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Complex Regional Pain Syndrome Associated with Cervical Disc Protrusion and Foraminotomy
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Study Design. Case report.Objective. To report a previously undescribed association between complex regional pain syndrome (CRPS) and surgery for cervical disc protrusion. Although CRPS has been associated with disc protrusion and lumbar spine surgery, there is no record in the literature of a similar association with cervical disc protrusion.Methods. Description of a clinical case.Results. A patient with radicular pain due to cervical disc protrusions underwent posterior foraminotomy, which did not relieve his pain. Within 3[ndash]4 weeks, he developed features of CRPS. Review at 16, 22, and 34 months revealed some, but limited, improvement.Conclusions. This case provides circumstantial evidence of a hitherto undescribed association between CRPS and cervical disc protrusion. The mechanism is elusive, but may involve damage to small nerves in or near the intervertebral foramina.
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Differences in Pain, Psychological Symptoms, and Gender Distribution among Patients with Left- vs Right-Sided Chronic Spinal Pain
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Objective. To determine pain levels, function, and psychological symptoms in relation to predominant sidedness of pain (right or left) and gender in patients being treated for chronic spinal pain.Design. Prospective cohort study.Patients. Patients with chronic neck or low back pain undergoing a nerve block procedure in a specialty pain medicine clinic.Interventions/Outcomes. Patients completed the Hospital Anxiety and Depression Scale and the Brief Pain Inventory just prior to the procedure. Pain history and demographic variables were collected from a chart review. Chi-square, Pearson correlations, and multivariate statistics were used to characterize the relationships between side of pain, gender, pain levels, pain interference, and psychological symptoms.Results. Among 519 subjects, men with left-sided pain (N = 98) were found to have significantly greater depression and anxiety symptoms and worse pain-related quality of life (P < 0.01), despite having similar pain levels as men with right-sided pain (N = 91) or women with left- or right-sided pain (N = 289). In men, psychological symptoms had a significantly greater correlation with pain levels than in women (P < 0.01).Conclusion. In this sample, men with left-sided spinal pain report worse quality of life and more psychological symptoms than women. These data provide clinical evidence corroborating basic neuroscience findings indicating that the right cerebral hemisphere is preferentially involved in the processing of pain and negative affect. These data suggest that men appear more right hemisphere dominant in pain and affect processing. These findings have implications for multidisciplinary assessment and treatment planning in men.
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Efficacy of Fluoroscopically Guided, Contrast-Enhanced Lumbosacral Interlaminar Epidural Steroid Injections: A Pilot Study
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Objective. To assess the efficacy of fluoroscopically guided, contrast-enhanced lumbar interlaminar epidural steroid injections (IL-ESI) for lower limb pain greater than axial low back pain using self-reported pain scores.Study Design. Prospective, single-arm, pilot, observational human study.Setting. An outpatient private practice interventional spine specialty referral center.Data/Results. Twenty-one patients were initially included in analysis. Thirteen patients had "complete data" and completed 3 months of data after their most recent IL-ESI. Their self-reported 3-day average Numeric Pain Rating Scale (NPRS) score (0 to 10) at inception, 2 weeks, 6 weeks, and 3 months were 6.38, 3.00, 2.88, and 3.04, respectively. The average NPRS score at 3 months was significantly lower than at inception after the IL-ESI for this group (P = 0.0001, 95% confidence interval [1.69, 5.00]). Eight patients had "incomplete data." Their self-reported 3-day average NPRS scores at inception, 2 weeks, and 6 weeks were 6.69, 4.25, and 4.00, respectively. Of the eight patients who had incomplete data, two patients had surgical intervention, five patients had lumbar transforaminal epidural steroid injections, and one patient was unable to be contacted after 6 weeks.Discussion/Conclusion. This prospective, single-arm pilot study demonstrates that subjects who have had fluoroscopically guided, contrast-enhanced lumbar IL-ESIs for radicular > axial pain can have improved (lowered) NPRS for at least 3 months. It would be worthwhile to pursue a more rigorous study.
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Obstetric Anesthesia Handbook
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The Effect of Repeated Zygapophysial Joint Radiofrequency Neurotomy on Pain, Disability, and Improvement Duration
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Objective. To assess the effectiveness of repeated radiofrequency neurotomy (RFN) on pain, disability, and treatment effect duration.Patients. One hundred-four patients who underwent repeat RFN for chronic neck or back pain were prospectively followed using a Pain Disability Questionnaire-Spine (PDQ-S). Complete data sets were available for 73, 73, and 36 patients for the 1st, 2nd, and 3rd RFN, respectively.Results. Pain intensity, pain frequency, and patient-specific disability measures were significantly improved post-initial, second, and third RFN. Moreover, there was no statistically significant difference among the PDQ-S scores post-RFN 1, 2, and 3. There was no statistical significance between the duration of pain relief post-RFN 1 and pain relief post-RFD 2.Conclusion. Repeated cervical and lumbar RFN reduces pain and disability with equal effectiveness for approximately 10 months in patients with facetogenic chronic neck and back pain.
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Dercum's Disease: An Unusual Presentation
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Dercum's disease, also known as adiposis dolorosa, is a rare disease characterized by the accumulation of painful subcutaneous deposits of mature adult fatty tissue around the thighs, trunk, and upper arms and usually in a multifocal distribution. We are reporting an unusual presentation of Dercum's disease, presenting as a single painful, erythematous lesion around the left hip in a 71-year old postmenopausal woman. This report emphasizes the unusual presentation of adiposa dolorosa with a new modality for therapy. A summary of the major clinical associations, diagnostic challenges, and treatment modalities are also included in this manuscript.
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Differences in Brain Structure and Function in Older Adults with Self-Reported Disabling and Nondisabling Chronic Low Back Pain
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Objective. The primary aim of this pilot study was to identify structural and functional brain differences in older adults with self-reported disabling chronic low back pain (CLBP) compared with those who reported nondisabling CLBP.Design. Cross-sectional.Participants. Sixteen cognitively intact older adults, eight with disabling CLBP and eight with nondisabling CLBP. Exclusions were psychiatric or neurological disorders, substance abuse, opioid use, or diabetes mellitus.Methods. Participants underwent: structural and functional brain MRI; neuropsychological assessment using the Repeatable Battery for the Assessment of Neuropsychological Status, Trail Making Tests A and B; and physical performance assessment using the Short Physical Performance Battery.Results. In the disabled group, there was significantly lower white matter (WM) integrity (P < 0.05) of the splenium of the corpus callosum. This group also demonstrated activation of the right medial prefrontal cortex at rest whereas the nondisabled demonstrated activation of the left lateral prefrontal cortex. Combined groups analysis revealed a strong positive correlation (rs = 0.80, P < 0.0002) between WM integrity of the left centrum semiovale with gait-speed. Secondary analysis revealed a strong negative correlation between total months of CLBP and WM integrity of the SCC (rs = [minus]0.59, P < 0.02).Conclusions. Brain structure and function is different in older adults with disabling CLBP compared with those with nondisabling CLBP. Deficits in brain morphology combining groups are associated with pain duration and poor physical function. Our findings suggest brain structure and function may play a key role in chronic pain related disability and may be important treatment targets.
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Negligible Analgesic Tolerance Seen with Extended Release Oxymorphone: A Post Hoc Analysis of Open-Label Longitudinal Data
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Objective. To examine the development of analgesic tolerance in patients on oxymorphone extended-release (OxymER).Design. Post hoc analysis of data from a previously conducted prospective 1 year multi-center open-label extension study in which patients were able to titrate as needed.Patients. Sample of 153 hip and knee osteoarthritis (OA) subjects on OxymER. Primary analyses were limited to study completers (n = 62) due to the large amount of missing data for the noncompleters (n = 91).Outcome Measures. Main outcome measures included OxymER doses (pill counts) and pain intensity ratings using a visual analog scale at monthly visits.Results. There were significant dose increases from weeks 1 to 2 and 2 to 6 (P < 0.05). Doses stabilized around week 6, suggesting the completion of what we defined as "titration." Both doses and pain ratings were stable when this titration phase was excluded from the analysis (P = 0.751; P = 0.056, respectively). Only 28% of the patients had any dose changes following this titration. While there was a significantly greater dose at week 52 compared with week 10 (P = 0.010), the increase in dose became insignificant after excluding four subjects who required two dose increases (P = 0.103).Conclusions. The results showed that most of the titration/dose stabilization changes occurred within the first 10 weeks. A minority (28%) of subjects required dosage increases after this (defined) titration period. Pain reports stabilized statistically after 2 weeks. The findings of this post hoc analysis suggest a lack of opioid tolerance in the majority (72%) of these OA patients who completed this study following a defined titration period on OxymER. This post hoc analysis of oxymorphone ER consumption in osteoarthritis pain vs pain report showed that most dose changes occurred during an initial "titration period" as defined. Following this titration few subjects increased dose and analgesia remained stable. These findings suggest a lack of longitudinal opioid tolerance in the majority of those OA subjects who completed the trial.
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Botulinum Toxin A for Treatment of Allodynia of Complex Regional Pain Syndrome: A Pilot Study
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Objective. To investigate the efficacy and tolerability of Botulinum toxin A (BoNT-A) in allodynia of patients with complex regional pain syndrome.Design. A total of 14 patients were studied. Eight patients were participants of a randomized, prospective, double-blind, placebo-controlled protocol. Six patients were studied prospectively in an open-label protocol. Patients were rated at baseline and at 3 weeks and 2 months after BoNT-A administration. Ratings included brief pain inventory, McGill pain questionnaire, clinical pain impact questionnaire, quantitative skin sensory test, sleep satisfaction scale, and patient global satisfaction scale. BoNT-A was injected intradermally and subcutaneously, five units/site into the allodynic area (total dose 40[ndash]200 units).Results. None of the patients with allodynia showed a significant response after treatment. The treatment was painful and poorly tolerated.Conclusion. Intrademal and subcutaneous administration of BoNT-A into the allodynic skin of the patients with complex regional pain syndrome (CRPS) failed to improve pain and was poorly tolerated.
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A Multi-Center, Randomized, Double-Blind Placebo-Controlled Trial of Intravenous-Ibuprofen (IV-Ibuprofen) for Treatment of Pain in Post-Operative Orthopedic Adult Patients
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Objective. To determine whether pre- and post-operative administration of intravenous ibuprofen (IV-ibuprofen) can significantly decrease pain and morphine use when compared with placebo in adult orthopedic surgical patients.Design. This was a multi-center, randomized, double-blind placebo-controlled trial.Setting. This study was completed at eight hospitals; six in the United States and two in South Africa.Patients. A total of 185 adult patients undergoing elective orthopedic surgery.Interventions. Patients were randomized to receive either 800 mg IV-ibuprofen or placebo every 6 hours, with the first dose administered pre-operatively. Additionally, all patients had access to intravenous morphine for rescue.Outcome Measures. Efficacy of IV-ibuprofen was demonstrated by measuring the patient's self assessment of pain using a visual analog scale (VAS; assessed with movement and at rest) and a verbal response scale (VRS). Morphine consumption during the post-operative period was also assessed.Results. In the immediate post-operative period, there was a 25.8% reduction in mean area under the curve-VAS assessed with movement (AUC-VASM) in patients receiving IV-ibuprofen (P < 0.001); a 31.8% reduction in mean AUC-VAS assessed at rest (AUC-VASR; P < 0.001) and a 20.2% reduction in mean VRS (P < 0.001) compared to those receiving placebo. Patients receiving IV-ibuprofen used 30.9% less morphine (P < 0.001) compared to those receiving placebo. Similar treatment emergent adverse events occurred in both study groups and there were no significant differences in the incidence of serious adverse events.Conclusion. Pre- and post-operative administration of IV-ibuprofen significantly reduced both pain and morphine use in orthopedic surgery patients in this prospective randomized placebo-controlled trial.
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Caution with Epidural Opioid Use in Sleep Apnea Patients
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Painful Medial Branch Neuroma Treated with Minimally Invasive Medial Branch Neurectomy
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Study Design. Case report.Objective. To report an unusual complication following lumbar facet radiofrequency denervation and describe a successful, minimally invasive treatment of a presumed medial branch neuroma. Radiofrequency medial branch neurotomy is a common procedure for the treatment of mechanical back pain. Deafferentation injury and neuroma formation is well known and reported following chemical, surgical, and cryoablation neurolysis; however, it is thought to be rare with radiofrequency ablation. When this problem is encountered, treatment options appear to be limited. Further radiofrequency ablations may be ineffective and indeed may cause further injury.Methods. A 17-year-old male who sustained a traumatic fracture of the right L3-4 facet joint presented with increasing back pain after multiple radiofrequency ablations of the medial branches of the L2 and L3 dorsal rami. The description of the back pain, initially nociceptive in nature, had become progressively neuropathic with clear focal areas of allodynia and hyperesthesia. Further medial branch radiofrequency denervation was found to be ineffective.Results. Diagnostic block of the right medial branch of the L2 dorsal ramus provided the patient with total relief of pain. This was followed by a minimally invasive open surgical ablation of the L2 medial branch neuroma using three-dimensional, fluoroscopy-based image guidance. At 7 months of follow-up, the patient reported complete resolution of pain, discontinuation of all pain medications, and return to all previous physical activities.Conclusion. Deafferentation injury is a rare but recognized complication of chemical, surgical, and thermal neuroablation. This case report presents a rare instance of presumed neuroma formation following multiple radiofrequency ablations for the treatment of facet-generated mechanical back pain. Open and minimally invasive medial branch neurectomy resulted in complete resolution of pain and return to baseline function.
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A Case of Sympathetically Mediated Headache Treated with Stellate Ganglion Blockade
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Background. Chronic pain following trauma may be mediated in part by the sympathetic nervous system. There is evidence of sympathetic nervous system dysfunction in patients who suffer from posttraumatic headaches. Not all patients will obtain relief from conventional and antineuropathic medications. Furthermore, the development of adverse effects may limit therapeutic dosing or continuation of these medications.Case Report. A pediatric case of posttraumatic headache is described. The patient failed medical therapy, and a single stellate ganglion blockade was performed for possible sympathetic involvement. Following sympathetic blockade, the patient's headaches resolved completely. The analgesia proved to be long lasting as the patient reported no further headaches at monthly follow-up intervals. The patient did not require any further analgesic medication after the single procedure.Conclusion. Posttraumatic headache is difficult to treat. Although there is evidence of sympathetic nervous system dysfunction in some patients, the extent to which this influences pain remains to be determined. While most cases are treated with a combination of nonpharmacological and pharmacological measures, sympathetic blockade via the stellate ganglion may be an alternative for those patients not responding to conventional therapy.
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Oxycodone in the Long-Term Treatment of Chronic Pain Related to Scleroderma Skin Ulcers
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Objective. To demonstrate the efficacy and safety of long-term therapy with oxycodone in severe pain of scleroderma skin ulcers.Design. Open study.Setting and Patients. Twenty-nine consecutive patients, referred to our Rheumatology Unit during 2006, affected by systemic sclerosis complicated by painful long-standing skin ulcers entered in the study. In all cases, pain was classified as severe according to World Health Organization guidelines, and oxycodone chloridrate (Oxycontin®; Mundipharma Pharmaceuticals, Milan, Italy) was administrated at the dosage of 10[ndash]20 mg twice daily for a mean period of 7.9 ± 3.2 standard deviation months.Outcome Measures. To evaluate the efficacy and safety of opioid therapy, the following parameters were recorded at standard time intervals: visual analog scale (VAS) pain, Pittsburgh sleep quality index (PSQI), hours of sleep per night, Health Assessment Questionnaire-Disability index, analgesics use (rescue therapy), side effects, vital signs, routine laboratory assessment.Results. After 1 month of therapy, all patients experienced relief of pain (VAS decreased from 93.8 ± 8.72 to 56.7 ± 10.4, P < 0.0001), and better quality of sleep (total hours of sleep increased from 3.68 ± 1.28 to 5.27 ± 0.75, P < 0.0001; PSQI decreased from 9.72 ± 3.95 to 3.37 ± 1.04, P < 0.0001). These parameters further improved after 3 months of therapy and remained stable during the follow-up; moreover, an increase of daily dosage of oxycodone was never required. The observed side effects were always transient and mild; only constipation, when present, was persistent.Conclusion. Oxycodone showed to be effective and safe in the treatment of pain due to severe scleroderma skin ulcers; contemporarily, it markedly improved the patient's compliance to local wound care procedures.
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CNS Measures of Pain Responses Pre- and Post-Anesthetic Ketamine in a Patient with Complex Regional Pain Syndrome
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Background. Previous reports have indicated that ketamine anesthesia may produce significant improvement if not complete recovery of patients with complex regional pain syndrome (CRPS).Aims. Here we report on a patient who had CRPS affecting mainly the right side of her body who underwent functional magnetic resonance imaging (fMRI) scans prior to and in the months following apparent successful treatment with anesthetic doses of ketamine.Materials and Methods. The patient underwent two imaging sessions: one during her pain state (CRPS+) and 1 month after her ketamine treatment in her pain-free state (CRPS-). Both spontaneous and evoked (brush, cold, and heat) pain scores decreased from 7[ndash]9/10 on a visual analog scale prior to the treatment to 0[ndash]1 immediately following and for months after the treatment. For each imaging session, the identical mechanical (brush) and thermal (cold and heat) stimuli were applied to the same location (the skin of the dorsum of the right hand).Results. Comparison of CRPS+ vs CRPS- for the three stimuli showed significant changes throughout the cerebral cortex (frontal, parietal, temporal, cingulate, and hippocampus), in subcortical regions such as caudate nucleus, and in the cerebellum. In addition, resting state network analysis showed a reversal of brain network state, and the recovered state paralleled specific default networks in healthy volunteers.Discussion. The observed changes in brain response to evoked stimuli provide a readout for the subjective response.Conclusion. Future studies of brain function in these patients may provide novel insight into brain plasticity in response to this treatment for chronic pain.
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