Injectables in your practice-feasible, effective
General pediatricians can train to use injectable substances such as bupivacaine (Marcaine) for intra-articular pain relief in children and botulinum toxin type A (Botox) to treat spasticity, according to Anne Marie Cahill, MD, attending interventional radiologist at the Children's Hospital of Philadelphia, who spoke last month at the Annual Scientific Meeting of SIR.
Cahill also reviewed data on the efficacy of various injectables, including those two agents and thrombin, during her presentation. She described how joint injection of a high-dose steroid, for example, can improve range of motion and decrease pain, and how the long-acting local anesthetic bupivacaine can be used after arthroscopic surgery to lessen pain.
"Putting Marcaine in the joint," Cahill told her audience, "helps the pediatrician determine if the pain is related to the joint. It may not be clear if the pain is related to the joint or soft tissues-the child will tell you if the pain is relieved when the Marcaine is released."
Botulinum toxin can be injected into muscles without image guidance to treat spasticity or cerebral palsy, explained Cahill.
"You can use a nerve stimulator needle blind. Botox decreases acetylcholine release from the nerve endings and decreases muscle spasm and muscle tension."
Cahill recommends that community pediatricians complete a training session in rheumatology before treating patients with an injectable so that they are comfortable gaining access to joints. They should also train in a rehabilitation program to learn about using botulinum toxin type A to treat spasticity.
Cahill cautioned against attempting to inject substances such as gadolinium or thrombin without full specialty training in interventional radiology because these agents require image guidance. Injection of botulinum toxin into salivary glands is also contraindicated without image guidance.
Trauma yields to interventional technique
Such pediatric traumas as pelvic fracture can be treated with interventional radiologic techniques that lessen the likelihood of complications, an interventional radiologist told the audience at the Annual Scientific Meeting of SIR.
"We are making minimal incisions, so we are disrupting very little tissue," said Kevin Baskin, MD, who is an interventional radiologist at Children's Hospital of Philadelphia. "When trauma has occurred, the tissue is usually damaged. If you are making a large incision in surgery, going through that tissue, you are subjecting children to long-term risk of complications."
Baskin, speaking about blunt trauma afterward in an interview with Contemporary Pediatrics, described some of the techniques being applied to pediatric fracture cases.
"In the case of pelvic fractures, early ambulation is important because it protects the child from long-term disability, such as gait disturbance and pain," he said. "When extensive excisions are made, it means a longer recovery time before a child is ambulatory."
The use of imaging also allows interventional radiologists to avoid structures such as nerves and vessels around the spine, Baskin noted.
"Surgeons have to be careful that the devices that they are implanting, such as plates or screws, don't injure the spine," he said. "A child who is injured this way can have unrelenting pain or gait or vascular disturbances that are permanent."
Another potential complication that interventional radiology technique can sidestep is profound hemorrhage upon surgical entrance to the pelvis-a development that can be lethal on the operating room table, added Baskin.
Last, interventional radiology techniques are now being used to stabilize and repair leg, hip, and arm fractures, said Baskin.
"It's important that primary-care pediatricians be aware of these opportunities when discussing the care of their patients," he concluded.