Papers by Kenneth Candido
Efficacy of Epidural Injections in Managing Chronic Spinal Pain: A Best Evidence Synthesis
Pain physician, 2015
Epidural injections have been used since 1901 in managing low back pain and sciatica. Spinal pain... more Epidural injections have been used since 1901 in managing low back pain and sciatica. Spinal pain, disability, health, and economic impact continue to increase, despite numerous modalities of interventions available in managing chronic spinal pain. Thus far, systematic reviews performed to assess the efficacy of epidural injections in managing chronic spinal pain have yielded conflicting results. To evaluate and update the clinical utility of the efficacy of epidural injections in managing chronic spinal pain. A systematic review of randomized controlled trials of epidural injections in managing chronic spinal pain. In this systematic review, randomized trials with a placebo control or an active-control design were included. The outcome measures were pain relief and functional status improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias...
Incidence of Intradiscal Injection During Lumbar Fluoroscopically Guided Transforaminal and Interlaminar Epidural Steroid Injections
Anesthesia & Analgesia, 2010
Intradiscal injections during transforaminal epidural steroid injections and interlaminar lumbar ... more Intradiscal injections during transforaminal epidural steroid injections and interlaminar lumbar epidural steroid injections have been reported rarely. In that regard, this retrospective observational report is the first attempt to quantify the overall rate of this complication. A retrospective analysis of 3 years of accrued data (2004-2007) showed that 2412 transforaminal epidural steroid injections were performed at the 2 training institutions (Loyola University Medical Center and Northwestern University/Feinberg School of Medicine). There were 6 intradiscal (annular) injections of contrast, for a rate of 1:402. Over the same interval, 4723 lumbar epidural steroid injections were performed, with 1 intradiscal injection, for a rate of 1:4723.
A rare case of delayed subarachnoid anesthetic blockade effects in a 103-year-old female patient
Surgical neurology international, 2015
The elderly represent a unique challenge for the effects of regional anesthesia, and very few cas... more The elderly represent a unique challenge for the effects of regional anesthesia, and very few cases of block onset delay have been described. Their delayed response is attributed to a number of factors that include: Physiologic deterioration, musculoskeletal contractures, degenerative joint disease, autonomic regulatory dysfunction, cognitive dysfunction, altered pharmacokinetics, and pharmacodynamics of local anesthetics and adjuvants. In this report we present the rare case of 45-min delay between the administration and onset of action of a subarachnoid blockade in a 103-year-old female, who was scheduled for left hip pinning, for repair of a femoral neck fracture. Patient received an injection of hyperbaric bupivacaine, 1.5 ml of 0.75% (11.25 mg), with 15 mcg of fentanyl into the subarachnoidal space and underwent the surgical procedure without complications. Delayed responses to subarachnoid anesthesia can be expected in extremely elderly patients. Anesthetic procedures should b...
Adding Particulate or Non-Particulate Steroids to the Local Anesthetics When Performing Parasagittal Interlaminar Epidural Injections
Pain physician
Faculty of 1000 evaluation for Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment
F1000 - Post-publication peer review of the biomedical literature, 2009
Faculty of 1000 evaluation for Anatomy and pathophysiology of spinal cord injury associated with regional anesthesia and pain medicine
F1000 - Post-publication peer review of the biomedical literature, 2009
Surgical neurology international, 2015
We describe three patients who received lumbar epidural steroid injections (LESI) for lumbosacral... more We describe three patients who received lumbar epidural steroid injections (LESI) for lumbosacral radicular pain that resulted in worsening of their symptoms. The procedures were performed following a review of remote diagnostic imaging studies. These cases demonstrate the lack of consensus in pain management domains for how to approach the workup and treatment of persistent/chronic low back pain, with a noted fragmentation in pain management strategies and applied therapies. We present three patients; two female patients (37 and 38 years old) undergoing LESI for remotely diagnosed disc herniations, and one 61-year-old male receiving an LESI for a presumed, unverified lumbar intervertebral disc disorder. Following a worsening of symptoms after LESI, neurosurgical consultations ultimately determined the presence of, respectively, an epidural hematoma, a neurilemoma, and a lung cancer metastasis to the sacrum as the source of symptoms, instead of being due to the intervertebral disc p...
Pain physician
Multiple studies have shown that perineural dexamethasone improves postoperative analgesia. Howev... more Multiple studies have shown that perineural dexamethasone improves postoperative analgesia. However, some studies have shown minimal benefit, and have raised concerns regarding adverse physio-chemical effects of perineural dexamethasone. Furthermore, there is a paucity of studies wherein control (IV) dexamethasone was considered. The purpose of this meta-analysis was to evaluate the effectiveness of different concentrations of perineural dexamethasone injection on postoperative analgesia, as well as complications from its use for brachial plexus blocks. A systematic literature search was conducted using the Cochrane Central Registry of Controlled Trials, PubMed, and Scopus. Trials comparing control and local dexamethasone-treated groups, and those which reported duration of analgesia and/or pain scores/opioid consumptions were selected. Meta-analysis was performed using the Review Manager (RevMan) software 5.1. Fourteen studies consisting of a total of 1,022 patients were included. ...
The Food and Drug Administration's recent action on April 23, 2014 failed to appropriately address safety concerns about epidural steroid use
Pain physician
A novel revision to the classical transnasal topical sphenopalatine ganglion block for the treatment of headache and facial pain
Pain physician
The sphenopalatine ganglion (SPG) is located with some degree of variability near the tail or pos... more The sphenopalatine ganglion (SPG) is located with some degree of variability near the tail or posterior aspect of the middle nasal turbinate. The SPG has been implicated as a strategic target in the treatment of various headache and facial pain conditions, some of which are featured in this manuscript. Interventions for blocking the SPG range from minimally to highly invasive procedures often associated with great cost and unfavorable risk profiles. The purpose of this pilot study was to present a novel, FDA-cleared medication delivery device, the Tx360® nasal applicator, incorporating a transnasal needleless topical approach for SPG blocks. This study features the technical aspects of this new device and presents some limited clinical experience observed in a small series of head and face pain cases. Case series. Pain management center, part of teaching-community hospital, major metropolitan city, United States. After Institutional Review Board (IRB) approval, the technical aspects...
Concordant pressure paresthesia during interlaminar lumbar epidural steroid injections correlates with pain relief in patients with unilateral radicular pain
Pain physician
Transforaminal and interlaminar epidural steroid injections are commonly used interventional pain... more Transforaminal and interlaminar epidural steroid injections are commonly used interventional pain management procedures in the treatment of radicular low back pain. Even though several studies have shown that transforaminal injections provide enhanced short-term outcomes in patients with radicular and low back pain, they have also been associated with a higher incidence of unintentional intravascular injection and often dire consequences than have interlaminar injections. We compared 2 different approaches, midline and lateral parasagittal, of lumbar interlaminar epidural steroid injection (LESI) in patients with unilateral lumbosacral radiculopathic pain. We also tested the role of concordant pressure paresthesia occurring during LESI as a prognostic factor in determining the efficacy of LESI. Prospective, randomized, blinded study. Pain management center, part of a teaching-community hospital in a major metropolitan US city. After Institutional Review Board approval, 106 patients ...
Can Chronic Pain Patients Be Adequately Treated Using Generic Pain Medications to the Exclusion of Brand-Name Ones?
American Journal of Therapeutics, 2014
According to the Food and Drug Administration (FDA) reports, approximately 8 in 10 prescriptions ... more According to the Food and Drug Administration (FDA) reports, approximately 8 in 10 prescriptions filled in the United States are for generic medications, with an expectation that this number will increase over the next few years. The impetus for this emphasis on generics is the cost disparity between them and brand-name products. The use of FDA-approved generic drugs saved 158 billion dollars in 2010 alone. In the current health care climate, there is continually increasing pressure for prescribers to write for generic alternative medications, occasionally at the expense of best clinical practices. This creates a conflict wherein both physicians and patients may find brand-name medications clinically superior but nevertheless choose generic ones. The issue of generic versus brand medications is a key component of the discussion of health payers, physicians and their patients. This review evaluates some of the important medications in the armamentarium of pain physicians that are frequently used in the management of chronic pain, and that are currently at the forefront of this issue, including Opana (oxymorphone; Endo Pharmaceuticals, Inc., Malvern, PA), Gralise (gabapentin; Depomed, Newark, CA), and Horizant (gabapentin enacarbil; XenoPort, Santa Clara, CA) that are each available in generic forms as well. We also discuss the use of Lyrica (pregabalin; Pfizer, New York, NY), which is currently unavailable as generic medication, and Cymbalta (duloxetine; Eli Lilly, Indianapolis, IN), which has been recently FDA approved to be available in a generic form. It is clear that the use of generic medications results in large financial savings for the cost of prescriptions on a national scale. However, cost-analysis is only part of the equation when treating chronic pain patients and undervalues the relationships of enhanced compliance due to single-daily dosing and stable and reliable pharmacokinetics associated with extended-duration preparations using either retentive technologies or delayed absorption strategies. Medications given to chronic pain patients should be individualized to best serve analgesic needs and assure patient safety primarily, based on high levels of scientific and economic evidence. Decisions regarding utilization should not be made based solely on limited or faulty assessments of cost-benefit analyses.
Dependence muscle of V O 2 on blood flow dynamics at the onset of forearm exercise. J. Appl. Phys... more Dependence muscle of V O 2 on blood flow dynamics at the onset of forearm exercise. J. Appl. Physiol. 81(4): 1619-1626, 1996.-The hypothesis that the rate of increase in muscle O 2 uptake (V O 2 mus ) at the onset of exercise is influenced by muscle blood flow was tested during forearm exercise with the arm either above or below heart level to modify perfusion pressure. Ten young men exercised at a power of ,2.2 W, and five of these subjects also worked at 1.4 W. Blood flow to the forearm was calculated from the product of blood velocity and cross-sectional area obtained with Doppler techniques. Venous blood was sampled from a deep forearm vein to determine O 2 extraction. The rate of increase in V O 2 mus and blood flow was assessed from the mean response time (MRT), which is the time to achieve ,63% increase from baseline to steady state. In the arm below heart position during the 2.2-W exercise, blood flow and V O 2 mus both increased, with a MRT of ,30 s. With the arm above the heart at this power, the MRTs for blood flow [79.8 6 15.7 (SE) s] and V O 2 mus (50.2 6 4.0 s) were both significantly slower. Consistent with these findings were the greater increases in venous plasma lactate concentration over resting values in the above heart position (2.8 6 0.4 mmol/l) than in the below heart position (0.9 6 0.2 mmol/l). At the lower power, both blood flow and V O 2 mus also increased more rapidly with the arm below compared with above the heart. These data support the hypothesis that changes in blood flow at the onset of exercise have a direct effect on oxidative metabolism through alterations in O 2 transport. oxygen uptake; handgrip exercise; Doppler velocimetry; echo Doppler; human Address for reprint requests: R. L. Hughson,
Buprenorphine Added to the Local Anesthetic for Brachial Plexus Block to Provide Postoperative Analgesia in Outpatients
Regional Anesthesia and Pain Medicine, 2001
Over the past 10 years, several studies have suggested that the addition of certain opiates to th... more Over the past 10 years, several studies have suggested that the addition of certain opiates to the local anesthetic used for brachial block may provide effective, long-lasting postoperative analgesia. One of these studies indicated that the agonist-antagonist, buprenorphine, added to bupivacaine provided a longer period of postoperative analgesia than the traditional opiates, but in this study, it is impossible to determine the relative contributions of the local anesthetic and the opiate to the postoperative analgesia because of the extremely long duration of the anesthesia provided by the local anesthetic, bupivacaine. By repeating the study using a local anesthetic of a shorter duration, the present study delineates more clearly the contribution of the buprenorphine to postoperative analgesia when added to a shorter-acting local anesthetic. Forty, healthy, consenting adult patients scheduled for upper extremity surgery were enrolled in the study. Premedication was provided by intravenous midazolam 2 mg/70 kg and anesthesia by a subclavian perivascular brachial plexus block. The patients were assigned randomly to 1 of 2 equal groups based on the agents used for the blocks. The patients in group I received 40 mL of a local anesthetic alone, while those in group II received the same local anesthetic plus buprenorphine 0.3 mg. The study was kept double-blind by having 1 anesthesiologist prepare the solutions, a second anesthesiologist perform the blocks, and a third anesthesiologist monitor the anesthesia and analgesia thereafter, up to and including the time of the first request for an analgesic medication. The data were reported as means (+/- SEM), and differences between groups were determined using repeated measures of analysis of variance (ANOVA) and chi(2), followed by the Fisher exact test for post hoc comparison. A P value of less than.05 was considered to be statistically significant. The mean duration of postoperative pain relief following the injection of the local anesthetic alone was 5.3 (+/- 0.15) hours as compared with 17.4 (+/- 1.26) hours when buprenorphine was added, a difference that was statistically (and clinically) significant (P <.0001). The addition of buprenorphine to the local anesthetic used for brachial plexus block in the present study provided a 3-fold increase in the duration of postoperative analgesia, with complete analgesia persisting 30 hours beyond the duration provided by the local anesthetic alone in 75% of the patients. This practice can be of particular benefit to patients undergoing ambulatory upper extremity surgery by providing prolonged analgesia after discharge from the hospital.
Buprenorphine Added to the Local Anesthetic for Axillary Brachial Plexus Block Prolongs Postoperative Analgesia
Regional Anesthesia and Pain Medicine, 2002
Buprenorphine added to local anesthetic solutions for supraclavicular block was found to triple p... more Buprenorphine added to local anesthetic solutions for supraclavicular block was found to triple postoperative analgesia duration in a previous study when compared with local anesthetic block alone. That study, however, did not control for potentially confounding factors, such as the possibility that buprenorphine was affecting analgesia through intramuscular absorption or via a spinal mechanism. To specifically delineate the role of buprenorphine in peripherally mediated opioid analgesia, the present study controlled for these 2 factors. Sixty American Society of Anesthesiologists (ASA) P.S. I and II, consenting adults for upper extremity surgery, were prospectively assigned randomly in double-blind fashion to 1 of 3 groups. Group I received local anesthetic (1% mepivacaine, 0.2% tetracaine, epinephrine 1:200,000), 40 mL, plus buprenorphine, 0.3 mg, for axillary block, and intramuscular (IM) saline. Group II received local anesthetic-only axillary block, and IM buprenorphine 0.3 mg. Group III received local anesthetic-only axillary block and IM saline. Postoperative pain onset and intensity were compared, as was analgesic medication use. The mean duration of postoperative analgesia was 22.3 hours in Group I; 12.5 hours in group II, and 6.6 hours in group III. Differences between groups I and II were statistically significant (P =.0012). Differences both between groups I and III and II and III were also statistically significant (P <.001). Buprenorphine-local anesthetic axillary perivascular brachial plexus block provided postoperative analgesia lasting 3 times longer than local anesthetic block alone and twice as long as buprenorphine given by IM injection plus local anesthetic-only block. This supports the concept of peripherally mediated opioid analgesia by buprenorphine.
Anesthetic management of toxic epidermal necrolysis: report of three adult cases
Journal of Clinical Anesthesia, 2001
Toxic epidermal necrolysis is a rare but acute life-threatening syndrome in which the epidermis b... more Toxic epidermal necrolysis is a rare but acute life-threatening syndrome in which the epidermis blisters and peels in large sheets. In general, patients with this syndrome are managed as severe second-degree burn patients, but special consideration should be given to mucous membrane involvement that reduces fluid intake and worsens the fluid deficit, systemic involvement that makes these patients hemodynamically unstable,
Brachial plexus block with a new local anaesthetic: 0.5 percent ropivacaine
Canadian Journal of Anaesthesia, 1990
A new local anaesthetic, ropivacaine hydrochloride, was used in a concentration of 0.5 per cent i... more A new local anaesthetic, ropivacaine hydrochloride, was used in a concentration of 0.5 per cent in 32 patients receiving a subclavian perivascular block for upper extremity surgery. One group (n = 15) received 0.5 per cent ropivacaine without epinephrine and a second group (n = 17) received 0.5 per cent ropivacaine with epinephrine in a concentration of 1:200,000. Anaesthesia was achieved in 87 per cent of the patients in both groups in all of the C5 through T1 brachial plexus dermatomes. Motor block was profound with 100 per cent of patients in both groups developing paresis at both the shoulder and hand and 100 per cent developing paralysis at the shoulder. There was a rapid initial onset of sensory block (a mean of less than four minutes for analgesia) with a prolonged duration (a mean of greater than 13 hr of analgesia). The addition of epinephrine did not significantly affect the quality or onset of sensory or motor block. The duration of sensory block was reduced by epinephrine at T1 for analgesia and at C7, C8, and T1 for anaesthesia. The duration of sensory block in the remaining brachial plexus dermatomes as well as the duration of motor block was not effected by epinephrine. There was no evidence of cardiovascular or central nervous system toxicity in either group with a mean dose of 2.5-2.6 mg.kg-1 ropivacaine.
Comments on the Case Report of Paraplegia After Intracord Injection
Anesthesia & Analgesia, 2006
Page 1. In Response: We appreciate the comments of Drs. Munir, Rastogi, and Nede-ljkovic (1) for ... more Page 1. In Response: We appreciate the comments of Drs. Munir, Rastogi, and Nede-ljkovic (1) for their comments on the case report of inadvertent intracord injection of triamcinolone (2) and without paresthesia in an awake-patient (3) presenting with complete paraplegia. ...
Nerve Stimulator-Assisted Evoked Motor Response Predicts the Latency and Success of a Single-Injection Sciatic Block
Anesthesia & Analgesia, 2004
Variable onset latency of single-injection sciatic nerve block (SNB) may result from drug deposit... more Variable onset latency of single-injection sciatic nerve block (SNB) may result from drug deposition insufficiently close to all components of the nerve. We hypothesized that this variability is caused by the needle tip position relative to neural components, which is objectified by the type of evoked motor response (EMR) elicited before local anesthetic injection. One-hundred ASA I-II patients undergoing reconstructive ankle surgery received infragluteal-parabiceps SNB using 0.4 mL/kg (maximum 35 mL) of levobupivacaine 0.625%. The end-point for injection was the first elicited EMR: inversion (I), plantar flexion (PF), dorsiflexion (DF), or eversion (E) at 0.2-0.4 mA. The frequencies of the EMRs were: I 40%, PF 43%, E 14%, and DF 3%. SNB was considered complete if both tibial and common peroneal nerves were blocked and failed if either analgesia to pinprick was not observed at 30 min or anesthesia at 60 min. Patients with an EMR of I demonstrated shorter mean times (+/-95% confidence interval [CI]) to complete the block with 8.5 (95% CI, 6.2-10.8) min compared to 27.0 (95% CI, 20.6-33.4) min after PF (P < 0.001) and 30.4 (95% CI, 24.9-35.8) min after E (P < 0.001). No rescue blocks were required in group I compared with 24% (P = 0.001) and 71% (P < 0.001) of patients in groups PF and E, respectively. We conclude that EMR type during nerve stimulator-assisted single-injection SNB predicts latency and success of complete SNB because the observed EMR is related to the positioning of the needle tip relative to the tibial and common peroneal nerves.
A Comparative Study of 0.25% Ropivacaine and 0.25% Bupivacaine for Brachial Plexus Block
Anesthesia & Analgesia, 1992
The present study compares the effectiveness of 0.25% ropivacaine and 0.25% bupivacaine in 44 pat... more The present study compares the effectiveness of 0.25% ropivacaine and 0.25% bupivacaine in 44 patients receiving a subclavian perivascular brachial plexus block for upper extremity surgery. The patients were assigned to two equal groups in this randomized, double-blind study; one group received ropivacaine 0.25% (112.5 mg) and the other, bupivacaine 0.25% (112.5 mg), both without epinephrine. Onset times for analgesia and anesthesia in each of the C-5 through T-1 brachial plexus dermatomes did not differ significantly between the two groups. The mean onset time for analgesia ranged from 11.2 to 20.2 min, and the mean onset time for anesthesia ranged from 23.3 to 48.2 min. The onset of motor block differed only with respect to paresis in the hand, with bupivacaine demonstrating a shorter onset time than ropivacaine. The duration of sensory and motor block also was not significantly different between the two groups. The mean duration of analgesia ranged from 9.2 to 13.0 h, and the mean duration of anesthesia ranged from 5.0 to 10.2 h. Both groups required supplementation with peripheral nerve blocks or general anesthesia in a large number of cases, with 9 of the 22 patients in the bupivacaine group and 8 of the 22 patients in the ropivacaine group requiring supplementation to allow surgery to begin. In view of the frequent need for supplementation noted with both 0.25% ropivacaine and 0.25% bupivacaine, we do not recommend using the 0.25% concentrations of these local anesthetics to provide brachial plexus block.
Uploads
Papers by Kenneth Candido