Christopher G. Gharibo, M.D.

Interlaminar versus transforaminal epidural steroids for the treatment of subacute lumbar radicular pain: A randomized, blinded, prospective outcome study
Gharibo C.G.; Varlotta G.P.; Rhame E.E.; Liu E.-C.J.; Bendo J.A.; Perloff M.D.
2011 ;14(6):499-511, Pain Physician
Background: There is uncertainty in the literature over the relative effectiveness of lumbar epidural interlaminar (IL) steroid injection versus transforaminal (TF) steroid injection for lumbar radiculopathy. Most studies to date have been retrospective, or technically focused. Objective: To complete a randomized, blinded, prospective outcome study of the short-term benefit for IL versus TF epidural steroids for the treatment of subacute lumbar radicular pain. Study design: Prospective, randomized, blinded, subacute efficacy trial. Setting: Tertiary care pain management center, major metropolitan city, United States Methods: After institutional review board approval, 42 age-matched patients with similar lower back pain and unilateral radicular symptoms were enrolled and randomized in a patient and evaluating physician blinded trial to IL or TF epidural steroids from 2007 through 2009. Prior to intervention and 10-16 days after injection, each participant was evaluated by questionnaire and physical exam by an independent physician. All injections were performed by the same physician. Thirty-eight participants completed the study, 18 in the IL group and 20 in the TF group. Four participants required a repeat injection, and 2 participants crossed over to the alternative injection type (IL to TF). Results: Overall, physical exam, diagnostic testing, disability, activity, depression measures, and opioid pill use were similar between the 2 groups, both pre-injection baseline and postinjection improvement. In primary outcomes, the post-injection follow-up Numeric Rating Scale (NRS) was more greatly reduced in the TF group. The NRS decreased from 7.0 +/- 1.9 to 3.9 +/- 3.1 (mean values +/- standard deviation) in the IL group and 6.4 +/- 2.1 to 1.7 +/- 1.4 in the TF group. The Oswestry Disability Index was reduced from 37.5 +/- 12.6 to 19.0 +/- 16.7 in the IL group and 38.3 +/- 6.4 to 21.6 +/- 16.8 in the TF group. In secondary outcomes, the depression scale was reduced from 4.39 +/- 3.22 to 2.28 +/- 3.20 in the IL group and 4.10 +/- 1.94 to 1.65 +/- 1.63 in the TF group. Walking tolerance was increased from 8.1 +/- 4.6 blocks to 10.6 +/- 4.4 in the IL group and 8.9 +/- 5.3 blocks to 11.8 +/- 4.2 in the TF group. Limitations: The study did not examine long-term outcomes. A single experienced interventionalist performed all injections. Conclusion: Results suggest that patients may experience greater subjective relief, at least initially, from TF epidural steroid injections over IL. However, more objective, and likely subacute, therapeutic effects are similar
— id: 145743, year: 2011, vol: 14, page: 499, stat: Journal Article,

Chronic pain syndromes
Gharibo, Christopher G; Kahn, M. Fahad
Medical aspects of disability : a handbook for the rehabilitation professional New York : Springer, c2011,
— id: 5785, year: 2011, vol: , page: ?, stat: Chapter,

Interlaminar versus transforaminal epidural steroids for the treatment of subacute lumbar radicular pain: a randomized, blinded, prospective outcome study
Gharibo, Christopher G; Varlotta, Gerald P; Rhame, Ellen E; Liu, En-Chia James; Bendo, John A; Perloff, Michael D
2011 Nov;14(6):499-511, Pain Physician
BACKGROUND: There is uncertainty in the literature over the relative effectiveness of lumbar epidural interlaminar (IL) steroid injection versus transforaminal (TF) steroid injection for lumbar radiculopathy. Most studies to date have been retrospective, or technically focused. OBJECTIVE: To complete a randomized, blinded, prospective outcome study of the short-term benefit for IL versus TF epidural steroids for the treatment of subacute lumbar radicular pain. STUDY DESIGN: Prospective, randomized, blinded, subacute efficacy trial. SETTING: Tertiary care pain management center, major metropolitan city, United States METHODS: After institutional review board approval, 42 age-matched patients with similar lower back pain and unilateral radicular symptoms were enrolled and randomized in a patient and evaluating physician blinded trial to IL or TF epidural steroids from 2007 through 2009. Prior to intervention and 10-16 days after injection, each participant was evaluated by questionnaire and physical exam by an independent physician. All injections were performed by the same physician. Thirty-eight participants completed the study, 18 in the IL group and 20 in the TF group. Four participants required a repeat injection, and 2 participants crossed over to the alternative injection type (IL to TF). RESULTS: Overall, physical exam, diagnostic testing, disability, activity, depression measures, and opioid pill use were similar between the 2 groups, both pre-injection baseline and post-injection improvement. In primary outcomes, the post-injection follow-up Numeric Rating Scale (NRS) was more greatly reduced in the TF group. The NRS decreased from 7.0 +/- 1.9 to 3.9 +/- 3.1 (mean values +/- standard deviation) in the IL group and 6.4 +/- 2.1 to 1.7 +/- 1.4 in the TF group. The Oswestry Disability Index was reduced from 37.5 +/- 12.6 to 19.0 +/- 16.7 in the IL group and 38.3 +/- 6.4 to 21.6 +/- 16.8 in the TF group. In secondary outcomes, the depression scale was reduced from 4.39 +/- 3.22 to 2.28 +/- 3.20 in the IL group and 4.10 +/- 1.94 to 1.65 +/- 1.63 in the TF group. Walking tolerance was increased from 8.1 +/- 4.6 blocks to 10.6 +/- 4.4 in the IL group and 8.9 +/- 5.3 blocks to 11.8 +/- 4.2 in the TF group. LIMITATIONS: The study did not examine long-term outcomes. A single experienced interventionalist performed all injections. CONCLUSION: Results suggest that patients may experience greater subjective relief, at least initially, from TF epidural steroid injections over IL. However, more objective, and likely subacute, therapeutic effects are similar
— id: 141704, year: 2011, vol: 14, page: 499, stat: Journal Article,

Interlaminar versus transforaminal epidural steroids for the treatment of lumbar radicular pain: A randomized, blinded, prospective outcome study
Perloff M.; Varlotta G.; Gharibo C.
2011 ;12(4 SUPPL 1):P65-P65, Journal of pain
Argument in the literature exists over lumbar epidural interlaminar steroid injection (LESI) verses transforminal (TF) technique as the most effective therapy in lumbar radiculopathy. However, all studies to date have been retrospective. After IRB approval, 42 age matched patients with similar lower back pain and unilateral radicular symptoms were enrolled and randomized in a double blind trial to LESI or TF from 2007 to 2009. Prior to intervention and 10-16 days after injection, each patient was evaluated by patient questionnaire and physical exam by an independent physician. 38 patients completed the study, 18 in the LESI and 20 in the TF group. In both groups, 2 patients required repeat injection, and 1 patient crossed over to the alternative injection type. Overall, physical exam, diagnostic testing, disability, activity and depression measures, and opioid pill use, were similar between the 2 groups, both pre-injection baseline and post-injection improvement. The Oswestry Disability Index (ODI%) was reduced from 37.5+/-12.6 (mean values +/- standard deviation) to 19.0+/-16.7 (49.3%+/-39.2%) in the LESI group and 38.3+/-6.4 to 21.6+/-16.8 (43.7%+/-34.8%) in the TF group. Depression scale was reduced from 4.39+/-3.22 to 2.28+/-3.20 (48.1%+/-52.0%) in the LESI group and 4.10+/-1.94 to 1.65+/-1.63 (61.0%+/-39.1) in the TF group. Walking tolerance was increased from 8.1+/-4.6 blocks to 10.6+/-4.4 (30.8%+/-133.2%) in the LESI group and 8.9+/-5.3 blocks to 11.8+/-4.2 (32.8%+/-318.7%) in the TF group. The follow-up patient numerical rating scale (NRS) was more greatly reduced in the TF group. NRS decreased from 7.0+/-1.9 to 3.9+/-3.1 (44.4%+/-37.6) in the LESI group and 6.4+/-2.1 to 1.7+/-1.4 in the TF group (73.2%+/-21.3%). Overall, results suggest that patients may experience greater subjective relief, as least initially, from TF epidural steroid injections over LESI. However, more objective, and likely subacute, therapeutic effects are similar
— id: 131849, year: 2011, vol: 12, page: P65, stat: Journal Article,

Oral prednisone response as an indicator for pain reduction with epidural injection in the treatment of lumbosacra radiculopathy
Chung J.; Gharibo C.
2010 ;11(2):287-287, Pain medicine
It is estimated that 10 million Americans are disabled by low back pain and lumbosacral radiculopathy (LSR), which leads to approximately 19 million physician visits per year. While there is debate over the best treatment paradigm for LSR, steroids are among the mainstays. Oral and epidural steroids have both shown favorable results in LSR. The purpose of this study is to evaluate whether response to oral steroids is a predictor of response to epidural steroid injections (ESI). Methods: A retrospective study of 142 patients with LSR presenting to the NYU Pain Management Center with >1 month of symptoms. Thirty two subjects received a five day course of oral prednisone 10 mg four times per day, and were later given interlaminar ESI when the oral steroids did not help or when the pain returned. All injections were administered under fluoroscopy, with epidural injectate consisting of 80 mg of DepoMedrol and 2 cc 0.9 NS. After 2 weeks, patients were assessed for pain relief on a scale of 0 to 10. Results: Of 32 people receiving oral steroids, 16 reported pain relief (>40% reductionresponders), with mean improvement score of 7 points, and 14 subjects did not show improvement (non-responders). After receiving ESI, both the responders and nonresponders had 70% pain reduction. Conclusion: Failure of oral steroids does not prognosticate failure of epidural steroids. Patients who did not respond to oral steroids can still get excellent pain relief after epidural steroid injections
— id: 111399, year: 2010, vol: 11, page: 287, stat: Journal Article,

Rapid acting analgesics
DeNatale C.E.; Rosenberg A.; Gharibo C.
2010 ;14(2):65-74, Techniques in Regional Anesthesia & Pain Management
A majority of patients with acute and chronic pain experience breakthrough pain above their baseline, despite a fixed regimen. The characteristics of current short-acting oral medications are not optimal because they often peak too late and last beyond the duration of pain. Oral absorption limits the onset time, whereas the development of newer routes can shorten onset times. A number of medications, both opioid and nonopioid, are being developed for intranasal delivery with promising results. In addition to the intranasal administration route being efficacious, it also provides better patient satisfaction by allowing the patient to titrate their own pain medication. There are legitimate concerns for abuse and addiction with these medications, which will need to be minimized with proper dispensing modifications. A number of nonopioid agents are also entering the market that will allow for multimechanistic analgesic plans. Although ketamine is not a common component of current pain treatment plans, the development of an intranasal formulation may potentially produce wider acceptance. Many traditional medications, including ibuprofen and acetaminophen, have been developed for parenteral administration. Intravenous ibuprofen or diclofenac can be administered for a longer duration and have a lower bleeding risk then ketorolac. Intravenous acetaminophen can provide balanced analgesia when nonsteroidal anti-inflammatory drugs are contraindicated, as is common in the postoperative period. The role of individual agents in each specialty is not currently clear, but the future treatment of pain, both acute and chronic, is brighter with the addition of these formulations. copyright 2010 Elsevier Inc. All rights reserved
— id: 110161, year: 2010, vol: 14, page: 65, stat: Journal Article,

Abuse deterrent opioids
Khan M.F.; Gharibo C.
2010 ;14(2):99-103, Techniques in Regional Anesthesia & Pain Management
Prescription opioid abuse is a growing problem that has become a critical public health issue. The development of abuse-resistant opioid formulations is an emerging strategy aimed at curbing the abuse of opioid analgesics. Over the next few months to years, new products within this category will enter the market. This article serves to provide an introduction to many of the upcoming formulations that may find their way into the therapeutic arsenal of pain management practitioners. copyright 2010 Elsevier Inc. All rights reserved
— id: 110160, year: 2010, vol: 14, page: 99, stat: Journal Article,

Preliminary observations of a novel topical oil with analgesic properties for treatment of acute and chronic pain syndromes
Pergolizzi, Joseph V; Pappagallo, Marco; Raffa, Robert B; Gharibo, Chris; Phillips, Reed B; Desjonqueres, Stephane; Tabor, Aaron
2010 May-Jun;10(3):201-213, Pain practice
OBJECTIVE: Essential oxygen oil (OxyRub from CreoMed Inc., Naples, FL, U.S.A.) is a novel topical analgesic currently commercially available in Europe and now available in the U.S.A. It represents an important alternative to other treatments (nonsteroidal anti-inflammatory drugs, acetaminophen, menthol, camphor) for managing mild to moderate acute and chronic pain. Several clinical trials of this oil will be reviewed. RESULTS: One large (n = 455) open-label trial found essential oxygen oil to be a safe and effective analgesic for a broad range of patients with acute and chronic pain. In that study, 80% of patients reported that their pain decreased by more than 75%. A double-blind placebo-controlled study (n = 50) found significant pain reduction for tendonitis in patients using essential oxygen oil. Another trial of essential oxygen oil vs. placebo (n = 50) with various pain diagnoses found that 98% of patients with various pain diagnoses reported 'very good' pain relief in the oil group compared to 48% in the placebo group. Furthermore, a randomized controlled trial in 10 women to measure oxygen microcirculatory effect in the skin showed an increased microcirculatory effect with improved oxygenation (increased partial pressure of oxygen in the skin) after application of essential oxygen oil. In all studies, the oil was well tolerated. None of these studies has been previously published. CONCLUSIONS: Based on studies completed, essential oxygen oil has shown itself to be safe, has demonstrated positive analgesic effects for the treatment of acute and chronic pain, and has improved oxygen content in the skin as well as other dermatological parameters
— id: 133769, year: 2010, vol: 10, page: 201, stat: Journal Article,

The role of urine drug testing for patients on opioid therapy
Pergolizzi, Joseph; Pappagallo, Macro; Stauffer, Joseph; Gharibo, Christopher; Fortner, Neil; de Jesus, Mathew N; Brennan, Michael J; Richmond, Charlotte; Hussey, Desmond
2010 ;10(6):497-507, Pain practice
Opioid analgesics must be prescribed with discernment and their appropriate use should be periodically assessed. Urine drug testing, although not designed specifically for this role, is a widely available and familiar method for monitoring opioid use in chronic pain patients. Urine drug testing can help track patient compliance and expose possible drug misuse and abuse. We sought to evaluate current attitudes and practices regarding the use of urine drug testing among chronic pain patients taking opioids. To the best of our knowledge, this is one of the first such attempts in the literature to examine and document the practice patterns of urine drug testing in this context. A total of 99 attendees at the American Congress of Pain Medicine were surveyed in 2008 about their urine testing practices for patients on opioid therapy. Surprisingly, more urine testing was motivated by a desire to detect undisclosed substances than to evaluate appropriate opioid use. Some respondents never urine-tested their opioid patients, and about two-thirds of respondents had no formal training in urine testing of patients on opioid therapy. The literature does not thoroughly address the role of urine drug testing in this patient population. Most respondents did random rather than scheduled testing; few had any urine testing protocol. The study found motivations for urine testing and testing practices varied widely, and urine testing, despite its clinical utility, is not used consistently.
— id: 129597, year: 2010, vol: 10, page: 497, stat: Journal Article,

Epidural steroid injections: An update on mechanisms of injury and safety
Gharibo C.; Koo C.; Chung J.; Moroz A.
2009 ;13(4):266-271, Techniques in Regional Anesthesia & Pain Management
Epidural steroid injections (ESIs) are the most commonly performed intervention in the United States to manage chronic and subacute low back and neck pain with radiculopathy. ESIs have been used for decades for the treatment of discogenic and osteoarthritic radicular conditions originating from the cervical, thoracic, and lumbar spine, as well as spondylosis, nonspecific radiculitis, and spinal stenosis. With the ever-increasing use of epidural steroids, there has been a disproportionate increase in popularity of transforaminal ESIs in particular. Since 2002, there has been a growing body of largely transforaminal epidural steroid case report literature that describes paralysis, stroke, and death that immediately follows the performance of these procedures. These complications are thought to be related to a combination of factors, which may include the technique used, underlying pathophysiology that is being treated, anatomical variations in the blood supply, as well as the specific injectate used. This article discusses the pathogenesis of these complications and puts the role of steroids in their causation into perspective. copyright 2009 Elsevier Inc. All rights reserved
— id: 106364, year: 2009, vol: 13, page: 266, stat: Journal Article,

Successful treatment of refractory pudendal neuralgia with pulsed radiofrequency
Rhame, Ellen E; Levey, Kenneth A; Gharibo, Christopher G
2009 May-Jun;12(3):633-638, Pain Physician
Pudendal neuralgia (PN) involves severe, sharp pain along the course of the pudendal nerve, often aggravated with sitting. Current therapies include medication management, nerve blocks, decompression surgery, and neuromodulation. The ideal management for PN has not been determined. We present a case of a female with 1.5 years of sharp, burning pain of the left gluteal and perineal regions. She could not sit for longer than 10 to 15 minutes. Sacroiliac joint, epidural, and piriformis injections did not improve her pain. She had tried physical therapy, occupational therapy, massage, and acupuncture but the pain persisted. Medication treatment with oxycodone-acetaminophen, extended release morphine sulfate, amitriptyline, and gabapentin provided only minor relief and she had failed other multianalgesic therapy. She had been unable to work at her desk job for over a year. She had a positive response to 2 diagnostic pudendal nerve blocks with lidocaine that provided pain relief for several hours. This patient elected to undergo pulsed radiofrequency (PRF) of the left pudendal nerve in hopes of achieving a longer duration and improved pain relief. PRF was carried out at a frequency of 2 Hz and a pulse width of 20 milliseconds for a duration of 120 seconds at 42 degrees Celsius. After the procedure she reported tolerating sitting for 4 to 5 hours. Her multianalgesic therapy was successfully weaned. At 5 months follow-up she felt motivated to return to work. One and a half years after the procedure the patient is only taking oxycodone-acetaminophen for pain relief and still has good sitting tolerance. There were no procedure-related complications. To our knowledge PRF for the treatment of PN has not been reported elsewhere in the literature. PRF is a relatively new procedure and is felt to be safer than continuous radiofrequency. Current literature suggests that PRF delivers an electromagnetic field, which modifies neuro-cellular function with minimal cellular destruction. We conclude that PRF of the pudendal nerve offers promise as a potential treatment of PN that is refractory to conservative therapy
— id: 99217, year: 2009, vol: 12, page: 633, stat: Journal Article,

Challenges to setting spinal cord stimulator parameters during intraoperative testing: factors affecting coverage of low back and leg pain
Gordon, Assaf T; Zou, Sheng Ping; Kim, Yong; Gharibo, Christopher
2007 Apr;10(2):133-141, Neuromodulation
Objective. Spinal cord stimulator (SCS) parameter settings have been well studied; however, the goal of this exploratory study was to examine the SCS parameters used during intra-operative stimulation (IOS) at trial lead placement. Methods. In this retrospective study, we report the IOS parameter settings for 22 patients who underwent thoracic SCS lead trial for treatment of refractory low back and/or leg pain. Results. Paresthesia coverage was shown to differ depending upon the pain syndrome and the region involved (back and/or leg, p = 0.03). Certain stimulation parameters were demonstrated to be linked, including pulse width with rate (p = 0.04) and bipolar activation distance with amplitude (p < 0.01). Important variations in field configuration practice patterns also emerged. Conclusions. Larger prospective studies are required to confirm and extend the current results. The ultimate goal for this report is to establish a foundation for future studies to create an evidence-based standardized algorithm for IOS to enhance the success rate of SCS trial screening
— id: 146259, year: 2007, vol: 10, page: 133, stat: Journal Article,

Successful treatment of phantom radiculopathy with fluoroscopic epidural steroid injections
Aydin, Steve M; Zou, Sheng Ping; Varlotta, Gerard; Gharibo, Christopher
2005 May-Jun;6(3):266-268, Pain medicine
Phantom limb pain has been well described in the literature. However, new-onset lumbar radicular pain superimposed on baseline lower extremity phantom pain is a clinical scenario that can be challenging to recognize. Furthermore, literature on recognition and treatment of phantom radiculopathy is all but lacking. We present a patient who experienced new-onset lumbar radiculopathy superimposed on her phantom pain that was successfully treated with fluoroscopic interlaminar and transforaminal epidural steroid injections
— id: 59240, year: 2005, vol: 6, page: 266, stat: Journal Article,

Spinal injections in diagnosis and treatment of low back pain
Gharibo CG
1999 ;13(24):423-437, Progress in anesthesiology
— id: 45564, year: 1999, vol: 13, page: 423, stat: Journal Article,

Desirable attributes of a pain clinic in caring for the patient with complex regional pain syndrome
Gharibo C
1998 ;11:3-3, RSDSA Review
— id: 45934, year: 1998, vol: 11, page: 3, stat: Journal Article,