for prescription drug misuse or addiction. The DSM IV only has a definition that is applicable to prescription drug abuse. Studies have employed a variety of definitions, from the clear-cut definition of abuse as defined in the DSM IV to the more liberal definitions such as “aberrant drug-related behaviors” or the subjective provider impression of misuse (Starrels et al. 2010). As a consequence, the current rate of opioid abuse, misuse, or addiction in the active duty U.S. military population is currently unknown.
Most wounded soldiers are treated with opioids for an extended period of time during the acute and convalescent phases after their injury. To date, however, this population has not been screened for opioid or other substance abuse risk factors prior to the initiation of opioid therapy. The military does not monitor substance abuse history unless a soldier is referred to the Army Substance Abuse Program (ASAP) for the treatment of substance addiction or abuse. This includes soldiers who enlisted in the military with prior substance abuse histories. The military medical community has recognized that opioid abuse, misuse, and addiction present clear risks to individual soldiers and military combat strength. There is also additional evidence that shows that male gender, low socio-economic status (SES), genetic factors, family background/environment may also play a role in an individual’s susceptibility for substance abuse disorders (Hall et al. 2008). The military population has some notable differences compared to the civilian population which include the predominantly young age, male sex, disposition for risk-taking behaviors, post-traumatic cognitive deficits, and the high prevalence of PTSD. While the current rate of opioid abuse, misuse, and addiction in the active duty military is not known, multiple initiatives at the local and national level have been undertaken to create and evaluate evidence-based best practices that balance the morale of the warfighter and medical necessities of appropriate pain treatment vs. the real individual and collective risk of pain medication, specifically opioid, abuse, or misuse (Chou et al. 2009; Benzon et al. 2010).
Alternatives to Opioid Analgesia
One alternative to opioid analgesia is the local anesthetic nerve blockage. Local anesthetic nerve blockade is the only other pain treatment modality capable of providing effective basal analgesia as part of an effective acute pain management strategy. Local anesthetic nerve blockade is commonly referred to as regional anesthesia, and is typically performed by placement of a catheter in either the epidural space or near a large peripheral nerve or nerve plexus by the anesthesiologist.
Studies have also shown improved patient outcomes and fewer adverse events with regional anesthesia (Guinard et al. 1992; Grass 1993). Improved outcome measures include decreased ICU and hospital stays (Yeager et al. 1987; Tuman et al. 1991); (Rawal et al. 1984), decreased cardiovascular mortality (Yeager et al. 1987; Tuman et al. 1991), decreased pulmonary dysfunction (Rawal et al. 1984; Guinard et al. 1992), earlier return of bowel function (Rawal et al. 1984), decreased neuroendocrine stress (Yeager et al. 1987), decreased infection rate (Yeager et al. 1987), and decreased mortality (Wu et al. 2004, 2006). Wu et al., in an analysis of the Medicare claims database from 1997 to 2001 involving 3,501 patients, revealed a significantly lower odds of death ratio at 7 and 30 days postoperatively for patients who received a postoperative epidural (Wu et al. 2006). At this time, insufficient evidence exists that can determine if regional anesthesia can prevent or lessen the development of chronic pain including phantom limb pain (PLP). Five prospective studies evaluated perioperative epidural and regional nerve blocks to prevent the development of PLP (Bach et al. 1988; Elizaga et al. 1994; Jahangir et al. 1994; Pinzur et al. 1996; Nikolajsen et al. 1997). Although all studies found improved short-term pain relief, only Jahangiri et al. reported a decrease in PLP at 6 and 12 months postoperatively (Jahangir et al. 1994). The other five studies were equivocal. Animal studies also show that it is possible to inhibit the development of long-term chronic pain states; but human studies designed to decrease the incidence of postamputation PLP show mixed results (Manchikanti and Singh 2004; Rooney et al. 2007) (see also Foell and Flor 2011). What these retrospective and short-term studies show is that regional anesthesia can provide physiologic and cognitive benefits. Additional long-term prospective human studies are required to confirm these effects.
Regional anesthesia is also the only modality that can control pain without cognitive or physiologic side effects. Effective regional anesthesia enables wounded service members to avoid the sequelae of untreated acute pain, prevent the transition of the transition of acute pain to chronic pain, and prevent the known dose-related side effects of opioids (Buckenmaier et al. 2005, 2006; Malchow and Black 2008). However, regional anesthesia is not without risks. Major risks include local anesthetic toxicity and nerve injury (Auroy et al. 2002). The incidence of nerve injury varies widely and ranges from 0.2 to 2% (Stan et al. 1995; Faccenda and Finucane 2001), which can be reduced even further with the use of image-guided ultrasound, or peripheral nerve stimulation. The incidence of seizures secondary to local anesthetic toxicity with a peripheral nerve catheter is approximately 1 in 1,000, compared to 1 in 8,000 for epidural catheters (Auroy et al. 2002). The incidence of cardiac arrest from local anesthetic toxicity is 1 in 10,000 and 1 in 7,000 for epidural and peripheral nerve blocks, respectively (Auroy et al. 2002). Other risks of regional anesthesia include pneumothorax, diaphragmatic paralysis secondary to phrenic nerve block for upper extremity blocks, inadvertent spinal anesthesia, epidural hematoma, bleeding, allergic reactions, and infection (Auroy et al. 2002; Greensmith and Murray 2006).
In summary, additional research is needed to determine the best pain treatment strategies in the polytrauma patient. Untreated acute pain has detrimental immediate physiologic effects that have the potential to adversely affect long-term outcomes, including the development of PTSD and the transition to other chronic pain syndromes (Saxe et al. 2001; Hoge et al. 2004; De Kock 2009; see also Short and Vetter 2011; Donovan et al. 2011). The best treatment regimen, however, is still a matter of controversy. This controversy will not be resolved without conducting large-scale, clinical prospective trials.
Nonbattle Injuries (NBI)
A recent epidemiological study by Cohen et al. (2005) showed that among medically evacuated soldiers from OIF treated in pain clinics in level IV military treatment centers, injuries incurred during combat missions accounted for only 17% of cases. Over half of the patients presented with LBP, and the majority were diagnosed with lumbosacral radiculopathy. In descending order, the most commonly utilized treatments were NSAIDs, short-acting opioids, physical therapy, anticonvulsants, and epidural steroid injections (ESI). In those soldiers in whom disposition data were available, only 2% returned to duty with their unit. Multiple reasons contribute this low return to duty rate including more severe disease that necessitated evacuation to level IV treatment, the logistical difficulty of returning to the war zone from a level IV MTF, and a decreased desire to return to the war zone once a soldier is in the United States (Cohen et al. 2005).
Johnson et al. performed a retrospective review of American military patients evacuated out of theater during the first 4 months of Operation Iraqi Freedom (OIF) (Johnson et al. 2005). A total of 1,236 patients were evacuated: there were 256 battle casualties (20.7%), 510 injuries (41.3%), and 470 disease patients (38.0%). The patients included 1,123 males (91%) and 113 females (9%). Battle casualties were predominately male, 252 men (98%) vs. 4 women (2%). Injuries and medical diseases including pregnancy were the primary cause of evacuation for women. However, the dominant cause of attrition among female soldiers is still disease and injury (e.g. falls) rather than combat wounds which is supported by the fact that 2% of all battle fatalities are female. Hope et al. in an epidemiologic study found similar on duty causes of injuries with falls being the most common between the sexes (need citation). Sex differences in pain have also been reported (see also Keogh 2011). Women had longer average hospital stays for injuries of similar severity. This is an important area for future research. A full review of sex differences and injury patterns in the battlefield injured has not been performed to date.
There is some evidence that chronic pain may persist in war veterans presenting with NBI. A cohort study conducted by Gironda et al. found that 47% of 793 OIF and OEF veterans reported at least some degree of pain during their initial visit to a veteran’s administration hospital (Gironda et al. 2006). Among these patients, 59% rated their pain as at least “moderate.” In descending order, the most common pain complaints were back pain (46%), leg pain (31%), arm pain (8%), and neck pain (6%). In large-scale studies performed in Gulf War veterans, the prevalence rate of chronic, diffuse pain symptomatology has ranged from 7% (Fukuda et al. 1998) to 45% in more recently studies (Kang et al. 2009). Other recent studies show that at least a portion of somatic symptoms in veterans may be due to concomitant psychopathology (e.g. PTSD) or other Axis I disorders (Amin et al. 2010). In a population-based survey of 3,682 Gulf War veterans and military combat nonparticipants, Barrett et al. (2002) found a strong association with PTSD and poor physical health symptoms. Over 95% of the 53 soldiers with PTSD experienced musculoskeletal symptoms, as compared to less than 50% of former soldiers without PTSD. The strong association between chronic pain and Axis I disorders indicate that chronic pain is a causative factor in the development of the psychiatric disorders including depression and anxiety (Fishbain 1999). Fishbain in a review of comorbid psychiatric disorders and chronic pain patients reported that over 94% of chronic pain patients have at least one associated comorbid axis I diagnosis (Fishbain 1999). Moreover, once a psychiatric disorder is manifest the treatment of the underlying pain condition is more complex and the long-term prognosis is worse. Therefore, early aggressive pain treatment as prevention is likely to improve clinical outcomes.
The low return-to-duty rate reported by Cohen et al. and the high prevalence of persistent pain in veterans have led some experts to advocate early and aggressive treatment of acute or recurrent chronic pain conditions in forward-deployed pain clinics. White and Cohen reported data on 126 soldiers and other Department of Defense beneficiaries who were treated over 1 year in the first pain treatment center established within a theater of combat operations (White and Cohen 2007). Similar to the data reported in fourth-level military treatment facilities (Cohen et al. 2005), the most common diagnosis was radiculopathy, which accounted for approximately two-thirds of all new consults. The next most common diagnoses were thoracic pain, groin pain, nonradicular leg pain, and axial LBP. Not surprisingly, the most frequently performed procedures were ESI, trigger point injections, intra-articular facet blocks, and inguinal area nerve blocks. The return-to-duty rate in this study was an impressive 95%, which represents a dramatic improvement over the 2% return-to-duty rate reported by Cohen et al. in an earlier study in a similar patient population (Cohen et al. 2005). Of note, all seven patients medically evacuated to the continental United States were male patients with groin pain. Groin pain can be difficult to treat and has a high association with psychological comorbidities.
Although the stark differences in return-to-duty rates also support aggressive pain management in forward-deployed areas; several confounding factors contribute to the large discrepancy in return-to-theater rates (Cohen et al. 2005; Johnson et al. 2005). These include: a higher percentage of secondary gain issues among soldiers treated at fourth-level MTF, more concomitant psychopathology in those soldiers already medically evacuated out of theater, and more stringent selection criteria in the latter study (Elkayam et al. 1996; Fishbain 1999; Barrett et al. 2002). Specifically, soldiers who were treated “in theater” may have been more motivated to remain with their units, more likely to be mission-essential personnel whose commanders requested treatment, and more likely to have conditions amenable to treatment and rapid recovery. Dragovich and Trainer in a recent epidemiological study also reported similar results. Between December 2008 and June 2009, 31 patients with either radicular or axial LBP were treated with interventional therapies at Ibn Sina Hospital in Baghdad, Iraq. The return-to-duty rate in this study was 97% (Dragovich and Trainer 2011).
In summary, pain management in the battlefield setting is fraught with a unique set of challenges almost unimaginable in civilian pain treatment facilities. Given the wide variations in medical resources and personnel, there is actually no “optimal” pain treatment for war injuries. Instead, treatment should be individually tailored based on a patient’s injury, hemodynamic condition, available resources, and the ability to adequately monitor treatment response. In modern warfare, the most common cause of soldier attrition are acute and recurrent nonbattle-related injuries, similar to those encountered in civilian pain treatment facilities and primary care offices. Recent evidence also suggests that the high return-to-unit rates observed in recent studies can be obtained through the deployment of aggressive pain management capabilities in mature theaters of operation.
Pain Conditions Encountered
Low Back Pain (LBP)
LBP is the most common presenting symptom likely to be encountered by the pain practitioner deployed to CSH. This is not surprising considering the repetitive stress of the previous training, heavy loads services members must carry, frequent transportation over rough terrain in military vehicles with stiff suspensions, heavy individual body armor (IBA) requiring abnormal posture that is worn for hours at a time, sleep deprivation, and the high degree of psychophysiological stressors faced by soldiers deployed to combat zones. A recent 5-year longitudinal cohort study conducted by Carragee and Cohen in 154 special operation U.S. Army reservists with no prior history of back pain, 84 and 64% reported mild and moderate LBP, respectively, when surveyed monthly after drill weekend (Carragee and Cohen Spine 2009). In deployed combat soldiers on duty 24 h/day, the authors estimated that the annual incidence of LBP would be higher. Among the various causes of LBP, radiculopathy from nerve root irritation may be the most commonly encountered condition. Compared to axial LBP, lumbosacral radiculopathy is generally associated with a more favorable prognosis (Carragee 2005).
The mainstay of interventional treatment for lumbar radiculopathy (sciatica) is ESI. ESI exert their beneficial effects by virtue of their anti-inflammatory properties, inhibition of the enzyme phospholipase A2, a critical enzyme necessary for the production of prostaglandins, suppression of ectopic discharges from injured neurons, and a reduction of capillary permeability (McLain et al. 2005). Although ESIs have been successfully used to treat axial back pain, the ideal candidates for treatment are those patients with pain of greater than 6 months duration, leg pain, increased back pain, young age, intermittent pain, and the absence of concomitant spinal stenosis (Benzon 1986; Butterman 2004). The use of fluoroscopic guidance is highly recommended for interlaminar ESI, and is necessary for transforaminal epidural steroid injections (TFESI). Even in experienced hands, the technical failure rate for “blind” ESI ranges from approximately 10% in the lumbar region to upwards of 50% for blinded cervical ESI (Renfrew et al. 1991; Fredman et al. 1999; Stitz and Sommer 1999; Stojanovic et al. 2002). Studies also show that only about 26% of blindly performed interlaminar ESI reached the targeted area of pathology in patients with previous back surgery (Fredman et al. 1999). TFESIs are technically more challenging than interlaminar ESI. However this intervention may provide additional clinical benefit since the medication is directly deposited over the affected nerve root, resulting in a higher incidence of ventral epidural spread, which is where the inciting disc pathology lies. In a recent comparative study, superior outcomes were found for TFESI compared to interlaminar ESI (Schaufele et al. 2006).
Patients who may have a diagnosis of radicular pain should receive CT scans of the appropriate spine area. Whereas MRI is the gold standard for imaging soft tissue and disc anatomy, these are not readily available in forward-deployed areas. In comparison to MRI, CT scans are approximately 90% sensitive and 70% specific in detecting disc pathology (Foristall and Marsh 1988). In comparison to drugs used to treat neuropathic pain such as gabapentin and amitriptyline, the advantages of ESI in combat-deployed service members include the speed of onset of treatment (e.g. 48–72 h) and the absence of central nervous system depressant effects such as lethargy, fatigue, and cognitive dysfunction. In addition, although ESIs are considered by many to be the best nonsurgical interventional therapy for radicular pain, controversy still exists regarding their long-term efficacy (Carette et al. 1997; Rozenberg et al. 1999; Riew et al. 2006).
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