Pain Practice最新文献

Background and objective: Thoracic epidural analgesia has traditionally been used for pain management after open abdominal surgery, but its use has declined. The quest for efficient alternatives has resulted in the increasing use of regional techniques. These can be applied as single-shot or continuous blocks using catheters. Long-acting liposomal bupivacaine could preclude the use of catheters. This review aimed to evaluate the effectiveness of ultrasound-guided abdominal wall blocks with liposomal bupivacaine for open abdominal surgery.

Databases and data treatment: Medline ALL, Embase, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and Google Scholar were systematically searched. Screening, data extraction, and quality assessment were done by two independent researchers. Inclusion criteria were (1) liposomal bupivacaine in ultrasound-guided abdominal wall blocks for open abdominal surgery, (2) outcome of pain and/or opioid consumption, (3) patients >18 years, and (4) reports published in English.

Results: Of the 1277 studies found, 22 met the inclusion criteria. The Cochrane Risk of Bias (Version 2) tool was used to assess randomized controlled trials. Studies were grouped for clarity. Transversus abdominis plane (TAP) blocks were mostly investigated. Data were heterogenic regarding types of surgery, approach to block placement, anesthetic solution injected, and use of intrathecal morphine (ITM).

Conclusions: Patients undergoing cesarean section with neuraxial anesthesia and intrathecal morphine benefit from TAP blocks with liposomal bupivacaine, demonstrating reduced opioid consumption and comparable pain. Evidence for other open abdominal surgeries was inconclusive. Abdominal wall blocks with liposomal bupivacaine could be a viable alternative when epidural analgesia is contraindicated.

Purpose: To determine whether preoperative magnetic resonance imaging (MRI) can reliably determine intraoperative measurements in the Vertiflex Interspinous Spacer (ISS) procedure.

Methods: Patients who underwent Vertiflex ISS with Lumbar Spinal Stenosis (LSS) and a preoperative MRI available in picture archiving and communication system (PACS) between January 2013 to February 2023 were identified retrospectively from the University of Chicago Medical Center Database. An experienced board-certified pain specialist and well-trained 2nd-year medical student independently performed measurements of the interspinous space where Vertiflex ISSs of various sizes are inserted. MRI measurements were taken blinded to intraoperative measurement and ISS implant size used in the procedure. Pearson's correlation, paired T-test, intraclass correlation coefficients (ICC), absolute agreement, and 2-way random effects model were used to determine the relationships between MRI, intraoperative measurement, and ISS size.

Results: A total of 79 patients who underwent the Vertiflex ISS procedure were included in the study. Median Vertiflex ISS size was 10 mm (10-12), mean intraoperative measurement was 11.40 mm (±1.23), and mean MRI measurement was 11.24 mm (±1.44). Mean differences were not significant in intraoperative and MRI measurements (p = 0.271). Pearson's correlation between ISS size and intraoperative measurement was 0.807 (p < 0.001), representing the current best practice model. Pearson's correlation was 0.668 (p < 0.001) between MRI measurement and ISS size and 0.542 (p < 0.001) between MRI and intraoperative measurement. ICC showed good agreement and moderate reliability (0.698) between intraoperative and MRI measurements. Observer interrater ICC agreement of the MRI interspinous space measurement was 0.95 (p < 0.001).

Conclusions: Measuring interspinous space on MRI yielded, on average, a value smaller than the intraoperative measurement in Vertiflex ISS procedures, but the mean differences were not significant. Good agreement and moderate reliability were found between observer MRI and surgeon intraoperative measurements, suggesting MRI can evaluate the intraoperative space for the Vertiflex ISS procedure. Preoperative MRI measurement may help decrease complications by aiding in surgical decision-making through providing a reference for intraoperative measurements. Further prospective study is necessary to determine if preoperative MRI measurement can predict and potentially replace the need for intraoperative measurement.

Objective: To compare the efficacy of closed-loop spinal cord stimulation (CL-SCS) and dorsal root ganglion (DRG) stimulation in managing chronic cancer-related pain.

Material/methods: A retrospective review was conducted with IRB exemption for four patients with cancer-related pain who underwent combination stimulator trials. Patients were trialed with both CL-SCS and DRG stimulation for 8-10 days, with assessments of pain relief, functional improvement, sleep improvement, pain medication changes, and overall satisfaction.

Results: All four patients reported significant relief and functional improvement with both CL-SCS and DRG stimulations. CL-SCS provided a range of 12.9-19.6 million adjustments during the trial period. Neural dose was delivered at a median dose ratio of 1.35 and median dose accuracy of 4.9 μV. Patients 1-3 preferred CL-SCS for paresthesia-based stimulation, having the potential to expand pain coverage, full-body MRI compatibility, and real-time automated adjustment features. Patient 4 favored DRG for its ability to provide slightly greater relief, over one aspect of his pain area, despite having comparable coverage with CL-SCS.

Conclusions: The consistent and adaptable delivery of CL-SCS may bridge the gap in efficacy that DRG therapy has held over traditional dorsal column stimulation for historically complex and focal conditions that suggests further investigation.

Objectives: Chronic pain is a debilitating, multifactorial condition. The purpose of this study was to examine patient characteristics of those who did not show up for their scheduled first pain medicine appointment in order to identify factors that may improve access to care.

Methods: This was a retrospective analysis of 810 patients from a single-center academic pain management clinic between January 1, 2022, and December 31, 2023.

Results: Overall no-show rate was 57%. There was a mean of 133 days (4.3 months) from scheduling to the appointment date. Patients age ≤ 30 years had the highest no-show rate (69%), and those ≥81 years had the lowest (49%). Hispanic and Caucasian patients had similar no-show rates (59% and 57%, respectively) and Asian patients had lower rate (41%). Referral from another specialty had a significantly lower no-show rate (36% vs. 89%, p < 0.001). The presence of referral (p < 0.001) was a significant predictor of lower no-show rates. Of the 191 patients with low back pain, internal medicine (38.7%) was the most referring specialty.

Discussion: High no-show rates were present particularly among younger patients. Having a referral from another specialty was an independent predictor of lower no-show rates.

Objectives: Chronic pain is multifactorial and has large social and economic costs. Comprehensive pain management through an interdisciplinary approach addressing the biopsychosocial model of pain is beneficial. The purpose of this study was to assess the feasibility and functional outcomes following participation in the 8-week virtual interdisciplinary Functional Integrative Restoration (FINER) program.

Design: Cohort study.

Setting: Virtual platform (Zoom) utilized by participants and clinicians within a large academic institution.

Subjects: 44 individuals with chronic pain meeting study criteria who participated in the virtual FINER program from September 2021 to April 2023 were included in final analysis.

Methods: Participants attended twice weekly seminars and group sessions focused on pain education, lifestyle medicine, integrative medicine, and psychological therapies virtually and completed pre- and post-program surveys. Outcomes included the Pain Catastrophizing Scale (PCS), Tampa Scale of Kinesiophobia (TSK), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29). Qualitative feedback was also obtained.

Results: From September 2021 to April 2023, 44 adult FINER participants with chronic low back and/or neck pain completed pre- and post-intervention surveys. We observed significant improvements in PCS, TSK, and various domains of the PROMIS-29, including pain interference, participation, physical function, and sleep, with modest effect sizes.

Conclusions: The FINER program reduced self-reported functional outcomes related to the participants' chronic pain. Positive qualitative feedback from FINER participants suggested mental and physical health benefits. Future investigation will include a larger cohort and will deploy active (patient-reported outcomes) and passive (mobility and sociability) digital measures to further characterize functional changes.

Objectives: Placebo effects can relieve acute and chronic pain in both research and clinical treatments by learning mechanisms. However, the application of placebo-based treatment strategies in routine medical care is questioned. The current study investigated the opinions of patients with fibromyalgia and healthy controls regarding learning of placebo effects and their practical applications.

Method: An online survey asked 158 age- and sex-matched adult patients and controls (79 per group) to rate the perceived influence of various placebo learning mechanisms on pain relief, and the acceptability and perceived effectiveness of placebo-based strategies (open-label, closed-label, dose-extending, and treatment-enhancing strategies). Respondents' knowledge about placebo effects was obtained through a 7-item quiz.

Results: The groups did not differ in the perceived influence of placebo learning mechanisms on pain relief (p = 0.217). Controls considered closed-label and treatment-enhancing strategies more acceptable than patients (p = 0.003 and p < 0.001), whereas controls perceived all strategies more effective. In both groups, closed-label strategies were significantly less acceptable than any other strategy (p-values < 0.001), and treatment-enhancing or dose-extending strategies were most acceptable. Higher acceptability was predicted by higher perceived effectiveness ratings (p < 0.001). Also, increased placebo knowledge was related to higher acceptability (p = 0.03) and perceived effectiveness (p < 0.001).

Discussion: This survey suggests that both the medical history of patients and knowledge about placebo effects affect the acceptability and perceived effectiveness of placebo-based strategies. Furthermore, strategies that are transparent, assumed effective, or combined with existing medical treatments are deemed most acceptable. Keeping these factors in mind is essential for the clinical implementation of placebo-based strategies in routine medical care.

Introduction: Prior to the permanent implant of a spinal cord stimulator, patients typically undergo a screening trial using a percutaneously placed lead to ensure adequate response. However, due to several factors, patients may not be candidates for this screening trial and therefore instead undergo a "permanent trial" where either a percutaneous lead or paddle lead is placed using a tunneled extension for the trial, with the intent of conversion to a permanent system. If these patients proceed with an implant, the epidural space is not re-accessed and only an impulse generator (IPG) is needed. Although this technique is commonly employed, there is a paucity of literature describing outcomes with the "permanent trial" methodology. We present here our clinical experience with this technique.

Methods: Participants who underwent permanent trials at a single institution between 2014 and 2020 were identified. Charts were reviewed to collect demographic information, numerical rating score (NRS) data, length of follow-up, revisions, complications, and removals.

Results: A total of 27 patients who underwent permanent trial placement were identified from a database of 762 patients who underwent SCS placement (3.54%). The permanent placement group included 7 paddle trials, 14 percutaneous trials, and 6 dorsal root ganglion (DRG) trials. The reasons for pursuing a permanent trial included previously aborted percutaneous trial (n = 8), inability to hold anticoagulation for a prolonged period (n = 4), previous thoracic spine surgery or presence of thoracic stenosis on MRI (n = 4), and significant medical comorbidities precluding typical percutaneous trial lead placement at a surgery center (n = 3). 24/27 (88.8%) proceeded to permanent implant, and 16/24 (66.7%) were considered responders (greater than 50% reduction in pain) after 3 months. Over an average follow-up of 28.7 months, complications included 1 peri-operative intracranial hemorrhage delaying IPG placement, 2 lead fractures, 1 lead migration, and 1 CSF leak. Three patients required revision surgery for lead migration, lead fracture, and CSF leak, respectively. One patient had his system explanted 25.9 months after initial placement due to increased pain from stimulation.

Conclusion: This study aims to characterize our experience with permanent trials for SCS. Here we demonstrate a higher rate of trial-to-implant conversion than previously documented for traditional percutaneous trials. We show similar rates of revisions and complications, elucidating the important role of permanent SCS trials in high-risk patients.

Objectives: In the last 20 years, we have seen the flourishing of multiple treatments targeting the dorsal root ganglion (DRG) for pain. However, there is concern regarding the variation in the location of the DRG, which could influence the long-term clinical outcomes. The aim of this work was to determine the exact position of the DRG in the spine and propose a pre-surgical planning.

Materials and methods: A systematic search was conducted following the principles recommended by PRISMA. Search terms "ganglia," "DRG," "dorsal root ganglia, anatomy," "radiological," "neuromodulation," "dorsal root ganglion stimulation" (PubMed, Scopus, Medline, Web of Science, and Embase) were identified 177 articles and subjected to the selection criteria (inclusion/exclusion) based on the independent review of the abstracts.

Results: Eighteen articles were selected (seven anatomical dissections on cadavers, five radiological studies, and six narrative reviews).

Discussion: Percutaneous procedure targeting the DRG for the treatment of chronic pain requires preoperative planning independent to the study of the etiology of pain. The DRG should be typified using magnetic resonance imaging. We propose a preoperative evaluation scale based on four specific items: A-position in the vertebral canal, B-position of the DRG within the foramen, C-number of ganglia in the root, and D-ratio (proportion) of foramen/DRG.

Conclusion: Percutaneous treatments for chronic pain directed at the DRG are effective. Clinical outcomes depend of good preoperative planning that allows for optimizing its effects. We propose a DRG morphology evaluation scale useful for the planning process prior to any treatment directed at the ganglion.

Radiofrequency ablation (RFA) is an interventional procedure that has been used to treat chronic back pain for over 50 years; this unique case report demonstrates the effectiveness of pulsed radiofrequency ablation (PRFA) on the dorsal root ganglion (DRG) in the treatment of chronic radicular pain (Russo et al., 2021, J Pain Res, 14, 3897). The RFA provides pain relief by using thermal energy to disrupt peripheral nerves carrying nociceptive signals back to the central nervous system (Abd-Elsayed et al. 2020, Pain Ther, 9, 709). However, there is a lack of literature about the safety and efficacy of PRFA of the DRG.