Reduction In NRS Research Articles

Effectiveness of Intra-articular Botulinum Toxin Type A with Hyaluronic Acid Compared to Intra-articular Platelet-rich Plasma with Hyaluronic Acid in Improving Pain and Functional Limitation in Knee Osteoarthritis

Abstract Background: Knee osteoarthritis (KOA) is the most common cause of chronic knee pain causing functional disability and dependency. Multiple interventions have been used in reducing pain and improving functionality. We intend to compare the efficacy of intra-articular platelet-rich plasma (PRP) and hyaluronic acid (HA) with botulinum toxin type A and HA in bilateral Grade 3 and 4 KOA. Methods: Prospective single-blinded randomized controlled trial conducted for 6 months. Among 54 participants, 27 received intra-articular botulinum toxin type A with HA (Group A), and the other 27 received intra-articular PRP with HA (Group B), single session. Pain (Numerical Rating Scale [NRS]) and functional limitation (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) were assessed at 2, 4, 12, and 24 weeks postintervention. Effect of weight and physiotherapy on NRS and WOMAC score were assessed. P <0.05 was considered statistically significant. Data were analyzed by statistical software R version 4.2.3. Results: Fifty-four participants were enrolled. There was no loss to follow-ups. Except for age (P < 0.001) and mean height (P = 0.013), other demographic data were insignificant. Preprocedural NRS was significantly high in Group A (P = 0.04). Overall NRS postprocedure was significantly lesser in Group B, P < 0.001. The mean WOMAC score postprocedure was significantly low in Group B, P < 0.001. Group B had increased heart rate which was statistically significant (P = 0.051). The mean reduction in WOMAC score was observed with regular physiotherapy in Group B (P = 0.023). Reduction in weight was directly proportional to reduction in NRS (P = 0.015). Conclusion: Intra-articular PRP with HA, single session, is effective in improving pain, functionality, and safe in Grade 3 and 4 KOA.

Evaluation of Pharmacotherapy of Cancer Pain in Patients with Head and Neck Cancer at a Tertiary Care Teaching Hospital

Background Head and Neck Cancers (HNC) account for 5% of all malignant tumours, but 80% of patients experience pain. As per the WHO analgesic ladder, analgesics are a cornerstone for the management of pain in HNC patients. Purpose Our study aims to analyse the prescribing pattern of analgesic drugs in patients with HNC pain. Materials and Methods A prospective, continuous, observational study was conducted among patients with HNC pain. Demographics, detailed history of pain (type, duration, location and Numerical Rating Scale [NRS] score), details of drugs prescribed and any adverse drug reactions (ADRs) were recorded at baseline visit and at first, second and sixth month follow-up. Descriptive statistics were used to analyse the above parameters. The mean reduction in NRS was analysed by the Z test. Results Out of 145 patients, 118 (81.37%) were male and 27 (18.62%) were female. The mean age of patients was 51.89 + 7.07 years. Tramadol (81.37%) followed by morphine (62.75%) were the commonly prescribed analgesics. Amitriptyline (20%) followed by pregabalin (19.31%) were commonly prescribed adjuvant analgesics. A statistically significant reduction in mean NRS was found at each follow-up visit ( p < .05). A total of 50 ADRs were observed. Constipation (38%) and drowsiness (24%) were the most frequently reported ADRs, with morphine and tramadol being the most common suspected causal drugs. Conclusion Tramadol and morphine were frequently prescribed analgesics in patients with HNC pain in accordance with the WHO analgesic ladder. The majority of patients with HNC pain achieved a significant reduction in NRS pain scores at the end of six months.

Efficacy of Lumbar Transforaminal Epidural Steroid Injections for Lumbosacral Radiculopathy in Individuals with Spine Surgery: A Retrospective Comparative Study

Introduction: Transforaminal epidural steroid injections (TFESI) have demonstrated their efficacy in both short-term and long-term treatment of radicular pain with their targets being the anterolateral epidural space and dorsal root ganglion. Although the evidence for transforaminal injections in treating radiculitis secondary to discherniation and lumbar stenosis is strong, evidence is limited regarding its effect on axial pain and in patients with failed back surgery syndrome (FBSS). Methodology: 61 patients were registered in this retrospective comparative study who underwent lumbar TFESI for lumbosacral radiculopathy from March 2021 to March 2022. All patients were assessed for difference in pain relief, disability and functional outcome at baseline and at the time of follow up using NRS, ODI & PROMIS. As a secondary objective the patients were divided into two groups those with previous history of spine surgery (Group A) and non-operated patients (Group B) to Compare the mean levels of pain relief, functional outcome and disability in spine surgery patients compared to non-operated patients. After Ethical committee approval and informed consent from patient baseline scores (NRS, ODI & PROMIS) were accessed from the MRD and follow up scores were obtained by sending a questionnaire across to the patient by email. The average follow up time was 1 year and 4 months (Mean). Results and Observations: A minimum clinically important difference (MCID) of >2.0 was selected for the change in NRS to further determine the proportion of responders who experienced a clinically significant reduction of pain. Success in achieving MCID is defined by ≥3 t score change for all PROMIS instruments. Success in achieving MCID for ODI is defined as at least 30% score change at follow up from baseline score. There is no significant difference in pain relief, disability improvement, functional outcome as assessed by NRS, ODI & PROMIS between the two groups. In this study the success in achieving MCID for NRS was 70% in Group A and 63% in group B and overall 67% indicating that total 41 patients (67%) had significant reduction in NRS after TFESI. In this study success of achieving MCID for ODI was 38.7% among Group A which was comparable to 23.3% among Group B and the difference was not statistically significant. The overall success of achieving MCID for ODI was total 19 patients (31.1%) indicating only 31% patients had significant improvement in disability post TFESI. There is no significant difference in functional outcome as assessed by PROMIS instruments between the two groups. For PROMIS PF, PI, SD the success of achieving MCID was greater than 70% overall and for both the groups. Conclusion: There is no doubt regarding the efficacy and therapeutic effect of TFESI in axial lumbosacral pain/radicular pain in non-operated patients. This study demonstrates the success rate of TFESI in spine surgery patients (FBSS) as well by utilizing PROMIS as an outcome measure and by use of a control group demonstrating improved Physical Function, less pain interference & improved sleep.

Randomized controlled trial comparing technical features and clinical efficacy of a multi-tined cannula versus a conventional cannula for cervical medial branch radiofrequency neurotomy in chronic neck pain

ObjectivesCompare procedural characteristics and clinical efficacy of cervical medial branch radiofrequency neurotomy (CMBRFN) using a multi-tined cannula (MTC) versus a conventional cannula (CC) to treat chronic neck pain. DesignProspective, double-blinded randomized controlled trial. MethodsPatients who responded to dual medial branch blocks with ≥75% pain relief were randomized to receive RFN with either the MTC or the CC. Primary outcomes: procedural pain, procedure duration, fluoroscopy time and radiation dose. Secondary outcomes: proportion of patients reporting ≥50% numerical rating scale reduction and ≥30% neck disability index reduction at 3, 6 and 12 months. ResultsForty-two patients underwent treatment. There was no difference in procedural pain between the MTC and CC groups (NRS 4.7 ± 2.0 vs. 4.2 ± 1.8, p = 0.465), but three patients, all in the CC group, could not complete the procedure due to pain. CMBRFN in the MTC group was significantly faster than in the CC group (35.5 ± 7.3 min vs. 58.2 ± 14.8 min, p < 0.001), with less fluoroscopy time (167.6 ± 76.4 s vs. 260.8 ± 123.5 s, p = 0.004). Radiation dose was 8.95 ± 7.9 mGy in the MTC group and 11.53 ± 10.3 mGy in the CC group (p = 0.36). Rates of ≥50% NRS reduction were not significantly different between the two groups at 3 months, but at 6 and 12 months, they were significantly higher in the CC group. At 3, 6 and 12 months, rates of ≥30% NDI reduction were significantly higher in the CC group. ConclusionsThe MTC offers technical advantages compared to the CC for both the operator and the patient. However, CMBRFN with the multi-tined cannula seems less effective to treat neck pain than with the conventional cannula.

High-power laser photobiomodulation therapy for immediate pain relief of refractory oral mucositis.

We aimed to evaluate the efficacy of high-power (class IV) laser photobiomodulation (PBM) therapy for immediate pain relief due to oral mucositis (OM) refractory to recommended first-line therapy. This retrospective study included 25 cancer patients with refractory chemotherapy- or radiotherapy-induced OM (16 and 9 patients, respectively) that were treated for pain relief with an intraoral InGaAsP diode laser (power density = 1.4 W/cm2). Pain was self-assessed immediately before and after laser treatment using a 0-to-10 numeric rating scale ([NRS], "0" = no pain, "10" = intolerable pain). Patients reported an immediate decrease in pain following 94% (74 of 79) of the PBM sessions, in 61% (48 sessions) the pain reduction was over 50%, and in 35% (28 sessions) the initial pain was completely eliminated. There were no reports of increased pain post-PBM. For chemotherapy and radiotherapy-treated patients, mean reduction in pain NRS post-PBM was 4.8 ± 2.5 (p < 0.001) and 4.5 ± 2.8 (p = 0.001), indicating a post-PBM reduction of 72% and 60% of the initial pain level, respectively. The analgesic benefit of PBM remained for a mean of 6.0 ± 5.1 days. One patient reported a transient burning sensation after one PBM session. High-power laser PBM may provide nonpharmacologic, patient-friendly, long-lasting, rapid pain relief for refractory OM.

Ultrasound-guided Percutaneous Laser Disc Decompression (PLDD) with Fluoroscopic Validation for the Treatment of Cervical Disc Herniation: Technical Note.

Percutaneous laser disc decompression (PLDD) has been regarded as an effective alternative for the treatment of cervical soft disc herniations. Repeated X-Ray scanning is essential when performing this technique. Technical note. We present a new method for the treatment of cervical disc herniation using ultrasound to guide the needle entry to the cervical disc, to avoid excess of radiation exposure during the surgical procedure. We evaluated the efficacy of this cervical approach. We retrospectively reviewed the clinical data of 14 cases who underwent a PLDD under ultrasound guidance for the treatment of contained cervical disc herniation using a 1,470 Nm diode laser. The lower cervical discs (C5-C6 and C6-C7) were the most affected sites, accounting for 78.6% of surgical discs. A significant NRS reduction between baseline and 1 month (P = .0002) and between baseline and 12 months (P = .0007) was observed. Our results support the conclusion that ultrasound guided PLDD with fluoroscopic validation is a minimally invasive technique for patients affected by herniated cervical discs, but proper choice of patients is critical. This approach should not be performed except after adequate training under close supervision of surgeons experienced in this procedure and in interventional US.

Peripheral Nerve Stimulation on the Brachial Plexus With Ultrasound-guided Percutaneous Technique: A Case Series

IntroductionThe aim of this case series was to assess the safety and effectiveness of peripheral nerve stimulation (PNS) of the brachial plexus performed using a low invasive percutaneous approach with ultrasound guide. Materials and MethodsPatients affected by neuropathic pain with a documented brachial plexus partial avulsion were included in this observational study. A totally implantable PNS system specifically designed for peripheral placement (Neurimpulse, Padua, Italy) was implanted and followed for 18 months, recording the level of pain (Numeric Rating Scale [NRS]), therapy satisfaction (Patient Global Impression of Improvement), quality of life (Short Form Health Survey questionnaire), and change in drug consumption and work status. Descriptive statistic (mean and SD) was used to compare pre- and postimplantation differences. ResultsA total of 18 patients were included in the observational study; 16 of them proceeded with the permanent implantation. System infection (N = 1) and lead migrations (N = 2) were recorded during a follow-up mean of 14.8 ± 5.4 months. The average NRS reduction at 18 months was 41%. Average quality-of-life physical and mental indexes increased by 14% and 32%, respectively. Drug intake was stopped in 22% and reduced in 56% of the patients. ConclusionsPNS systems of the brachial plexus implanted with percutaneous approach appear to be safe and effective in a follow-up period of 18 months. Longer and larger studies are needed to confirm and extend these outcomes.

The Efficacy of Cervical Lordosis Rehabilitation for Nerve Root Function and Pain in Cervical Spondylotic Radiculopathy: A Randomized Trial with 2-Year Follow-Up.

Sagittal cervical alignment is a clinically related feature in patients suffering from chronic cervical spondylotic radiculopathy (CSR). We designed this randomized trial to explore the effects of cervical lordosis (CL) correction in thirty chronic lower CSR patients with CL &lt; 20°. Patients were assigned randomly into two equal groups, study (SG) and control (CG). Both groups received neck stretching and exercises and infrared radiation; additionally, the SG received cervical extension traction. Treatments were applied 3× per week for 10 weeks after which groups were followed for 3 months and 2 years. The amplitude of dermatomal somatosensory evoked potentials (DSSEPS), CL C2-C7, and pain scales (NRS) were measured. The SG had an increase in CL post-treatment (p &lt; 0.0001), this was maintained at 3 months and 2 years. No statistical improvement in CL was found for the CG. A significant reduction in NRS for SG after 10 weeks of treatment with non-significant loss of change at 3 months and continued improvement at 2 years was found. CG had less significant improvement in post-treatment NRS; the 3-month and 2-year measures revealed significant worsening in NRS. An inverse linear correlation between increased CL and NRS was found (r = -0.49; p = 0.005) for both groups initially and maintained in SG at the final 2-year follow-up (r = -0.6; p = 0.01). At 10 weeks, we found significant improvements in DSSEPS for both groups (p &lt; 0.0001). We identified a linear correlation between initial DSSEPs and CL for both groups (p &lt; 0.0001), maintained only in the SG at the final follow-up for all levels (p &lt; 0.0001). Improved CL in the SG correlated with significant improvements in nerve root function and pain rating in patients with CSR at short and long-term follow-up. These observed effects indicate that clinicians involved in the treatment of patients with symptoms of cervical degenerative disorders should add sagittal curve correction to their armamentarium of rehabilitation procedures for relevant patient populations.

MIRIKIZUMAB REDUCES ABDOMINAL PAIN IN PATIENTS WITH MODERATELY TO SEVERELY ACTIVE CROHN’S DISEASE

Abstract BACKGROUND Mirikizumab (miri), an anti-IL-23p19 inhibitor, has demonstrated efficacy in patients with ulcerative colitis and moderately to severely active Crohn’s disease (CD) in a Phase 2, randomised, double-blind, placebo-controlled study (NCT02891226). This analysis evaluated the effect of miri versus placebo (PBO) on worst abdominal pain (AP) utilising an 11-point AP Numeric Reporting Scale (AP NRS). METHODS During induction, patients were randomised 2:1:1:2 to receive PBO, 200mg, 600mg, or 1000mg miri administered intravenously (IV) every four weeks (Q4W). At week (W)12, patients entered a blinded maintenance treatment. Patients who received miri during induction and achieved ≥1 point improvement in Simple Endoscopic Score for Crohn’s Disease (SES-CD) at W12 were randomised 1:1 to either continue induction treatment (IV 200mg, 600mg, 1000mg miri Q4W) or receive 300mg miri Q4W administered subcutaneously (SC) for 40W (maintenance). Because of small patient numbers, the randomised maintenance groups results were combined for those who continued the same IV induction treatment (All IV-C) and those who were randomised to SC treatment (All SC). SES-CD non-improvers (NI/1000mg IV Miri) and patients who received PBO (PBO/1000mg IV Miri) during induction received 1000mg miri IV Q4W during maintenance. Patients recorded “worst AP in the past 24 hours” each day using an 11-point AP NRS (0=no pain to 10=worst possible pain) on an electronic diary. The Pain NRS is a valid, reliable, and responsive patient reported outcome that can be used to assess pain among patients with CD. Weekly average score was calculated and compared to placebo using a mixed model for repeated measures (MMRM) for visits in the induction period. Observed change in Pain NRS is presented for maintenance. RESULTS Significant reduction in AP NRS was reported by patients treated with 600mg miri compared to patients treated with placebo at W8 (least square mean difference ± standard error [95% confidence interval]: -1.01 ± 0.4 [-1.87, -0.14], p=0.02) (Table 1) and in all miri treatment groups: 200mg (-0.92 ± 0.4 [-1.80, -0.03], p=0.04), 600mg (-1.23 ± 0.4 [-2.11, -0.36], p=0.006) and 1000mg (-0.86 ± 0.4 [-1.57, -0.15], p=0.02) miri versus PBO at W12 (Table 1). Patients who received miri during induction continued to show improvements at W52 (Table 1). Patients treated with PBO/1000mg IV during maintenance reported similar improvements to patients who received miri from W0-52 (Table 1). CONCLUSION Using an 11-point Abdominal Pain Numeric Reporting Scale, mirikizumab treatment was associated with statistically significant improvements in abdominal pain when compared to placebo after 12 weeks in patients with moderately to severely active Crohn’s disease. Additional numeric reductions in abdominal pain were observed through 52 weeks in all mirikizumab treated patient groups.

Usability and effectiveness of inhaled methoxyflurane for prehospital analgesia - a prospective, observational study

BackgroundPain relief in the prehospital setting is often insufficient, as the administration of potent intravenous analgesic drugs is mostly reserved to physicians. In Australia, inhaled methoxyflurane has been in routine use by paramedics for decades, but experience in Central European countries is lacking. Thus, we aimed to assess whether user friendliness and effectiveness of inhaled methoxyflurane as sole analgesic match the specific capabilities of local ground and air-based EMS systems in Austria.MethodsObservational study in adult trauma patients (e.g. dislocations, fracture or low back pain following minor trauma) with moderate to severe pain (numeric rating scale [NRS] ≥4). Included patients received a Penthrop® inhaler containing 3 mL of methoxyflurane (maximum use 30 min). When pain relief was considered insufficient (NRS reduction < 3 after 10 min), intravenous analgesics were administered by an emergency physician. The primary endpoint was effectiveness of methoxyflurane as sole analgesic for transport of patients. Secondary endpoints were user friendliness (EMS personell), time to pain relief, vital parameters, side effects, and satisfaction of patients.ResultsMedian numeric pain rating was 8.0 (7.0–8.0) in 109 patients. Sufficient analgesia (reduction of NRS ≥3) was achieved by inhaled methoxyflurane alone in 67 patients (61%). The analgesic effect was progressively better with increasing age. Side effects were frequent (n = 58, 53%) but mild. User satisfaction was scored as very good when pain relief was sufficient, but fair in patients without benefit. Technical problems were observed in 16 cases (14.7%), mainly related to filling of the inhaler. In every fifth use, the fruity smell of methoxyflurane was experienced as unpleasant. No negative effects on vital signs were observed.ConclusionIn prehospital use, inhaled methoxyflurane as sole analgesic is effective for transport of trauma patients (62%) with moderate to severe pain. Older patients benefit especially from inhaled methoxyflurane. Side effects are mild and vital parameters unaffected. Thus, inhaled methoxyflurane could be a valuable device for non-physician EMS personnel rescue services also in the central Europe region.

Safety and efficacy of alpha-lipoic acid oral supplementation in the reduction of pain with unknown etiology: A monocentric, randomized, double-blind, placebo-controlled clinical trial

IntroductionExtensive evidence suggests that alpha-lipoic acid (ALA) is effective in diabetic neuropathy pain management. However, little is known on its safety and efficacy in reducing idiopathic pain in normoglycemic subjects. The aim of this study was to evaluate ALA food supplement safety and efficacy in the reduction of different forms of idiopathic pain. MethodsTwo-hundred and ten normoglycemic adults suffering from idiopathic pain (i.e. 57 subjects with primitive neuropathic pain, 141 subjects with arthralgia with unknown etiology, and 12 subjects with idiopathic myalgia) were randomized to receive placebo, 400 mg/day, or 800 mg/day of ALA. Participants underwent two visits (at baseline = t0, and after 2 months = t1) in which two validated questionaries for pain (numerical rating scale [NRS] and visual analogue scale [VAS]) were collected; fasting blood glucose assessment, adverse effects, and renal and hepatic toxicity were also monitored. ResultsAt t1, none of subjects treated with ALA reported a decreased glycemia or adverse effects. The treated subjects showed a significant reduction in NRS (p < 0.001) while the placebo group did not show any NRS reduction (p = 0.86). Similar results were also obtained for VAS. Statistical analysis aimed at detecting possible differences in NRS and VAS scores among treatment groups based on the source of pain did not reveal any significant effect. ConclusionsSince the management of idiopathic pain is challenging for physicians, the use of ALA food supplements could be a feasible option, based on its safety and efficacy compared to commonly-used analgesic drugs.

The Predictive Value of Transcutaneous Electrical Nerve Stimulation for Patient Selection in Peripheral Nerve Field Stimulation for Chronic Low Back Pain: A Prospective Study

Peripheral nerve field stimulation (PNFS) is an effective alternative treatment for patients with chronic low back pain. Transcutaneous electrical nerve stimulation (TENS) is frequently used in pain therapy. Aim of this prospective study was to examine the predictive value of TENS for later PNFS treatment. Between 2014 and 2019, a prospective cohort study of 41 patients with chronic lumbar pain was conducted. Pain intensity (NRS) was assessed before and after TENS use, preoperatively/postoperatively and in the follow-up after three and sixmonths, SF12v2 questionnaires with physical (PCS) and mental component summary (MCS) scores, and Oswestry disability index (ODI) questionnaire at baseline as well as three and six months after PNFS implantation. Implantation of the PNFS-system with two percutaneous leads was performed after four to seven days of positive testing. Statistical analysis was performed using depending t-test, ANOVA, and Spearman correlation. The cohort consisted of 41 patients (19 females, 22 males) with a median age of 60.5 years (IQR25-75 52-67). Two patients were lost to follow-up. After positive PNFS testing a pulse generator (IPG) was implanted in 15 patients with positive TENS effect and 15 patients without TENS effect. Leads were explanted in nine patients after negative PNFS trial phase. TENS positive patients showed significant correlation to a positive effect in the PNFS trial phase in NRS reduction (p=0.042) indicating that TENS responders will also respond to PNFS (94% patients). After three and six months follow-up median NRS and SF12v2 (PCS) improved significantly in both cohorts, SF12v2 (MCS) and ODI only in the TENS positive cohort, respectively. TENS can be predictive for patient selection in PNFS, as TENS positive patients showed significant correlation with a positive PNFS trial period. Therefore, TENS positive patients might be justifiable to be directly implanted with leads and IPG. TENS positive patients further tend to show a better improvement in the follow-up.

Pain and Disability in Low Back Pain Can be Reduced Despite No Significant Improvements in Mechanistic Pain Biomarkers.

Altered balance in nociception in response to noxious stimuli is commonly reported in chronic low back pain (LBP). However, it is unclear whether an improvement in the clinical presentation is contingent on a reduction in pain sensitivity. This study investigated whether the quantitative sensory testing (QST) profile changes in people undergoing rehabilitation for LBP. A prospective, observational case-control study. Forty males and females, 18 to 40 years' old (20 with LBP) participated in 2 sessions. QST was performed at baseline and after discharge from rehabilitation (LBP) or after 3 to 8 weeks (controls). The QST battery consisted of determining pressure-pain thresholds at the low back and shoulder, temporal summation of pain, and conditioned pain modulation. Questionnaire data was used to determine pain (Numeric Rating Scale [NRS]), disability (Roland-Morris Questionnaire [RMQ]), Fear Avoidance Beliefs (FABQ), and The Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) at baseline and discharge. The treatment effect was determined by calculating the Cohen d. No significant group×time interactions or main factor effect was found for any of the QST measures. The LBP group reported a significant reduction in NRS (P<0.0002, d=1.23), RMQ (P<0.0001, d=1.58), FABQ (P<0.001, d=0.87), and in the ÖMPSQ (P<0.00001, d=1.44). The results indicate that an improvement of clinical LBP is not contingent upon changes in the pain sensory profile. The value of screening pain sensitivity in LBP patients in primary care, needs to be investigated further, due to the patient population heterogeneity and the sensitivity of assessment methods.

Chemical Ablation of Genicular Nerve with Phenol for Pain Relief in Patients with Knee Osteoarthritis: A Prospective Study.

Radiofrequency ablation of the genicular nerve is performed for knee osteoarthritis (KOA) when conservative treatment is not effective. Chemical ablation may be an alternative, but its effectiveness and safety have not been examined. The objective of this prospective open-label cohort study is to evaluate the effectiveness and safety of ultrasound-guided chemical neurolysis for genicular nerves with phenol to treat patients with chronic pain from KOA. Forty-three patients with KOA with pain intensity score (Numeric Rating Scale, NRS) ≥4, and duration of pain of more than 6months were considered for enrollment. Ultrasound-guided diagnostic blocks of genicular nerves (superomedial, inferomedial, and superolateral) with 1.5mL of 0.25% bupivacaine at each site were performed. Those who reported more than 50% reduction in NRS went on to undergo chemical neurolysis, using 1.5mL 7% glycerated phenol in each genicular nerve. NRS and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were assessed before intervention and at 2weeks and 1, 2, 3, and 6months following the intervention. NRS and WOMAC scores improved at all time points. Mean pain intensity improved from 7.2 (95% confidence interval [CI]: 6.8 to 7.7) at baseline to 4.2 (95%CI: 3.5 to 5.0) at 6-month follow-up (P<0.001). Composite WOMAC score improved from 48.7 (95%CI: 43.3 to 54.2) at baseline to 20.7 (95%CI: 16.6 to 24.7) at 6-month follow-up (P<0.001). Adverse events did not persist beyond 1month and included local pain, hypoesthesia, swelling, and bruise. Chemical neurolysis of genicular nerves with phenol provided efficacious analgesia and functional improvement for at least 6months in most patients with a low incidence of adverse effects.

Spinal cord stimulation for the treatment of complex regional pain syndrome leads to improvement of quality of life, reduction of pain and psychological distress: a retrospective case series with 24 months follow up.

Background and aims Complex regional pain syndrome (CRPS) is a common pain condition which is characterized by pain, functional impairment, and trophic changes. Neurosurgical treatment is not widely offered. In this study the treatment with spinal cord stimulation (SCS) was evaluated over 24 months follow up. Methods A retrospective case analysis of six patients with severe CRPS was performed. Pain chronicity was recorded with the Mainz Pain Staging System (MPSS). Pain intensity (NRS), activity level and health-related quality of life (EQ-5D-5L), the actual mood state (ASTS), and treatment satisfaction (CSQ-8) were assessed. All patients received conventional pharmacological treatments including multimodal pain therapy through their local pain therapist or in specialized centers as well as physical therapy. A SCS electrode was implanted for trial stimulation. After successful trial a neurostimulator was implanted and connected to the electrode. Patients were retrospectively analyzed before implantation and 6, 12 and 24 months postoperatively. Statistical analysis was performed using Mann-Whitney U and Wilcoxon rank-sum test. Results Patients median age was 43 years (IQR25-75 37-43 years). The median MPSS Score was 3 of 3 indicating a high pain chronicity. Median NRS before implantation of the neurostimulator was 8.8 (IQR25-75 7.6-9.3). A reduction to 7.8 (IQR25-75 4.8-8.1; p = 0.14) after 6 months, 6.5 (IQR25-75 3.8-8.1; p = 0.08) after 1 year, and 6.8 (IQR25-75 3.8-8.5; p = 0.15) after 2 years was achieved. Median EQ-5D-5L index value before treatment was 0.27 (IQR25-75 0.25-0.41) indicating a severely lowered quality of life. A significant improvement to 0.53 (IQR25-75 0.26-0.65; p = 0.03) after 6 months, 0.58 (IQR25-75 0.26-0.84; p = 0.03) after 1 year as well as after 2 years was seen. ASTS scale showed an increase of values for positive mood, and a reduction in values for sorrow, fatigue, anger and desperation during the whole follow up period. The treatment satisfaction in the whole cohort with a median CSQ-8 value of 29.5 of 32 was very high. Conclusion The results of this small case series showed a significant improvement of the EQ-5D-5L after implantation of a neurostimulator. NRS reduction was not significant but a clear tendency towards reduced values was observed. We therefore conclude that SCS is an alternative option to relieve chronic pain and psychological distress originating from CRPS if non-invasive managements of severe CRPS failed. The preoperative selection plays a crucial role for good results. Implications CRPS is difficult to treat. SCS is an alternative option to improve the quality of life and relieve chronic pain originating from severe CRPS if conservative treatment modalities fail. Further psychological distress is reduced in long-term follow up. SCS should be kept in mind for therapy refractory cases.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P50. A randomized prospective comparative trial of water-cooled versus traditional radiofrequency ablation of the median branch nerve in the treatment of zygapophyseal joint pain: six-month outcomes

BACKGROUND CONTEXT No study has compared the effectiveness of water-cooled radiofrequency ablation (WC-RFA) and traditional RFA (T-RFA) of the medial branch nerves (MBNs) for lumbar zygapophyseal joint (Z-joint) pain. PURPOSE Evaluate six-month pain, functional, psychometric, and medication usage outcomes of MBN WC-RFA versus T-RFA for lumbar Z-joint pain. STUDY DESIGN/SETTING Randomized comparative trial at an urban, tertiary, academic spine or pain center. PATIENT SAMPLE Individuals with Z-joint pain diagnosed by clinical evaluation and positive diagnostic MBN blocks (>50% relief) were randomized to WC-RFA or T-RFA. OUTCOME MEASURES The primary outcome was the proportion of “responders” (≥50% NRS reduction) at 6-months. Secondary outcomes included the NRS, ODI, Patient Anxiety Symptom Scale (PASS-20), McGill Pain Inventory (MPI), Center for Epidemiologic Studies Depression scale (CESD-10), daily morphine equivalents (DME), and Patient Global Impression of Change (PGIC). METHODS Six-month clinical outcomes were compared in the the group that was randomized to WC-RFA and the group that was randomized to T-RFA. Data were analyzed by descriptive statistics, chi-square tests, one-sample t-tests, independent t-tests, and Mann-Whitney-Wilcoxon tests RESULTS Forty participants (mean age=55.9, 24 females, mean BMI 30.2 kg/m2) underwent MBN WC-RFA (n=21) or T-RFA (n=19). There were no differences in demographic variables (p>.05). A ≥50% NRS reduction was observed in 52% (95% CI 31%–74%) and 47% (95% CI 26%–71%) of participants undergoing WC-RFA and T-RFA, respectively, at 6 months (p=.75). A ≥15-point or ≥30% reduction 6 months was observed in 62% (95% CI 39%–80%) and 42% (95% CI 22%–66%) of participants in the WC-RFA and T-RFA groups, respectively (p=.21). Significant reductions in mean NRS and ODI scores were observed in both groups: WC-RFA (NRS 7.4–3.6; ODI 29–18) and T-RFA (NRS 7.1–4.2; ODI 26–19) (NRS p 0.05). CONCLUSIONS Approximately half of participants reported clinically meaningful improvements in pain and function with MBN WC-RFA and T-RFA at 6 months, with no intergroup differences observed. These results are representative of a selection protocol with a high false-positive rate; use of dual comparative MBN blocks for patient selection would likely result in a higher success rate regardless of RFA modality.

Pulsed Radiofrequency Application on Femoral and Obturator Nerves for Hip Joint Pain: Retrospective Analysis with 12-Month Follow-up Results

Osteoarthritis of the hip joint is a common cause of pain and disability. Patients not responding to conservative management often cannot undergo joint replacement due to the presence of multiple comorbidities, while some other patients prefer to postpone surgery as long as possible. Radiofrequency denervation of articular branches of the femoral and obturator nerves, which supply innervation of the joint, is a novel technique to reduce hip joint pain. Previous studies reported positive results after application of continuous radiofrequency to the target nerves; however, this approach carries the potential risk of neuritis and neuroma formation. Pulsed radiofrequency (PRF) is a safer alternative to continuous radiofrequency not creating necrosis but a complex neuromodulatory effect on target nerves. There is no published evidence of PRF efficacy after 3 month follow-up. This single-center study objective was to evaluate the short and medium term effectiveness of PRF on the femoral articular branches and obturator nerves in patients with chronic hip pain. Retrospective single-center study. Italian National Health Service Public Hospital. Retrospective analysis of 14 patients treated with PRF for severe hip joint pain (mean numericAL rating scale (NRS) 7.7 ± 1.2 mean Oxford Hip Score (OHS) 20 ± 8.4). Mean pain and disability scores were evaluated with NRS and OHS respectively at 1, 3, 6 and 12-month follow-up. Mean pain and disability scores were evaluated with NRS and OHS respectively at 1, 3, 6, and 12-month follow-up. All patients were treated with pulsed radiofrequency applied under fluoroscopy on the articular branches of the femoral and obturator nerves for 300 seconds each. Eight patients out of 14 (57%) reported an NRS reduction > 50% at 1 month post procedure. Overall, both pain and disability scores were significantly (P < 0.01) lower at all follow-up until 6 months, mean NRS at 1, 3, and 6 months was 3.6 ± 3; 4.1 ± 3.3; 4.8 ± 2.9 while OHS was 37.6 ± 17.7; 35.8 ± 17.7; 35.8 ± 14 respectively. At 12 months, NRS was 5.8 ± 2.4 while OHS 23.3 ± 12.7, it must be pointed out that even if both scores are significantly (P < 0.01) lower than basal, only 3 patients out of 14 (21%) maintained a NRS reduction > 50% from basal at 12 months post procedure. We reported 2 femoral artery punctures without any significant complication. Retrospective study, small sample size. Pulsed radiofrequency is a safe and effective modality to treat hip joint pain in the short and medium term. Definition of positive outcome predictors is required to reserve radiofrequency treatment only for those patients who can benefit from this procedure. Hip joint pain, pulsed radiofrequency, obturator nerve, femoral nerve, interventional pain management, radiofrequency.

Effect of Prophylactic Fentanyl Buccal Tablet on Episodic Exertional Dyspnea: A Pilot Double-Blind Randomized Controlled Trial

ContextEpisodic dyspnea is one of the most common, debilitating, and difficult-to-treat symptoms. ObjectiveWe conducted a pilot study to examine the effect of prophylactic fentanyl buccal tablet (FBT) on exercise-induced dyspnea. MethodsIn this parallel, double-blind randomized placebo-controlled trial, opioid-tolerant patients were asked to complete a six-minute walk test (6MWT) at baseline and then a second 6MWT 30 minutes after a single dose of FBT (equivalent to 20–50% of their total opioid dose) or matching placebo. We compared dyspnea Numeric Rating Scale (NRS, 0–10, primary outcome), walk distance, vital signs, neurocognitive function, and adverse events between the two 6MWTs. ResultsAmong 22 patients enrolled, 20 (91%) completed the study. FBT was associated with a significant within-arm reduction in dyspnea NRS between 0 and six minutes (mean change −2.4, 95% CI −3.5, −1.3) and respiratory rate (mean change −2.6, 95% CI −4.7, −0.4). Placebo was also associated with a nonstatistically significant decrease in dyspnea (mean change −1.1). Between-arm comparison of dyspnea scores in the second 6MWT favored FBT, albeit not statistically significant (estimate −0.25, P = 0.068). Global impression revealed more patients in the FBT group than placebo group reporting their dyspnea was at least “somewhat better” in the second 6MWT (4 of 9 vs. 0 of 11, P = 0.03). The other secondary outcomes did not differ significantly between arms. ConclusionsThis study supports that prophylactic FBT was associated with a reduction of exertional dyspnea and was well tolerated. Our findings support the need for larger trials to confirm the therapeutic potential of rapid-onset opioids.

Effect of prophylactic fentanyl buccal tablet (FBT) on exertional dyspnea in patients with cancer: A pilot double-blind, placebo-controlled, randomized trial.

10085 Background: Exertional dyspnea is one of the most common, debilitating and difficult-to-treat symptoms in cancer patients. Few clinical trials have been conducted. We tested the hypothesis that FBT, a rapid onset opioid, given prophylactically prior to exertion can improve exertional dyspnea. Methods: In this double-blind parallel (1:1) RCT, we asked cancer patients who were opioid-tolerant and had exertional dyspnea to complete a 6 minute walk test (6MWT) at baseline, and then randomly assigned them to either FBT proportional to 20-50% of daily dose or placebo 30 minutes before a second 6MWT. The primary outcome was a validated 11-point dyspnea NRS assessing dyspnea “now” (where 0 = none and 10 = worst possible) every minute during each 6MWT. Secondary outcomes included walk distance, vital signs and neurocognitive testing, adverse effects, and global impression. Ten evaluable patients in the FBT provided 80% power to detect an effect size as small as 1.0 using a two-sided paired t-test with a significance level of 5% to compare the change of dyspnea between the first and second walk tests. We compared the outcomes between the first and second 6MWTs using paired t-test. Results: Among 22 patients enrolled, 20 (91%) completed the study (9 FBT, 11 placebo). FBT was associated with a significant within-arm reduction in dyspnea NRS between 0 and 6 minutes (mean change -2.4, 95% confidence interval [CI] -3.5, -1.3) and respiratory rate (mean change -2.6, 95% CI -4.7, -0.4). Placebo was also associated with a non-statistically significant decrease in dyspnea (mean change -1.1). Between arm comparison of dyspnea scores in the second 6MWT favored FBT, albeit not statistically significant (estimate -0.25, P = 0.068). Global impression revealed more patients in the FBT group than placebo group reporting their dyspnea was at least “somewhat better” in the second 6MWT (4/9 vs. 0/11, P = 0.03). The other secondary outcomes did not differ significantly between arms. Conclusions: These data support our hypothesis that proportionally dosed FBT was associated with improvement in exertional dyspnea, and highlights the need for larger confirmatory trials. Clinical trial information: NCT01856114.

Muscle elastography: a new imaging technique for multiple sclerosis spasticity measurement.

Multiple sclerosis (MS) spasticity is currently evaluated on the basis of neurological examinations such as Ashworth Scale (AS) and 0-10 NRS. Severity of spasticity is difficult to quantify. We investigated the use of real time elastography (RTHE) ultrasounds for evaluating objectively the muscle fibers status in MS spasticity patients and their changes after a new antispasticity treatment. Two studies were performed. In study A, 110 MS patients underwent a neurological evaluation based on the AS and RTHE. The RTHE images were scored with the new 1-5 muscle fibers rigidity imaging scale, here called MEMSs (Muscle Elastography Multiple Sclerosis Score). The correlation between AS and MEMSs was found to be statistically significant. In study B, 55 MS patients treated with THC:CBD oromucosal spray for their resistant spasticity were followed prospectively. MS spasticity was evaluated by the 0-10 NRS scale at baseline and after 4weeks of treatment. MEMSs' figures were obtained at both timepoints. Responders to THC:CBD oromucosal spray (pre-defined as an improvement ≥20% in their 0-10 NRS spasticity score vs. baseline)were 65% of sample. These patients had a mean 0-10 NRS reduction of 1.87 and a MEMSs reduction of 1.97 (P values <0.0001). The remaining 35% of patients, classified as clinically non-responders, showed still a significant mean reduction in MEMSs (0.8, P=0.002). Our overall results showed that RTHE, operativized throughout MEMSs, could be an objective gold standard to evaluate MS muscle spasticity as well as the effectiveness of antispasticity therapy.