Nonsurgical Low Back Pain Research Articles

ID: 207794 Hematoma Complications After Spinal Cord Stimulation Trials and Implantations: A Meta-Analysis

Spinal cord stimulation (SCS) has been successful in the treatment of many chronic pain disorders, including failed back surgery syndrome, angina pectoris, complex regional pain syndrome, peripheral vascular disease, diabetic neuropathy, and nonsurgical low back pain. Although major complications are rare, the consequences can be devastating. For example, epidural hematomas can result in paralysis and typically require urgent surgery to prevent permanent neurologic damage. The aim of this study was to perform a meta-analysis to identify the incidence of neuraxial and non-neuraxial hematomas after SCS trials and implantations.

Differential target multiplexed spinal cord stimulator: a review of preclinical/clinical data and hardware advancement.

Spinal cord stimulation (SCS) is an effective neuromodulation technique for treating chronic neuropathic pain. Recent rapid growth in understanding its mechanism has led to the development of glial cell-based differential target multiplexed (DTM) stimulation and its derivative algorithm. Both preclinical research and clinical trials in humans showed superior pain relief using DTM SCS compared with traditional SCS. Another multicenter prospective clinical trial showed significant pain score reduction and energy saving using the DTM derivative algorithm. This review paper summarizes the evidence related to using DTM stimulation for other painful conditions such as nonsurgical low back pain and upper-limb pain. All these advanced programming options can be delivered using an innovative platform, the Medtronic Intellis™ neurostimulator.

Dorsal root ganglion stimulation device explantation: A multicenter pooled data analysis.

Dorsal root ganglion stimulation (DRG-S) is a relatively new neuromodulation modality. Therefore, data on long-term device explantation rates is limited. This investigation aimed to assess DRG-S device explantation rates at long-term follow-up. We retrospectively reviewed individuals implanted with DRG-S in four pain centers from different continuous periods between April 2016 to September 2020. We recorded patient demographics, diagnoses, duration to explantation or last follow-up, treatment complications, and failure etiologies. A total of 249 patients with 756 leads and a mean 27-month follow-up were included. The mean age was 55 ± 15 years; 148 (63%) were female. Leading diagnoses were CRPS (n= 106, 43%), followed by FBSS (n= 64, 26%), and non-surgical low back pain (n=23, 9%). The explantation rate was ~2% per year (n=10 total). At explantation, the average time from implantation was 13 ± 10 months. Six patients were explanted for inadequate pain relief. Two patients were explanted due to device-related complications. One patient was explanted secondary to infection and subsequently reimplanted. Five explanted patients experienced a therapy-related complication before eventual explantation: one transient post-procedural neuritis and pocket site pain, one lead fracture, two lead migrations, and one experienced a fracture, a migration, and pocket site pain. This large retrospective study of DRG-S revealed a low therapy-termination rate. The rate of infection leading to explantation was objectively very low at 0.4%. The leading cause of explantation was inadequate pain relief. Explanted patients often had a therapy-related complication. Therefore, minimizing adverse treatment events may reduce ultimate explantation rates.

Ketofol vs Dexamedetomidine Effect on Conscious Sedation for Patients with Chronic Nonsurgical Low Back Pain

Abstract Context Treatment of low back pain is challenging. A variety of therapeutic interventions is available, but no single modality appears to be superior, and evaluations vary depending on the cause of pain and on individual, social, and occupational factors. Scientific evidence supports the use of some nonsurgical treatment alternatives in patients with acute and chronic low back pain. Dexmedetomidine had been successfully used in conscious (moderate) sedation as a good competitive to the popular agent (midazolam). Also different concentrations of ketamine and propofol combinations (ketofol) have been used for procedural sedation and analgesia. Objective The aim of this study is to compare the effect of dexamedetomidine and ketofol on conscious sedation in patients undergoing non-surgical interventions for chronic low back pain regards the efficacy of sedation, hemodynamic stability, respiratory effects, speed of recovery, analgesic effects and incidence of complications. Methodology This study was conducted in Ain Shams University affiliated hospitals on 60 patients of both sexes between 30 and 50 years old, of ASA physical status I–II scheduled for nonsurgical intervention for chronic low back pain. In the current study, the patients were randomly divided into 2 equal groups of 30 patients each. Patients received either sedation with Ketofol (group K) or Dexmedetomidine (group D). Results As regards the demographic data (age, sex and body weight); there was no statistically significant variation between the two study groups. This provided a uniform platform to evenly compare the results obtained. Concerning the duration of the procedure, the time recorded for each patient showed statistically non-significant difference between the two groups. Regarding sedation of the patients during the procedure evaluated according to Ramsay sedation score, there was a highly significant difference between the two groups (p-value < 0.001), where the dexmedetomidine group needed more time (17.71 ± 2.86 min) to reach the targeted Ramsay sedation score (3-4) to commence the surgical procedure while the ketofol group needed less time (9.79 ± 1.87 min) to reach the same score. Conclusion Both drugs provided hemodynamic stability althrough the procedure although dexmedetomidine group showed lower heart rates and lower mean arterial blood pressures towards the end of the procedure which makes it difficult to be used in older population or those having low baseline heart rates. Both drugs proved to be safe concerning respiration, SPO2 and CO2 values, however dexmedetomidine showed higher respiratory rates during the procedure.

Short Term Analgesic Effects of 5% Dextrose Epidural Injections for Chronic Low Back Pain: A Randomized Controlled Trial.

BackgroundHypertonic dextrose injection (prolotherapy) is reported to reduce pain including non-surgical chronic low back pain (CLBP), and subcutaneous injection of 5% dextrose is reported to reduce neurogenic pain, hyperalgesia and allodynia. The mechanism in both cases is unclear, though a direct effect of dextrose on neurogenic pain has been proposed. This study assessed the short-term analgesic effects of epidural 5% dextrose injection compared with saline for non-surgical CLBP.MethodsRandomized double-blind (injector, participant) controlled trial. Adults with moderate-to-severe non-surgical low back pain with radiation to gluteal or leg areas for at least 6 months received a single epidurogram-confirmed epidural injection of 10 mL of 5% dextrose or 0.9% saline using a published vertical caudal injection technique. The primary outcome was change in a numerical rating scale (NRS, 0 - 10 points) pain score between baseline and 15 minutes; and 2, 4, and 48 hours and 2 weeks post-injection. The secondary outcome was percentage of participants achieving 50% or more pain improvement at 4 hours.Results and ConclusionsNo baseline differences existed between groups; 35 participants (54 ± 10.7 years old; 11 female) with moderate-to-severe CLBP (6.7 ± 1.3 points) for 10.6 ± 10.5 years. Dextrose participants reported greater NRS pain score change at 15 minutes (4.4 ± 1.7 vs 2.4 ± 2.8 points; P = 0.015), 2 hours (4.6 ± 1.9 vs 1.8 ± 2.8 points; P = 0.001), 4 hours (4.6 ± 2.0 vs 1.4 ± 2.3 points; P < 0.001), and 48 hours (3.0 ± 2.3 vs 1.0 ± 2.1 points; P = 0.012), but not at 2 weeks (2.1 ± 2.9 vs 1.2 ± 2.4 points; P = 0.217). Eighty four percent (16/19) of dextrose recipients and 19% (3/16) of saline recipients reported ≥ 50% pain reduction at 4 hours (P < 0.001). These findings suggest a neurogenic effect of 5% dextrose on pain at the dorsal root level; waning pain control at 2 weeks suggests the need to assess the effect of serial dextrose epidural injections in a long-term study with robust outcome assessment.

Vertical Small-Needle Caudal Epidural Injection Technique.

BackgroundAnecdotal evidence suggests that a vertical small-needle injection method enters the caudal epidural space with comparable efficacy to cephalad-directed methods, with less intravascular injection.ObjectivesAssess the success rate of vertical caudal epidural injection using epidurography and the frequency of intravascular injection using a vertical small-needle approach.Patients and MethodsParticipants had chronic generalized non-surgical low back pain and either gluteal and/or leg pain and were enrolled in a simultaneous clinical trial assessing the analgesic effect of 5% dextrose epidural injection. A 25 gauge 3.7 cm hypodermic needle was placed at the sacral hiatus using a fingertip-guided vertical technique without imaging assistance, followed by fluoroscopic epidurography. Minimal needle redirection was allowed up to 10 degrees from the vertical plane if the initial epidurogram showed an extradural pattern, followed by repeat epidurography.ResultsFirst needle placement without imaging resulted in blood return in 1/199 participants and positive epidurography in 179/199 (90%). Minimal needle repositioning resulted in a positive epidurogram in the remaining 19 attempts. No intravascular injection patterns were observed.ConclusionsThis compares favorably to published success rates of fluoroscopically-guided technique and was well tolerated. Vertical caudal epidural injection may be suitable for combination with ultrasound-guided methods with Doppler flow monitoring.

Do Manual Therapies Help Low Back Pain? A Comparative Effectiveness Meta-analysis

Meta-analysis methodology was extended to derive comparative effectiveness information on spinal manipulation for low back pain. Determine relative effectiveness of spinal manipulation therapies (SMTs), medical management, physical therapies, and exercise for acute and chronic nonsurgical low back pain. Results of spinal manipulation treatments of nonsurgical low back pain are equivocal. Nearly 40 years of SMT studies were not informative. Studies were chosen on the basis of inclusion in prior evidence syntheses. Effect sizes were converted to standardized mean effect sizes and probabilities of recovery. Nested model comparisons isolated nonspecific from treatment effects. Aggregate data were tested for evidential support as compared with shams. Of 84% acute pain variance, 81% was from nonspecific factors and 3% from treatment. No treatment for acute pain exceeded sham's effectiveness. Most acute results were within 95% confidence bands of that predicted by natural history alone. For chronic pain, 66% of 98% was nonspecific, but treatments influenced 32% of outcomes. Chronic pain treatments also fit within 95% confidence bands as predicted by natural history. Though the evidential support for treating chronic back pain as compared with sham groups was weak, chronic pain seemed to respond to SMT, whereas whole systems of clinical management did not. Meta-analyses can extract comparative effectiveness information from existing literature. The relatively small portion of outcomes attributable to treatment explains why past research results fail to converge on stable estimates. The probability of treatment superiority matched a binomial random process. Treatments serve to motivate, reassure, and calibrate patient expectations--features that might reduce medicalization and augment self-care. Exercise with authoritative support is an effective strategy for acute and chronic low back pain.

Effectiveness and Safety of Loxoprofen Compared with Naproxen in Nonsurgical Low Back Pain

Effectiveness and Safety of Loxoprofen Compared with Naproxen in Nonsurgical Low Back Pain

Patterns in Low Back Pain Hospitalizations

To examine patterns in both surgical and nonsurgical low back pain (LBP) hospitalizations through time and among geographic regions and to explore the practical implications of these patterns for health care reform. For time trends, the U.S. (1979-1987); for geographic variations, major regions of the U.S. (1987). DATE SOURCE: The National Hospital Discharge Survey. Rates of both surgical and nonsurgical LBP hospitalization varied twofold among regions of the U.S., and average lengths of stay for these types of hospitalization varied considerably as well. The U.S. rate of LBP surgery increased sharply during the period covered by the study. Over the same time, the U.S. rate of nonsurgical LBP hospitalization declined, as did average lengths of stay for both types of LBP hospitalization. Wide variations in LBP hospitalization practices raise the issue of which practices are most appropriate. Outcomes research addresses this issue, as does research on patient preferences for certain types of treatment. As indicated by the increasing rate of LBP surgery, more research also needs to be done on changing physician practice style. If such research were to result in a reduction in LBP hospitalization, savings in health care costs would be considerable.

Transcutaneous electrical neurostimulation in functional pain.

Transcutaneous electrical neurostimulation (TENS) has recently emerged as a distinct therapeutic modality in the alleviation of acute and chronic pain. We applied this modality to 15 nonsurgical low-back pain patients having diagnoses of functional pain, with 40% initially having significant pain relief (50% of greater). However, this pain-alleviating effect of TENS did not last longer than two months. After initiation of neurostimulation, increased pain and/or bizarre and inappropriate sensations and behavior frequently developed. We also applied this modality in the diagnostic evaluation and treatment of 24 patients having diagnoses of postsurgical chronic intractable low-back pain of psychosomatic origin and achieved similar results. In both groups, we utilized a simplified poststimulation "normal-saline-sterile-water intramuscular injection test" to confirm the findings from transcutaneous electrical neurostimulation and to verify the functional basis of the present low-back pain.