Significant Improvement In Pain Scores Research Articles

Early Prospective Clinical Results of a Modern Fixed-Bearing Total Ankle Arthroplasty

Several fixed-bearing total ankle arthroplasty systems are available in the United States. We report on the early clinical results of the largest known cohort of patients in the United States who received a Salto Talaris total ankle replacement for the treatment of end-stage arthritis of the ankle. We prospectively followed sixty-seven patients with a minimum clinical follow-up of two years. Patients completed standardized assessments and underwent physical examination, functional assessment, and radiographic evaluation preoperatively and at six weeks, three months, and six months postoperatively and yearly thereafter through their most recent follow-up. Implant survival at a mean follow-up time of 2.8 years was 96% when metallic component revision, removal, or impending failure was used as the end point. Three patients developed aseptic loosening, and all instances involved the tibial component. One of the three patients underwent revision to another fixed-bearing total ankle arthroplasty system, one patient is awaiting revision surgery, and the third patient has remained minimally symptomatic and fully functional without additional surgery. Forty-five patients underwent at least one additional procedure at the time of the index surgery. The most common concurrent procedure performed was a deltoid ligament release (n = 21). Eight patients underwent additional surgery following the index arthroplasty, most commonly debridement for medial and/or lateral impingement (n = 4). As of the most recent follow-up, patients demonstrated significant improvement in pain scores, American Orthopaedic Foot & Ankle Society hindfoot score, and functional scores. Early clinical results indicate that the Salto Talaris fixed-bearing total ankle arthroplasty system can provide significant improvement in pain, quality of life, and standard functional measures in patients with end-stage ankle arthritis. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Isolated Ulnar Shortening Osteotomy for the Treatment of Extra-Articular Distal Radius Malunion

To report the clinical outcomes and complications for a cohort of patients who had extra-articular distal radius malunions treated with isolated ulnar-shortening osteotomy (USO). A second purpose was to define the dorsal angulation limit that would still result in clinical and functional improvement after isolated USO for distal radius malunion. We postulated that patients with up to 20° dorsal or volar tilt could be successfully treated with isolated USO. We conducted a retrospective chart review for all patients who had an isolated USO for the treatment of ulnar impaction syndrome after distal radius malunion between January 1990 and December 2011. A total of 18 patients underwent isolated USO after distal radius malunion. The mean age of the patients was 53 years and the mean duration of follow-up was 34 months. We used Wilcoxon signed-rank tests to compare preoperative and postoperative range of motion; pain; Quick Disabilities of the Arm, Shoulder, and Hand scores; and radiographic measurements. Average intraoperative ulna shortening was 5.6 mm. Average flexion-extension arc improved from 79° preoperatively to 105° postoperatively. Average pronation-supination arc improved from 121° preoperatively to 162° postoperatively. Average visual analog scale pain score improved from 4.1 to 1.9. Average Quick Disabilities of the Arm, Shoulder, and Hand score improved from 43 to 11. This case series demonstrated a significant improvement in pain score and range of motion after isolated USO for distal radius malunion. Patients with up to 20° dorsal tilt and radial inclination as low as 2° demonstrated improved clinical and functional outcomes after isolated USO. Given the comparable functional outcomes with shorter operative times and lower complication rate requiring fewer secondary surgeries, isolated USO is an attractive alternative to distal radius osteotomy for the management of distal radius malunion in patients with up to 20° dorsal tilt. Therapeutic IV.

PP128: Twice-weekly palliative radiotherapy in locally very advanced, incurable head and neck cancers

Purpose To evaluate the efficacy of a twice-weekly hypofractionated palliative radiotherapy schedule in locally very advanced head and neck cancers. Material and methods Patients with locally advanced, incurable head and neck cancers were prospectively evaluated after treatment with a twice-weekly palliative radiotherapy regimen of 32 Gy in eight fractions. The median age was 55.5 years and the predominant primary site was oral cavity (46%). The majority (70.6%) had Stage IV B disease. Disease related distressing symptoms like pain, bleeding, fungation, respiratory distress, difficulty in self care and mobility were prospectively assessed before the start of treatment, at conclusion and at 6–12 weeks of completion of treatment. Results A total of 126 patients were enrolled in the study. Ninety-three (73.8%) patients who completed the planned treatment of 32 Gy in eight fractions were included in the symptom analysis. Overall response rates were 42% at primary disease and 55% at nodal disease. At conclusion of radiotherapy 76.3% of the patients reported improvement in pain scores ( p = 0.001), and 42.8% patients reported improvement in anxiety and depression levels ( p = 0.001). Twenty-five percent of the patients reported worsening of dysphagia scores after treatment ( p = 0.27). At first follow-up after 6–12 weeks significant improvement in pain scores ( p = 0.001) and anxiety/depression levels ( p = 0.001) persisted. The median survival of the patients was 5.5 months. On multivariate analysis advance stage of the disease (IVB) had significant impact on overall survival ( p = 0.045). Acute grade III mucositis was seen in one patient (1.2%) while none had grade III skin reactions. Conclusion The hypofractionated radiotherapy regimen evaluated prospectively is effective for sustained symptom palliation with acceptable toxicity in locally very advanced head and neck cancers. It delivers a reasonably high dose while being logistically simpler for the patient.

Educational Exhibit Abstract No. 420 - Lumbar facet joint cyst intervention: A minimally invasive treatment option we can offer our spine patients for a common cause of radiculopathy

Learning Objectives The purpose is to illustrate the potential clinical usefulness of CT guided lumbar facet synovial cyst rupture/decompression as a minimally invasive treatment of associated radicular back pain. Background Since starting a CT guided spine practice within the last two years, we treated 5 patients with symptomatic lumbar facet cysts. They consisted of 2 men and 3 women, mean age 62 with ongoing radicular pain referred by either Orthopedic Surgery or Neurosurgery. All patients had MR lumbar spine imaging showing unilateral lumbar facet synovial cysts causing mass effect upon the adjacent thecal sac and nerve root. All patients had congruent radicular pain at the level of the cyst on physical exam by their referring physician and prior to treatment. All 5 patient underwent CT guided facet joint injection with dilute contrast followed by a steroid/anesthetic combination until the cyst ruptured and/or a second needle was placed directly into the cyst via an interlaminar approach to aspirate and fenestrate the cyst. Cyst rupture was verified with contrast seen free flowing in the epidural space. Clinical Findings/Procedure Details Successful rupture/decompression of the cysts was achieved in all cases. Contiguity of contrast from the facet joint into the cyst was 100%. All patients reported significant improvement in pain score as measured by VAS. The mean pre and post procedure VAS were 6.4 and 1, respectively. Conclusion and/or Teaching Points Lumbar facet joint cysts are a more and more recognized cause of low back pain. Procedural treatments have ranged from epidural steroid injections, facet joint injections to surgical resection. Unfortunately, the literature is not robust in the description of CT guided facet joint cyst rupture/decompression for the treatment of associated radicular pain. The largest series may include just a half dozen or so patients. For many radiologist, whether Interventional, Neuro, or Musculoskeletal who have embarked to treat spine patients, CT guided lumbar facet joint cyst rupture/decompression appears to be a viable treatment option for their patients. Certainly larger cohorts and longer follow up is needed to assess the long term efficacy and durability of the procedure.

Abstract No. 349 - Management of back pain in myeloma patients using kyphoplasty: a practical approach to the reduction of pain, improvement of functional status, and palliative success

Purpose To determine the utility of MR STIR imaging findings relative to fluoroscopic exam in the efficacy of treating vertebral compression fractures due to multiple myeloma. Materials and Methods Ten consecutive MM patients from a single center with vertebral compression fractures refractory to conservative treatment were treated with kyphoplasty. After a thorough review of pre-procedure magnetic resonance imaging (MRI), fluoroscopic examination of the spine was performed. Demographic, clinical, and procedural data on patients were retrospectively analyzed. Primary measure of outcome was pain relief and functional status, as assessed by the pre and post-procedure Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). Paired-Samples T test was used for comparison of pre and post measures of outcome. Results Ten patients with refractory back pain representing 36 levels of vertebral compression by MRI were evaluated for potential kyphoplasty. After fluoroscopic assisted palpation of the spine eliciting a moderate to severe pain-response, the ten patients represented 18 treated vertebral levels. A review of the MRI findings of the treated levels showed the absence of traditional MR signal finding of marrow edema; and had little utility in guiding therapy at the time of exam. All patients experienced significant improvement in pain score as measured by VAS. The mean pre and post-procedure VAS were 6.8 and 1.3 (p=0.001), respectively. All patients experienced significant improvement in there functional ability as measured by their ODI questionnaire. Mean pre and post-procedure ODI were 51.4 and 29.8, (p=0.001), respectively. Conclusion Solely relying on MRI alone to determine who may benefit from vertebral augmentation is not sufficient, and often may preclude a patient’s potential to gain significant benefit if treatment is withheld due to the absence of traditional MR STIR imaging findings of bone marrow edema. Symptomatic levels may be missed due to the presence of multilevel, heterogeneous MR signal abnormalities in multiple myeloma, but by using a clinical-based approach and utilizing the fluoroscopic exam, excellent results may be achieved, which is critical to palliative success.

Prospective comparison study of one-year outcomes for all titanium total temporomandibular joint replacements in patients allergic to metal and cobalt–chromium replacement joints in patients not allergic to metal

We aimed to ascertain whether there are any early differences in outcome between all titanium temporomandibular joint (TMJ) prostheses in patients allergic to metal and standard cobalt–chromium prostheses in patients not allergic to metal. All patients who had primary TMJ prostheses placed with one-year follow-up between March 2003 and February 2011 were included. We reviewed the basic characteristics of patients. The outcome variables measured included disease, pain, mouth opening, and diet. A total of 55 patients with 77 joint replacements fulfilled the inclusion criteria. Forty patients had standard cobalt–chromium alloy (Co–Cr–Mo) prostheses (20 unilateral and 20 bilateral), and 15 had all titanium prostheses (13 unilateral and 2 bilateral). Osteoarthritis was the most common disease in both groups. There was significant improvement in pain score at reviews at 6 weeks (p=0.001) and 12 months (p=0.03). Values between groups were not significant (p=0.48 at 6 weeks, and p=0.10 at 1 year). Mouth opening in each group improved significantly with continued gains between assessments at 6 weeks and 12 months (p=0.001) but there were no significant differences between groups. Diet scores were significantly improved one year postoperatively in both groups (p=0.001), but differences between groups were not significant (p=0.90). At one year, outcomes for all titanium prostheses in patients allergic to metal were similarly favourable to those in patients who had no hypersensitivity to metal and had standard prostheses. No patient developed a hypersensitivity reaction, and no all titanium prosthesis failed during the one-year follow-up period.

Management of Back Pain in Myeloma Patients Using Vertebral Augmentation: A Practical Approach to Elimination of Pain and Improvement of Functional Status

Abstract 4713 Background:Management of pain and height restoration in multiple myeloma (MM) patients with vertebral compression fractures remains an important area of symptom management among a group of patients that is living longer through advances in therapeutic approaches. Prior studies demonstrated that pain reduction after vertebral augmentation was associated with reduction in patient-reported symptom relief, but clearly more emphasis is needed in this quarter (Julka A, 2012; Mendoza TR, 2012).We report the multidisciplinary approach adapted at our center to management of back pain in MM patients through early and aggressive intervention. Materials and Methods:Our study evaluated ten consecutive MM patients from a single center with vertebral compression fractures refractory to conservative treatment and treated with vertebral augmentation. Per our protocol, after a thorough review of pre-procedure magnetic resonance imaging (MRI), fluoroscopic examination of the spine was performed. Symptomatic levels were topographically localized by marking the skin. Demographic, clinical, and procedural data on patients were retrospectively analyzed. The primary measure of outcome is pain relief and functional status, as assessed by the pre and post-procedure Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). Paired-Samples T test is used for comparison of pre and post measures of outcome. Results:Ten patients with refractory back pain and 36 levels of vertebral compression by MRI were evaluated for potential cement augmentation. Of these levels, 50% (18 levels) were selected for treatment based on fluoroscopic assisted palpation of the spine eliciting a moderate to severe pain-response. A review of the MRI findings of the treated levels showed the absence of traditional MR signal finding of marrow edema; and had little utility in guiding therapy at the time of exam. 15 levels were treated with kyphoplasty alone and 3 levels by a combination of pediculoplasty and kyphoplasty with no adverse outcomes. All patients experienced significant improvement in pain score as measured by VAS. The mean pre and post-procedure VAS were 6.8 and 1.3 (p=0.000), respectively. All patients experienced significant improvement in there functional ability as measured by their ODI questionnaire. Mean pre and post-procedure ODI were 51.4 and 29.8, (p=0.001), respectively. Conclusion:Solely relying on MRI alone to determine who may benefit from vertebral augmentation and pain relief is not sufficient, and often may preclude patient's potential to gain significant benefit. Careful selection of symptomatic levels may be difficult due to the presence of multilevel MR signal abnormalities, but by utilizing a clinical-based approach and primarily relying on palpation of the spine under direct fluoroscopy, excellent results may be achieved, which is critical to palliative success. Disclosures:No relevant conflicts of interest to declare.

Safety and efficacy of esreboxetine in patients with fibromyalgia: A fourteen‐week, randomized, double‐blind, placebo‐controlled, multicenter clinical trial

To evaluate the efficacy, tolerability, and safety of multiple fixed dosages of esreboxetine for the treatment of fibromyalgia. Patients meeting the American College of Rheumatology criteria for fibromyalgia were randomized to receive esreboxetine at dosages of 4 mg/day (n=277), 8 mg/day (n=284), or 10 mg/day (n=283) or matching placebo (n=278) for 14 weeks. The primary efficacy outcomes were the weekly mean pain score and the Fibromyalgia Impact Questionnaire (FIQ) total score at week 14. Secondary efficacy measures included scores for the Patient's Global Impression of Change (PGIC) scale, the Global Fatigue Index (GFI), and the 36-item Short-Form health survey (SF-36; physical function scale only) at week 14. The safety profile of esreboxetine was evaluated based on adverse events and other safety measures. Patients receiving all dosages of esreboxetine demonstrated statistically significant improvements in the pain score (P≤0.025), the FIQ score (P≤0.023), and the PGIC score (P≤0.007) compared with patients in the placebo group. Additionally, patients receiving esreboxetine at dosages of 4 mg/day and 8 mg/day showed statistically significant improvements in the GFI score compared with those receiving placebo (P=0.001). No significant differences in SF-36 physical function scores were observed between patients receiving esreboxetine (any dosage) and those receiving placebo. Adverse events were mostly mild to moderate in severity; insomnia, constipation, dry mouth, nausea, dizziness, hot flush, headache, hyperhidrosis, and palpitations were reported most frequently. Esreboxetine was generally well tolerated and was associated with significant improvements in pain, FIQ, PGIC, and fatigue scores compared with placebo. The lack of a dose-response relationship in both the efficacy and safety analyses suggests that esreboxetine at a dosage of 4 mg/day would offer clinical benefit with the least risk of drug exposure.

The Use of Gabapentin to Decrease Morphine Consumption After Surgical Debridement for Burns

I read with great interest the recent manuscript by Siamak Rimaz on “ Effect of Gabapentin on Morphine Consumption and Pain after Surgical Debridement of Burn Wounds: A Double-Blind Randomized Clinical Trial Study” published in Archives of Trauma Research (1). In this article they recruited 50 patients and through a randomized, double-blind, placebo-controlled study demonstrated a significant improvement in pain scores and clinical parameters after administration of a single oral dose of 1200mg gabapentin. The family of opioid analgesics has been the backbone of analgesia in burn patients. However, it is well known that this group of drugs tend to have numerous side effects and recent data has implicated them as being capable of inducing pain N-methyl-D-aspartate (NMDA) receptor antagonists such as ketamine and gabapentin have recently became popular due to the marked opiate sparing effects. The effect of pain modulation on the descending pathways with the use of gabapentin has been shown in numerous studies (2, 3). Indeed I believe that the pain post-mastectomy is different from a post surgical debridement of burn wounds, accounting for the difference in clinical results in studies comparing the effect of gabapentin in different procedures. The authors have recorded down respiratory rate as one of the clinical indicators of pain. Despite no significant difference was demonstrated between the gabapentin group and the placebo group, I note that there was a decrease in respiratory rate at all-time points in the gabapentin group. I understand the rational of using these parameters as a mean in recording pain but would one not expect the increased use of opiates in the placebo group to result in a greater influence on respiratory depression? It would be worth commenting on this. Lastly, the authors have focused on the analgesic effect of gabapentin in burn patients. However, it would worth to mention the effect of Please cite this paper as: Ee G, Ho R. The Use of Gabapentin to Decrease Morphine Consumption After Surgical Debridement for Burns. Arch Trauma Res. 2012; 1(2):83-4. DOI: 10.5812/atr.6468

Safety and Efficacy of CT-Guided Transforaminal Cervical Epidural Steroid Injections Using a Posterior Approach

Image-guided cervical transforaminal epidural injections play an important role in the management of cervical radicular pain syndromes. The safety and efficacy of these injections via an anterolateral approach has been well-studied. The goal of this retrospective review was to determine the safety and efficacy of CT-guided transforaminal epidural injections by using a posterior approach. Retrospective review of patient records was used to define VNPS and RMDI of patients undergoing CT-guided transforaminal cervical epidural injections between 2006 and 2010. Pain scores were recorded preprocedure, immediately postprocedure, at 2 weeks, and at 2 months. The RMDI was recorded preprocedure, at 2 weeks, and at 2 months. Data analysis of 247 patients was completed. Differences in VNPS scores and the RMDI were then compared on the basis of a CT-guided approach (anterolateral versus posterior). There was no statistical difference in the degree of pain relief and improvement in the RMDI between the CT-guided transforaminal anterolateral approach and the posterior approach at 2 weeks and at 2 months. Both groups demonstrated a statistically significant improvement in pain scores and the RMDI. Approximately 35% of patients in both groups demonstrated >50% pain relief at 2 months. There were no serious complications in either group. CT-guided transforaminal cervical epidural injections by using a posterior approach are safe and effective.

The Pain Alleviation Using Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis in Patients With Unresectable Pancreatic Cancer

Background: Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) represents an alternative approach to pain palliation in patients with advanced pancreatic cancer. Aim: to evaluate the safety and initial efficacy of EUS-CPN in patients with painful unresectable pancreatic cancer. Methods: Patients with inoperable body-tail pancreatic adenocarcinoma without prior chemotherapy and pain requiring opioid analgesia were included prospectively in this cohort study in a tertiary medical center. Central EUS-CPN was performed and the brief pain inventory and the Functional Assessment of Cancer Therapy measurement were applied before and 2 weeks after the procedure. Results: Thirty-two patients underwent the procedure in one session without complications. Follow-up revealed overall pain relief in 24 patients (75%) and significant improvement in pain scores. Ratings of pain interfering with general activity, walking, work, mood, enjoyment of life, relations with others, and sleep improved significantly. Physical, functional, and emotional well-being improved significantly, except for acceptance of illness and enjoyment of life. Conclusion: Central EUS-CPN was an efficient and safe method for palliative pain management in our patients with inoperable pancreatic body-tail adenocarcinoma. The pain alleviation improved the patients’ functional status, sleep, and quality of life, although other variables could also be involved, but acceptance of the illness and enjoyment of life did not change after treatment.

Short-term outcomes using the Christensen patient-specific temporomandibular joint implant system: a prospective study

Thirty-one patients were assessed for changes in pain and maximal mouth opening (MMO) before and after total temporomandibular joint (TMJ) replacement. All prosthetic joint replacements used the Christensen fossa-eminence prosthesis system; 18 were unilateral and 13 bilateral. There were more women (n=22) than men (n=9), and their mean age was 45 years (women 46, range 18–74, and men 42, range 28–69). Indications for replacement included osteoarthritis, ankylosis, and “other”. There were overall significant improvements in pain scores for the whole group at one year (95% CI 6.3–8.5 compared with 0.2–3.0) and for women alone (6.5 to 9.2 compared with −0.5 to 2.0). There were also significant improvements in pain scores in both those with osteoarthritis (95% CI 8.1 to 8.9 compared with −0.8 to 3.8) and the group with “other” diagnoses at the 12-month follow-up (95% CI 4.4 to 10.7 compared with −0.2 to 0.5). Finally, there was a significant improvement in MMO in the whole group at the time of 12-month follow-up (95% CI 15.8–23.5 compared with 24.0–32.3).

The effect of isolytic contraction and passive manual stretching on pain and knee range of motion after hip surgery: A prospective, double-blinded, randomized study

Abstract Stretching has its impact on both contractile and noncontractile tissues and is the most important rehabilitation technique utilised used to prevent and treat joint stiffness. Passive manual stretch (PMS) and muscle energy technique (MET) are two of the most commonly used techniques. Our study evaluates the effectiveness of isolytic form of MET in gaining knee range of motion (ROM) and decreasing pain in acute knee involvement and comparing it with standard PMS. We used the clinical scenario of knee joint mobilization in patients operated for hip fractures. Fifty-two subjects were alternatively randomized to two groups, isolytic contraction (ILC) group (n = 26) and PMS group (n = 26). In both the PMS and ILC groups, significant improvements in pain score (measured by the visual analog scale) and knee ROM were reported after the treatment period (p 0.05). Thus, isolytic form of MET may be a viable method to decrease pain and improve knee ROM in patients who had undergone surgery after a hip fracture.

Arthroscopic surgery for treatment of anterior displacement of the disc without reduction of the temporomandibular joint

The aim of this study was to investigate the clinical results and efficacy of an arthroscopic approach to correct anterior displacement of the disc without reduction of the temporomandibular joint (TMJ) with limitation of mouth opening. We studied 28 joints with internal derangement in 23 patients, all of whom had had arthroscopic surgery (lavage, lysis of adhesions in the superior compartment, incision parallel to the disc-synovial crease of the upper joint compartment, and pull back of the anteriorly located disc). Objective and subjective data (increase in maximal interincisal opening, magnetic resonance imaging, and visual analogue pain score, VAS) were collected preoperatively and at 7, 30, 60days, and 6 months or more postoperatively. Maximal interincisal opening improved from a mean (SD) of 20.4 (±4.5) mm preoperative measurement to 38.9 (±3.2) mm by 6 months postoperatively where indicated in previous line. The VAS showed a significant improvement in pain score (p=0.0023). Sixty days postoperatively the positions of the discs in 14 of the TMJs had improved considerably. In 13 of the TMJs the positions had improved slightly. Only 1 of the TMJs had not improved at all. There were no complications in any patient. Our arthroscopic procedure is safe, minimally invasive, and effective for the treatment of patients with displacement of the disc anteriorly without reduction of the TMJ.

A Double Blind, Randomized, Placebo Controlled Clinical Study Evaluates the Early Efficacy of Aflapin® in Subjects with Osteoarthritis of Knee

Aflapin(®) is a novel synergistic composition derived from Boswellia serrata gum resin (Indian Patent Application No. 2229/CHE/2008). Aflapin is more efficacious as an anti-inflammatory agent compared to the existing Boswellia products, 5-Loxin(®) and traditional 65% Boswellia extract. A 30-day, double-blind, randomized, placebo-controlled study was conducted to validate the efficacy of Aflapin(®) in the management of clinical symptoms of osteoarthritis (OA) of the knee (Clinical trial registration number: ISRCTN69643551). Sixty eligible OA subjects selected through screening were included in the study. The subjects received either 100 mg (n=30) of Aflapin(®) or placebo (n=30) daily for 30 days. Each subject was evaluated for pain and physical functions by using the standard tools (visual analog scale, Lequesne's Functional Index, and Western Ontario and McMaster Universities Osteoarthritis Index) at the baseline (day 0), and at days 5, 15 and 30. A series of biochemical tests in serum, urine and hematological parameters established the safety of Aflapin. The observations suggest that Aflapin conferred clinically and statistically significant improvements in pain scores and physical function scores in OA subjects. Aflapin provided significant improvements in pain score and functional ability in as early as 5 days of treatment. In conclusion, our observations suggest that Aflapin is a safe, fast acting and effective alternative intervention in the management of OA.

Injection Treatment and Back Pain Associated with Degenerative Lumbar Spinal Stenosis in Older Adults

Lower back pain is one of the most common health-related complaints in the adult population. Thirty percent of Americans 65 years and older reported symptoms of lower back pain in 2004 (NCHS, 2006). Injection treatment is a commonly used non-surgical procedure to alleviate lower back pain in older adults. However, the effectiveness of injection treatment, particularly in older adults, has not been well documented. This study quantified the effectiveness of injection treatment on pain relief among adults 60 years and over who were diagnosed with degenerative lumbar spinal stenosis, a common cause of lower back pain in older adults. The variations of the effectiveness were examined by selected patient attributes. Prospective, non-randomized, observational human study. Single institution spine clinic. Patients scheduled for lumbar injection treatment between January 1 and July 1, 2008 were prospectively selected from the study spine clinic. Selection criteria included patients age 60 and over, diagnosed with degenerative lumbar spinal stenosis and no previous lumbar injection within 6 months or lumbar surgery within 2 years. The pain sub-score of the SF-36 questionnaire was used to measure pain at baseline and at one and 3 months post injection. Variations in longitudinal changes in pain scores by patient characteristics were analyzed in both unadjusted (univariate) analyses using one-way analysis of variance (ANOVA), and adjusted (multiple regression) analyses using linear mixed effects models. This study is limited by its sample size and observational design. Of 62 patients receiving epidural steroid injections, the mean Pain score at baseline was 27.4 (SD =13.6), 41.7 (SD = 22.0) at one month and 35.8 (SD = 19.0) at 3 months. Mean Pain scores improved significantly from baseline to one month (14.1 points), and from baseline to 3 months (8.3 points). Post injection changes in pain scores varied by body mass index (BMI) and baseline emotional health. Based on a linear mixed effects model analysis, higher baseline emotional health, as measured by the SF-36 Mental Component Score (MCS >/= 50), was associated with greater reduction in pain over 3 months when compared to lower emotional health (MCS), was associated with greater reduction in pain over 3 months when compared to lower emotional health (MCS <50). In patients with higher emotional health, pain scores improved by 14.1 (P < .05: 95% CI 6.9, 21.3). Patients who were obese also showed significant improvement in pain scores over 3 months compared to non-obese patients. In obese patients, pain scores increased by 7.9 (P <.05; 95% CI:1.0, 14.8) points. Lower back pain in older adults with degenerative lumbar spinal stenosis might be clinically significantly alleviated after injection treatment. Pain relief varies by a patients personal and clinical characteristics. Healthier emotional status and obesity appears to be associated with more pain relief experienced over 3 months following injection.

Prospective evaluation of combined local bupivacaine and steroid injections for the management of chronic vaginal and perineal pain

Vaginal/perineal pain is common following obstetric trauma or vaginal surgery for prolapse and may have a serious impact on sexual function and quality of life. Local injections of corticosteroids, local anaesthetic and hyaluronidase are treatment options for chronic pain; however, there are no published studies to support their efficacy. The objective of this study was to evaluate prospectively the efficacy of perineal/vaginal injections for chronic localised pain following childbirth or vaginal surgery. Consecutive women with chronic vaginal/perineal pain were recruited in this prospective series (audit). Pain severity and sexual function were determined using a visual analogue scale (VAS 0-10) and the abbreviated sexual function questionnaire (ASFQ) respectively. Patients underwent local injections with a combination of 0.5% bupivacaine (10 ml), hydrocortisone (100 mg) and hyaluronidase (1,500 IU). Follow-up was undertaken at four-weekly intervals. Further injections were performed as clinically indicated. Fifty-three women underwent ≥1 injections [mean: 1.86 (range: 1-4)]. Mean interval from index childbirth [43/53 (81%)] or surgical intervention [10/53 (19%)] was 8 months (range 12 weeks-20 years). Twenty-seven women (51%) were sexually active. All reported dyspareunia. Fifteen (28%) women required 1 and 31(59%) two injections. Pre treatment VAS pain scores were 6.1 versus 4.1 after first injection (p = 0.0002, 95% CI 1.01-3.05) and mean ASFQ scores increased from 18.1 to 29.1 (p = 0.01, 95% CI -17.2 to -2.3) 4 weeks post-injection. There were no adverse events or morbidity. 24/27 (89%) sexually active women with dyspareunia resolved and 18/26 (69%) sexually inactive women resumed satisfactory sexual activity 8 weeks post-injection. In our series, this treatment was well tolerated and significant improvements in pain scores and sexual function were observed.

Experts' agreement on therapy for bone metastases

Experts' agreement on therapy for bone metastases

Treatment of endometriosis and chronic pelvic pain with letrozole and norethindrone acetate

Background: Endometriosis is encountered in 7-10% of actively menstruating women, with a suspected prevalence as high as 22% in asymptomatic women. It is an important cause of chronic pelvic pain. The aim of this study was to evaluate the efficacy and safety of letrozole in combination with norethindrone acetate and calcium in the management of endometriosis associated pelvic pain. Methods: Prospective non-randomized open label study was carried out including 20 patients with endometriosis related pelvic pain that was refractory to previous treatments. Result: In all 14 patients completed the study. All patients showed significant improvement of pain scores and revealed significant improvement of features of endometriosis on being given letrozole in combination with norethindrone acetate and calcium. Conclusion: Letrozole is an effective drug for treatment of endometriosis.

Technical Aspects of Spinal Cord Stimulation for Managing Chronic Visceral Abdominal Pain: The Results from the National Survey

BACKGROUND, OBJECTIVES, AND METHODS: A few recent reports suggested that spinal cord stimulation (SCS) effectively suppresses chronic abdominal pain. However, there is no consensus on patient selection or technical aspects of SCS for such pain. That is why we conducted national survey and collected 76 case reports. There were six incompletely filled reports, so we analyzed 70 cases. There were 43 female and 27 male patients. SCS was trialed in an average of 4.7 days (median of 4 days). In most patients, the leads were positioned for the SCS trial with their tips at the level of the T5 vertebral body (26 patients) or T6 vertebral body (15 patients). Four patients failed SCS trial: their average baseline visual analog scale (VAS) pain score was 7 +/- 2.4 cm and did not improve at the conclusion of the trial (6.5 +/- 1.9 cm; P = 0.759). Pain relief exceeded 50% in 66 of 70 patients reported. Among those, VAS pain score before the trial averaged 7.9 +/- 1.8 cm. During the trial VAS pain scores decreased to 2.45 +/- 1.45 cm (P < 0.001). The opioid use decreased from 128 +/- 159 mg of morphine sulfate equivalents a day to 79 +/- 112 mg (P < 0.017). During permanent implantation most of the physicians used two octrode leads and were positioned midline at T5-6 levels. The average patient follow-up was 84 weeks. VAS pain scores before an implant were 8 +/- 1.9 cm, while after the implant 2.49 +/- 1.9 cm. The opioid use before an implant was 158 +/- 160 mg and at the last office visit after the implant 36 +/- 49 mg. In conclusion, it seems that the SCS for the treatment of the abdominal visceral pain may provide a positive patient long-term experience, significant improvements in pain scores and a decrease in opioid use.