Baseline Numerical Rating Scale Score Research Articles

Low-dose short infusion ketamine as adjunct to morphine for acute long bone fracture in the emergency department: a randomized controlled trial

BackgroundKetamine is recognized as an alternative for pain management; however, concerns about emergent adverse reactions have limited its widespread adoption. This study aimed to assess the efficacy of a short infusion of low-dose ketamine (LDK) compared to intravenous morphine (MOR) as adjunctive analgesia for acute long bone fracture pain.MethodsThis single-blinded, randomized controlled trial was conducted in a single emergency department. Patients with acute long bone fractures and numerical rating scale (NRS) pain scores ≥ 6 following an initial dose of intravenous morphine were assigned to receive either a LDK (0.3 mg/kg) over 15 min or intravenous MOR at a dose of 0.1 mg/kg administered over 5 min. Throughout a 120-min observation period, patients were regularly evaluated for pain level (0–10), side effects, and the need for additional rescue analgesia.ResultsA total of 58 subjects participated, with 27 in the MOR group and 31 in the LDK group. Demographic variables and baseline NRS scores were comparable between the MOR (8.3 ± 1.3) and LDK (8.9 ± 1.2) groups. At 30 min, the LDK group showed a significantly greater mean reduction in NRS scores (3.1 ± 2.03) compared to the MOR group (1.8 ± 1.59) (p = 0.009). Similarly, at 60 min, there were significant differences in mean NRS score reductions (LDK 3.5 ± 2.17; MOR mean reduction = 2.4, ± 1.84) with a p-value of 0.04. No significant differences were observed at other time intervals. The incidence of dizziness was higher in the LDK group at 19.4% (p = 0.026).ConclusionShort infusion low-dose ketamine, as an adjunct to morphine, is effective in reducing pain during the initial 30 to 60 min and demonstrated comparability to intravenous morphine alone in reducing pain over the subsequent 60 min for acute long bone fractures. However, it was associated with a higher incidence of dizziness.Trial registrationNMRR17318438970 (2 May 2018;www.nmrr.gov.my).

Factors associated with increased length of stay in degenerative cervical spine surgery: a cohort analysis from the Canadian Spine Outcomes and Research Network.

Postoperative length of stay (LOS) significantly contributes to healthcare costs and resource utilization. The primary goal of this study was to identify patient, clinical, surgical, and institutional variables that influence LOS after elective surgery for degenerative conditions of the cervical spine. The secondary objectives were to examine the variability in LOS and institutional practices used to decrease LOS. This was a multicenter observational retrospective cohort study of patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN) between January 2015 and October 2020 who underwent elective anterior cervical discectomy and fusion (ACDF) (1-3 levels) or posterior cervical fusion (PCF) (between C2 and T2) with/without decompression for degenerative conditions of the cervical spine. Prolonged LOS was defined as LOS greater than the median for the ACDF and PCF populations. The principal investigators at each participating CSORN healthcare institution completed a survey to capture institutional practices implemented to reduce postoperative LOS. In total, 1228 patients were included (729 ACDF and 499 PCF patients). The median (IQR) LOS for ACDF and PCF were 1.0 (1.0) day and 5.0 (4.0) days, respectively. Predictors of prolonged LOS after ACDF were female sex, myelopathy diagnosis, lower baseline SF-12 mental component summary score, multilevel ACDF, and perioperative adverse events (AEs) (p < 0.05). Predictors of prolonged LOS after PCF were nonsmoking status, education less than high school, lower baseline numeric rating scale score for neck pain and EQ5D score, higher baseline Neck Disability Index score, and perioperative AEs (p < 0.05). Myelopathy did not significantly predict prolonged LOS within the PCF cohort after multivariate analysis. Of the 8 institutions (57.1%) with an enhanced recovery after surgery (ERAS) protocol or standardized protocol, only 3 reported using an ERAS protocol specific to patients undergoing ACDF or PCF. Patient and clinical factors predictive of prolonged LOS after ACDF and PCF are highly variable, warranting individual consideration for possible mitigation. Perioperative AEs remained a consistent independent predictor of prolonged LOS in both cohorts, highlighting the importance of preventing intra- and postoperative complications.

Prospective Six-Month Analysis of Multiarea Burst Spinal Cord Stimulation: Correlating Intraoperative Neuromonitoring With Postoperative Programming and Clinical Outcomes

IntroductionDeRidder burst spinal cord stimulation (SCS) has shown superior relief from overall pain to traditional tonic neurostimulation therapies and a reduction in back and leg pain. However, nearly 80% of patients have two or more noncontiguous pain areas. This affects the ability to effectively program stimulation and deliver long-term efficacy of the therapy. Multiple DeRidder burst region programming is an option to treat multisite pain by interleaving stimulation at multiple areas along the spinal cord. Previous intraoperative neuromonitoring studies have shown that DeRidder burst stimulation provides broader myotomal coverage at a lower recruitment threshold. The goal of this study is to correlate intraoperative electromyogram (EMG) threshold and postsynaptic excitability with postoperative paresthesia thresholds and optimal burst stimulation programming. Materials and MethodsNeuromonitoring was performed during permanent implant of SCS leads in ten patients diagnosed with chronic intractable back and/or leg pain. Each patient underwent the surgical placement of a Penta Paddle electrode through laminectomy at the T8–T11 spinal levels. Subdermal electrode needles were placed into lower extremity muscle groups, in addition to the rectus abdominis muscles, for EMG recording. Evoked responses were compared across multiple trials of burst stimulation in which the number of independent burst areas was varied. After intraoperative data collection, all patients were programmed with single- and multiarea DeRidder burst. Intermittent dosing was delivered at 30:90, 120:360, 120:720, and 120:1440 (seconds ON/OFF) intervals. Numerical rating scale (NRS) and Patient Global Impression of Change scores were evaluated at one, two, three, four, and six months after permanent implant. ResultsThe thresholds for EMG recruitment after DeRidder burst differed across all patients owing to anatomical and physiological variations. After a 30-second dose of stimulation, the average decrease in thresholds was 1.25 mA for two-area and 0.9 mA for four-area DeRidder burst. Furthermore, a 30-second dose of multisite DeRidder burst produced a 0.25 mA reduction in the postoperative paresthesia thresholds. Across all patients, the baseline NRS score was 6.5 ± 0.5, and the NRS score after single or multiarea DeRidder burst therapy was 2.87 ± 1.50. Eight of ten patients reported a ≥50% decrease in their pain scores through the six-month follow-up visit. Pain outcomes using intermittent multiarea stimulation with longer OFF times (120:360, 120:720, 120:1440) were comparable to those using single-area DeRidder burst at 30:90 up to six months after implant with patient preference being two-area DeRidder burst. ConclusionsThis study aims to evaluate the use of intraoperative neuromonitoring to optimize stimulation programming for multisite pain and correlate it with postoperative programming and efficacy. These results suggest that multisite programming can be used to further customize DeRidder burst stimulation to each individual patient and improve outcomes and quality of life for patients receiving SCS therapy for multisite pain.

Analgesic effect of neuromodulation using the AT-04 portable magnetic field-generating device in a patient with neuropathic pain: a case report

BackgroundNeuromodulation by magnetic field through the AT-04 (ait® (AT-04); Peace of Mind Co., Ltd., Kumamoto, Japan) has improved allodynia in neuropathic pain model rats. This report focuses on neuromodulation through magnetic field exposure using the AT-04 that provided an analgesic effect in a patient with neuropathic pain.Case presentationA 47-year-old man presented with flaccid paralysis and extensive neuropathic pain and scored 7 on the 11-point Numerical Rating Scale (NRS) for his left upper limb. The patient was treated with neuromodulation by magnetic field exposure using the AT-04. Baseline NRS scores were obtained three times daily during the baseline period (days 1–5). Magnetic field exposure was then performed for 30 min three times daily (morning, noon, and evening) at home for 36 days, which was termed the intervention period (days 6–41). During the baseline period, the median NRS score was 7 and the baseline NRS score for calculating the percentage of nonoverlap data (PND) was 6. During the intervention period, the median NRS score was 4 and the PND value of the NRS score was 77.8% (28/36). Neuromodulation by magnetic field exposure using the AT-04 effectively decreased the patient’s NRS score. The patient had no adverse effects during the intervention period.ConclusionsNeuromodulation by magnetic field exposure using the AT-04 was effective in decreasing the NRS score in a patient with neuropathic pain. The AT-04 portable magnetic field-generating device shows potential as a therapeutic option for refractory neuropathic pain.

Clinical outcomes and predictors of bleomycin polidocanol foam sclerotherapy treatment response in venous malformations.

To evaluate the safety and efficacy of bleomycin polidocanol foam (BPF) sclerotherapy for venous malformations (VMs) and analyze the associated clinical outcomes and predictors. We retrospectively assessed BPF sclerotherapy outcomes in 138 patients with VMs. We analyzed pain levels, lesion volume reduction, and subjective perception of response. Logistic regression analysis was performed to identify potential predictors of treatment outcome. Additionally, we carefully monitored and recorded complications. There was a notable average reduction in lesion volume by 78.50% ± 15.71%. The pain numerical rating scale (NRS) score decreased from 4.17 ± 2.63 prior to treatment to 1.05 ± 1.54 afterward, and 70.3% of the patients experienced effective relief after a single BPF treatment. Multivariate analysis revealed that a high baseline NRS (odds ratio [OR]: 4.026) and elevated activated partial thromboplastin time (APTT, OR: 1.200) were positive predictors of pain reduction. Additionally, a high baseline NRS score (OR: 1.992) and elevated thrombocytocrit (PCT, OR: 2.543) were positive predictors of incomplete postoperative pain relief. Minor complications occurred in 31 (22.46%) patients. BPF sclerotherapy is safe and effective for VMs, resulting in significant reduction in lesion volume, improved symptoms, and minimal complications. APTT and PCT levels are important predictors of pain outcomes following BPF treatment.

Evaluating the Effectiveness of Escalating Intravenous Infusions of Lignocaine and Ketamine in Reducing Pain and Disability for Fibromyalgia Syndrome: A Prospective Observational Study

Introduction: Fibromyalgia is a chronic syndrome characterised by widespread musculoskeletal pain accompanied by fatigue, disability, sleep, memory and mood issues. The pain of fibromyalgia is difficult to manage and has no complete remission. While there is no cure for fibromyalgia, a variety of medications have been tried to minimise symptoms and improve general health. Hence, a trial was conducted to evaluate lignocaine and ketamine as pharmacological modalities to treat fibromyalgia. Aim: To evaluate effectiveness of intravenous (i.v.) lignocaineketamine infusions in reducing pain and disability in fibromyalgia syndrome. Materials and Methods: A prospective observational study was conducted at Basaveshwara Medical College and Hospital, Chitradurga, Karnataka, India, between March 2021 and March 2022, on patients aged between 18-60 years diagnosed with fibromyalgia syndrome. Sixty patients were included in the study. Escalating doses of i.v. lignocaine of 5 mg/kg, 6 mg/ kg and 7 mg/kg followed by escalating doses of i.v. ketamine of 0.4 mg/kg, 0.5 mg/kg and 0.6 mg/kg were administered on alternate days over a period of 12 days. Infusions were given in 50 mL normal saline through syringe pump over a period of 45 minutes. Pre and postinfusion 11 point Numerical Rating Scale (NRS) score was used to assess pain and World Health Organisation Disability Assessment Schedule (WHODAS) 2.0 score to assess disability. Data are presented as mean and standard deviation. Statistical analysis was done by using the t-test for pre and post-treatment score, with a p-value&lt;0.05 was considered statistically significant. Results: The present study showed female predominance of 42 out of 60 patients (70%) compared to males 18 out of 60 (30%). Pretreatment average baseline NRS score was 8.8. The mean reduction in NRS scores after lignocaine-ketamine infusions at the end of one month was 1.40 and at sixth month 1.25 which was statistically significant (p-value=0.001). Pretreatment mean average disability score was 2.70 and at the end of sixth month it was 0.59 which was statistically significant (p-value=0.001). Three patients did not have reduction in NRS scores and reported mild to moderate side-effects in the form of dizziness, headache and raised blood pressure. Conclusion: Combined infusions of lignocaine-ketamine resulted in significant reduction in pain and disability in patients with fibromyalgia. Higher and repeated doses seem to be more effective and resulted in longer pain relief. Long-term follow-up periods are needed to determine the effectiveness, dose response and safety of these infusions as a therapeutic modality for fibromyalgia.

A stepwise approach for the management of primary erythromelalgia: A prospective single-arm study

A stepwise approach for the management of primary erythromelalgia: A prospective single-arm study

Surgical Treatment Outcomes of Achilles Tendon Rupture and Tendinosis Augmented with Synthetic Graft

Category:Hindfoot; Sports; TraumaIntroduction/Purpose:Surgical treatments for Achilles tendon ruptures (ATR) or insertional Achilles tendinitis (IAT) traditionally have prolonged postoperative recoveries. Patients are typically kept non-weight bearing or protected weight bearing on the operative extremity for weeks after surgery to protect the repairs. The purpose of this study is to show that augmentation of typical Achilles tendon repairs with a synthetic scaffold is safe, allows for early weight bearing while preserving functional outcome and has a high patient satisfaction.Methods:A retrospective chart review was performed on all patients surgically treated for ATR or IAT from 2018 - 2020. The surgeries were performed by two fellowship trained Foot and Ankle Orthopaedic surgeons. All repairs were augmented with a synthetic scaffold made of polycaprolactone-based polyurethane urea (PUUR). Achilles tendon ruptures were direct end-to-end repairs and IAT repairs were performed with double row biocomposite anchors in the calcaneus after a calcaneus exostectomy. Exclusion criteria included flexor hallucis longus transfer, non-insertional achilles tendinosis, patients undergoing additional surgical procedures, and ATR or IAT repairs not treated with PUUR. Patients were evaluated as a cohort as well as acute ruptures, chronic ruptures (defined as more than 6 weeks old), and IAT subgroups. Primary outcomes were date of weight bearing and patient satisfaction. Secondary outcomes were final strength and ankle dorsiflexion. The Wilcoxon signed-rank test (WSR) was used to compare baseline and final follow-up NRS scores.Results:A total of 33 patients met the inclusion criteria with 12 ATR (9 acute and 3 chronic) and 21 IAT. Mean follow-up length was 150 days (43 - 314). Mean weight bearing began on postoperative day (POD) 7.33 (6-13) for acute ruptures, 14.33 (6-19) for chronic ruptures, and 9.9 (5-42) for IAT. Patient satisfaction, based on a binary yes/no response at final followup, was obtained on 27 of 33 patients with 92.6% positive indicating satisfaction with surgical outcome. Final strength averaged 5/5 for 83.9% and 4/5 for 16.1% of all patients. Final active dorsiflexion of at least 10 degrees was obtained in 93.5%. Mean numerical rating scale (NRS) for pain significantly decreased from 5.2 to 0.6 for all patients (WSR p<0.001). No patients had loss of fixation or had a re-rupture. Complications included one patient with sural neuritis and another with minor wound breakdown that did not require surgical intervention.Conclusion:Augmentation of Achilles tendon ruptures and insertional Achilles tendonitis with PUUR graft is safe, allows for early weight-bearing, has a high patient satisfaction and has acceptable functional outcomes in regards to strength and motion.

A randomized, noninferiority, controlled trial of two doses of intravenous subdissociative ketamine for analgesia in the emergency department.

This study aimed to determine if 0.15mg/kg intravenous (IV) subdissociative ketamine is noninferior to 0.3mg/kg in emergency department (ED) patients with acute pain. This randomized, prospective, double-blinded, noninferiority trial included patients' age 18 to 59years presenting to the ED with acute moderate to severe pain. Subjects were randomized to IV subdissociative ketamine, 0.15mg/kg ("low" dose) or 0.30mg/kg ("high" dose), over 15 minutes. The primary endpoint was the 11-point numeric rating scale (NRS) pain score between groups at 30 minutes. Secondary endpoints included NRS pain scores at 15 and 60 minutes; change in NRS at 15, 30, and 60 minutes; rescue analgesia; and adverse effects. The noninferiority limit, δ0 , was set to 1.3. Forty-nine patients were included in each group. After the differences in the baseline NRS score were adjusted for, the mean NRS score at 30 minutes was 4.7 (95% confidence interval [CI]= 3.8 to 5.5) in the low-dose group and 5.0 (95% CI= 4.2 to 5.8) in the high-dose group (mean difference= 0.4, 95% CI= -0.8 to 1.5), indicating that the low-dose subdissociative ketamine was noninferior to the high dose (lower limit of 95% CI=-0.8 to ≥1.3= -δ0 ). Adverse effects were similar at 30 minutes. At 15 minutes, the high-dose group experienced greater change in NRS; however, more adverse effects occurred. Our data did not detect a large difference in analgesia or adverse effect profile between0.15mg/kg IV ketamine and0.30mg/kg in the short-term treatment of acute pain in the ED.

Impaired exercise-induced hypoalgesia in individuals reporting an increase in low back pain during acute exercise.

Exercise therapy is recommended for low back pain (LBP) although the immediate effects on pain are highly variable. In 96 individuals with LBP this cross-sectional study explored (a) the magnitude of exercise-induced hypoalgesia (EIH) and (b) measures of pain sensitivity and clinical pain manifestations in individuals reporting a clinical relevant increase in back pain during physical activity compared with individuals reporting low or no increase in back pain during physical activity. Cuff algometry was performed at baseline on the leg to assess pressure pain threshold (cPPT), tolerance (cPTT) and temporal summation of pain (cTSP). Manual PPTs were assessed on the back and leg before and after a 6-min walk test (6MWT). Back pain was scored on a numerical rating scale (NRS) after each minute of walking. The EIH-effect was estimated as the increase in PPTs after the walk exercise. Twenty-seven individuals reported an increase of ≥2/10 in pain NRS scores during walking and compared with the individuals with <2/10 NRS scores: cPPT and EIH-effects were lower whereas cTSP, pain intensity and disability were increased (p<0.03). Baseline NRS scores, EIH and pain thresholds were associated with the likelihood of an increase of ≥2/10 in back pain intensity during walking (p<0.05). Pain flares in response to physical activity in individuals with LBP seem to be linked with baseline pain sensitivity and pain intensity, and impair the beneficial EIH. Such information may better inform when individuals with LBP will have a beneficial effect of physical activity. Pain flares in response to physical activity in individuals with LBP seem to be linked with baseline pain sensitivity and pain intensity, and impair the beneficial exercise-induced hypoalgesia. Such information may better inform when individuals with LBP will have a beneficial effect of physical activity.

Day of peak pain reduction by a single session of dry needling in the upper trapezius myofascial trigger points: A 14 daily follow-up study

BackgroundDry needling (DN) is commonly used to inactivate myofascial trigger points (MTrPs). However, a daily report of pain reduction has not been determined. ObjectiveThe aim was to evaluate the time of the greatest pain relief after performing a single session of DN in MTrPs of the upper trapezius muscle. MethodsA patient who had MTrPs in the upper trapezius muscle was enrolled into a prospective descriptive study. Each patient received a single session of DN, using a fast-in-fast-out technique, with needle retention for 30 min. Numerical rating scale (NRS) scores were collected daily for 14 days. The mean difference of pain and an effect size were calculated. The 1–5 satisfaction score was a secondary outcome. ResultsSixty-seven subjects completed the intervention. The mean duration of the symptom was 27.32 months. The mean baseline NRS score was 5.30. The pain decreased significantly between immediate post-procedure and 1 day after the DN treatment from 5.16 to 3.40 (mean difference 1.76, p < 0.01, effect size = 0.87). The pain continuously reduced until day 10 and then it gradually rose. The pain on day 10 was compared with the baseline that revealed the largest effect size of 3.08 (mean difference 4.67, p < 0.01). Eighty-eight percent of the subjects were very satisfied with their treatment. ConclusionsA single session of DN treatment in the upper trapezius MTrPs combined with self-stretching exercises could greatly reduce pain between immediate post-procedure and 1 day after DN treatment. The peak effect on pain reduction occurred on day 10.

Comparison of ropivacaine with ropivacaine and fentanyl in continuous epidural analgesia for postherpetic neuralgia: A STROBE-compliant retrospective study.

Continuous epidural analgesia (CEA) using local anesthetics is frequently used to control herpes zoster pain and prevent postherpetic neuralgia (PHN). However, few studies have been conducted to determine the efficacy of epidural drugs administered as CEA to manage PHN. This retrospective study was designed to evaluate the effectiveness of CEA with ropivacaine alone or with ropivacaine and fentanyl for controlling pain caused by PHN.We reviewed the medical records of 71 patients. We studied 2 groups: epidural ropivacaine (ER; CEA with ropivacaine alone; n = 44) and epidural ropivacaine and fentanyl (Epidural ropivacaine and fentanyl (ERF); CEA with ropivacaine and fentanyl; n = 27). To evaluate pain, a numeric rating scale (NRS) was evaluated at 6 time points: immediately before the procedure (baseline NRS score); 1 hour after the procedure; 14 days after the procedure; and 1, 3, and 6 months after the procedure. Complication rates were recorded during CEA. We also investigated whether additional invasive procedures were needed due to insufficient pain control during the 6-month follow-up period.After adjusting for confounding variables, there were no significant differences in the NRS scores between the 2 groups at any time point. The adjusted odds ratio for additional invasive procedures within 6 months after CEA was 1.03-times higher in the ERF group than in the ER group, but this difference was not statistically significant (95% confidence interval: 0.33-3.23, P = .96). Rates of complication (dysuria, vomiting, nausea, itching sensation, and hypotension) during CEA were higher in the ERF group than in the ER group. However, the differences were not statistically significant.There was no difference in the management of pain in patients with PHN between the groups. Epidural administration of fentanyl with ropivacaine did not improve pain management when compared to ropivacaine alone. Although not statistically significant, the incidence of complications during CEA was higher in the opioid combination group.

Does changing weight change pain? Retrospective data analysis from a national multidisciplinary weight management service.

Musculoskeletal (MSK) pain is common in obese populations. Multidisciplinary Tier 3 weight management services (WMS) are effective in reducing weight; however, MSK pain as an outcome is not routinely reported post-WMS interventions. Following ethical approval this retrospective design study using anonymized data from a national WMS established changes in anthropometric and pain prevalence and intensity scores as well as establishing variables predictive of achieving clinically significant changes (CSC) in pain scores. Of the 806 patients registered to the WMS (January 2011-February 2015), 59% (n=476; CI=56-62) attended their reassessments at 6months. The overall mean age was 45.1±12years and 62% (n=294) were female. At baseline 70% (n=281; CI=65-75) reported low back pain (LBP) and 59% (n=234; CI=54-64) had knee pain. At reassessment 37.3% (n=177) of patients lost≥5% body weight, 58.7% (n=279) were weight stable (5% weight loss or gain) and 4.0% (n=19) gained≥5% body weight. Low back and knee pain prevalence reduced significantly for those who lost≥5% body weight. Variables predictive of a CSC in LBP numerical rating scale (NRS) score included a higher baseline NRS score, weighing more, and rating losing weight as being important (p<0.05). Higher baseline NRS and being younger resulted in higher odds of a CSC in knee pain NRS (p<0.05). Overall this WMS was effective for clinical weight loss. For those who lost most weight prevalence of knee and LBP reduced. Imbedding pain management strategies within WMS's may provide a more holistic approach to obesity management. Weight loss can reduce musculoskeletal pain, particularly for those who lose more weight. Imbedding pain management strategies within these services may provide a more holistic approach to obesity management.

Clinical outcome of percutaneous lumbar foraminoplasty using a safety-improved device in patients with lumbar foraminal spinal stenosis.

Lumbar foraminal spinal stenosis (LFSS) is defined as the narrowing of the nerve root exit associated with a herniated intervertebral disc, osteoarthritic changes in the facet joints, or a hypertrophied ligamentum flavum, which can provoke neurogenic claudication. To achieve effective and safe decompression of the lumbar spinal foramen, a specially designed instrument (Claudicare, SEAWON Meditech, Bucheon-si, Gyeonggi-do, Republic of Korea) for percutaneous lumbar foraminoplasty (PLF) was invented. The purpose of this study was to evaluate the clinical efficacy and safety of the newly devised instrument in patients with LFSS.PLF was performed for LFSS by a single pain physician. For each patient, an 11-point numerical rating scale (NRS) pain score—the Oswestry Disability Index (ODI)—and the duration of walking without radicular pain were evaluated at the 3-month follow-up. The successful responder percentage was defined as ≥50% reduction from the baseline NRS score with improvement in ODI and duration of walking.Among 24 patients who underwent PLF, 15 patients showed successful responses. The NRS pain score and duration of walking without radicular pain were improved significantly from baseline at the 3-month follow-up (P < .01). The ODI was also decreased, but the difference was not statistically significant (P = .09). The NRS pain score and walking duration without pain at 3 months were statistically significantly different between the groups (P < .001 and P = .01, respectively), whereas there was no statistically significant difference in improvement in ODI between the groups (P = .23). No serious adverse events occurred in the study.In conclusion, PLF using the Claudicare device may be an optimal and safe option for managing intractable LFSS on an outpatient basis.

Pain reduction after lumbar epidural injections using particulate versus non-particulate steroids: intensity of the baseline pain matters.

To compare pain relief after CT-guided lumbar epidural steroid injections (ESI) using particulate (triamcinolone) and non-particulate (dexamethasone) steroids, and to explore factors affecting the effectiveness of both steroid types. This retrospective observational study included 806 patients with lumbar radiculopathy and corresponding MRI or CT abnormalities of the lumbar spine, who were matched using the propensity score method, yielding two cohorts of 209 patients each. Pain intensity was evaluated prior to the procedure using a pain numerical rating scale (NRS) with range 0-10. Reevaluation took place 1day and 4weeks post-injection. Logistic regression analysis and cubic splines applied to generalized additive models were implemented to assess the differences in pain reduction after ESI in the analyzed patient groups. Four weeks post-injection, the overall chance of ≥ 50% pain reduction was lower in the dexamethasone group than that in the triamcinolone group (odds ratio [OR] = 0.55; p < 0.012). In the dexamethasone cohort, the intensity of baseline pain and the presence of a herniated intervertebral disc in the infiltrated segment were both significant and independent predictors of ≥ 50% pain relief. Patients with baseline NRS score ≥ 7 points had markedly less chance of ≥ 50% pain relief than patients with NRS score < 7 (OR = 0.53; p < 0.032), whereas disc herniation increased the chances more than twofold (OR = 2.29; p < 0.044). There was no significant correlation between the effectiveness of triamcinolone and any analyzed concomitant variables. Triamcinolone was superior for lumbar radiculopathy of severe intensity. For mild to moderate pain, no benefit of using triamcinolone over dexamethasone was found. The effectiveness of dexamethasone was lower for stenotic spinal lesions than for disc herniation. • Triamcinolone is superior to dexamethasone for epidural treatment of severe lumbar radiculopathy. • For mild to moderate pain, dexamethasone could be equally effective. • Dexamethasone reduces pain caused by disc herniation much better than it does to pain caused by fixed stenotic spinal lesions.

Effectiveness of Percutaneous Lumbar Extraforaminotomy in Patients with Lumbar Foraminal Spinal Stenosis: A Prospective, Single-Armed, Observational Pilot Study.

In lumbar foraminal spinal stenosis (LFSS), numerous ligaments may play an important role in causing radiculopathy by narrowing the exit of the nerve root. In order to achieve effective decompression of lumbar foraminal ligaments, a specially designed instrument for percutaneous lumbar extraforaminotomy (PLEF) was invented. The purpose of this study was to evaluate the effectiveness of PLEF in patients with intractable radiculopathy from LFSS. A prospective, single-armed, observational pilot study. A pain center in a tertiary university-based hospital. The PLEF was performed in patients who suffered from radiculopathy with concordant imaging evidence of a mild to severe degree of LFSS. For each patient, an 11-point numerical rating scale (NRS) pain score, the Oswestry Disability Index (ODI), the Roland Morris Disability Questionnaire (RMDQ) score, and any adverse events were evaluated at three-month follow-ups. Successful responder percentage defined as 40% or greater reduction from baseline NRS score with no increase in ODI, and the RMDQ score was assessed at three months. Among 26 patients who underwent PLEF, 20 patients completed the study protocol. PLEF was successful in 12 patients (60%). The overall mean pain reduction at three months was 36.3%. Patients who responded well also showed improvement in the ODI (-20%) and RMDQ score (-8.4) at their three-month follow-up. No serious complications were reported in the study. The PLEF can be an effective and safe treatment option, as well as a minimally invasive procedure, for the management of patients suffering from refractory radiculopathy caused by LFSS.

Predicting morphine related side effects in the ED: An international cohort study

Study objectivesMorphine is the reference treatment for severe acute pain in an emergency department. The purpose of this study was to describe and analyse opioid-related ADRs (adverse drug reactions) in a large cohort of emergency department patients, and to identify predictive factors for those ADRs. MethodsIn this prospective, observational, pharmaco-epidemiological international cohort study, all patients aged 18years or older who were treated with morphine were enrolled. The study was done in 23 emergency departments in the US and France. Baseline numerical rating scale score and initial and total doses of morphine titration were recorded. Logistic regression analysis was used to study the effects of demographic, clinical and medical history covariates on the occurrence of opioid-induced ADRs within 6h after treatment. ResultsA total of 1128 patients were included over 10months. Median baseline initial pain scores were 8/10 (7–10) versus 3/10 (1–4) after morphine administration. Median titration duration was 10min (IQR, 1–30). The occurrence of opioid-induced ADRs was 25% and 2% were serious. Patients experienced mainly nausea and drowsiness. Medical history of travel sickness (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.01–2.86) and history of nausea or vomiting post morphine (OR, 3.86; 95% CI, 2.29–6.51) were independent predictors of morphine related ADRs. ConclusionSerious morphine related ADRs are rare and unpredictable. Prophylactic antiemetic therapy could be proposed to patients with history of travel sickness and history of nausea or vomiting in a postoperative setting or after morphine administration.

Predictors of Responses to Corticosteroids for Cancer-Related Fatigue in Advanced Cancer Patients: A Multicenter, Prospective, Observational Study

ContextAlthough corticosteroids are widely used to relieve cancer-related fatigue (CRF), information regarding the factors predicting responses to corticosteroids remains limited. ObjectivesThe aim of this study was to identify potential factors predicting responses to corticosteroids for CRF in advanced cancer patients. MethodsInclusion criteria for this multicenter, prospective, observational study were patients who had metastatic or locally advanced cancer and had a fatigue intensity score of 4 or more on a 0–10 Numerical Rating Scale (NRS). Univariate and multivariate analyses were conducted to identify the factors predicting two-point reduction or more in NRS on day 3. ResultsAmong 179 patients who received corticosteroids, 86 (48%; 95% CI 41%–56%) had a response with two-point reduction or more. Factors that significantly predicted responses were performance status score of 3 or more, Palliative Performance Scale score more than 40, absence of ascites, absence of drowsiness, absence of depression, serum albumin level greater than 3 mg/dL, serum sodium level greater than 135 mEq/L, and baseline NRS score greater than 5. A multivariate analysis showed that the independent factors predicting responses were baseline NRS score greater than 5 (odds ratio [OR] 6.6, 95% CI 2.8–15.4), Palliative Performance Scale score more than 40 (OR 4.4, 95% CI 2.1–9.3), absence of drowsiness (OR 3.4, 95% CI 1.7–6.9), absence of ascites (OR 2.3, 95% CI 1.1–4.7), and absence of pleural effusion (OR 2.2, 95% CI 1.0–5.0). ConclusionTreatment responses to corticosteroids for CRF may be predicted by baseline symptom intensity, performance status, drowsiness, and severity of fluid retention symptoms. Larger prospective studies are needed to confirm these results.

Vertebral Bone Drilling (Puncture) Attenuates the Intractable Pain Due to Vertebral Fractures without Collapse

Purpose: Osteoporotic vertebral fractures with no sign of vertebral collapse on initial radiographs, which is so-called occult vertebral fractures (VFs), exist. Occult VFs have a high rate of missed diagnosis, and the treatment of these fractures has rarely been discussed in the literature. We evaluated the effects of vertebral bone drilling for the pain due to occults VFs. Materials and Methods: Eighteen patients with painful osteoporotic occult VFs underwent the vertebral bone drilling. We evaluated the clinical outcome by comparing numerical rating scale (NRS) and activity of daily life (ADL) values between before and after the vertebral bone drilling. Comparisons were made by using Wilcoxon signed rank test. Results: The mean baseline NRS and ADL score, and the mean NRS and ALD score after the bone drilling were 8.4 ± 0.8, 2.2 ± 0.6, 2.4 ± 1.0, 4.6 ± 0.5, respectively. Among the patients, we detected significant improvements in NRS pain score and ADL score after the drilling compared with baseline score (p < 0.0002). Conclusion: Vertebral bone drilling at the site of painful vertebral compression fractures alleviated the intractable pain due to osteoporotic occult VFs.

Long-Term Data of Efficacy, Safety, and Tolerability in a Real-Life Setting of THC/CBD Oromucosal Spray-Treated Multiple Sclerosis Patients.

Delta-9-tetrahydrocannabinol (THC)/cannabidiol (CBD) oromucosal spray was approved as add-on therapy for spasticity in patients with multiple sclerosis (MS). We show our 40-week postmarketing experience regarding efficacy and safety of THC/CBD spray in an Italian cohort of 102 MS patients. Patients were evaluated using the Expanded Disability Status Scale (EDSS) score, the Numerical Rating Scale (NRS) for spasticity, the Ambulation Index (AI), and Timed 25-Foot Walk (T25-FW) at the beginning of treatment and then every 3 months. After 4 weeks, if a clinically significant improvement in spasticity (at least 20% of baseline NRS score) was not seen, administration of the drug was stopped. In our cohort, patients received an average of 6.5 ± 1.6 sprays each day. The mean reduction to the NRS spasticity score was 2.5 ± 1.2 points (P < .0001). Thirty-seven patients (36.2%) discontinued the treatment. The incidence of adverse events (AEs) was 40.2%. Fifty-eight patients (56.9%) were also assessed using the NRS for pain, and 46 patients (45.1%) with bladder dysfunction were assessed for the IPSS (International Prostatic Symptoms Score) score, showing a significant improvement in these scales (P = .011 and P = .001, respectively). In conclusion, treatment with THC/CBD spray appears to be a valid answer to some of the unmet needs in MS patients, such as spasticity and other refractory-to-treatment symptoms.