Pain Management Physicians Research Articles

Development of Psoas Hematoma After Lumbar Sympathetic Block in a Patient on Anticoagulants

BACKGROUND: Lumbar sympathetic blocks (LSB) play an important role in the therapeutic management of patients who suffer from neuropathic pain conditions such as complex regional pain syndrome (CRPS). LSB is a generally safe and well-tolerated procedure, however rare complications may occur. While case reports of iliopsoas hematomas related to bleeding disorders, surgical interventions, and trauma are well reported in the literature, similar complications after LSB have not been reported. CASE REPORT: Development of an 18 x 6.1-cm hematoma in the left iliopsoas muscle after a fluoroscopically-guided LSB in an anticoagulated patient despite following recommended periprocedural anticoagulation management guidelines resulted in pain, impaired mobility, and likely femoral neuropathy. CONCLUSION: Pain management physicians should be aware that hematomas are a possible complication of LSB and should weigh the risks and benefits of holding anticoagulation therapy in patients undergoing such procedures. KEY WORDS: Anticoagulation, complex regional pain syndrome, hematoma, lumbar sympathetic block, lumbar sympathetic block complications

Differences in Attitudes and Practices of Cancer Pain Management between Medical Oncologists and Palliative Care Physicians.

This study aimed to evaluate whether there are differences in the attitudes and practices of cancer pain manage-ment between medical oncologists and palliative care physicians. An online nationwide survey was used to collect responses from board-certified medical oncologists and palliative care physicians in Japan. The survey questionnaire comprised 30 questions. The differences in responses between medical oncologists and palliative care physicians were examined. Out of the 1,227 questionnaires sent, 522 (42.5%) were returned. After apply-ing the exclusion criteria, 445 questionnaires (medical oncologists: n = 283; palliative care physicians: n = 162) were retained for analysis. Among the questions about potential barriers to optimal cancer pain man-agement, both medical oncologists and palliative care physicians considered the reluctance of patients to take opioids due to fear of adverse effects as the greatest barrier. Significantly different ratings between medical oncologists and palliative care physicians were observed on 5 of the 8 questions in this area. Significantly differ-ent ratings were observed for all questions concerning pain specialists and their knowledge. For effective cancer pain management, it is important to account for differences in attitudes and practice between medical oncolo-gists and palliative care physicians.

California court defers to Board of Pharmacy expertise

Pharmacists sometimes get caught in the middle between prescribers who insist that their opioid prescriptions be honored, and regulations that require pharmacists to decline suspicious opioid prescriptions. Disputes between pharmacists and prescribers may lead to litigation based on alternative interpretations of pharmacy laws. A court in California recently ruled that the State Board of Pharmacy has primary jurisdiction to consider any such dispute prior to resolution of the dispute in a court of law. A pain management physician sued a pharmacy that declined to honor the physician's hydrocodone prescriptions. The physician's lawsuit sought an injunction that would force the pharmacy to honor his prescriptions. The physician based his legal argument on a state pharmacy law that says “a licensee shall not obstruct a patient in obtaining a prescription drug or device that has been legally prescribed or ordered for that patient.” The pharmacy opposed the injunction, citing another state law that recognizes a “pharmacist's responsibility to ensure that prescriptions for controlled substances are issued only for a legitimate medical purpose.” The trial court explained that a judicial order requiring the pharmacy to honor particular prescriptions “would involve judgments concerning the statutory obligations of pharmacists that the Board is both expected and equipped to resolve.” The trial court ruled that the physician should first take his complaint to the Board before pursuing his claim in court. The physician appealed this ruling. The appellate court first noted that the Board has the “background to evaluate the specific facts that are relevant to these issues.” The physician contended that the doses he prescribes “are not excessive,” and that “hydrocodone is the lowest potency pure µ-receptor opiate agonist available.” The court concluded that “the Board is better equipped than the courts to evaluate how such technical claims affect a pharmacy's statutory corresponding responsibility.” The appellate court then referred to “the context of a national opioid problem,” agreeing with the trial judge that “the Board has more experience in evaluating a pharmaceutical licensee's responsibilities in this context.” The court also noted the need for “regulatory uniformity” since pharmacy opioid prescription screening programs are likely to affect many prescribers. The court said, the “Board is well positioned to adopt a uniform approach to determining whether such programs—and implementation of them—are consistent with pharmacists’ professional obligations.” The court applied the “doctrine of primary jurisdiction” to the case. Under this doctrine, the issue is not whether courts are capable of adjudicating claims based on state laws, but whether those claims require the “resolution of issues which, under a regulatory scheme, have been placed within the special competence of an administrative body.” The court explained that referral of the physician's case to the Board will not have any effect on the physician's right to eventually proceed with his case in a court of law, but “a ruling from the Board will provide a benefit to the court in ruling on issues that are reserved for its decision.” The physician was instructed to file a complaint with the State Board of Pharmacy prior to proceeding with his court case against the pharmacy. Judicial restraint has not been frequently exercised in the numerous legal cases brought against pharmacists and/or pharmacies based on allegations that opioid prescriptions were unlawfully honored when they should have been declined, or that opioid prescriptions were declined when they should have been honored. The California case is a very sensible and welcome exception. State Boards of Pharmacy are well positioned and well qualified to review claims of illegal conduct by the pharmacists or pharmacies that are licensed by them. Under the doctrine of primary jurisdiction, the determination of a Board of Pharmacy is not binding on a court of law, yet it can be useful and persuasive. Justice is best served when legal claims are examined by knowledgeable reviewers.

Declines and pronounced regional disparities in meperidine use in the United States.

There have been increasing concerns about adverse effects and drug interactions with meperidine. The goal of this study was to characterize meperidine use in the United States. Meperidine distribution data were obtained from the Drug Enforcement Administration's Automated of Reports and Consolidated Orders System. The Medicare Part D Prescriber Public Use File was utilized to capture overall trends in national prescriptions in this observational report. Nationally, meperidine distribution decreased by 94.6% from 2001 to 2019. In 2019, Arkansas, Alabama, Oklahoma, and Mississippi saw significantly greater distribution when compared with the US state average of 9.27 mg per 10 persons (SD = 6.82). Meperidine distribution showed an 18‐fold difference between the highest state (Arkansas = 36.8 mg) and lowest state (Minnesota = 2.1 mg). Five of the six states with the lowest distribution were in the Northeast. Meperidine distribution per state was correlated with the prevalence of adult obesity (r(48) = +0.48, p < .001). Family medicine and internal medicine physicians accounted for 28.9% and 20.5%, respectively, of meperidine total daily supply (TDS) in 2017. Interventional pain management (5.66) and pain management (3.48) physicians accounted for the longest TDS per provider. The use of meperidine declined over the last two decades. Meperidine varied by geographic region with south‐central states, and those with more obesity, showing greater distribution. Primary care doctors continue to account for the majority of meperidine daily supply. Increasing knowledge of meperidine's undesirable adverse effects like seizures and serious drug–drug interactions is likely responsible for these pronounced reductions.

Integrative Medicine Clinical Centers Keys to Success: Innovative Programming, Education, and Collaboration

Integrative Medicine Clinical Centers Keys to Success: Innovative Programming, Education, and Collaboration

Racism in Pain Medicine: We Can and Should Do More

Racism in Pain Medicine: We Can and Should Do More

Experience of Botulinum Toxin A Injections for Chronic Migraine Headaches in a Pediatric Chronic Pain Clinic.

Prevalence of chronic migraine in children can reach 7.7%, causing decreased school performance, difficulty with extracurricular activities (including sports, theater, or music), and changes in sleep and mood. Many studies confirm that botulinum toxin type A injections effectively alleviate chronic migraines in adults; however, the literature regarding children is sparse. This study aims to analyze the safety and effectiveness of botulinum type A injections in a group of pediatric patients diagnosed with chronic migraines in a pediatric pain clinic. In this retrospective (2013-2018) study, the effects of botulinum toxin type A injections were analyzed using data from 65 pediatric patients diagnosed with chronic migraines. The study group ranged from 11 to 18 years of age. A pediatric pain management physician administered the botulinum using the Phase 3 Research Evaluating Migraine Prophylaxis Therapy program protocol and followed the pain pattern. Dosages, tolerance, and side effects were measured. In this study, 74% of the patients tried more than 6 medications before the injections. There was a decrease in the visual analog scale score of 5.2 ± 2.2 points upon 6-week follow-up. The mean amount of medication used was 173.2 ± 35 units, and patients received an average of 2.8 ± 1.1 units/kg. Adverse events include one patient who developed dizziness and another who had low-grade fevers with enlarged cervical lymph nodes; both resolved within few minutes. This study supports the use of botulinum type A for chronic migraines in pediatric patients. Multicentered, randomized studies with larger population are needed to evaluate the long-term safety and efficacy of this therapy.

Pain management practices in the emergency departments in Turkey.

OBJECTIVES:This study aimed to evaluate pain management practices in the emergency departments (EDs) in Turkey and to evaluate the prevalence and etiologies of oligoanalgesia to identify possible improvement strategies.METHODS:This multicenter cross-sectional observational study was conducted in 10 tertiary care hospitals in Turkey. Patients who were admitted to the ED with pain chief complaints were included in the study. Both patients and physicians were surveyed with two separate forms by the research associates, respectively. The patient survey collected data about the pain and the interventions from the patients' perspective. The pain was evaluated using the Numerical Rating Scale. The physician survey collected data to assess the differences between study centers on pain management strategies and physician attitudes in pain management.RESULTS:Ten emergency physicians and 740 patients (male/female: 365/375) enrolled in the study. The median pain score at admission at both triage and ED was 7 (interquartile range: 5–8). The most frequent type of pain at admission was headache (n = 184, 24.7%). The most common analgesics ordered by physicians were nonsteroidal anti-inflammatory drugs (n = 505, 67.9%), and the most frequent route of administration was intramuscular injection (n = 396, 53.2%). About half of the patients (n = 366, 49.2%) received analgesics 10–30 min from ED admission. The posttreatment median pain score decreased to 3 (P < 0.001). About 79.2% of patients did not need a second analgesic administration (n = 589), and opioid analgesics were the most frequently administered analgesic if the second application was required. Physicians prescribed an analgesic at discharge from the ED in 55.6% of the patients (n = 414) and acute pain was present in 7.5% (n = 56) of the patients.CONCLUSION:Our study on the pain management practices in the EDs in Turkey suggested that high rate of intramuscular analgesic use and long emergency room stay durations are issues that should constitute the focus of our quality improvement efforts in pain management.

Pelvic venous insufficiency - an often-forgotten cause of chronic pelvic pain.

Chronic pelvic pain is a common health problem that afflicts 39% of women at some time in their life. It is a common challenge for gynecologists, internists, surgeons, gastroenterologists, and pain management physicians. Pelvic venous insufficiency (PVI) accounts for 16-31% of cases of chronic pain but it seems to be often overlooked in differential diagnosis. The aim of this article was to summarize current data concerning PVI. The embolization of insufficient ovarian veins remains the gold standard of therapy but the optimal procedure is yet to be determined. Well-designed randomized trials are required to establish the best treatment modalities.

The Effect of COVID-19 on Interventional Pain Management Practices: A Physician Burnout Survey

Background: Burnout has been a commonly discussed issue for the past ten years among physicians and other health care workers. A survey of interventional pain physicians published in 2016 reported high levels of emotional exhaustion, often considered the most taxing aspect of burnout. Job dissatisfaction appeared to be the leading agent in the development of burnout in pain medicine physicians in the United States. The COVID-19 pandemic has drastically affected the entire health care workforce and interventional pain management, with other surgical specialties, has been affected significantly. The COVID-19 pandemic has placed several physical and emotional stressors on interventional pain management physicians and this may lead to increased physician burnout. Objective: To assess the presence of burnout specific to COVID-19 pandemic among practicing interventional pain physicians. Methods: American Society of Interventional Pain Physicians (ASIPP) administered a 32 question survey to their members by contacting them via commercially available online marketing company platform. The survey was completed on www.constantcontact.com. Results: Of 179 surveys sent, 100 responses were obtained. The data from the survey demonstrated that 98% of physician practices were affected by COVID and 91% of physicians felt it had a significant financial impact. Sixty seven percent of the physicians responded that inhouse billing was responsible for their increased level of burnout, whereas 73% responded that electronic medical records (EMRs) were one of the causes. Overall, 78% were very concerned. Almost all respondents have been affected with a reduction in interventional procedures. 60% had a negative opinion about the future of their practice, whereas 66% were negative about the entire health care industry. Limitations: The survey included only a small number of member physicians. Consequently, it may not be generalized for other specialties or even pain medicine. However, it does represent the sentiment and present status of interventional pain management. Conclusion: The COVID-19 pandemic has put interventional pain practices throughout the United States under considerable financial and psychological stress. It is essential to quantify the extent of economic loss, offer strategies to actively manage provider practice/wellbeing, and minimize risk to personnel to keep patients safe. Key Words: Interventional pain management, burnout, interventional pain physician, corona COVID-19, financial stress, anxiety, depression

Ohio Response to COVID-19 and Its Impact on Interventional Pain Management Practices

Background: The coronavirus disease 2019 (COVID-19) pandemic has drastically altered daily living and medical care for Ohio residents and the practice of medicine for the interventional pain management physician. As a state, Ohio tends to be demographically representative of the broader US population. Objective: Reviewing the efforts deployed by Ohio to flatten the COVID-19 infection curve and reduce the spread of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an important component of determining optimal procedures for mitigating the effects of the COVID-19 pandemic. Methods: Over the course of several announcements and orders during the months of March and April, new policies were put into place to prevent COVID-19 transmission, which included efforts to facilitate social distancing and ensure the health care system could manage the number of COVID-19 cases at peak infection rate. Efforts directed toward medical providers included delay of elective procedures, expansion of telehealth options, and new temporary guidance for prescribing controlled substances. Results: The Ohio COVID-19 containment approach resulted in a substantial reduction in COVID-19 cases compared with early models of disease spread, and the state has begun a phased reopening. Continued vigilance in applying social distancing and infection control measures will be a critical component of preventing or reducing the impact of a second wave of COVID-19 in Ohio. Limitations: A narrative review with paucity of literature. Key words: COVID-19, infection rates, mitigating effects, pandemic, infection control

Review of Physician Referrals to Orthopedic Spine versus Neurosurgery.

BackgroundPrevious studies have reported what patients value while choosing their surgeon, but there are no studies exploring the patterns of referral to spine surgeons among primary care physicians (PCPs). This study aims to identify any trends in PCPs' referral to orthopedic surgery versus neurosurgery for spinal pathology.MethodsIn total, 450 internal medicine, family medicine, emergency medicine, neurology, and pain management physicians who practice at one of three locations (suburban community hospital, urban academic university hospital, and urban private practice) were asked to participate in the study. Consenting physicians completed our 24-question survey addressing their beliefs according to pathologies, locations of pathologies, and surgical interventions.ResultsOverall, 108 physicians (24%) completed our survey. Fifty-seven physicians (52.8%) felt that neurosurgeons would provide better long-term comprehensive spinal care. Overall, 66.7% of physicians would refer to neurosurgery for cervical spine radiculopathy; 52.8%, to neurosurgery for thoracic spine radiculopathy; and 56.5%, to orthopedics for lumbar spine radiculopathy. Most physicians would refer all spine fractures to orthopedics for treatment except cervical spine fractures (56.5% to neurosurgeons). Most physicians would refer to neurosurgery for extradural tumors (91.7%) and intradural tumors (96.3%). Most would refer to orthopedic surgeons for chronic pain. Finally, physicians would refer to orthopedics for spine fusion (61.1%) and discectomy (58.3%) and to neurosurgery for minimally invasive surgery (59.3%).ConclusionsEven though both orthopedic surgeons and neurosurgeons are intensively trained to treat a similar breath of spinal pathology, physicians vary in their referring patterns according to spinal pathology, location of pathology, and intended surgery. Education on the role of spine surgeons among PCPs is essential in ensuring unbiased referral patterns.

Drivers, Beliefs, and Barriers Surrounding Surgical Opioid Prescribing: A Qualitative Study of Surgeons’ Opioid Prescribing Habits

BackgroundRecent data demonstrate that surgeons overprescribe opioids and vary considerably in the amount of opioids prescribed for common procedures. Limited data exist about why and how surgeons develop certain opioid prescribing habits. We sought to identify surgeons’ knowledge, attitudes, and beliefs about opioid prescribing and elicit barriers to guideline-based prescribing. MethodsWe conducted qualitative semistructured interviews accompanied by demographic surveys at an academic medical center. Surgical residents and faculty members were selected by maximum variation purposive sampling. We used thematic analysis to identify themes associated with opioid prescribing. ResultsTwenty surgical residents and twenty-one surgical faculty members were interviewed. Characteristics of individual surgeons, patients, health care teams, practice environments, and the complex interplay between these domains drove prescribing habits. Attending-resident communication about opioid prescribing was extremely limited. Surgeons received little training and feedback about opioid prescribing and were rarely aware of negative long-term consequences, limiting motivation to change prescribing habits. Although surgeons frequently interacted with pain management physicians to comanage patients postoperatively, few involved pain management physicians in preoperative planning. Perceived barriers to guideline-based prescribing included the following: limitations to electronic prescribing, cross-coverage problems, inadequate time for patient education, and impediments to use of nonopioid alternatives. ConclusionsInterventions to improve compliance with opioid prescribing guidelines should include surgeon education and personal feedback. Future interventions should aim to improve attending-resident communication about opioid prescribing, reduce hurdles to electronic prescribing, provide clear pain management plans for cross-covering physicians, assess alternative methods for efficient patient education, and maximize use of nonnarcotic pain medications.

The Experience of a Pain Patient.

The Experience of a Pain Patient.

SARCOPENIA, SARCOPENIC OBESITY AND FRAILTY; LINKS TO COGNITIVE PERFORMANCE IN ELDERS: Session 412

Background: According to 2011 CDC data, more than 2.6 million adults aged 60 and older with cognitive impairment reported difficulty performing one or more ADLs. There are studies that link cognitive decline and physical impairment in terms of low-level chronic inflammation, oxidative stress, and depression. Skeletal muscle can produce IL-1, IL-6 and other important myokines that have been implicated in cognitive and physical functional degenerative processes. Oxidative stressors have been linked to physical frailty and sarcopenia as well as neurodegenerative processes further worsening cognitive impairment. What are Sarcopenia and Sarcopenic Obesity and its impacts on elders? Sarcopenia is a primary disease of the elderly population, characterized by loss of skeletal muscle mass and function. Sarcopenia is correlated with physical disability, poor quality of life, frailty, cognitive impairment, and death. Age, gender, and level of physical activity are the risk factors for the Sarcopenia. In addition to aging, malignancy and rheumatoid arthritis causes loss of lean body mass and even increase in body fat mass. The loss of muscle mass associated with increased body fat mass i.e. sarcopenic obesity causes weakness in aging. Sarcopenia, with or without obesity, results in impairment of IADL (Instrumental Activity of Daily Living) and eventually ADLs (Activities of Daily Living) among elders and results in need for long-term care and increased cost of health care. What is the link between Sarcopenia and Cognitive Impairment? Sarcopenia has not only has a greater effect on survival but also on cognitive impairment. Sarcopenia has been linked to global cognitive impairment and dysfunction in specific cognitive skills including memory, speed, and executive functions. While obesity may impair the executive functions of aging, the exact mechanism linking obesity to cognitive dysfunction is not clear. Improvement in muscular function of obese older adults has been linked to improvement of executive functions. Obesity and Sarcopenia were associated with the lower executive function such as working memory, mental flexibility, self-control and orientation when assessed independently and even more so when they occurred together. Sarcopenia is highly correlated with frailty and risk of falls in elders; it also represents an important risk factor for disability and mortality. Frailty is an independent predictor of dementia. How do you assess for the Sarcopenia? Sarcopenia with or without obesity can be used in clinical practice to assess the potential risk of cognitive impairment in elders. There are several ways to measure Sarcopenia – DEXA (Dual-Energy X-ray Absorptiometry), biometric impedance analysis (BIA), CT (Computed Tomography) scan and MRI (Magnetic Resonance Imaging). However, assessing BMI and testing grip strength by dynamometry can be easily administered during annual wellness visits to assess the risk of sarcopenic related cognitive impairments. Sarcopenia can be assessed using parameters such as 1) Measure walking speed in elderly (>65 years). If the walking speed is below 0.8 m/s at the 4-m walking test, measure the muscle mass. 2) Hand- grip strength if this value is lower than 20kg in women and 30kg in man then muscle mass must be analyzed. 3) Defining Fat mass and lean body mass using BIA 4) Muscle Mass assessment by DEXA or CT. What is the significance of assessing the Sarcopenia? It is important to identify the risk of cognitive impairment by assessing for the onset of this condition. Preventing or delaying onset will likely enhance survival and reduce the demand for long-term care. Increasing resistance physical training will help to improve physical deconditioning, strengthen skeletal muscle hypertrophy, overcome the pain syndrome and enhance overall mental well-being. Interventions such as resistance exercise and nutritional therapy need to be developed specifically to delay the onset of Sarcopenia. What is the need in the future? Team-based approach including multidisciplinary model involving primary care physicians, geriatric psychiatrists, pain management physicians and physical therapists is required to combat the complex interlinked Sarcopenia associated cognitive impairment. Screening programs that include identification of cognitive and functional impairment in the office setting will serve as the starting point for specific interventions. The training regimen that includes supervision and correct equipment with resistance exercise will be necessary to get proper training and delay the muscle loss in elderly.

03:18 PM Abstract No. 201 Changing trends in utilization and physician payments for vertebroplasty and kyphoplasty procedures among Medicare beneficiaries: 2010-2017

To study and provide an update on utilization of vertebroplasty and kyphoplasty procedures among Medicare beneficiaries and analyze the changing trends in total volumes and payments by physician specialty for a recent eight-year period. Claims from the Medicare Part B Physician/Supplier Procedure Summary Master File (PSPSMF) for the years 2010 and 2017 were extracted using the CPT codes for vertebroplasty and kyphoplasty. Total volumes, payment amounts (professional component), and trends were analyzed by physician specialty. Between 2010 and 2017, the total volume of vertebroplasties decreased by 58.9% (29,995 to 12,344), while the volume of kyphoplasties increased modestly by 11.8% (59,691 to 66,730). Radiologists performed 20,546 (68.5%) vertebroplasties in 2010, which decreased to 9,515 (77.1%) in 2017. Similar trends were observed for orthopedic surgeons (3,101 to 612) and neurosurgeons (2,108 to 1,373). For kyphoplasty, radiologists performed 17,215 (28.9%) procedures in 2010, which increased to 24,231 (36.3%) in 2017, whereas orthopedic surgeons’ volume decreased from 21,645 to 16,513 and the volume for neurosurgery remained relatively stable at 13,704 to 13,950. Total payment for vertebroplasties decreased by 72.4% from $14.8 million in 2010 to $4.1 million in 2017; whereas it increased by 208.1% for kyphoplasty procedures from $26.7 million to $82.4 million. From 2010 to 2017, the average per-procedure payment decreased for vertebroplasty by 32.9% (from $493.7 to $331.3) but increased for kyphoplasty by 175.6% (from $448.1 to $1234.7). Average per-procedure amount was considerably higher for anesthesiologists and interventional pain management physicians ($547.5 for vertebroplasty and $2897.0 for kyphoplasty in 2017). Previous studies have demonstrated mixed evidence for the benefits of vertebroplasty procedures with decreasing volumes over time. While no causality can be determined by this observational study, the data shows a continued downtrend in vertebroplasty and increased utilization of kyphoplasty among Medicare beneficiaries. In addition, total and average per-procedure payment amount for kyphoplasty have increased considerably.

Single S1 Dorsal Root Ganglia Stimulation for Intractable Complex Regional Pain Syndrome Foot Pain After Lumbar Spine Surgery: A Case Series

Intractable complex regional pain syndrome (CRPS)-related chronic foot pain, is a common therapeutic challenge for interventional pain management physicians and patients alike. Dorsal root ganglia (DRG) stimulation is a very target specific dorsal column stimulation technique with very promising clinical outcomes. Patients with CRPS foot pain and previous back surgery can benefit from DRG stimulation but also run a significant risk of epidural trauma from the DRG sheath advancement. Most sensory innervation to the foot is from L5 and S1 dermatomes. Although there is dual modulation from L5 and S1 DRG, significant "cross talk" exists between these structures such that a DRG lead solely at S1 could provide pain relief for the entire foot. In this case series, we examined the outcomes obtained from placement of solely S1 DRG stimulating electrodes in patients with CRPS-related chronic foot pain, and examine whether this may provide a reduced risk of dural injury. Furthermore, we describe the technical aspects of a S1 DRG placement and discuss relevant anatomical issues pertaining to this approach. Five patients (four female, one male) with chronic foot pain participated. The oldest was 71 and the youngest 49. Three patients were diagnosed with foot CRPS-1, and two patients with foot CRPS-2. All patients had back surgery in the past and all underwent a trial and subsequent S1 DRG implantation. The patients were evaluated with a numeric rating score (NRS) for pain and function before the procedure and one, two, three, and six months after the procedure. The first patient underwent an L5 and S1 trial and developed CSF leak and postdural puncture headache. Two months later, the patient was re-trialed and implanted with a single S1 electrode. The other four patients were trialed and implanted with single S1 DRG electrodes. All five patients had severe pain (8-10 NRS) and significant loss of function and quality of life (2-4 NRS) before the procedure. All five patients had excellent (0-3 NRS) pain relief and functional restoration (8-10 NRS) with a single S1 electrode trial, and all five proceeded with permanent implantation. The pain relief from the S1 DRG stimulation extended to the entire foot without any sparing. All patients were able to discontinue or significantly reduce their oral pain medications. The one-, two-, three-, and six-month follow-up showed preservation of therapeutic efficacy. A single S1 DRG electrode placement in patients diagnosed with CRPS of the foot and who had previous back surgery is therapeutically effective and can minimize the risk of dural trauma and CSF leak.

The Experience of a Pain Patient

The Experience of a Pain Patient

A Longitudinal Analysis of Total Pain Scores for a Panel of Patients Treated by Pain Clinics.

Background:There is a critical necessity to identify psychometric properties of the total pain score as a measurement of pain management effectiveness in the clinic.Purpose:In this article, we perform the analysis of the global pain scores from a panel of patients treated by 10 pain management physicians in a single group practice.Basic Procedures:The pain measurement consists of 4 pain subscales, namely physical pain, emotions, clinical outcome, and activities. A panel of 130 patients with 4 pain measurements is available to perform longitudinal analysis of the total pain scores. The analysis includes the following: (1) confirmatory factor analysis of the global pain scores with 4 related dimensions, (2) the stability of the pain scores between 2 clinical visits, (3) the change trajectories of pain scores in 4 waves of the pain measurement, and (4) the detection of physician variability in patients’ treatment outcomes measured by the reduction of total pain scores.Main Findings:The global pain scores were relatively stable between time 1 and time 2 clinical visits. The analysis indicated that there was a decrease in pain with longitudinal advancement in treatment. It also indicated that there was no significant change in this improvement with respect to difference in physicians involved in providing treatment.Principal Conclusion:While the results indicated a decrease in pain with an alleviation in treatment provided to the patient, the article delineates a well-thought scientific approach to the targeted problem.

Spinal epidural lipomatosis presenting to a U.S. Veterans Affairs pain and rehabilitation department: a report of two cases

BackgroundSpinal epidural lipomatosis is an uncommon source of neurogenic claudication. We present two cases of spinal epidural lipomatosis as it relates to diagnosis, management, and a possible association with common medical intervention.Case presentationCase 1: 63-year old male patient presented with neurogenic claudication symptoms, but without evidence of bony central canal stenosis on lumbar computed tomography. He entered a trial of spinal manipulation with transient beneficial gains after seven appointments, but no durable change in neurogenic claudication. An MRI was recommended at this point which revealed grade III spinal epidural lipomatosis at the L5/S1 level.Case 2: 51-year old male patient presented to a pain management physician with radicular symptoms for a series of lumbar epidural steroid injections. He completed a series of three lumbar epidural steroid injections with only short-term benefit. A repeat MRI demonstrated the presence of grade I (borderline grade II) spinal epidural lipomatosis.ConclusionsThe first case illustrates a limitation of ruling out central canal stenosis with computed tomography for patients unable to undergo an MRI. The second case demonstrates a possible association between steroid injections and spinal epidural lipomatosis. An association of this kind has not been established; further research is needed to determine the significance.