Pain Medicine最新文献

Objectives: Despite significant medical treatment advancements, interventional treatments for intractable headache disorders are limited. This study's objective is to detail a novel percutaneous approach ("Q2-approach") and its technical considerations for implanting peripheral neuromodulation stimulators (PNS) to the C2 dorsal root ganglion (C2-DRG) at C2 lamina, a previously unattempted target, as a treatment for intractable headache.

Design and methods: In an outpatient setting, PNS electrodes could be percutaneously implanted at C2-DRG in patients under moderate sedation using combined ultrasound and fluoroscopic guidance. The final electrode position was determined by intraoperative patient feedback to ensure optimal stimulation. Four patients were included to demonstrate technical parameters and feasibility. Follow-ups were conducted on postoperative days 10, 30, 60, and 100-120.

Results: The Q2-approach allows safe C2-DRG PNS implants in an outpatient setting. Average operative duration was <60 minutes. All four patients achieved >50% pain relief during the 60-day implant period and 3/4 demonstrated sustained benefit beyond the implant period. No complications (e.g., lead migration or infection) were observed.

Conclusions: The current technical note demonstrated the feasibility of a novel, safe, minimally invasive approach to access C2-DRG at the C2 lamina for the treatment of intractable headaches. The utilization of PNS on C2-DRG fills an important gap in headache management as it provides an alternative neuromodulation treatment modality to the existing destruction/denervation-based techniques.

Objective: We examined the intersection between chronic pain stigma and racial discrimination, separately among Black and White U.S. adults with chronic low back pain.

Methods: Participants completed measures of chronic pain stigma, lifetime experiences of racial discrimination, pain severity and interference. A composite variable representing the intersectionality of stigma and discrimination was created, and Black and White participants were separately categorized into 4 groups. Black participants were categorized as: 1) high discrimination/high stigma, 2) high discrimination/low stigma, 3) low discrimination/high stigma, and 4) low discrimination/low stigma. White participants were categorized as: 1) any discrimination/high stigma, 2) any discrimination/low stigma, 3) no discrimination/high stigma, and 4) no discrimination/low stigma.

Results: Black participants reported more frequent experiences of racial discrimination than White participants (p<.05), but there was not a racial difference in chronic pain stigma (p>.05). Among Black participants, those in the high discrimination/high stigma and low discrimination/high stigma groups reported greater pain severity and interference than those in the high discrimination/low stigma and low discrimination/low stigma groups (p<.05). Among White participants, those in the any discrimination/high stigma group reported greater pain severity and interference than those in the no discrimination/low stigma group (p<.05), but there were no differences in pain severity or interference between the any discrimination/no stigma and no discrimination/high stigma groups (p>.05).

Conclusion: Our findings suggest that the relationship of intersectional chronic pain stigma and racial discrimination with pain is nuanced and differs across racial groups.

Introduction: Radiofrequency ablation is a treatment for facetogenic low back pain that targets medial branches of lumbar dorsal rami to denervate facet joints. Clinical outcomes vary; optimizing cannula placement to better capture the medial branch may improve clinical outcomes. A novel parasagittal technique was proposed from an anatomical model; this technique was proposed to optimize capture of the medial branch. The anatomical feasibility of the novel technique has not been evaluated.

Objective: To simulate and evaluate the proposed parasagittal technique in its ability to achieve proper cannula placement, and proximity of uninsulated cannula tips to the medial branches of the dorsal rami in cadaveric specimens.

Materials and methods: Under fluoroscopic guidance, 14 cannulae were placed using the parasagittal technique targeting the lumbar medial branches of two cadavers. Meticulous dissection was undertaken to assess cannula alignment and measure proximities to target nerves using a digital caliper.

Results: The novel parasagittal technique was successfully performed in a cadaveric model in 12/14 attempts. The technique achieved close proximity of cannula tips to medial branches (0.8 ± 1.1 mm). In two instances cannulae were placed unsuccessfully, where one cannula was too far anterior, the other too far retracted.

Conclusion: In this cadaveric simulation study, the feasibility of performing the parasagittal technique for lumbar radiofrequency ablation was evaluated. This study suggests the parasagittal technique is a feasible option for lumbar medial branch radiofrequency ablation.

Background: The NIH Pain Common Data Elements (CDEs) provide a standardized framework for pain research, but their implementation and interpretation present challenges.

Objectives: To review the NIH CDE Program's selected pain domains, provide best practices for implementing required questions, and offer a checklist for appropriate CDE use in clinical trials and secondary data analysis.

Methods: This work analyzed the ten core pain research domains selected by the NIH CDE Program and discuss their limitations and considerations for use.

Results: The manuscript provides an overview of the ten core pain research domains, including pain intensity, interference, physical function, sleep, catastrophizing, depression, anxiety, global impression of change, substance use screening, and quality of life. It offers sample scenarios for implementing required questions and presents a checklist to guide researchers in using pain CDEs effectively for clinical trials and secondary data analysis.

Discussion: Key challenges identified include contextual variability, lack of validation across all pain conditions and populations, and potential misuse or misinterpretation of measures. This work proposes solutions such as supplementary measures, context-specific guidance, comprehensive training programs, and ongoing refinement of the CDE framework.

Conclusion: While NIH Pain CDEs are valuable tools for standardizing pain assessment in research, addressing challenges in their implementation and interpretation is crucial for improving the consistency, validity, and interpretability of pain research data, ultimately advancing the field and enhancing patient care.

Objective: Despite careful design of clinical trials, unforeseen disruptions can arise. The PICOTS (Patient population, Intervention, Comparator, Outcomes, Timepoints, Setting) framework was used to assess disruptions in pain management research imposed by coronavirus disease 2019 (COVID-19) within the Pain Management Collaboratory.

Methods: Rapid qualitative methods were employed to identify trial disruptions due to COVID-19 in 11 pragmatic clinical trials of nonpharmacological approaches for pain management. The PICOTS framework was applied by investigators of 4 Collaboratory trials selected to cover 4 types of trial designs (individually randomized, stepped-wedge, cluster, sequential multiple assignment randomized trial-SMART). Interviews with the lead investigators of these trials were completed, and findings were presented/discussed on video calls over a 6-month period (March-August 2021) from which themes/lessons learned were identified and consensus reached.

Results: Investigators indicated that patient populations remained generally stable. A major COVID-19 trial disruption was moving from in-person to virtual care affecting delivery of interventions/comparators and outcome assessments. The resultant mixed-mode of care delivery created issues with intervention fidelity posing analytic challenges. COVID-19 also induced ongoing/intermittent delays and other barriers to accessing primary and specialty care at some facilities, creating research capacity issues affecting delivery of experimental interventions requiring sustained, reliable participation of clinical partners. Study designs most affected by COVID-19 were stepped-wedge (intervention/comparator changing over time), cluster (increased site variability inflating intracluster correlation), and SMART (second-stage randomizations disrupted); stratified individually-randomized trials were less vulnerable because of individual-level randomization.

Conclusions: PICOTS provides a framework for assessing the impact of trial disruptions in a structured manner. Given the COVID-19 experience, it is important for researchers to consider the potential impact of future trial disruptions during study planning.

Background: Despite the increased availability of evidence-based treatments for chronic pain, many patients in rural areas experience poor access to services. Patients receiving care through the VA may also need to navigate multiple systems of care.

Objective: To examine the effectiveness of a remotely delivered collaborative care intervention for improving pain interference among veterans with high-impact chronic pain living in rural areas.

Design: We will conduct a four-site pragmatic effectiveness trial of remotely delivered collaborative care for high-impact chronic pain. Participants (n = 608) will be randomized to the Tele-Collaborative Outreach to Rural Patients (CORPs) intervention or to minimally enhanced usual care (MEUC). Participants randomized to CORPs will complete a biopsychosocial assessment and five follow-up sessions with a nurse care manager (NCM), who will collaborate with a consulting clinician to provide personalized recommendations and care management. CORP participants will also be invited to a virtual 6-session pain education group class. Participants randomized to MEUC will receive a one-time education session with the NCM to review available pain services. All participants will complete quarterly research assessments for one year. The primary study outcome is pain interference. This trial will oversample veterans of female birth sex and minoritized race or ethnicity to test heterogeneity of treatment effects across these patient characteristics. We will conduct an implementation process evaluation and incremental cost-effectiveness analysis.

Discussion: This pragmatic trial will test the real-world effectiveness of a remotely delivered collaborative care intervention for chronic pain. Study findings will inform future implementation efforts to support potential uptake of the intervention.