Pain physician
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Randomized Controlled Trial
Effect of High-Volume Injectate in Lumbar Transforaminal Epidural Steroid Injections: A Randomized, Active Control Trial.
There have been many studies proving the effectiveness of lumbar transforaminal epidural steroid injections (TFESIs) for the treatment of radicular pain. Dexamethasone has been suggested as an alternative to particulate steroids. However, no controlled trials have investigated the effect of different injected volumes for a same dose of dexamethasone. ⋯ Injectate at a volume of 8 mL was more effective than injectate at a volume of 3 mL for radicular pain in a lumbar transforaminal steroid injection, although both of the injectates contained the same dose of dexamethasone.
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Some patients with lumbar herniated intervertebral disc disease (HIVD) suffer from both pain and lateral shift or trunk list. In addition to pain, patients have concerns regarding whether trunk list is reversible. Surgical treatment is performed when pain is intractable to conservative management, but a reversal of trunk list is an incidental outcome. Percutaneous lumbar endoscopic discectomy (PELD) is one of the surgical treatment options for lumbar HIVD, but no results concerning its effect on trunk list have been reported. ⋯ Trunk list, scoliosis or lateral shift, was observed in 18% of the patients at the time of surgery. Female gender and L4-5 disc herniation were risk factors for trunk list. Trunk list was reversible in more than 50% of patients within 6 months of PELD.
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Combined pharmacological treatments are the most used approach for neuropathic pain. Carbamazepine, an antiepileptic agent, is generally used as a third-line treatment for neuropathic pain and can be considered an option only when patients have not responded to the first- and second-line medications. In the case presented herein, a patient with neuropathic pain was treated using a combined pharmacological regimen. ⋯ This clinical case demonstrates that carbamazepine may have a synergistic effect on the analgesic effectiveness of morphine and may inhibit or postpone opioid-induced hyperalgesia. We postulate that a probable mechanism of action of carbamazepine may involve -aminobutyric acid-ergic potentiation and the interruption of glutamatergic function via N-methyl-D-aspartate receptors. Further research is warranted to clarify the analgesic action of carbamazepine and its potential use for the prevention of opioid-induced hyperalgesia in chronic neuropathic pain patients.
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Observational Study
National Perioperative Outcomes for Intrathecal Pump, Spinal Cord Stimulator, and Peripheral Nerve Stimulator Procedures.
There is abundant literature on the long-term complications of intrathecal pumps (ITP), spinal cord stimulators (SCS), and peripheral nerve stimulators (PNS) used in the treatment of chronic pain. There is less information, however, on the perioperative complications of these procedures. ⋯ Databases such as NACOR can provide rich information on ITP, SCS, and PNS for physicians performing these procedures. In this sample, ITP procedures, performed on the patients with the most severe cormobidities and often-requiring general anesthesia, were the most likely to be associated with hemodynamic instability, inadequate pain control, and extended PACU stays. Complications relating to the ITP are also the most common reason for an operation. These findings underscore the importance of proper patient selection for ITP and other implantable pain devices, in particular for patients with malignant pain or multiple co-morbidities. To identify the root causes of complications, additional information is needed on the procedure performed (e.g., an implant vs a revision), the surgical technique used, and the device implanted, as well as on specific patient comorbidities. Such information will likely become more available as resources like NACOR expand and as electronic medical record systems and coding become more integrated.
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Some patients have pelvic, pudendal, or low lumbar pain radiating into the legs that is worse while sitting but differs from pudendal neuralgia. The purpose of this study was to present a new clinical entity of neuropathic pelvic pain by pelvic neuro-vascular entrapment. ⋯ Neuro-vascular entrapment is a pathophysiologic phenomenon implicated in several pelvic neuropathies. The most common are L5-S1 sciatica, pudendal neuralgia, and sacral radiculopathy. After intraoperative confirmation, laparoscopic exploration of the entire sacral plexus is essential to diagnose conflict. Laparoscopic decompression is a treatment of choice, based on the separation of the offending vessel from the nerves. Those procedures are safe, with a high success rate; the neuropelveological approach is essential in order to obtain good treatment results. The laparoscopic approach gives the possibility of reducing morbidity and improving results by providing wider insight into the operating field with smaller intraoperative injury.