Showing papers in "Pain Physician in 2006"

Opioid guidelines in the management of chronic non-cancer pain.

Abstract: lation of the essentials of guidelines, a series of potential evidence linkages representing conclusions, followed by statements regarding relationships between clinical interventions and outcomes. Methods: Consistent with the Agency for Healthcare Research and Quality (AHRQ) hierarchical and comprehensive standards, the elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentations, formal endorsement by the Board of Directors of the American Society of Interventional Pain Physicians (ASIPP), and blinded peer review. Evidence was designated based on scientifi c merit as Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), or Level V (indeterminate). Results: After an extensive review and analysis of the literature, the authors utilized two systematic reviews, two narrative reviews, 32 studies included in prior systematic reviews, and 10 additional studies in the synthesis of evidence. The evidence was limited. Conclusion: These guidelines evaluated the evidence for the use of opioids in the management of chronic non-cancer pain and recommendations for management. These guidelines are based on the best available scientifi c evidence and do not constitute infl exible treatment recommendations. Because of the changing body of evidence, this document is not intended to be a “standard

Interlaminar versus transforaminal epidural injections for the treatment of symptomatic lumbar intervertebral disc herniations.

Abstract: BACKGROUND Epidural steroid injections are commonly used for the treatment of radicular symptoms associated with symptomatic lumbar intervertebral disc herniations. Transforaminal epidural injections are believed to produce better clinical outcomes than interlaminar epidural injections. OBJECTIVE To determine a difference in short-term pain improvement and longterm surgical rates between interlaminar and transforaminal injection techniques. DESIGN Case Control Study. METHODS For each technique, 20 patients were retrospectively identified who received their first fluoroscopically guided epidural steroid injection for radicular symptoms caused by a lumbar intravertebral disc herniation over an 18 months interval. All patients had corresponding MRI findings and failed previous non-invasive therapies. The Verbal Numerical Rating Scale (VNRS, 0-10 scale) before the treatment, within one hour after the treatment and upon follow-up (average 17.1 days) were analyzed, along with the need for repeat injections and surgical interventions over a 1-year follow-up interval. The patient groups were matched for symptom duration, MRI findings and pre-injection VNRS scores. RESULTS In the transforaminal group, there was a statistically significant improvement in the VNRS scores from before the injection (VNRS mean 5.9) to immediately after the injection (VNRS mean 2.9, p<0.01), and upon follow-up (VNRS mean 3.2, p<0.01, mean 18.7 days). Nine patients (45%) required 1 or 2 repeated injections, 2 patients (10%) underwent surgery. In the interlaminar group, there was a statistically significant improvement in the VNRS scores from before the injection (VNRS mean 7.3) to immediately after the injection (VNRS mean 3.1, p<0.01), and upon follow-up (VNRS mean 5.9, p<0.01, mean 15.6 days). Eight patients (40%) required 1 or 2 repeated injection, 5 patients (25%) underwent surgery. Fourteen patients (70%) had an improvement of 2 points or more on the VNRS scale in the transforaminal group, compared to 9 (45%) in the interlaminar group. CONCLUSIONS In the current study, transforaminal epidural steroid injections for the treatment of symptomatic lumbar disc herniation resulted in better short-term pain improvement and fewer long-term surgical interventions than interlaminar epidural steroid injection.

Controlled substance abuse and illicit drug use in chronic pain patients: An evaluation of multiple variables.

Abstract: Background: Opioids are used extensively for chronic pain management in the United States. The frequency of opioid use prior to presenting to interventional pain management settings and in interventional pain management settings has been shown to be above 90%. Opioid abuse has been demonstrated in 9% to 41% of patients receiving chronic pain management. Illicit drug use has been reported in 14% to 34% of patients in chronic pain management settings. Objectives: To evaluate and correlate multiple variables with opioid abuse and illicit drug use. Design: A prospective, consecutive study. Setting: Interventional pain management practice setting in the United States. Methods: A total of 500 consecutive patients prescribed opioids, considered to be receiving stable doses of opioids supplemental to their interventional techniques were evaluated for opioid abuse and for illicit drug use. Abuse was defined as a patient receiving controlled substances from any source other than the prescribing physician at our center with the exception of controlled substances for acute injuries unrelated to the problem being treated, or for emergencies. Urine drug testing for illicit drugs was performed by urine rapid drug screen (Instant Technologies, iCup(R) Norfolk, VA). Results were considered positive if one or more of the monitored illicit drugs including cocaine, marijuana (THC), phencycledane methamphetamine or amphetamines were detected. Results: Opioid abuse was seen in 9% of patients, with illicit drug use in 16% of patients. Significant differences were noted in the prevalence of opioid abuse in patients who developed chronic pain following motor vehicle accident(s) and in patients presenting with pain in three regions of the body. Illicit drug use (marijuana) was more common in females. Illicit drug use was also more common in patients younger than 45, after motor vehicle injury, and in patients with involvement of three regions of the body. Conclusion: Opioid abuse and illicit drug use were common in chronic pain patients with a prevalence of 9% and 16%, respectively. Age, pain after motor vehicle accident, involvement of multiple regions and past history of illicit drug use were identified as risk factors. Language: en

The sacroiliac joint: anatomy, physiology and clinical significance.

Abstract: The sacroiliac joint (SIJ) is a putative source of low back pain. The objective of this article is to provide clinicians with a concise review of SIJ structure and function, diagnostic indicators of SIJ-mediated pain, and therapeutic considerations. The SIJ is a true diarthrodial joint with unique characteristics not typically found in other diarthrodial joints. The joint differs with others in that it has fibrocartilage in addition to hyaline cartilage, there is discontinuity of the posterior capsule, and articular surfaces have many ridges and depressions. The sacroiliac joint is well innervated. Histological analysis of the sacroiliac joint has verified the presence of nerve fibers within the joint capsule and adjoining ligaments. It has been variously described that the sacroiliac joint receives its innervation from the ventral rami of L4 and L5, the superior gluteal nerve, and the dorsal rami of L5, S1, and S2, or that it is almost exclusively derived from the sacral dorsal rami. Even though the sacroiliac joint is a known putative source of low back and lower extremity pain, there are few findings that are pathognomonic of sacroiliac joint pain. The controlled diagnostic blocks utilizing the International Association for the Study of Pain (IASP) criteria demonstrated the prevalence of pain of sacroiliac joint origin in 19% to 30% of the patients suspected to have sacroiliac joint pain. Conservative management includes manual medicine techniques, pelvic stabilization exercises to allow dynamic postural control, and muscle balancing of the trunk and lower extremities. Interventional treatments include sacroiliac joint, intra-articular joint injections, radiofrequency neurotomy, prolotherapy, cryotherapy, and surgical treatment. The evidence for intra-articular injections and radiofrequency neurotomy has been shown to be limited in managing sacroiliac joint pain.

Prescription drug abuse: what is being done to address this new drug epidemic? Testimony before the Subcommittee on Criminal Justice, Drug Policy and Human Resources.

Abstract: This comprehensive health policy review of the prescription drug abuse epidemic is based on the written and oral testimony of witnesses at a July 26, 2006 Congressional Hearing, including that of Laxmaiah Manchikanti, MD, the chief executive officer of the American Society of Interventional Pain Physicians and additions from review of the literature. Honorable Mark E. Souder, chairman of the Subcommittee on Criminal Justice, Drug Policy, and Human Resources, introduced the issue as follows: "Prescription drug abuse today is second only to marijuana abuse. In the most recent household survey, initiates to drug abuse started with prescription drugs (especially pain medications) more often than with marijuana. The abuse of prescription drugs is facilitated by easy access (via physicians, the Internet, and the medicine cabinet) and a perception of safety (since the drugs are FDA approved). In addition to the personal toll of drug abuse using prescription drugs, indirect costs associated with prescription drug abuse and diversion include product theft, commission of other crimes to support addiction, law enforcement costs, and encouraging the practice of defensive medicine." The Administration witnesses, Bertha Madras, Nora D. Volkow, MD, Sandra Kweder, MD, and Joe Rannazzisi reviewed the problem of drug abuse and discussed what is being done at the present time as well as future strategies to combat drug abuse, including prescription drug monitoring programs, reducing malprescriptions, public education, eliminating Internet drug pharmacies, and the development of future drugs which are not only tamper-resistant but also non-addictive. The second panel, consisting of consumers and advocates, included Misty Fetco, Linda Surks, and Barbara van Rooyan, all of whom lost their children to drugs, presented their stories and strategies to prevent drug abuse, focusing on education at all levels, development of resistant drugs, and non-opioid treatment of chronic pain. Mathea Falco, JD, and Stephen E. Johnson presented issues related to drug abuse and measures to curb drug abuse by various means. Stephen J. Pasierb presented startling statistics on teen drug abuse and various educational programs to deter abuse. Laxmaiah Manchikanti, MD presented an overview of prescription drug abuse, strategies to prevent drug abuse, including immediate funding and rapid implementation of NASPER, education at all levels and improving relations with the DEA and the provider community.

Does random urine drug testing reduce illicit drug use in chronic pain patients receiving opioids

Abstract: Background Prescription drug abuse and illicit drug use are common in chronic pain patients. Adherence monitoring with screening tests, and urine drug testing, periodic monitoring with prescription monitoring programs, has become a common practice in recent years. Random drug testing for appropriate use of opioids and use of illicit drugs is often used in pain management practices. Thus, it is expected that random urine drug testing will deter use of illicit drugs, and also improve compliance. Objectives To study the prevalence of illicit drug use in patients receiving opioids for chronic pain management and to compare the results of illicit drug use with the results from a previous study. Design A prospective, consecutive study. Setting Interventional pain management practice setting in the United States. Methods A total of 500 consecutive patients on opioids, considered to be receiving stable doses of opioids supplemental to their interventional techniques, were studied by random drug testing. Testing was performed by rapid drug screen. Results were considered positive if one or more of the monitored illicit drugs including cocaine, marijuana (THC), methamphetamine or amphetamines were present. Results Illicit drug use was evident in 80 patients, or 16%, with marijuana in 11%, cocaine in 5%, and methamphetamine and/or amphetamines in 2%. When compared with previous data, the overall illicit drug use was significantly less. Illicit drug use in elderly patients was absent. Conclusion The prevalence of illicit drug abuse in patients with chronic pain receiving opioids continues to be a common occurence. This study showed significant reductions in overall illicit drug use with adherence monitoring combined with random urine drug testing.

Pulsed radiofrequency of the dorsal root ganglia is superior to pharmacotherapy or pulsed radiofrequency of the intercostal nerves in the treatment of chronic postsurgical thoracic pain.

Abstract: pulsed RF of the intercostal nerves (ICN) and pulsed RF of the dorsal root ganglia (DRG) in CPTP. Methods: Retrospective data analysis involving 49 patients. Results: At 6-week follow-up, 61.5% of the pulsed RF DRG group reported ≥ 50% pain relief vs. 27.3% in the medical management (MM) group and 21.4% in the ICN group (P=0.12). At 3-month follow-up, 53.8% in the DRG group continued to report ≥ 50% pain relief vs. 19.9% in the MM and 6.7% in the ICN groups, respectively (P=0.02). Among the pulsed RF patients

Role of epidural steroids in the management of chronic spinal pain: a systematic review of effectiveness and complications.

Abstract: Background Epidural steroid injections are commonly used for chronic spinal pain. However, there is no conclusive evidence regarding their effectiveness, and debate continues as to their value in managing chronic spinal pain. Objective To evaluate various types of epidural injections (interlaminar, transforaminal, and caudal) for managing chronic spinal pain (axial and radicular). Study design A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials, and criteria of the Cochrane Musculoskeletal Review Group for randomized trials. Methods Data sources included relevant English literature identified through searches of MEDLINE and EMBASE (January 1966 to November 2004), manual searches of bibliographies of known primary and review articles and abstracts from scientific meetings within the last 2 years. Three reviewers independently assessed the trials for the quality of their methods. Subgroup analyses were performed for trials with different control groups, with different modes of epidurals (interlaminar, transforaminal, and caudal), with different injection sites (cervical/thoracic, lumbar/sacral), and with timing of outcome measurement (short- and long-term). Outcome measures The primary outcome measure was pain relief. Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term improvement was defined as less than 6 weeks, and long-term improvement was defined as 6 weeks or longer. Results For lumbar radicular pain with interlaminar lumbar epidural steroid injections, the level of evidence was strong for short-term relief and limited for long-term relief. For cervical radicular pain with cervical interlaminar epidural steroid injections, the evidence was moderate. The evidence for lumbar transforaminal epidural steroid injections for lumbar nerve root pain was strong for short-term and moderate for long term improvement. The evidence for cervical transforaminal epidural steroid injections for cervical nerve root pain was moderate. The evidence was limited for lumbar radicular pain in post lumbar laminectomy syndrome. The evidence for caudal epidural steroid injections was strong for short-term relief and moderate for long-term relief. For managing chronic postlumbar laminectomy syndrome and spinal stenosis the evidence was limited for low back and radicular pain. The evidence was moderate for chronic low back pain. Conclusion The evidence for effectiveness of epidural injections in managing chronic spinal pain ranged from limited to strong.

Does adherence monitoring reduce controlled substance abuse in chronic pain patients

Abstract: BACKGROUND Opioids are used extensively for chronic pain management in the United States. The frequency of opioid use prior to presenting to interventional pain management settings and in interventional pain management settings has been shown to be above 90%. Given that controlled substance abuse and illicit drug use are prevalent phenomena, adherence monitoring of patients that are prescribed opioids is becoming common. Adherence monitoring is carried out by an appropriate history, periodic evaluation of appropriate intake of drugs, random drug testing, and pill counts. Crucial to adherence monitoring is an initial controlled substance agreement and repeated review of the terms of this agreement with on-going education. However, the effect of adherence monitoring on drug abuse is unclear. OBJECTIVE To identify controlled substance abuse through implementation of the terms of a controlled substance agreement, including periodic review and monitoring outside the organization. STUDY DESIGN Prospective evaluation with historical controls. METHODS Five hundred consecutive patients receiving prescription controlled substances were followed in a prospective manner. The evaluation consisted of a chart review to monitor controlled substance intake, with special attention to drugs obtained from outside the organization. Data collection for this purpose included information from records, pharmacies, referring physicians, and all the physicians involved in the treatment of the patient. RESULTS Results from 500 consecutive patients were evaluated. Controlled substance abuse was seen in 9% of patients; overall, 5% of patients were obtaining controlled substances from other physicians, and 4% from illegal sources. CONCLUSION Adherence monitoring, including controlled substance agreements and various periodic measures of compliance was associated with a 50% reduction in opioid abuse.

Peripheral nerve field stimulation in chronic abdominal pain.

Abstract: INTRODUCTION Spinal Cord Stimulation (SCS) has become an accepted therapeutic modality for the treatment of intractable pain syndromes, primarily used today in the settings of failed back surgery syndrome, neuropathic back and limb pain. The use of spinal cord stimulators for peripheral nerve field electrostimulation is becoming increasingly recognized as a safe, effective alternative for chronic pain conditions that are refractory to medical management and do not respond to traditional dorsal column stimulation. Advances in technology have allowed for minimally invasive percutaneous placement of multipolar leads with complex programmable systems to provide patient- controlled relief of pain in precisely targeted regions. With these improvements in hardware, the use of Peripheral Nerve Field Stimulation (PNFS) appears to have an untapped potential for providing patients with pain relief for a wider range of underlying conditions than was previously believed possible. We present three cases, each with a different etiology of chronic abdominal pain: one with inguinal neuralgia, one with chronic pancreatitis, and one with pain following liver transplant. Each patient was refractory to conventional medical approaches. For all three patients, PNFS provided significant relief from pain, enabling patients to decrease or discontinue their opioid medications and to enjoy significant improvement in their quality of life. We conclude that PNFS is a safe, effective and minimally invasive treatment that may be used successfully for a wide variety of indications including chronic abdominal pain.

A systematic review of sacroiliac joint interventions

Abstract: Background The sacroiliac joint is an accepted source of low back pain with or without associated lower extremity symptoms. The diagnosis and management of sacroiliac joint pain and the role of interventional techniques have been controversial. Objective To evaluate the clinical usefulness of sacroiliac joint interventions in the diagnosis and management of sacroiliac joint pain. Study design A systematic review using the criteria as outlined by the Agency for Healthcare Research and Quality (AHRQ), Cochrane Review Group Criteria, and QUADAS criteria for diagnostic studies. Methods The databases of EMBASE and MEDLINE (1966 to November 2004), and Cochrane Review were searched. The searches included systematic reviews, narrative reviews, prospective and retrospective studies, and cross-references from articles reviewed. The search strategy included sacroiliac joint pain and dysfunction, sacroiliac joint injections, interventions, and radiofrequency. Results The results of this systematic evaluation showed that for diagnostic purposes, there is moderate evidence showing the accuracy of comparative, controlled local anesthetic blocks. Prevalence of sacroiliac joint pain was demonstrated to be 10% to 19% by a double block paradigm. The false-positive rate of single, uncontrolled, sacroiliac joint injections was reported as 20%.For therapeutic purposes intraarticular sacroiliac joint injections with steroid and radiofrequency neurotomy were evaluated. Based on this review, there was moderate evidence for short-term and limited evidence for long-term relief with intraarticular sacroiliac joint injections. Evidence for radiofrequency neurotomy in managing sacroiliac joint pain was limited or inconclusive. Conclusions The evidence for the specificity and validity of diagnostic sacroiliac joint injections was moderate.The evidence for therapeutic intraarticular sacroiliac joint injections was limited to moderate. The evidence for radiofrequency neurotomy in managing chronic sacroiliac joint pain was limited.

Lumbosacral transitional vertebrae: incidence in a consecutive patient series

Abstract: Background Great variability exists in the reported frequency of transitional vertebra in the general population as well as in symptomatic lumbar spine patients. Objective To determine the occurrence rate of transitional vertebra in consecutive lumbar spine patients in our practice. Design A prospective, observational study Methods Plain films were viewed and the presence or absence of a lumbar transitional vertebra was documented. Transitional vertebrae were classified as incomplete or complete. Results Of the 300 consecutive patients, 30% had a transitional vertebra. Conclusion Our percentage of patients with a transitional vertebra was higher than the percentages reported for the general population. This supports our belief that the alteration in mechanics caused by a transitional vertebra may at times contribute to pain generation. Additionally, as a transitional segment may not always be visualized on MRI, obtaining plain films prior to an injection or surgery will help prevent confusion over the appropriate level for the procedure.

Therapeutic facet joint interventions in chronic spinal pain: a systematic review of effectiveness and complications.

Abstract: Background Facet joint interventions are used frequently for managing chronic spinal pain. Evidence continues to accumulate supporting the clinical effectiveness of these procedures and defining potential complications. Objective To evaluate the effectiveness of three types of facet joint interventions (facet joint injections, medial branch blocks and facet joint neurotomy) in managing spinal pain. Study design A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials and Cochrane Musculoskeletal Review Group for randomized trials. Methods Data sources included relevant literature of the English language identified through searches of MEDLINE and EMBASE (January 1966 to November 2004), manual searches of bibliographies of known primary and review articles, and abstracts from scientific meetings within the last 2 years. Analyses were performed for the different modes of facet joint interventions of cervical, thoracic and lumbar spine, to determine short- and long-term outcome measurements and complications associated with the procedures. Outcome measures The primary outcome measure was pain relief. For facet joint injections and medial branch blocks, short-term pain relief was defined as relief less than 6 weeks, and long-term as 6 weeks or longer. For medial branch radiofrequency neurotomy, short-term relief was defined as pain relief of less than 3 months, and long-term as 3 months or longer. Other outcome measures included functional improvement, improvement of psychological status, and return to work. Results For lumbar intraarticular facet joint injections, there was moderate evidence for short-term improvement, and limited evidence for long-term improvement. The evidence was negative for cervical intraarticular facet joint injections. For cervical and lumbar medial branch blocks with local anesthetics and steroids, the evidence was moderate. The evidence for pain relief with radiofrequency neurotomy of medial branch nerves was moderate to strong. Conclusion The evidence for facet joint interventions ranged from negative to strong.

Treatment of intractable discogenic low back pain. A systematic review of spinal fusion and intradiscal electrothermal therapy (IDET).

Abstract: Background: A growing number of patients suffer from severe low back pain of discogenic origin that is not responsive to conservative medical management. These patients must consider the option of surgical spinal fusion or minimally-invasive intradiscal electrothermal therapy (IDET). Objective: To conduct a systematic review of clinical outcomes in patients undergoing spinal fusion or the intradiscal electrothermal therapy (IDET) procedure for intractable discogenic low back pain. Design: Systematic literature review. Methods: English-language journal articles published from January 1995 to December 2005 were identified through computerized searches of the PubMed database and bibliographies of identified ar ticles and review papers. Articles were selected if disc degeneration or disruption was the primary indication for spinal fusion or the IDET procedure and if followup outcome data included evaluations of back pain severity, condition-specific func tional impairment and/or health-related quality of life. The literature reviewed encompassed 33 spinal fusion articles: 10 randomized controlled trials, 1 nonrandomized controlled trial, 9 before-after trials, and 13 case series. There were 18 IDET articles: 2 randomized controlled trial, 2 nonrandomized controlled trials, 11 before-after trials, and 3 case series. Data were extracted and summarized on patient characteristics, surgical methods, and clinical outcomes. Results: Overall, there were similar median percentage improvements realized after spinal fusion and the IDET procedure, respectively, for 2 of the 3 outcomes evaluated: pain severity (50%, 51%), back function (42%, 14%) and quality of life (46%, 43%). There was an identifiable random ized controlled trials trend of both treatments reporting a smaller magnitude of improvement in all 3 primary outcomes (pain severity, back function, quality of life) compared to other types of trials. Perioperative complications were commonly associated with spinal fusion (median: 14%, range: 2% to 54%, n=31 study groups) whereas adverse events were rarely experienced with the IDET procedure (median: 0%, range: 0% to 16%, n=14 studies). Randomized controlled trials of spinal fusion, in particular, had important methodological limitations. Conclusion: The majority of patients reported improvement in symptoms following both spinal fusion and the IDET procedure. The IDET procedure appears to offer sufficiently similar symptom amelio ration to spinal fusion without the attendant complications.”

Fluoroscopy radiation safety for spine interventional pain procedures in university teaching hospitals.

Abstract: BACKGROUND: Fluoroscopic guidance is frequently utilized in performing various types of interventional techniques. The major purpose of fluoroscopy is accurate needle placement to ensure target specificity and accurate delivery of the injected drug. However, radiation exposure may be associated with risks to physician, patient, and personnel. Multiple studies have evaluated the risk of radiation exposure and techniques to reduce the risk in private practice settings. However, the literature is scant in evaluating the risk of radiation exposure in teaching hospitals in university settings. OBJECTIVE: To evaluate safety and duration of radiation exposure for fluoroscopy guided interventional pain procedures in university pain clinics. STUDY DESIGN: Retrospective, case study. METHODS: The data was reviewed from the fluoroscopy machines from March 2004 to April 2004 at two university pain clinics. Mean fluoroscopy time (FT), mean radiation dose per procedure, and utilization of pulsed fluoroscopy were analyzed. RESULTS: Data of a total of 165 cases of spine injection procedures were collected. The mean fluoroscopy time for lumbar epidural steroid injection, facet joint block, sympathetic nerve block, sacroiliac joint injection, and discography were 46.6 +/- 4.2; 81.5 +/- 12.8; 64.4 +/- 11; 50.6 +/- 41.9 and 146.8 + 25.1 seconds respectively. There were significant differences in fluoroscopy exposure times and radiation dosage for epidural steroid injection among different teaching physicians. Pulsed fluoroscopy was used in less than 10% of cases. CONCLUSION: The results of this study show that the fluoroscopy exposure time for various interventional procedures performed in the university settings are significantly higher than the radiation exposure periods in private practice settings. This study also showed significant differences among physicians in the same university setting.

Therapeutic cervical medial branch blocks in managing chronic neck pain: a preliminary report of a randomized, double-blind, controlled trial: clinical trial NCT0033272.

Abstract: Background Based on the criteria established by the International Association for the Study of Pain, the prevalence of persistent neck pain, secondary to involvement of cervical facet or zygapophysial joints has been described in controlled studies as varying from 54% to 67%. Intraarticular injections, medial branch nerve blocks and neurolysis of medial branch nerves have been described in managing chronic neck pain of facet joint origin. Objectives To determine the clinical effectiveness of therapeutic cervical medial branch blocks in managing chronic neck pain of facet joint origin and to evaluate the effectiveness of the addition of Sarapin and steroids to local anesthetics. Design A double-blind, randomized, controlled trial. Setting An interventional pain management setting in the United States. Methods In this preliminary analysis, data from a total of 60 patients were included, with 15 patients in each of the 4 groups. Thirty patients were in a non-steroid group (combined Group I and II); and 30 patients were in a steroid group (combined Group III and IV). All of the patients met the diagnostic criteria of cervical facet joint pain by means of comparative, controlled diagnostic blocks. Four types of interventions were included. Group I served as control, receiving medial branch blocks using bupivacaine. Group II consisted of cervical medial branch blocks with bupivacaine and Sarapin. Group III consisted of cervical medial branch blocks with bupivacaine and betamethasone. Group IV consisted of cervical medial branch blocks with bupivacaine, Sarapin and betamethasone. Outcome measures Numeric pain scores, Neck Pain Disability Index, opioid intake, and work status were evaluated at baseline, 3 months, 6 months and 12 months. Results Significant pain relief (> or =50%), and functional status improvement was observed at 3 months, 6 months and 12 months. The average number of treatments for 1 year was 3.8 +/- 0.7 in the non-steroid group and 3.4 +/- 1.0 in the steroid group with no significant difference among the groups. Duration of average pain relief with each procedure was 13.4 +/- 3.5 weeks in the nonsteroid group, and it was 15.9 +/- 8.0 weeks in the steroid group with no significant difference among the groups. Conclusion Therapeutic cervical medial branch nerve blocks, with or without Sarapin or steroids, may provide effective management for chronic neck pain of facet joint origin.

Medicare in interventional pain management: A critical analysis.

Abstract: Recent years have been quite eventful for interventional pain physicians with numerous changes in the Medicare payment system with a view for the future and what it holds for interventional pain management for 2006 and beyond. On February 8, 2006, President Bush signed the Deficit Reduction Act of 2005, which cuts the federal budget by 39 billion dollars and Medicare and Medicaid by almost 11 billion dollars over five years. The Act contains a number of important provisions that effect physicians in general and interventional pain physicians in particular. This Act provides one year, 0% conversion factor update in payments for physicians services in 2006. Medicare has four programs or parts, namely Medicare Parts A, B, C, and D, and two funds to pay providers for serving beneficiaries in each of these program. Part B helps pay for physician, outpatient hospital, home health, and other services for the aged and disabled who have voluntarily enrolled. Before 1922, the fees that Medicare paid for those services were largely based on physician's historical charges. Despite Congress's actions of freezing or limiting the fee increases, spending continued to rise because of increases in the volume and intensity of physician services. Medicare spending per beneficiary for physician services grew at an average annual rate of 11.6% from 1980 through 1991. Consequently Congress was forced to reform the way that Medicare sets physician fees, due to ineffectiveness of the fee controls and reductions. The sustained growth rate (SGR) system was established because of the concern that the fee schedule itself would not adequately constrain increases in spending for physicians' services. The law specifies a formula for calculating the SGR, based on changes in four factors: (1) estimated changes in fees; (2) estimated change in the average number of Part B enrollees (excluding Medicare Advantage beneficiaries); (3) estimated projected growth in real gross domestic product (GDP) growth per capita; and (4) estimated change in expenditures due to changes in law or regulation. Overall, the frequency of utilization of interventional procedures has increased substantially since 1998. In 2006 and beyond, interventionalists will face a number of evolving economic and policy-related issues, including reimbursement discrepancies, issues related to CPT coding, issues related to utilization, fraud, and abuse.

Pulsed radiofrequency of lumbar nerve roots for treatment of chronic inguinal herniorraphy pain.

Abstract: Background Inguinal hernia repairs are commonly performed and although not seen in a majority of patients, chronic inguinal pain can be a debilitating state resulting after inguinal hernia repairs. Treatment options exist, including pharmacological and surgical management, but with associated risks and side effects. Methods In this case series report, five patients with chronic inguinal pain were selected. After initial positive response to T12, L1 and L2 nerve root blocks, pulse radiofrequency (PRF) was performed. Results All patients reported 75% to 100% pain relief lasting from six to nine months. Discussion Several hypotheses have been proposed, including selective delta and c-nerve fiber destruction, upregulation of intermediate early gene expression (IEG) and increase in c-fos protein that modulated pain transmission. Conclusion The mechanism of action of pulsed radiofrequency remains unclear. This case study demonstrates the effectiveness of minimally invasive neurodestruction of T12, L1 and L2 nerve roots utilizing Pulse Radiofrequency fields.

Role of adhesiolysis in the management of chronic spinal pain: a systematic review of effectiveness and complications.

Abstract: BACKGROUND Percutaneous epidural adhesiolysis and spinal endoscopic adhesiolysis are interventional pain management techniques that play an active role in managing chronic intractable low back pain. There have not been any systematic reviews performed on this subject. OBJECTIVE To evaluate the effect of percutaneous adhesiolysis and spinal endoscopic adhesiolysis in managing chronic low back and lower extremity pain. STUDY DESIGN A systematic review utilizing the methodologic quality criteria of the Cochrane Musculoskeletal Review Group for randomized trials and the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials. METHODS Search identified the relevant literature, through searches of MEDLINE and EMBASE (January 1966 to November 2004), BioMed Central and Cochrane Review database. Manual searches of bibliographies of known primary and review articles, and abstracts from scientific meetings within the last 2 years, in English language. Randomized and non-randomized studies were included in the review based on the criteria established. Three reviewers independently assessed the trials for the quality of their methods. Percutaneous adhesiolysis and endoscopic adhesiolysis were analyzed separately. OUTCOME MEASURES Primary outcome measure was significant pain relief (50% or greater). Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term relief was defined as less than 3 months, and long-term relief was defined as 3 months or longer. RESULTS There was strong evidence to indicate effectiveness of percutaneous epidural adhesiolysis with administration of epidural steroids for short term and long term in chronic, refractory low back pain and radicular pain. There was moderate evidence of effectiveness of addition of hypertonic saline. The evidence of effectiveness of hyaluronidase was negative. There was strong evidence to indicate effectiveness of spinal endoscopic adhesiolysis and epidural steroid administration for short-term improvement, and moderate evidence for long-term improvement in managing chronic, refractory, low back and lower extremity pain. CONCLUSION The evidence of effectiveness of percutaneous adhesiolysis with administration of hypertonic sodium chloride administration, and spinal endoscopic adhesiolysis with epidural steroid administration in managing chronic, refractory low back and lower extremity pain of post lumbar laminectomy syndrome or epidural fibrosis was moderate to strong.

Treatment of painful advanced internal lumbar disc derangement with intradiscal injection of hypertonic dextrose.

Abstract: Background Degenerative discs are thought to produce nerve root pain either mechanically or chemically. Particularly in the case of advanced degenerative disc disease, this clinical entity has often proven to be symptomatically resistant to peridural steroids, Intra-discal Electrothermoplasty (IDET) and direct surgical intervention. Exposure of irritated nerves to hypertonic dextrose is thought to have chemoneuromodulatory potential. Sustained pain reduction has been demonstrated in a pilot study involving injection of a combination of dextrose, glucosamine, chondroitin and dimethylsulfoxide into degenerative discs of patients with chronic low back pain of discogenic origin. Objective To assess the effects of disc space injections of hypertonic dextrose in patients experiencing chronic advanced degenerative discogenic leg pain, with or without low back pain. Study design Prospective consecutive patient series. Methods Patients with moderate to severe degenerative disc disease without herniation and with concordant pain reproduction with CT discography were included. All had failure of a physical therapy trial and substantial but temporary relief with two fluoroscopically guided epidural steroid injections. Patients underwent bi-weekly disc space injection of a solution consisting of 50% dextrose and 0.25% Bupivacaine in the disc(s) found positive on discography. The study was performed in an out-patient surgery center in the United States. Outcome measures included an 11-scale numeric pain score (0-10). Results Each patient was injected an average of 3.5 times. Overall, 43.4% of patients fell into the sustained improvement group with an average improvement in numeric pain scores of 71%, comparing pretreatment and 18 month measurements. Conclusion The results suggest that intradiscal injection of hypertonic dextrose may have a place in the management of pain arising from advanced lumbar degenerative disc disease.

Evaluation of therapeutic thoracic medial branch block effectiveness in chronic thoracic pain: a prospective outcome study with minimum 1-year follow up.

Abstract: Background The prevalence of persistent upper back and mid back pain due to involvement of thoracic facet joints has been described in controlled studies as varying from 43% to 48% based on IASP criteria. Therapeutic intraventions utilized in managing chronic neck pain and low back pain of facet joint origin include intraarticular injections, medial branch nerve blocks, and neurolysis of medial branch nerves by means of radiofrequency. These interventions have not been evaluated in managing chronic thoracic pain of facet joint origin. Objective To determine the clinical effectiveness of therapeutic thoracic medial branch blocks in managing chronic upper back and mid back pain of facet joint origin. Design A prospective outcome study. Setting Interventional pain management setting in the United States. Methods Fifty-five consecutive patients meeting the diagnostic criteria of thoracic facet joint pain by means of comparative, controlled diagnostic blocks were included in this evaluation. All medial branch blocks were performed in a sterile operating room under fluoroscopic visualization with mild sedation with midazolam and/or fentanyl. Statistical methods incorporated intent-to-treat analysis. Outcome measures Numeric pain scores, significant pain relief > or = 50%), Oswestry Disability Index, work status and Pain Patient Profile (P-3). Significant pain relief was defined as an average 50% or greater reduction of numeric pain rating scores. Results The results showed significant differences in numeric pain scores and significant pain relief (50% or greater) in 71% of the patients at three months and six months, 76% at 12 months, 71% at 24 months, and 69% at 36 months, compared to baseline measurements. Functional improvement was demonstrated at one year, two years, and three years from baseline. There was significant improvement with increase in employment among the patients eligible for employment (employed and unemployed) from baseline to one year, two years, and three years (61% vs 96% to 100%) and improved psychological functioning. Conclusion Therapeutic thoracic medial branch blocks were an effective modality of treatment in managing chronic thoracic pain secondary to facet joint involvement confirmed by controlled, comparative local anesthetic blocks.

A novel approach to transnasal sphenopalatine ganglion injection.

Abstract: Background Sphenopalatine ganglion block is used to treat headache and facial pain. There are transnasal, transoral and lateral approaches to establish the blockade. The transnasal application of topical anesthetic is the simplest and most common technique among the three. However, the diffusion of topical anesthetic to the ganglion is unpredictable and the blockade is not durable. Objective To describe a novel transnasal injection technique to block sphenopalatine ganglion. Methods The technique includes topical anesthesia to the nasal mucosa between the middle and inferior turbinates from nares to the nasopharynx, followed by a needle insertion in the same tract guided by its tailored plastic cover-sheath for blocking agent injection to the ganglion. Results Fluoroscopy revealed that with this technique the needle tip located near the medial pterygoid plate at the level of the middle concha and contrast flowed superoposteriorly to the maxilla without vascular uptake. Pain relief for this patient was prolonged from one day with topical technique to four weeks with this technique. The subsequent blocks without fluoroscopy provided similar prolonged pain relief. Conclusion This method preserves the technical simplicity of the original transnasal approach and includes the predictability and durability of the blockade from needle injection.

Percutaneous lumbar disc decompression.

Abstract: Chronic low back pain is a major social, economic, and healthcare issue in the United States. Various techniques are utilized in managing discogenic pain, with or without disc herniation. Percutaneous techniques are rapidly replacing traditional open surgery in operations requiring discectomy, decompression, and fusion. The percutaneous access to the disc was first used in the 1950s to biopsy the disc with needles. Percutaneous access to the disc using endoscopic techniques was developed in the 1970s. Technical advances in the use of intradiscal therapies led to the development of intradiscal electrothermal annuloplasty (IDET), DISC Nucleoplasty, and DeKompressor, along with laser-assisted, endoscopic, and Nucleotome disc decompressions. The indications for percutaneous lumbar disc decompression include low back and lower extremity pain caused by a symptomatic disc. Internal disc disruptions and disc herniations are common causes of low back and/or lower extremity pain which may become chronic, if not diagnosed and treated. Annular tears lead to migration of the nuclear material and deranged internal architecture. In the chronically damaged intervertebral disc, leakage of nuclear material from annular tears can initiate, promote, and continue the inflammatory process and delay or stop recovery of vital remaining intradiscal tissue. The most often stated goal of central nuclear decompression is to lower the pressure in the nucleus and to allow room for the herniated fragment to implode inward. Provocative discography prior to percutaneous lumbar disc decompression is recommended. Percutaneous disc decompression may result in a small number of complications but occasionally, these could be serious.

The effect of sedation on diagnostic validity of facet joint nerve blocks: an evaluation to assess similarities in population with involvement in cervical and lumbar regions (ISRCTNo: 76376497).

Abstract: Background Zygapophysial or facet joint pain in patients suffering with chronic spinal pain without disc herniation or radiculopathy may be diagnosed with certainty by the use of controlled diagnostic blocks. But, in patients suffering with either lumbar or cervical facet joint pain, even this diagnostic approach may be confounded by false-positives when using a single diagnostic block. It may also be confounded by the administration of anxiolytics and narcotics prior to, or during, the controlled diagnostic facet joint blocks. The effect of sedation on the validity and potential differential results in patients suffering with combined cervical and lumbar facet joint pain has not been evaluated. Objective To assess the effects of midazolam and fentanyl on the diagnostic validity of facet joint blocks in patients suffering with both cervical and lumbar facet joint pain. Study design Randomized, double-blind, placebo-controlled study. Methods The design consisted of a placebo group receiving a sodium chloride solution and two experimental groups receiving either midazolam or fentanyl. Patients included in the study had been diagnosed with facet joint pain using controlled comparative local anesthetic blocks of the medial branches and L5 dorsal rami. They had been treated with lumbar and cervical facet joint nerve blocks and experienced good pain relief; and were presenting for repeat treatment after a period of symptom relief. The study was performed in an interventional pain management practice in the United States; a total of 60 patients participated with 20 patients randomly allocated into each group. Outcome measures included numeric pain scores, proportion of pain relief, and ability to perform prior painful movements. Outcome measures Outcomes were assessed at baseline and after the administration of 1 of the 3 solutions (Group I, sodium chloride solution; Group II, midazolam; or Group III, fentanyl). Results Overall, 50% of the patients were relaxed or sedated in the placebo group, while 100% of the patients in the midazolam and fentanyl groups were relaxed or sedated. As many as 10% of the patients reported significant relief (>= 80%) with the ability to perform prior painful movements. Conclusions Perioperative administration of sodium chloride, midazolam, or fentanyl can confound results in the diagnosis of combined cervical and lumbar facet joint pain. False-positive results with placebo or sedation may be seen in a small proportion of patients.

Spinal Cord Stimulation for Refractory Angina Pectoris and Peripheral Vascular Disease

Abstract: Spinal cord stimulation has been used in clinical practice for more than three decades. The primary use of this therapy has been in spine-related disorders. In recent years, the therapy has been used more extensively in diseases of the vascular system. Increasingly, interest has piqued in using this mode of treatment for refractory angina and ischemic pain secondary to peripheral vascular disease. In this publication, we review the current literature on these two indications and present case examples of both therapies.

Partial regeneration of the human hip via autologous bone marrow nucleated cell transfer: A case study.

Abstract: HISTORY: This is a case report of a 64-year-old white male with a 20 year history of unilateral hip pain that had become debilitating over the last several years. On intake, Harris hip score was rated as: Pain subscale = 10, Function subscale = 32, Deformity subscale = 4, Motions subscale = 4.775 with a total score of 50.8 out of 100. MRI of the affected hip showed severe degeneration with spurring, decrease in joint space, and several large subchondral cysts. The patient had been evaluated by an orthopedic surgeon and told he was a candidate for bipolar hip replacement. METHOD: Two autologous nucleated cell collections were performed from bone marrow with subsequent isolation and transfers into the intra-articular hip using a hyaluronic acid and thrombin activated platelet rich plasma scaffold. Marrow samples were processed by centrifugation and lysis techniques to isolate nucleated cells. CONCLUSION: This report describes partial by articular surface regeneration 8 weeks after intraarticular bone marrow transfer. Post-op 3.0T FGRE MRI showed neocortex formation when compared to immediate pre-op MRI and objective improvements were noted that coincided with subjective reports of improvement.

Treatment challenges and complications with ziconotide monotherapy in established pump patients.

Abstract: Background The U.S. Food and Drug Administration (FDA) recently approved Ziconotide intrathecal infusion for the management of severe chronic pain in patients for whom intrathecal therapy is warranted, and who are intolerant of, or refractory to, other methods of treatment, including intrathecal morphine. Ziconotide is approved as a monotherapy, but there are challenges associated with the decision to wean intrathecal opioids for Ziconotide alone. Maintaining adequate analgesia and managing opioid withdrawal symptoms may be difficult. Additionally, a variety of adverse physiological, cognitive and psychiatric events may be associated with this new drug. Patients with pretreatment psychiatric disorders may be at increased risk for treatment complications. Objective To present a report of a case series describing treatment challenges and complications associated with the decision to convert established pump patients from intrathecal opioid therapy to Ziconotide monotherapy. Description of cases Three established pump patients, refractory to intrathecal opioid therapy, were converted to Ziconotide monotherapy. All of these patients experienced significant emotional distress or psychological symptoms that threatened the success of the treatment. Achieving adequate analgesia, reducing Ziconotide to mitigate adverse physiological effects, managing opioid withdrawal symptoms, and supportive psychological consultation were combined to achieve successful outcomes in two of our three patients. Conclusion This report describes challenges associated with the decision to convert established pump patients from intrathecal opioid therapy to Ziconotide monotherapy. Inadequate analgesia, adverse medication effects, and opioid withdrawal symptoms can precipitate a stressful situation that may be perceived as dangerous or threatening by patients who are predisposed to anxiety. Screening patients for psychiatric disorders, anxiety-proneness and/or vulnerability to stress should be considered to reduce the risk of treatment complications. A multimodal approach is strongly advocated, including rapid responses of treating physicians and nurses along with strong psychological support.

A comparison of pulsed radiofrequency and continuous radiofrequency on thermocoagulation of egg white in vitro.

Abstract: Background Clinical studies have demonstrated the efficacy of pulsed radiofrequency (PRF). PRF energy is delivered to neural structures via specifically designed, percutaneously placed needles to treat some chronic pain states. PRF was introduced as a non-destructive alternative to destructive lesioning produced by continuous radiofrequency (CRF) energy. However, there is an ongoing controversy regarding the potential tissue-destructive effects of PRF used for pain management. Objective To evaluate the ability of PRF to coagulate egg white at various temperatures used clinically and to compare with CRF. Methods A commercially available (TYCO-Radionics Labs) 5 cm, 22G (0.7 mm) SMK needle with 5 mm active tip was inserted into a 10 mL test tube containing raw egg white at 37 degrees C and the tip was heated up to 80 degrees C. The photographic patterns of thermocoagulation of egg white in vitro produced by continuous and pulsed radiofrequency (RF) were compared and the lowest temperature at which PRF produced thermocoagulation was determined. Results Pulsed RF produced barely detectable thermocoagulation at 60 degrees C. Above 60 degrees C, the pattern of coagulation produced by PRF resembled that observed with CRF. However, the density and size of the coagulation ball appeared somewhat greater with CRF. Conclusion PRF coagulated egg white at temperatures above 60degrees C in a manner similar to CRF. Monitoring needle tip temperature using the thermode supplied with the needle during PRF and keeping the recorded tip temperature below 60degrees C may minimize unwanted thermal destruction of tissue.

Moral agency in pain medicine: philosophy, practice and virtue.

Abstract: Although established as a field of spe- cialization, pain medicine remains some- what fractionated. Such lack of cohesion cre- ates dissonance on multiple levels, and thus, impedes the provision of effective pain care. This paper asserts that there is a core philos- ophy of medicine that reflects the intellectual and moral quality of the healing relationship. I argue that pain medicine, in all its constitu- ent disciplines, is bound to this philosophy. The intricate relationship between pain, the pain patient, and the pain physician creates pragmatic and moral dilemmas that may not be well served by the use of prima facie prin- ciples. It is argued that an agent-based, vir- tue ethics best enable the clinician to both apprehend the complexity of this relation- ship and appreciate other ethical approaches in the discourse arising from issues of care.

Evidence synthesis and development of guidelines in interventional pain management.

Abstract: BACKGROUND The past decade has been marked by unprecedented interest in evidence-based medicine and various types of avenues that can provide valid and reliable information about healthcare, including clinical practice guidelines. Thus, healthcare decisions are purportedly and increasingly being made on research-based evidence rather than on expert opinion or clinical experience alone. The methods describing evidence synthesis or development of guidelines in interventional pain management are scarce. OBJECTIVE To describe the methods of evidence synthesis and development of guidelines in interventional pain management in practical terms. DESCRIPTION This review sought to provide an understanding of evidence-based medicine, the importance and synthesis of clinical practice guidelines, and the variety of issues related to rating the quality of individual articles, understanding narrative and systematic reviews, grading the strength of the body of evidence, searching for evidence, and finally, the analytical preparation of guidelines, with a focus on interventional pain management. CONCLUSION Evidence synthesis and development of guidelines in interventional pain management is a complex and difficult task. It is emphasized that practice guidelines are not intended as standards or absolute requirements. Consequently, practice guidelines may be adapted, modified, or rejected, according to the clinical needs and constraints of each practitioner and patient.