Search

Background The increase in the number of interventions for the management of chronic pain and associated escalation of healthcare costs has captured the attention of health policymakers, in no small part due to the lack of documentation of efficacy, cost-effectiveness, or cost utility analysis. A recent cost utility analysis of caudal epidural injections in managing chronic low back pain of various pathologies showed a high cost utility with improvement in quality of life years, competitive with various other modalities of treatments. However, there are no analyses derived from high-quality controlled studies related to the cost utility of percutaneous adhesiolysis in the treatment of post-lumbar surgery syndrome or lumbar central spinal stenosis. Study Design This analysis is based on 2 previously published controlled studies. Objective To assess the cost utility of percutaneous adhesiolysis procedures in managing chronic low back and lower extremity pain secondary to post-lumbar surgery syndrome and lumbar central spinal stenosis. Setting A private, specialty referral interventional pain management center in the United States. Methods Two controlled studies were conducted assessing the clinical effectiveness of percutaneous adhesiolysis for post-lumbar surgery syndrome and lumbar central spinal stenosis in an interventional pain management setting utilizing contemporary interventional pain management practices. A cost utility analysis was performed with direct payment data for a total of 130 patients in treatment groups over a 2-year period. Various outcome measures were included with significant improvement, defined as at least 50% improvement with reduction in pain and disability status. Results The results of 2 controlled studies of low back pain with 60 and 70 patients and a 2-year follow-up with the actual reimbursement data showed cost utility for 1 year of quality-adjusted life year (QALY) of USD $2,652 for post-lumbar surgery syndrome and USD $2,649 for lumbar central spinal stenosis. The results of this assessment show that the cost utility of managing chronic, intractable low back pain with percutaneous adhesiolysis at a QALY that is similar or lower in price than medical therapy only, physical therapy, manipulation, spinal cord stimulation, and surgery. Limitations The limitations of this cost utility analysis are that it is a single-center evaluation, with the inclusion of costs of adhesiolysis procedures in an ambulatory surgery center and physician visits, rather than all related costs including drug therapy and costs of disability in multiple settings. Conclusion This cost utility analysis of percutaneous adhesiolysis in the treatment of post-lumbar surgery syndrome and lumbar central spinal stenosis shows the clinical effectiveness and cost utility of these procedures at USD $2,650 per one year of QALY when performed in an ambulatory surgery center.

We report Heidelberg Retina Tomography (HRT) findings in a case of bilateral acute macular neuroretinopathy in a 22-year-old man. In addition to fundus photography, fluorescein and indocyanine green angiography, and visual field testing, HRT scans of the macula were performed early in the disease and at a follow up of 2 months. We found typical paracentral scotomata in visual field testing corresponding to sharply delineated, hyporeflective areas of the macula as visualized in HRT II scans. Those lesions were almost invisible on regular fundus photographs. Angiography results were unremarkable. The lesion size decreased over time. The visibility of the lesions was markedly enhanced by HRT scans, thus the diagnosis and follow up of acute macular neuroretinopathy could be facilitated by this non-invasive imaging technique.

Background and Objectives: There are numerous treatments for complex regional pain syndrome (CRPS). These treatments are varied in scope and include pain management therapies, psychological therapies, and physiotherapy. Treatment guidelines have been published in the past, but little information exists as to how clinicians utilize these guidelines. Moreover, there has been a paradigm shift from the older “reflex sympathetic dystrophy” (RSD) nomenclature, with largely sympathetic block driven diagnosis and therapy to more recent trends towards more inclusive “CRPS” diagnostic criteria and multidisciplinary treatment. There remains controversy regarding the selection of various techniques, and the timing of advancement through the treatment algorithm to the more aggressive, interventional techniques. We set out to determine current CRPS treatment practices of interventional pain specialists. Methods: The authors developed a 36-item, 15–20-minute questionnaire. This questionnaire was sent to 453 interventional pain specialists. Results: One-hundred-five surveys were returned, with 100 being complete. Eighty-three percent of our respondents were practicing anesthesiology pain specialists who on average treat 14.9 (SD = 16.8) CRPS patients per month. Conclusions: Our survey results revealed the use of a treatment algorithm for CRPS that consists of treatment using medical therapies (pharmacologic, blocks, catheters, and implantable devices), psychological therapies, and physiotherapy in a coordinated fashion. The trend among our survey respondents is to utilize increasingly interventional techniques after a failed 2- to 4-week trial of any one particular therapy.

We are following with great interest the increasing generally favorable impressions of the long-term results of the MILD (minimally invasive lumbar decompression) procedure for treating spinal stenosis due to hypertrophied ligamentum flavum (LF). We are also influenced by the cautionary surgical observations and opinions of Tumialan et al and publications about the lack of efficacy or placebo effect. The impression indeed has been virtual safety of the MILD procedure, but Tumialan et al describe some major complications resulting from the procedure. An algorithm for clinical use is needed.

Background and Objectives: Complications associated with interventional pain procedures have raised questions regarding the relative safety of sharp vs. blunt needles. It has been speculated that the incidence of hemorrhage, intraneural and/or intravascular injections may be reduced by the use of blunt needles. In this study we compared penetration and bleeding associated with sharp vs. blunt needle punctures. Methods: Attempts were made to insert blunt and sharp needles (18-, 20-, 22-, and 25-gauge) directly or percutaneously into kidney, liver, renal artery, intestine or spinal nerve/nerve root of anesthetized dogs. Penetration and bleeding were ascertained by direct vision through a surgical wound. Results: All attempts to directly puncture the kidney and liver with sharp needles were successful. All but one attempt to puncture a spinal nerve/nerve root with 20-, 22-, and 25-gauge sharp needles were successful but half or less attempts to puncture the intestines were successful. All attempts to puncture the renal artery with sharp needles were successful. Blunt needles never punctured the renal artery, spinal nerve/nerve root and intestines and rarely penetrated the kidney (22- and 25-gauge one time each). All attempts to puncture the liver with blunt needles were successful. Bleeding scores for kidney punctures were generally higher for larger sharp needles than for smaller ones. Bleeding scores for blunt needle punctures of the liver were generally smaller than for sharp needle puncture. Conclusion: Blunt needles are less likely than sharp ones to enter vital structures and/or produce hemorrhage. Thus, blunt needles may be preferable to sharp ones for performing interventional pain procedures.

A CSF leak that persists despite conservative therapy may significantly increase the morbidity associated with implantable intrathecal drug delivery systems. This report presents 2 cases where the application of a subdural blood patch led to the satisfactory resolution of a persistent CSF leak after previous epidural blood patches had failed.

After the first 5 years of life, cancer is one of the three most common causes of death. Most investigations of cancer pain have shown that 50-70% of patients suffer needlessly. Pain may be due to the tumor or a co-existant benign pain syndrome. Methods of pain management include: 1) neurolytic blockade: stellate ganglion block, celiac plexus block, lumbar sympathetic block, epidural phenol, subarachnoid neurolysis; and 2) non-pharmacologic methods: radiofrequency thermocoagulation lumbar sympathectomy, transcutaneous nerve stimulation (TENS), dorsal column stimulation (DCS). In summary, we utilize every possible combination of therapeutic modalities for cancer pain management. With so many safe procedures available, we encourage the primary physician to refer patients early in their disease process. Neurolytic procedures should be performed prior to initiation of high dose narcotic therapy, radiation, chemotherapy, and surgery when possible.

The molecular weight of selected polyvinylpyrrolidone samples was determined by light scattering and by osmotic pressure in methanol. The corresponding limiting viscosity numbers were also determined, as well as the limiting viscosity number of the same samples in water. The data relating to the methanolic system conform with theory and the values for K and α in [η] = KMα were determined. The data relating to aqueous solutions do not show such conformity but an unexplained dependence on the degree of homogeneity of the samples. Nevertheless some empirical constants were deduced which may aid in industrial practice in which aqueous viscosity measurements are usual.

Die [M]D-Werte der epimeren 1-Amino-1.2-diphenyl-propanole-(3) (5), 2-Oxo-4.5-diphenyl-(6) und 4.5-Diphenyl-2-[p-nitro-phenyl]-tetrahydro-1.3-oxazine (7), deren bevorzugte Konformationen schon fruher festgestellt wurden, werden nun mit Hilfe der Brewster-Methode berechnet. Auf Grund der Ergebnisse sind zuverlassige Aussagen uber die absoluten Konfigurationen dieser Verbindungen moglich sowie die Schlusfolgerung berechtigt, das der grosere Unterschied zwischen dem Drehungsvermogen des erythro-Aminopropanols und dem seines Oxazin-Derivats auch eine betrachtlichere Konformationsanderung beim Ringschlus andeutet als im Fall des threo-Isomeren. Ferner werden die absoluten Konfigurationen und bevorzugten Konformationen der l-Menthylester samtlicher optisch aktiver Formen der 3-Amino-2.3-diphenyl-propansauren zugeordnet, die mit den erstgenannten Verbindungen genetisch verknupft sind.

2-Pyridylethylcarbinol (I) has been resolved and the antipodes hydrogenated as free bases. The (+) form gave (+) conhydrine (II) while the (-) form afforded the levorotatory base stereoselectively with minor contamination of the other epimer. Hydrogenation of racemic I as well as of 2-pyridyl ethyl ketone in acid solution led formerly to the mixture of both racemates.

Additional polyvinylpyrrolidone samples of great homogeneity have been prepared, and their intrinsic viscosity and molecular weight (by light scattering) have been determined in water and chloroform. In view of the new results the previous data were reinterpreted particularly with respect to the shift in K (in [η] = KMα) with homogeneity. All data were evaluated by objective statistical techniques and revised intrinsicviscosity molecular weight equations are proposed.