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Background: Severe upper back/interscapular, neck and shoulder pain during labor epidural analgesia (PLEA) is not uncommon. The objective of this quality initiative was to evaluate the incidence, demographic associations and management of PLEA., Methods: An eight-month, single-center quality improvement initiative was performed for the detection and management of PLEA. After survey-based consensus among obstetric anaesthetist attendings and fellows, a three-step PLEA treatment protocol with interventions and numeric rating scale (NRS, 0 - 10 scale) pain assessments was introduced. Demographic data and outcomes were compared among parturients with and without PLEA., Results: Among 2888 women who received labor epidural analgesia from October 2022 through May 2023, 36 (1.2% [95% CI 0.9% to 1.7%]) reported PLEA. Women with PLEA were younger, more likely to be nulliparous, and had a higher body mass index (BMI) than women without PLEA (p < 0.05 for all). A total of 72.2% (26/36) of women with PLEA received at least one protocol treatment. Twenty-three women received first-line therapy, with pain relief in 91.3% (21/23). The median NRS score decreased from 9 [IQR 8-10] to 3 [1-4]. Women with PLEA had a higher incidence of cesarean delivery (CD) and a longer interval between epidural placement and delivery; 52.8 vs. 17.5% (p < 0.001) and 16.5 vs. 6.9 hours (p < 0.001), respectively., Conclusions: The incidence of PLEA was higher than previously reported. Patients with PLEA were younger, more commonly nulliparous, had higher BMI, longer epidural infusion times and higher CD rates. A three-step treatment protocol was successful in managing PLEA., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Context: Back pain is one of the most common problems experienced by patients after the cardiac electrophysiological study procedure. In addition, limitation of movement after the procedure negatively affects the comfort and satisfaction of patients., Objectives: The aim of this study was to determine the effect of back massage with frankincense and myrrh oil on back pain severity and comfort in patients who were to undergo cardiac electrophysiological study., Methods: This is a randomized controlled study with a pretest-posttest design. This study was conducted from October 2020 to March 2021, at the angio unit of a heart hospital at a university in Turkey. The study was completed with 30 patients in each group, a total of 90 people. Data were collected using a patient information form, a Visual Analogue Scale (VAS) and the General Comfort Questionnaire (GCQ). The intervention group and the placebo group received back massage with frankincense and myrrh essential oil and with jojoba fixed oil respectively. No intervention was applied to the control group., Results: There was no statistically significant difference between the post-procedure VAS values according to the groups. Except for sociocultural comfort, there were significant differences between the groups in terms of GCQ total scores and subscales at the first and last follow-up., Conclusions: Back massage with frankincense and myrrh oil increased overall comfort, physical comfort, the psychospiritual comfort. Additional research with a rigorous design is needed to determine its effect on pain., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Competing Interests: MDS and JCB are board members (unpaid) of Physicians for Responsible Opioid Prescribing and have been paid consultants in opioid litigation.

Background: The ability to accurately predict pain generators for chronic neck and back pain remains elusive., Objective: We evaluated whether injections targeted at foci with uptake on single-photon emission computerized tomography-computed tomography (SPECT-CT) were associated with improved outcomes in patients with chronic neck and back pain., Methods: A retrospective review was completed on patients undergoing SPECT-CT for chronic neck and back pain between 2016 and 2020 at a tertiary academic center. Patients' records were reviewed for demographic, clinical, imaging, and outcomes data. Only those patients who had facet injections after SPECT-CT were included in this evaluation. Patients undergoing injections targeted at foci of abnormal radiotracer uptake were compared with patients without uptake concerning immediate positive response, visual analog scale, and the need for additional injection or surgery at the target level., Results: A total of 2849 patients were evaluated with a SPECT-CT for chronic neck and back pain. Of those, 340 (11.9%) patients received facet joint injections after SPECT-CT. A propensity score regression analysis adjusted for age, gender, body mass index, hypertension, multiple target injections, and injection location showed uptake targeted injections not being associated with an improved immediate positive response (odds ratio: 0.64; 95% confidence interval: 0.34-1.21; P = 0.172). In patients with a failed facet injection preceding SPECT-CT, adding SPECT-CT to guide facet injections was associated with a decrease in visual analog scale pain scores 2 weeks after injection (P = 0.018), particularly when changes were made to the facets being targeted (P = 0.010)., Conclusion: This study suggests that there is benefit with SPECT-CT specially to guide facet injections after failed prior facet injections., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Condoliase-induced chemonucleolysis is a less-invasive alternative treatment for lumbar disc herniation (LDH); however, its long-term clinical outcome is still unclear. This study aimed to investigate 1-year clinical outcomes and assess radiographs after chemonucleolysis with condoliase., Methods: We enrolled patients with LDH who received condoliase injection with a follow-up period of >1 year. Sixty patients (37 men, 23 women; mean age, 44.5 ± 18.9 years; mean follow-up period, 22.0 ± 6.0 months) were analyzed. Changes in disc height and degeneration were evaluated using magnetic resonance imaging. Visual analog scale (VAS) scores for leg and back pain and the Oswestry disability index (ODI) were obtained. All data were assessed at baseline, 1-month, 3-month, and 1-year follow-up., Results: Surgical treatment was subsequently required in 8 patients (12.5%) after condoliase therapy. Their ODI and VAS scores for leg pain and back pain significantly improved at 1 year, as in those who received condoliase therapy only. On MRI, progression of Pfirrmann grade was observed in 23 patients (44.2%) at 3 months; however, 8 patients recovered to baseline at 1 year. The mean disc height decreased at 3 months; however, it recovered at 1 year. Disc height recovery (disc recovery rate >50%) was observed in 30.8% of the patients. Patients with disc height recovery were significantly younger than those without. Patients with longer symptom duration (≥1 year) showed significantly lower rates of effectiveness compared with those with shorter symptom durations (<1 year)., Conclusions: Chemonucleolysis with condoliase is a safe and minimally invasive treatment. Disc degeneration induced by chemonucleolysis could be recovered, particularly in younger patients. Prolonged symptom duration had adverse effects on outcome; thus, therapeutic intervention at the optimal time is needed., Competing Interests: Declaration of competing interest We have nothing to disclose., (Copyright © 2021 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: Making surgery as less aggressive as possible is best for elderly patients with osteoporotic vertebral compression fractures (OVCFs). Recently, we attempted a more precise, minimally invasive, and robot-assisted kyphoplasty in our clinical setting., Objective: We sought to compare the clinical and radiologic outcomes of robot-assisted percutaneous kyphoplasty (rPKP) with those of fluoroscopy-assisted percutaneous kyphoplasty (fPKP) in treating OVCFs., Methods: We retrospectively reviewed the clinical and radiologic data of patients with single-segment OVCF who received either rPKP or fPKP between January 2020 and December 2020 at our institution. The operation time, injected volume of cement, length of hospital stays, visual analog scale for back pain, Oswestry Disability Index, local kyphosis angle (LKA), height of fractured vertebra (HFV), and perioperative complications were compared between the 2 groups., Results: A total of 212 cases were included in this study, among whom 81 cases received rPKP and 131 cases received fPKP. Both techniques exhibited satisfying improvement in pain relief and radiologic outcomes. Specifically, the rPKP costed less operation time and achieved better correction and maintenance regarding LKA, HFV, and instant pain relief (P < 0.05). The length of hospital stays, incidence of cement leakage, visual analog scale for back pain, and Oswestry Disability Index at final follow-up were comparable between 2 groups., Conclusions: rPKP provides a precise puncture and exhibits superiority in the correction and maintenance of LKA and HFV when compared with traditional fPKP. The cost-effectiveness and specific application scenarios of this technique shall be confirmed via further extensive studies., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Radicular low back pain is difficult to treat and commonly encountered in the Emergency Department (ED). Pain associated with acute radiculopathy results in limited ability to work, function, and enjoy life, and is associated with increased risk of chronic opioid therapy. In this case report, we describe the first ED-delivered ultrasound-guided caudal epidural steroid injection (ESI) used to treat medication-refractory lumbar radiculopathy, which resulted in immediate and sustained resolution of pain., Case Report: A 56-year old man with a past medical history of chronic lumbar radiculopathy presented to the ED with acute low back and right lower-extremity pain. Based on history and physical examination, a right L5 radiculopathy was suspected. His pain was poorly controlled despite multimodal analgesia, at which point he was offered admission or an ultrasound-guided caudal ESI. The procedure was performed using dexamethasone, preservative-free normal saline, and preservative-free 1% lidocaine solution, after which the patient reported 100% resolution of his pain and requested discharge from the ED. Why Should an Emergency Physician Be Aware of This? The safety and efficacy of ultrasound-guided caudal ESIs have been established, but there is a paucity of literature exploring their application in the ED. We present a case of a refractory lumbar radiculopathy successfully treated with an ultrasound-guided caudal ESI. ED-performed epidurals can be one additional tool in the emergency physician arsenal to treat acute or chronic lumbar radiculopathy., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objective: Pharmacogenomics may help personalize medicine and improve therapeutic selection. This is the first study investigating how pharmacogenomic testing may inform analgesic selection in patients with spine disease. We profile pharmacogenetic differences in pain medication-metabolizing enzymes across patients presenting at an outpatient spine clinic and provide preliminary evidence that genetic polymorphisms may help explain interpatient differences in preoperative pain refractory to conservative management., Methods: Adults presenting to our outpatient spine clinic with chief symptoms of neck and/or back pain were prospectively enrolled over 9 months. Patients completed the Wong-Baker FACES and numeric pain rating scales for their chief pain symptom and provided detailed medication histories and cheek swab samples for genomic analysis., Results: Thirty adults were included (mean age, 60.6 ± 15.3 years). The chief concern was neck pain in 23%, back pain in 67%, and combined neck/back pain in 10%. At enrollment, patient analgesic regimens comprised 3 ± 1 unique medications, including 1 ± 1 opioids. After genomic analysis, 14/30 patients (47%) were identified as suboptimal metabolizers of ≥1 medications in their analgesic regimen. Of these patients, 93% were suboptimal metabolizers of their prescribed opioid analgesic. Nonetheless, pain scores were similar between optimal and suboptimal metabolizer groups., Conclusions: This pilot study shows that a large proportion of the spine outpatient population may use pain medications for which they are suboptimal metabolizers. Further studies should assess whether these pharmacogenomic differences indicate differences in odds of receiving therapeutic benefit from surgery or if they can be used to generate more effective postoperative analgesic regimens., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Preoperative chronic narcotic use has been linked to poor outcomes after surgery for degenerative spinal disorders in the form of lower health-related quality of life scores, higher revision rates, increased infections, lower likelihood of return to work, and higher 90-day readmission rates. This study evaluated the impact of preoperative chronic narcotic use on patient reported outcome measures following adult spinal reconstructive surgery., Methods: Patients who underwent adult spinal reconstructive surgery over 2 years at our institution were identified from a prospectively maintained spine registry. These patients were grouped into chronic opiate users as defined by a 6-month duration of use with a minimum morphine equivalent dose of 30 mg/day. Patient reported outcome measures were collected prospectively., Results: Of 140 patients included for analysis, 30 (21.4%) patients were categorized as chronic opiate users. No differences were identified in mean preoperative patient reported outcome measures, including Oswestry Disability Index, health state, visual analog scale, and EQ-5D indices. At both 6 weeks and 6 months postoperatively, patients in the opiate group demonstrated significantly worse mean visual analog scale back pain scores relative to the nonopiate group. At 6 months postoperatively and at the last known clinical follow-up, Oswestry Disability Index scores were higher in the opiate group., Conclusions: Chronic opiate use before adult spinal reconstructive surgery was associated with worse pain and disability following intervention. Further work is needed to understand the role of opiate weaning as part of a larger prehabilitation strategy for adult spinal reconstructive surgery., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To evaluate the association between opioid prescribing during pregnancy and new persistent opioid use in the year following delivery., Materials and Methods: This nationwide retrospective cohort study included patients aged 12-55 years in Optum's deidentified Clinformatics Data Mart Database who were undergoing vaginal delivery or cesarean delivery from 2008 to 2016, with continuous enrollment from 2 years before birth to 1 year postdischarge. Women were included if they were opioid naive in pregnancy (ie, did not fill an opioid prescription 2 years to 9 months before delivery) and did not undergo a procedure within the year after discharge. The exposure was filling an opioid prescription in pregnancy. The primary outcome was new persistent opioid use, defined as a pharmacy claim for ≥1 opioid prescription between 4 and 90 days postdischarge and ≥1 prescription between 91 and 365 days postdischarge. Clinical and demographic covariates were included. Analyses included descriptive statistics and multivariable logistic regression, adjusting for clinical and demographic covariates., Results: Of 158,425 childbirths identified, 101,013 (63.8%) were by vaginal delivery and 57,412 (36.2%) cesarean delivery. Among all patients, 6.0% (9429) filled an opioid prescription during pregnancy. The factors associated with filling an opioid in pregnancy were having a nondelivery procedure in pregnancy (adjusted odds ratio, 9.60; 95% confidence interval, 8.81-10.47) and having an emergency room visit during pregnancy (adjusted odds ratio, 2.48; 95% confidence interval, 2.37-2.59). Of women who received an opioid in pregnancy, 4% (379) developed new persistent opioid use. The factors most associated with new persistent opioid use were receiving an opioid prescription during pregnancy (adjusted odds ratio, 3.45; 95% confidence interval, 3.04-3.92) and filling a peripartum opioid prescription (1 week prior to 3 days postdischarge) adjusted odds ratio, 2.28, 95% confidence interval (2.02-2.57). Though having a procedure during pregnancy was associated with increased receipt of an opioid prescription, it was also associated with reduced new persistent opioid use (adjusted odds ratio, 0.72; 95% confidence interval, 0.52-0.99)., Conclusion: Women who receive an opioid prescription during pregnancy are more likely to experience new persistent opioid use. Maternity care providers must balance pain management in pregnancy with potential risks of opioids., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Multisite pain, including low-back and knee pain, is a major health issue that greatly decreases quality of life., Objectives: This study analyzed the effects of l-serine, which provides necessary components for nerve function, and EPA, which exerts anti-inflammatory properties, on pain scores of adults with pain in at least the low back and knee for ≥3 mo., Methods: This was a randomized, double-blind, placebo-controlled, parallel-group study. The Japan Low Back Pain Evaluation Questionnaire (JLEQ) and Japanese Knee Osteoarthritis Measure (JKOM) were applied as primary outcomes. The Brief Pain Inventory (BPI) and safety evaluation were secondary outcomes. We enrolled 120 participants aged ≥20 y (36 men and 84 women: mean ± SD age = 40.8 ± 10.9 y). The participants were randomly allocated to either the active group (daily ingestion of 594 mg l-serine and 149 mg EPA) or placebo group. The study period consisted of 8-wk dosing and 4-wk posttreatment observation. ANCOVA between groups for each time point was conducted using the baseline scores as covariates., Results: The JLEQ scores (active compared with placebo: 14.2 ± 11.2 compared with 19.0 ± 10.2) at week 8 were lower in the active group (P < 0.001). The JKOM scores at week 4 (11.7 ± 9.0 compared with 13.9 ± 7.9), week 8 (10.4 ± 7.9 compared with 13.1 ± 7.1), and week 12 (10.3 ± 7.4 compared with 13.8 ± 7.5) were lower in the active group (P ≤ 0.04). Additionally, the active group had 11-27% better scores compared with the placebo group for BPI1 (worst pain), BPI3 (average pain), and BPI5D (pain during moving) at week 4 (P ≤ 0.028) and week 8 (P ≤ 0.019), respectively, and BPI5D was 23% better in the active group at week 12 (P = 0.007). No adverse events were observed., Conclusions: l-Serine and EPA were effective for pain relief in adults with low-back and knee pain after multiplicity adjustment.This trial was registered at the University Hospital Medical Information Network Clinical Trials Registry as UMIN000035056., (Copyright © The Author(s) on behalf of the American Society for Nutrition 2020.)

Background: Epidural injections are routinely used for management of radicular pain and are prevalent nonsurgical interventions for chronic low back pain. Pneumocephalus is a rare complication that may occur as a result of inadvertent dural puncture with an epidural needle. Pneumocephalus-induced cranial nerve deficit is also rare, with only a few reported cases., Case Report: We report a case of a 61-year-old woman with a chief complaint of diplopia after she underwent epidural injection for chronic lumbar pain. Her examination was remarkable for a partial right oculomotor nerve palsy. We obtained a computed tomography brain scan, which revealed pneumocephalus. She was managed conservatively and reported complete symptom resolution after 2 weeks. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pneumocephalus is an uncommon complication of epidural spinal injections. Emergency physicians should include this on the differential for a patient presenting with cranial nerve deficit after this procedure., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Prescription opioids account for 40% of all U.S. opioid overdose deaths, and national efforts have intensified to reduce opioid prescriptions. Little is known about the relationship between peripheral artery disease (PAD) and high-risk opioid use. The objectives of this study were to evaluate this relationship and to assess the impact of PAD treatment on opiate use., Methods: In this retrospective cohort study, the Truven Health MarketScan database (Truven Health Analytics, Ann Arbor, Mich), a deidentified national private insurance claims database, was queried to identify patients with PAD (two or more International Classification of Diseases, Ninth Revision diagnosis codes of PAD ≥2 months apart, with at least 2 years of continuous enrollment) from 2007 to 2015. Critical limb ischemia (CLI) was defined as the presence of rest pain, ulcers, or gangrene. The primary outcome was high opioid use, defined as two or more opioid prescriptions within a 1-year period. Multivariable analysis was used to determine risk factors for high opioid use., Results: A total of 178,880 patients met the inclusion criteria, 35% of whom had CLI. Mean ± standard deviation follow-up time was 5.3 ± 2.1 years. An average of 24.7% of patients met the high opioid use criteria in any given calendar year, with a small but significant decline in high opioid use after 2010 (P < .01). During years of high opioid use, 5.9 ± 5.5 yearly prescriptions were filled. A new diagnosis of PAD increased high opioid use (21.7% before diagnosis vs 27.3% after diagnosis; P < .001). A diagnosis of CLI was also associated with increased high opioid use (25.4% before diagnosis vs 34.5% after diagnosis; P < .001). Multivariable analysis identified back pain (odds ratio [OR], 1.89; 95% confidence interval [CI], 1.84-1.93; P < .001) and illicit drug use (OR, 1.87; 95% CI, 1.72-2.03; P < .001) as the highest predictors of high opioid use. A diagnosis of CLI was also associated with higher risk (OR, 1.61; 95% CI, 1.57-1.64; P < .001). A total of 43,443 PAD patients (24.3%) underwent 80,816 PAD-related procedures. After exclusion of periprocedural opioid prescriptions (4.9% of all opioid prescriptions), the yearly percentage of high opioid users increased from 25.8% before treatment to 29.6% after treatment (P < .001)., Conclusions: Patients with PAD are at increased risk for high opioid use, with nearly one-quarter meeting described criteria. CLI and treatment for PAD additionally increase high opioid use. In addition to heightened awareness and active opioid management, our findings warrant further investigation into underlying causes and deterrents of high-risk opioid use., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Compartment syndrome is a life-threatening complication of traumatic injury, most commonly, direct trauma. Back pain is a common cause of visits to the emergency department (ED) and often is treated without imaging or diagnostic testing. Lumbar paraspinal compartment syndrome is a rare cause of acute back pain., Case Report: A 43-year-old woman presented to the ED after direct trauma to the lower back. Laboratory studies revealed rhabdomyolysis and acute kidney injury, with examination findings and imaging consistent with lumbar paraspinal compartment syndrome. She was taken to the operating room for emergent fasciotomy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is the job of the emergency physician to identify the red flags in history and physical examination that warrant further diagnostic testing. Early diagnosis and surgical consultation is the key in avoiding morbidity and achieving good outcomes in all forms of compartment syndrome., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Pregnancy and lactation-associated osteoporosis (PLO) is a rare disease, which can lead to vertebral fractures in women of reproductive age. No treatment strategy for PLO has been established. Here we report a case of PLO treated with teriparatide followed by denosumab, in which remarkable improvement in bone mineral density (BMD) was achieved., Case Report: A 27-year-old woman experienced severe back pain two weeks after her first delivery. PLO was diagnosed from her low BMD and multiple vertebral compression fractures. She was treated with teriparatide for 6 months, followed by denosumab. After 1 year, her BMD increase from baseline was 16.5% in L2∼4 and her pain had been relieved., Conclusion: In addition to weaning, administration of teriparatide followed by denosumab led to remarkable improvement in the patient's symptoms and BMD. Therefore, we regard this method as a promising choice for the treatment of PLO., (Copyright © 2017. Published by Elsevier B.V.)

This manuscript describes the study protocol, recruitment outcomes, and baseline participant characteristics for the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial. SPACE is a pragmatic randomized comparative effectiveness trial conducted in multiple VA primary care clinics within one VA health care system. The objective was to compare benefits and harms of opioid therapy versus non-opioid medication therapy over 12months among patients with moderate-to-severe chronic back pain or hip/knee osteoarthritis pain despite analgesic therapy; patients already receiving regular opioid therapy were excluded. Key design features include comparing two clinically-relevant medication interventions, pragmatic eligibility criteria, and flexible treat-to-target interventions. Screening, recruitment and study enrollment were conducted over 31months. A total of 4491 patients were contacted for eligibility screening; 53.1% were ineligible, 41.0% refused, and 5.9% enrolled. The most common reasons for ineligibility were not meeting pain location and severity criteria. The most common study-specific reasons for refusal were preference for no opioid use and preference for no pain medications. Of 265 enrolled patients, 25 withdrew before randomization. Of 240 randomized patients, 87.9% were male, 84.1% were white, and age range was 21-80years. Past-year mental health diagnoses were 28.3% depression, 17% anxiety, 9.4% PTSD, 7.9% alcohol use disorder, and 2.6% drug use disorder. In conclusion, although recruitment for this trial was challenging, characteristics of enrolled participants suggest we were successful in recruiting patients similar to those prescribed opioid therapy in usual care., (Published by Elsevier Inc.)

Background: A previous report demonstrated predictive power of short-term leg pain relief after lumbar transforaminal epidural steroid injections for 1-month treatment response. The question whether the long-term response could be similarly predicted remained unanswered., Methods: A prospective cohort of 57 patients who underwent a transforaminal epidural steroid injection for sciatica secondary to a lumbar disc herniation was followed for 24 months. Leg and back pain on the visual analog scale, health-related quality of life using the 12-Item Short Form Survey, and functional outcome using the Oswestry Disability Index were assessed. Responders were defined as not receiving any additional invasive treatment after a single injection. Patients who underwent a second injection or surgery were defined as treatment failures (nonresponders)., Results: At 24 months, 31 (54.4%) patients were responders, and 26 (45.6%) were nonresponders. Nonresponders left follow-up at 1 month (n = 9), 3 months (n = 9), 6 months (n = 6) and 12 months (n = 2). No patients were injected again or operated on between the 12- and 24-month follow-up. Responders at 24 months had significantly lower visual analog scale leg pain (P < 0.05) than nonresponders starting from the second week after TFESI and better 12-Item Short Form Survey scores and less disability on the Oswestry Disability Index., Conclusions: Most patients with a symptomatic lumbar disc herniation who opt for a second injection or surgery do so within the first 6 months. Reliable prediction of the long-term treatment response based on short-term pain relief is not possible., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Spinal hematomas (SHs) are rare yet potentially debilitating causes of acute back pain. Although spontaneous SHs have been described in the setting of anticoagulation with warfarin or enoxaparin, few cases of spontaneous SH on direct oral anticoagulants (DOACs) have been reported., Case Report: We report a case of spontaneous spinal epidural hematoma in a patient on rivaroxaban. A 72-year-old man on rivaroxaban and aspirin presented with a 4-day history of nontraumatic back pain. In the emergency department he developed lower-extremity weakness and numbness, followed by urinary incontinence. Magnetic resonance imaging revealed spinal epidural hematoma at T11-L2. The patient underwent emergent decompression and hematoma evacuation and was discharged home 8 days later with complete resolution of symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early recognition and surgical intervention for SHs with neurologic compromise is key to favorable outcome. Optimal timing of surgery in patients on DOACs requires an assessment of the risk of intraoperative or postoperative bleeding, an assessment of the patient's symptom progression, as well as an understanding of the pharmacokinetics of the DOAC used and possible reversal options available. We also review all published cases of spontaneous SHs in patients on DOACs and report on their management and outcomes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: User testing evaluates written medicine information (WMI) usability by examining participants' ability to find and understand information. It can also be an effective method to determine how consumers say they will act on information on an over-the-counter (OTC) label., Objective: To examine consumers' proposed behaviors regarding dosage and storage as a measure of a medicine label's usability and consumers' functional health literacy., Material and Methods: User testing of 5 diclofenac OTC labels (by 50 subjects; 10 per label) measured consumers' ability to find and understand key points of information using a 13-item questionnaire. Consumers were required to elaborate on their behavior in regard to 2 additional questions: 1) when they would take diclofenac if they had constant back pain from 8 am (dosage-related) and; 2) where they would store it in their home (storage-related). Responses were transcribed verbatim, and coded by 2 pharmacists., Results: Appropriate dosing for constant back pain was reported by 29 consumers. However, dosing intervals shorter than the specified 8 h were often reported (n = 19), due to adjusting intervals to accommodate up to the maximum of 8 tablets in 24 h, desire for pain relief, and/or pragmatic dosing (e.g. around bedtime). Only 29 consumers stated completely appropriate storage location examples (e.g. medicine cabinet)., Conclusions: Consumers may act inappropriately on OTC label information about dosage and/or storage, which could potentially adversely impact medication use. User testing can contribute to the development of high quality WMI and help identify where label wordings are inappropriate for the health literacy levels of consumers., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Oral baclofen toxicity is extremely rare, but can affect patients with renal disease due to the drug's predominant renal clearance of approximately 69-85%. Patients with severely impaired renal function typically develop symptoms soon after initiating baclofen therapy, even at relatively low doses., Case Report: A 69-year-old woman with a history of hemodialysis-dependent end-stage renal disease presented to the Emergency Department with encephalopathy, ataxia, and dystonia after the addition of a recent baclofen prescription for back pain (10 mg twice daily). She had been taking baclofen as prescribed for approximately 1 week when, the day prior to admission, she had increased her dose to a total of 40 mg. Diagnostic studies demonstrated the patient had chronic, end-stage renal disease and a supratherapeutic concentration of baclofen. Signs and symptoms resolved with hemodialysis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is of critical importance for emergency physicians to appreciate impaired baclofen clearance in those with underlying renal disease to obviate the potential for significant drug toxicity., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The incidence of opioid-related death in women has increased 5-fold over the past decade. For many women, their initial opioid exposure will occur in the setting of routine medical care. Approximately 1 in 3 deliveries in the United States is by cesarean, and opioids are commonly prescribed for postsurgical pain management., Objective: The objective of this study was to determine the risk that opioid-naïve women prescribed opioids after cesarean delivery will subsequently become consistent prescription opioid users in the year following delivery and to identify predictors for this behavior., Study Design: We identified women in a database of commercial insurance beneficiaries who underwent cesarean delivery and who were opioid naïve in the year prior to delivery. To identify persistent users of opioids, we used trajectory models, which group together patients with similar patterns of medication filling during follow-up, based on patterns of opioid dispensing in the year following cesarean delivery. We then constructed a multivariable logistic regression model to identify independent risk factors for membership in the persistent user group., Results: A total of 285 of 80,127 (0.36%, 95% confidence interval, 0.32-0.40), opioid-naïve women became persistent opioid users (identified using trajectory models based on monthly patterns of opioid dispensing) following cesarean delivery. Demographics and baseline comorbidity predicted such use with moderate discrimination (c statistic = 0.73). Significant predictors included a history of cocaine abuse (risk, 7.41%; adjusted odds ratio, 6.11, 95% confidence interval, 1.03-36.31) and other illicit substance abuse (2.36%; adjusted odds ratio, 2.78, 95% confidence interval, 1.12-6.91), tobacco use (1.45%; adjusted odds ratio, 3.04, 95% confidence interval, 2.03-4.55), back pain (0.69%; adjusted odds ratio, 1.74, 95% confidence interval, 1.33-2.29), migraines (0.91%; adjusted odds ratio, 2.14, 95% confidence interval, 1.58-2.90), antidepressant use (1.34%; adjusted odds ratio, 3.19, 95% confidence interval, 2.41-4.23), and benzodiazepine use (1.99%; adjusted odds ratio, 3.72, 95% confidence interval, 2.64-5.26) in the year prior to the cesarean delivery., Conclusion: A very small proportion of opioid-naïve women (approximately 1 in 300) become persistent prescription opioid users following cesarean delivery. Preexisting psychiatric comorbidity, certain pain conditions, and substance use/abuse conditions identifiable at the time of initial opioid prescribing were predictors of persistent use., Competing Interests: The authors report no relevant conflicts of interest., (Copyright © 2016 Elsevier Inc. All rights reserved.)

This case study describes the effects of the use of curanderismo, an indigenous healing modality combining techniques in massage, sound, and aromatherapy, on a patient with chronic pain. Despite being a commonly used health practice in certain populations, little is reported in the medical literature about the use of curanderismo. Case report as part of a larger randomized trial of curanderismo for chronic pain. Setting was a community-based hospital affiliated primary care clinic. An adult patient with chronic, opioid dependent back pain following an injury, and subsequent spinal fusion was treated. Intervention was the patient received 33 curanderismo treatment sessions over 10 months in addition to ongoing conventional treatment at a community-based chronic pain management clinic. Main outcomes measures were self-reported assessments of pain, functional ability, mood, insomnia, and narcotic usage. Secondary outcome measure was qualitative interview. Although there was no change in quantitative self-reported pain measures, the patient reported improved function, mood, and sleep as well as decreased narcotic usage. Curanderismo, in addition to conventional pain management, improved patient reported symptoms and functional ability, led to healthy lifestyle changes, and decreased narcotic usage. Controlled studies are needed to confirm the benefit of curanderismo as safe, non-interventional, and cost-effective adjunct for chronic pain management., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Stercoral perforation of the colon is a rare complication of constipation, and there have only been a few reported cases of stercoral perforation of the colon secondary to opioid-induced constipation. This article describes such a case in a cancer survivor with chronic cancer-related pain and reviews the medical/surgical literature on stercoral perforation of the colon., (Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: We examined the direct and indirect means by which patients express a desire for analgesic medication., Methods: Back pain patients presenting to an academic ED were invited to participate in a study of patient-provider communication. Audio-recorded encounters were transcribed verbatim and transcripts analyzed using a qualitative approach based on conversation analysis., Results: Requests for analgesics were documented in 15 out of 74 interactions (20%). We identified three basic patterns: direct requests, in which the patient explicitly asked for medication; indirect requests, in which the patient hinted at a desire for medication but did not ask for it outright; and no request, in which the provider discussed a prescription without the patient requesting it., Conclusion: Most patients did not request analgesics. When they did so, they utilized strategies of mitigation, indirection, and deference that presented themselves as deserving patients while upholding the physician's autonomy., Practice Implications: Patients come to the clinical encounter with a variety of expectations, of which a desire for an analgesic may be only part of the picture. Rather than focusing on strategies for inuring providers to inappropriate patient requests, it may be useful to devote clinical resources to examining patients' priorities and expectations for treatment., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Context: Normeperidine accumulates in patients with impaired renal function and may cause central neurotoxicity. However, some uremic patients still undergo meperidine treatment for chronic pain., Objectives: To prevent normeperidine side effects and complications, we investigated the clearance rate and extraction ratio of meperidine and normeperidine in hemodialysis patients with chronic pain., Methods: Three hemodialysis patients, with diagnoses of chronic pancreatitis, chronic back pain, and intractable intra-abdominal pain, received long-term (more than six months) administration of meperidine for chronic noncancer pain. During regular hemodialysis, 72 blood samples in total were collected from the afferent port, efferent port, and ultradiafiltrate port at eight time points. The plasma concentrations of meperidine and normeperidine were determined by high-performance liquid chromatography., Results: The prehemodialysis plasma concentrations of meperidine and normeperidine were 2963 ± 315 and 2369 ± 1974 ng/mL, which declined to 591 ± 109 and 853 ± 765 ng/mL, with 80% and 65% reduction, respectively. The plasma clearance and extraction ratios of meperidine were 22.7 ± 9.8 mL/minute and 10.1 ± 5.6% and for normeperidine 26.0 ± 11.4 mL/minute and 10.8 ± 2.5%, respectively., Conclusion: Hemodialysis can efficiently remove meperidine and its active metabolite, normeperidine, in uremic patients receiving long-term meperidine therapy for chronic noncancer pain., (Copyright © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Context: Either a two-factor representation (pain intensity and interference) or a three-factor representation (pain intensity, activity interference, and affective interference) of the modified Brief Pain Inventory (BPI) is appropriate among cancer patients., Objectives: To evaluate the extent to which a three-factor representation (pain intensity, activity interference, and affective interference) is appropriate for BPI among patients with noncancer pain seen in an outpatient setting., Methods: We conducted a prospective, multicenter, observational, nonrandomized study using patient pain registry data from outpatient settings. Seven hundred forty-one patients with acute episodes of noncancer pain requiring treatment with a prescription medication containing oxycodone immediate-release on an as-needed basis for at least five days participated. Baseline measurements included the modified BPI pain intensity (right now, average, and worst in 24 hours) and pain interference with general activities, walking, work, mood, relations with others, sleep, and life enjoyment. Confirmatory factor analysis was conducted for the overall sample and among postoperative patients (n = 133), patients with back and neck pain (n = 202), patients with arthritis (n = 148), and patients with injury or trauma (n = 204)., Results: Both the two-factor and three-factor models were statistically better than the one-factor model (P < 0.05), with the two-factor model performing better than the three-factor model. Configural invariance, but not metric invariance by patient cohort group was demonstrated., Conclusion: Consistent with analyses among cancer patients, a two-factor representation of BPI is appropriate for noncancer patients seen in an ambulatory setting. This work lends additional support for the psychometric properties of BPI., (Copyright © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.)

Objectives: Improved device technology has caused a renewed interest in peripheral nerve field stimulation (PNfS). This study sought to obtain preliminary estimates of the safety and efficacy of PNfS in patients with localized chronic intractable pain of the back., Materials and Methods: This Institutional Review Board-approved, prospective, randomized, controlled, crossover study consisted of two phases. During phase I, patients rotated through four stimulation groups (minimal, subthreshold, low frequency, and standard stimulation). If a 50% reduction in pain was achieved during any of the three active stimulation groups (responder), the patient proceeded to phase II, which began with implant of the permanent system and lasted 52 weeks. The primary endpoint was a reduction in pain, assessed by the visual analog scale (VAS). Analysis of variance, including the effects of patient, treatment, and study period, was used for phase I results. Phase II results were analyzed by paired t-tests., Results: A total of 44 patients were enrolled at five sites. Of these patients, 32 were implanted with a trial system and 30 completed phase I. During phase I, there were significant differences in mean VAS scores between minimal stimulation and subthreshold stimulation (p = 0.003), low frequency stimulation (p < 0.001), and standard stimulation (p < 0.001). Twenty-four patients were classified as responders to the therapy, and 23 patients received permanent system placement. Significant differences in VAS scores were observed between baseline and all follow-up visits during phase II (p < 0.001) CONCLUSIONS: The results provide evidence to support safety and effectiveness of PNfS as an aid in the management of chronic, localized back pain., (© 2013 International Neuromodulation Society.)

Increased opioid prescribing for back pain and other chronic musculoskeletal pain conditions has been accompanied by dramatic increases in prescription-opioid addiction and fatal overdose. Opioid-related risks appear to increase with dose. Although short-term randomised trials of opioids for chronic pain have found modest analgesic benefits (a one-third reduction in pain intensity on average), the long-term safety and effectiveness of opioids for chronic musculoskeletal pain remains unknown. Given the lack of large, long-term randomised trials, recent epidemiologic data suggest the need for caution when considering long-term use of opioids to manage chronic musculoskeletal pain, particularly at higher dosage levels. Principles for achieving more selective and cautious use of opioids for chronic musculoskeletal pain are proposed., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Spinal epidural lipomatosis is a rare condition of adipose tissue hypertrophy in the epidural space. Through nerve root and spinal canal compression, it may lead to both sensory and motor compromise. Chronic steroid use, obesity and other metabolic derangements are known causes of spinal epidural lipomatosis. Recently, several cases have been attributed to antiretrovirals taken to treat human immunodeficiency virus, given their side effects of lipodystrophy and altered fat metabolism. We report a patient on highly active antiretroviral therapy (HAART) who developed debilitating back, hip and thigh pain during the third trimester of pregnancy that prevented ambulation. Epidural lipomatosis was diagnosed by magnetic resonance imaging. Given her evolving symptoms, neuraxial anesthesia was considered to be contraindicated. We present her management and labor course., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Athletes represent a specific subgroup of highly motivated patients with a unique set of social and psychological incentives. Demands placed on the lumbosacral system are high, and athletes may be particularly prone to the pathology discussed above. For this reason, it is crucial to consider the athlete as a functional whole operating in concert with intrinsic and extrinsic factors and to consider the lumbosacral system within the context of the complete kinetic chain. Spinal interventions should never be considered in isolation but rather as part of a comprehensive rehabilitation program targeting psychosocial as well as biomechanical opportunities. When interventional procedures are warranted, they should be performed according to existing guidelines regarding indication, patient selection, and technique where possible and with systems in place to maximize patient safety and to consistently monitor for response. Each of the interventions discussed above should be performed with fluoroscopic guidance, given the lack of accuracy without fluoroscopy, and generally be reserved for athletes not responding to conservative care. When returning an athlete to play after ESI, we recommend careful serial evaluation as well as involvement of appropriate family members, athletic trainers, and coaches in the decision-making process. Athletes should not return to play with any significant objective neurologic deficits. In appropriate athletes, return to play should occur with graduated and comprehensive rehabilitation as discussed above. Because evidence concerning the interventions discussed in this article is often lacking, clinical judgment is paramount regarding their allocation. The interventions explored above likely do provide viable treatment adjuncts in the carefully selected athlete but are not without risk. Athlete safety and global well being should guide any decision to pursue interventional treatment options.

Background: Cannabis is the most commonly used illicit substance worldwide. Cannabinoids or cannabinoid receptor agonists are often used to treat nausea, vomiting, and anorexia. However, in recent years, several medical journals have published reports of patients with nausea and vomiting thought to be induced by chronic cannabis use., Objective: The authors seek to inform readers about Cannabinoid Hyperemesis Syndrome (CHS)., Method: The authors describe four patients with chronic cannabis abuse, episodic, intractable nausea and vomiting, and compulsive hot water bathing. Previous cases of CHS are reviewed, pathophysiology is hypothesized, and difficulties with making the diagnosis are discussed., Conclusion: CHS should be strongly considered in the differential diagnosis of patients with intractable vomiting and/or compulsive hot water bathing., (Copyright © 2012 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.)

Symptomatic treatment of stiff-person syndrome (SPS) might be challenging and a significant improvement of stiffness and rigidity is generally reached with high doses of benzodiazepines or baclofen causing side effects. A 71-year old woman diagnosed with SPS complained of marked stiffness of trunk and lower limb muscles with sudden painful spasms. She was unable to walk and she could not lean on her right leg. Cortical silent period (CSP) duration evaluated from right abductor pollicis brevis (APB) with transcranial magnetic stimulation was shortened. Polygraphic electromyographic (EMG) evaluation from paraspinal and leg muscles disclosed continuous motor unit activity at rest with interference muscular pattern. Symptomatic treatment with diazepam was withdrawn because of excessive sedation. In order to relieve the intense lumbar pain, she was prescribed pregabalin; since the day after, rigidity and painful spasms dramatically improved and she could walk without assistance. The clinical benefit persisted at 3 months follow-up and was paralleled by almost complete disappearance of EMG activity at rest and prolongation of CSP. The clinical and electrophysiological data in this SPS patient suggest the possible efficacy of pregabalin as symptomatic treatment without any significant side effects, which needs to be replicated in larger case series., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Introduction:   Intrathecal (IT) medication delivery is a commonly used technique for the treatment of chronic intractable pain. Cerebrospinal fluid (CSF) loculation at the catheter tip has been described as a cause of progressive loss of drug effect that can often be difficult to diagnose., Methods:   The clinical course of a 56-year-old woman was reviewed, including past imaging studies., Results:   The patient presented with acute lower extremity paresis secondary to air trapped within an arachnoid cyst thought to be due to long-term use of IT morphine and an undiagnosed CSF loculation. She rapidly recovered after surgical decompression., Discussion:   Symptomatic pneumorachis is rare. In this case, because of radiographically impressive compression and severe deficit, we felt that the trapped air was equivalent to a mass lesion and treated it aggressively. The arachnoid cyst was near the level of the catheter tip prior to revision, and we have retrospectively inferred a causal relationship., (© 2011 International Neuromodulation Society.)

Ms TS is a 66-year-old woman who receives warfarin for prevention of systemic embolization in the setting of hypertension, diabetes, and atrial fibrillation. She had a transient ischemic attack about 4 years ago when she was receiving aspirin. Her INR control was excellent; however, over the past few months it has become erratic, and her average dose required to maintain an INR of 2.0 to 3.0 appears to have decreased. She has had back pain over this same period and has been taking acetaminophen at doses at large as 650 mg four times daily, with her dose varying based on her symptoms. You recall a potential interaction and wonder if (1) her acetaminophen use is contributing to her loss of INR control, and (2) does this interaction place her at increased risk of warfarin-related complications?

Background: Methylnaltrexone, a selective peripheral acting mu-opioid receptor antagonist, alleviates the constipating effects of opioids without affecting centrally mediated analgesia., Objectives: To assess the effect of subcutaneous (SC) methylnaltrexone injection on patient-reported constipation symptoms and pain scores., Methods: A total of 469 subjects on opioids for chronic non-malignant pain with opioid-induced constipation were randomized to methylnaltrexone SC with once daily (QD) or every other day (QOD) dosing or placebo for 4 weeks. Constipation symptoms and pain were assessed using the patient assessment of constipation-symptoms (PAC-SYM) questionnaire and a 11-point scale, respectively, at baseline, Day 14 and Day 28. Change from baseline in PAC-SYM and pain scores were compared between methylnaltrexone and placebo arms at Day 28 using analysis of covariance, with treatment group as factor and baseline score as covariate., Results: A majority of patients were women (60%), average age was 49 years old, and back pain (60%) was the primary pain condition. At Day 28, the methylnaltrexone SC QD group showed a significant improvement over placebo for rectal symptoms (-0.56 vs. -0.30; P < 0.05), stool symptoms (-0.76 vs. -0.43; P < 0.001) and global scores (-0.62 vs. -0.37; P < 0.001). Improvement in stool symptoms (-0.69 vs.-0.43; P < 0.05) and the global scores (-0.52 vs. -0.37; P < 0.05) were significantly greater than placebo in the methylnaltrexone QOD group. Differences in change from baseline in abdominal symptoms and pain scores between the methylnaltrexone SC QD or QOD dosing arms and placebo were not significant., Conclusion: The results of our study indicate significant improvement in constipation symptoms with methylnaltrexone QD or QOD dosing compared to placebo without a significant effect on pain scores., (Copyright © 2011 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Intramuscular diclofenac is used extensively for pain relief in medical practice. Tissue necrosis is a rare but serious complication of intramuscular injections. The pathogenetic mechanism is still not completely understood. A case of tissue necrosis following self-administration of diclofenac inadvertently injected into an arterial perforator branch of the superficial femoral artery is reported, supporting a vascular pathogenesis., (Copyright (c) 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Diffuse and abundant sweating in a middle age patient evolving for several weeks should raise suspicion of malignant lymphoma and infectious or neuroendocrine disorders before considering a drug origin. We report a patient who presented with severe and invalidating excessive sweating related to hydromorphone therapy for vertebral pain. Amongst their many reported side-effects, excessive sweating disappearing with discontinuation of the drug have been reported with some opiates.

This is a clinical presentation of a 14-year-old female who had weight loss and vomiting following spinal fusion surgery. Her case was complicated by social and behavioral issues. After an initial diagnosis of atypical eating disorder, an upper gastrointestinal study revealed superior mesenteric artery syndrome. Her course continued to be complicated until consistent follow-up with a nutritionist was established.

Background and Objective: Enrichment strategies which select subjects who appear to respond to the drug have been used in drug studies to demonstrate clinical efficacy. We have used clinical trial simulation techniques to examine factors that are relevant in clinical trial design based on enrichment where poor responders are excluded from the double-blind phase of the study., Methods: Simulations were performed for an analgesic trial design involving an open-dose titration phase (enrichment phase) followed by a double-blind, randomized, placebo-controlled maintenance phase. Enrichment was examined by excluding subjects above a predefined pain score (cutoff) from analysis of efficacy for the maintenance phase. Cutoff pain scores ranging from 4 to 7 on a 0 to 10 categorical scale were examined. A database consisting of chronic pain patients who participated in studies with a new formulation of buprenorphine was used to build the simulation model. Since no data were available for the key model variable "correlation between treatment and placebo response", values of 0.25, 0.5, and 0.75 were used for the simulations., Results: A correlation between treatment and placebo effect ranging from 0.75 to 0.25 will cause the likelihood of trial success to vary from 50% to 95%. This model also shows that recruitment efficiency will decrease with the use of lower cutoff pain scores., Conclusion: Prior to using enrichment techniques, investigators must consider the correlation between treatment effect and placebo response to optimize clinical trial design.