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Fabíola Costa,1 Dora Janela,1 Maria Molinos,1 Robert G Moulder,2 Jorge Lains,3,4 Virgílio Bento,1 Justin Scheer,5 Vijay Yanamadala,1,6,7 Fernando Dias Correia,1,8 Steven P Cohen9,10 1SWORD Health, Inc, Clinical Research, Draper, UT, USA; 2Institute for Cognitive Science, University of Colorado Boulder, Boulder, CO, USA; 3Rovisco Pais Medical and Rehabilitation Centre, Tocha, Portugal; 4Faculty of Medicine, Coimbra University, Coimbra, Portugal; 5Department of Neurological Surgery, University of California, San Francisco, CA, USA; 6Department of Surgery, Quinnipiac University Frank H. Netter School of Medicine, Hamden, CT, USA; 7Department of Neurosurgery, Hartford Healthcare Medical Group, Westport, CT, USA; 8Neurology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal; 9Departments of Anesthesiology & Critical Care Medicine, Physical Medicine and Rehabilitation, Neurology, and Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA; 10Departments of Anesthesiology and Physical Medicine and Rehabilitation and Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD, USACorrespondence: Fernando Dias Correia, 65 E Wadsworth Park Dr Ste 230, Draper, UT, 84020, USA, Tel +1 385-308-8034, Fax +1 801-206-3433, Email fcorreia@swordhealth.comBackground: Low back pain (LBP) has a lifetime prevalence of 70– 80%. Access to timely and personalized, evidence-based care is key to prevent chronic progression. Digital solutions may ease accessibility to treatment while reducing healthcare-related costs.Purpose: We aim to report the results of a fully remote digital care program (DCP) for acute LBP.Patients and Methods: This was an interventional, single-arm, cohort study of patients with acute LBP who received a DCP. Primary outcome was the mean change in disability (Oswestry Disability Index – ODI) after 12 weeks. Secondary outcomes included change in pain (NPRS), analgesic consumption, surgery likelihood, depression (PHQ-9), anxiety (GAD-7), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI) and engagement.Results: A total of 406 patients were enrolled in the program and of those, 332 (81.8%) completed the intervention. A significant disability reduction of 55.1% (14.93, 95% CI 13.95; 15.91) was observed, corresponding to a 76.1% responder rate (30% cut-off). Disability reduction was accompanied by significant improvements in pain (61.0%), depression (55.4%), anxiety (59.5%), productivity (65.6%), fear-avoidance beliefs (46.3%), intent to pursue surgery (59.1%), and analgesic consumption (from 35.7% at baseline to 10.8% at program end). DCP-related patient satisfaction score was 8.7/10.0 (SD 1.4).Conclusion: This study demonstrated the utility of a multimodal DCP for patients with acute LBP. Very high adherence rates and patient satisfaction were observed, alongside significant reductions in all assessed outcomes, consistent with the growing body of evidence supporting the management of acute LBP with DCPs.Keywords: physical therapy, telerehabilitation, digital therapy, eHealth, musculoskeletal conditions

Dora Janela,1 Fabíola Costa,1 Maria Molinos,1 Robert G Moulder,2 Jorge Lains,3,4 Gerard E Francisco,5 Virgílio Bento,1 Steven P Cohen,6,7 Fernando Dias Correia1,8 1SWORD Health Technologies, Inc, Clinical Validation, Draper, UT, USA; 2Institute for Cognitive Science, University of Colorado Boulder, Boulder, CO, USA; 3Rovisco Pais Medical and Rehabilitation Centre, Tocha, Portugal; 4Faculty of Medicine, Coimbra University, Coimbra, Portugal; 5Department of Physical Medicine and Rehabilitation, The University of Texas Health Science Center McGovern Medical School, and TIRR Memorial Hermann, Houston, TX, USA; 6Departments of Anesthesiology & Critical Care Medicine, Physical Medicine and Rehabilitation, Neurology, and Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA; 7Departments of Anesthesiology and Physical Medicine and Rehabilitation and Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; 8Neurology Department, Centro Hospitalar e Universitário do Porto, Porto, PortugalCorrespondence: Fernando Dias CorreiaSWORD Health Technologies, Inc, Clinical Validation, 65 E Wadsworth Park Dr Ste 230, Draper, UT, 84020, USATel +1 385-308-8034Fax +1 801-206-3433Email fcorreia@swordhealth.comBackground: Chronic shoulder pain (SP) is responsible for significant morbidity, decreased quality of life and impaired work ability, resulting in high socioeconomic burden. Successful SP management is dependent on adherence and compliance with effective evidence-based interventions. Digital solutions may improve accessibility to such treatments, increasing convenience, while reducing healthcare-related costs.Purpose: Present the results of a fully remote digital care program (DCP) for chronic SP.Patients and Methods: Interventional, single-arm, cohort study of individuals with chronic SP applying for a digital care program. Primary outcome was the mean change between baseline and 12 weeks on the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Secondary outcomes were change in pain (NPRS), analgesic consumption, intention to undergo surgery, anxiety (GAD-7), depression (PHQ-9), fear-avoidance beliefs (FABQ-PA), work productivity (WPAI) and engagement.Results: From 296 patients at program start, 234 (79.1%) completed the intervention. Changes in QuickDASH between baseline and end-of-program were both statistically (p < 0.001) and clinically significant, with a mean reduction of 51.6% (mean − 13.45 points, 95% CI: 11.99; 14.92). Marked reductions were also observed in all secondary outcomes: 54.8% in NPRS, 44.1% ceased analgesics consumption, 55.5% in surgery intent, 37.7% in FABQ-PA, 50.3% in anxiety, 63.6% in depression and 66.5% in WPAI overall. Higher engagement was associated with higher improvements in disability. Mean patient satisfaction score was 8.7/10.0 (SD 1.6).Conclusion: This is the first real-world cohort study reporting the results of a multimodal remote digital approach for chronic SP rehabilitation. High completion and engagement rates were observed, which were associated with clinically significant improvement in all health-related outcomes, as well as marked productivity recovery. These promising results support the potential of digital modalities to address the global burden of chronic musculoskeletal pain.Keywords: chronic pain, physical therapy, telerehabilitation, digital therapeutic, eHealth

David E Jamison,1,2 Steven P Cohen1–6 1Department of Anesthesiology, Walter Reed National Military Medical Center (WRNMMC), Bethesda, MD, USA; 2Department of Anesthesiology, Uniformed Services University of Health Sciences (USUHS), Bethesda, MD, USA; 3Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA; 4Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA; 5Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD, USA; 6Department of Physical Medicine and Rehabilitation, USUHS, Bethesda, MD, USA Background: The use of radiofrequency ablation (RFA) procedures to treat chronic knee pain has surged in the past decade, though many questions remain regarding anatomical targets, selection criteria, and evidence for effectiveness. Methods: A comprehensive literature review was performed on anatomy, selection criteria, technical parameters, results of clinical studies, and complications. Databases searched included MEDLINE and Google Scholar, with all types of clinical and preclinical studies considered. Results: We identified nine relevant clinical trials, which included 592 patients, evaluating knee RFA for osteoarthritis and persistent postsurgical pain. These included one randomized, placebo-controlled trial, one randomized controlled trial evaluating RFA as add-on therapy, four comparative-effectiveness studies, two randomized trials comparing different techniques and treatment paradigms, and one non-randomized, controlled trial. The results of these studies demonstrate significant benefit for both reduction and functional improvement lasting between 3 and 12 months, with questionable utility for prognostic blocks. There was considerable variation in the described neuroanatomy, neural targets, radiofrequency technique, and selection criteria. Conclusion: RFA of the knee appears to be a viable and effective treatment option, providing significant benefit to well-selected patients lasting at least 3 months. More research is needed to better identify neural targets, refine selection criteria to include the use of prognostic blocks, optimize treatment parameters, and better elucidate relative effectiveness compared to other treatments. Keywords: Knee pain, osteoarthritis, radiofrequency, ablation, denervation, genicular nerve

David S Chang,1 Eugene Hsu,2 Daniel G Hottinger,1 Steven P Cohen1,3–5 1Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 2Clinical Excellence Research Center, Stanford University School of Medicine, Stanford, CA, 3Department of Anesthesiology, 4Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda 5Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA Abstract: There continues to be an unmet need for safe and effective pain medications. Opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) dominate the clinical landscape despite limited effectiveness and considerable side-effect profiles. Although significant advancements have identified myriad potential pain targets over the past several decades, the majority of new pain pharmacotherapies have failed to come to market. The discovery of nerve growth factor (NGF) and its interaction with tropomyosin receptor kinase A (trkA) have been well characterized as important mediators of pain initiation and maintenance, and pharmacotherapies targeting this pathway have the potential to be considered promising methods in the treatment of a variety of nociceptive and neuropathic pain conditions. Several methodologic approaches, including sequestration of free NGF, prevention of NGF binding and trkA activation, and inhibition of trkA function, have been investigated in the development of new pharmacotherapies. Among these, NGF-sequestering antibodies have exhibited the most promise in clinical trials. However, in 2010, reports of rapid joint destruction leading to joint replacement prompted the Food and Drug Administration (FDA) to place a hold on all clinical trials involving anti-NGF antibodies. Although the FDA has since lifted this hold and a number of new trials are under way, the long-term efficacy and safety profile of anti-NGF antibodies are yet to be established. Keywords: nociceptive pain, neuropathic pain, drug discovery, tanezumab, fulranumab, fasinumab

Eugene Hsu,1 Steven P Cohen21Johns Hopkins School of Medicine, Baltimore, MD, USA; 2Johns Hopkins School of Medicine and Uniformed Services, University of the Health Sciences, Bethesda, MD, USAAbstract: Postamputation pain (PAP) is highly prevalent after limb amputation but remains an extremely challenging pain condition to treat. A large part of its intractability stems from the myriad pathophysiological mechanisms. A state-of-art understanding of the pathophysiologic basis underlying postamputation phenomena can be broadly categorized in terms of supraspinal, spinal, and peripheral mechanisms. Supraspinal mechanisms involve somatosensory cortical reorganization of the area representing the deafferentated limb and are predominant in phantom limb pain and phantom sensations. Spinal reorganization in the dorsal horn occurs after deafferentation from a peripheral nerve injury. Peripherally, axonal nerve damage initiates inflammation, regenerative sprouting, and increased "ectopic" afferent input which is thought by many to be the predominant mechanism involved in residual limb pain or neuroma pain, but may also contribute to phantom phenomena. To optimize treatment outcomes, therapy should be individually tailored and mechanism based. Treatment modalities include injection therapy, pharmacotherapy, complementary and alternative therapy, surgical therapy, and interventions aimed at prevention. Unfortunately, there is a lack of high quality clinical trials to support most of these treatments. Most of the randomized controlled trials in PAP have evaluated medications, with a trend for short-term efficacy noted for ketamine and opioids. Evidence for peripheral injection therapy with botulinum toxin and pulsed radiofrequency for residual limb pain is limited to very small trials and case series. Mirror therapy is a safe and cost-effective alternative treatment modality for PAP. Neuromodulation using implanted motor cortex stimulation has shown a trend toward effectiveness for refractory phantom limb pain, though the evidence is largely anecdotal. Studies that aim to prevent PAP using epidural and perineural catheters have yielded inconsistent results, though there may be some benefit for epidural prevention when the infusions are started more than 24 hours preoperatively and compared with nonoptimized alternatives. Further investigation into the mechanisms responsible for and the factors associated with the development of PAP is needed to provide an evidence-based foundation to guide current and future treatment approaches.Keywords: phantom pain, stump pain, residual limb pain

Background: Perineural inhibitors of tumor necrosis factor have recently generated intense interest as an alternative to epidural steroid injections for lumbosacral radiculopathy.Objective: To evaluate whether epidural steroids, etanercept, or saline better improves pain and function in adults with lumbosacral radiculopathy.Design: A multicenter, 3-group, randomized, placebo-controlled trial conducted from 2008 to 2011. Randomization was computer-generated and stratified by site. Pharmacists prepared the syringes. Patients, treating physicians, and nurses assessing outcomes were blinded to treatment assignment. (ClinicalTrials.gov registration number: NCT00733096)Setting: Military and civilian treatment centers.Patients: 84 adults with lumbosacral radiculopathy of less than 6 months' duration.Intervention: 2 epidural injections of steroids, etanercept, or saline, mixed with bupivacaine and separated by 2 weeks.Measurements: The primary outcome measure was leg pain 1 month after the second injection. All patients had 1-month follow-up visits; patients whose condition improved remained blinded for the 6-month study period.Results: The group that received epidural steroids had greater reductions in the primary outcome measure than those who received saline (mean difference, -1.26 [95% CI, -2.79 to 0.27]; P = 0.11) or etanercept (mean difference, -1.01 [CI, -2.60 to 0.58]; P = 0.21). For back pain, smaller differences favoring steroids compared with saline (mean difference, -0.52 [CI, -1.85 to 0.81]; P = 0.44) and etanercept (mean difference, -0.92 [CI,-2.28 to 0.44]; P = 0.18) were observed. The largest differences were noted for functional capacity, in which etanercept fared worse than the other treatments: steroids vs. etanercept (mean difference, -16.16 [CI, -26.05 to -6.27]; P = 0.002), steroids vs. saline (mean difference, -5.87 [CI, -15.59 to 3.85]; P = 0.23), and etanercept vs. saline (mean difference, 10.29 [CI, 0.55 to 20.04]; P = 0.04). More patients treated with epidural steroids (75%) reported 50% or greater leg pain relief and a positive global perceived effect at 1 month than those who received saline (50%) or etanercept (42%) (P = 0.09).Limitation: Short-term follow-up, small sample size, and a possibly subtherapeutic dose of etanercept.Conclusion: Epidural steroid injections may provide modest short-term pain relief for some adults with lumbosacral radiculopathy, but larger studies with longer follow-up are needed to confirm their benefits.Primary Funding Source: The John P. Murtha Neuroscience and Pain Institute, International Spinal Intervention Society, and Center for Rehabilitation Sciences Research. [ABSTRACT FROM AUTHOR]

Postamputation pain (PAP) affects over 60% of major limb amputees. One of the main challenges in treating PAP is the difficulty involved in identifying pain mechanism(s), which pertains to both residual limb pain (RLP) and phantom limb pain (PLP). In this study, sympathetic blocks were performed on 17 major limb amputees refractory to treatment, including 2 placebo-controlled blocks done for bilateral amputations. One hour postinjection, mean RLP scores at rest declined from 5.2 (SD 2.8) to 2.8 (SD 2.6) (P = .0002), and PLP decreased from 5.3 (SD 3.1) to 2.3 (SD 2.1) (P = .0009). By 1 week, mean pain scores for RLP and PLP were 4.3 (SD 2.9) and 4.2 (SD 3.0), respectively. Overall, 8 of 16 (50%) patients experienced >=50% reduction in RLP 1-hour postinjection, with the beneficial effects being maintained at 1 and 8 weeks in 4 and 1 patient(s), respectively. For PLP, 8 of 15 (53%) patients obtained >=50% decrease in pain 1-hour postblock, with these numbers decreasing to 2 patients at both 1 and 8 weeks. In the 2 bilateral amputees who received controlled injections, mean PLP and RLP at rest scores went from 4.0 and 3.3 to 4.0 and 2.5 1-hour postblock, respectively, on the placebo side. On the treatment side, mean PLP and RLP scores decreased from 7.5 and 6.5, respectively, to 0. PERSPECTIVE: The results of this study suggest that sympathetic mechanisms play a role in PLP and to a lesser extent, RLP, but that blocks confer long-term benefits in only a small percentage of patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: Medical errors exact an inordinate toll on healthcare costs. One of the most publicized and analyzed type of medical error is wrong-site surgery. Yet, despite the burgeoning number of procedures performed, no literature exists on wrong-site pain management injections. The purpose of this study was to estimate the relative incidence and determine the causes of wrong-site pain management procedures. METHODS: Quality improvement records were examined during a 2-yr period from four civilian academic teaching hospitals, three military treatment facilities, and three private practices, for 'sentinel' events involving wrong-site pain management procedures. A total of 13 cases (incidence 0.027%; 95% CI 0.01-0.05%) were identified from approximately 48,941 collective procedures of which 52.4% were deemed to be 'at risk' for the occurrence. Root cause analyses were then conducted to determine the origin of each error. RESULTS: The 13 cases included five wrong-side transforaminal epidural steroid injections, six other wrong-side injections, and two wrong-level minimally invasive surgical procedures. In only one case was the 'universal protocol' completely followed, and in nine procedures, multiple lapses occurred in protocol. Three patients had bilateral pathology, and in seven cases, the patient knew at the time that the wrong side was being injected. In no instance did any technical, legal, or professional consequences ensue from the error. CONCLUSIONS: Wrong-site nerve blocks occur more frequently in pain management centers than has previously been acknowledged. Adaptation of the universal protocol to nerve blocks and strict adherence to widely accepted guidelines may prevent wrong-site interventional pain procedures. [ABSTRACT FROM AUTHOR]

Many patients with fibromyalgia syndrome (FMS) receive inadequate or ineffective treatment, often because of multifactorial barriers that stand in the way of appropriate care. These barriers include the high prevalence of medical and psychiatric comorbidities in patients with FMS, the challenges inherent in diagnosing FMS, and the perception among many that FMS is not a 'real' disease. Another major obstacle is that there is often little or no coverage for patients with FMS who do have health insurance, and restricted access to healthcare for those who do not. This article reviews these and other patient-, physician-, and process-related barriers and explains how they interfere with treatment. The article also suggests several common-sense strategies aimed at overcoming these obstacles and improving care for patients with FMS. [ABSTRACT FROM AUTHOR]

Background and Objectives: The placement of lumbar spinal drains is being done with increasing frequency to facilitate high-risk surgical procedures. One risk associated with these procedures is catheter shearing, resulting in a retained foreign body in the intrathecal space. Unlike retained epidural fragments, there are no guidelines on the management of this complication. The purpose of this article was to synthesize the literature on this subject to come up with guidelines for preventing and managing this complication.Methods: Case report and review of all published cases.Results: Most cases of retained catheters are associated with difficulty inserting or advancing the catheter. Among those cases treated conservatively, approximately one third of patients developed symptoms. Factors that must be considered when weighing the decision to surgically remove the retained catheter include patient comorbidities and desires, size and location of the fragment, infectious risk, the presence of neurologic symptoms, and scheduled surgical procedure.Conclusions: A retained intrathecal catheter can be managed conservatively in certain contexts. Periodic follow-up visits, with or without repeat imaging, are recommended in these circumstances. [ABSTRACT FROM AUTHOR]

BACKGROUND: Recent evidence implicates the inflammatory cytokine tumor necrosis factor as a major cause of radiculopathy. Yet, whereas open-label studies with systemically delivered tumor necrosis factor inhibitors have yielded positive results, a placebo-controlled study failed to demonstrate efficacy. One variable that may have contributed to poor outcomes is low drug levels at the site of nerve inflammation. To date, no studies have evaluated the efficacy or safety of epidurally administered anti-tumor necrosis factor agents. METHODS: A double-blind, placebo-controlled, dose-response study was conducted to evaluate an epidural tumor necrosis factor inhibitor. Twenty-four patients with subacute lumbosacral radiculopathy were randomly assigned to receive two transforaminal epidural injections of 2, 4, or 6 mg of entanercept 2 weeks apart in successive groups of eight. In each group, two patients received epidural saline. A parallel epidural canine safety study was conducted using the same injection doses and paradigm as in the clinical study. RESULTS: The animal and human safety studies revealed no behavioral, neurologic, or histologic evidence of drug-related toxicity. In the clinical arm, significant improvements in leg and back pain were collectively noted for the etanercept-treated patients, but not for the saline group, one month after treatment. One patient in the saline group (17%), six patients in the 2-mg group (100%), and four patients each in the 4-mg and 6-mg groups (67%) reported at least 50% reduction in leg pain and a positive global perceived effect one month after treatment. Six months after treatment, the beneficial effects persisted in all but one patient. CONCLUSION: Epidural entanercept holds promise as a treatment for lumbosacral radiculopathy. [ABSTRACT FROM AUTHOR]

Background: Sacroiliac joint pain is a challenging condition accounting for approximately 20% of cases of chronic low back pain. Currently, there are no effective long-term treatment options for sacroiliac joint pain.Methods: A randomized placebo-controlled study was conducted in 28 patients with injection-diagnosed sacroiliac joint pain. Fourteen patients received L4-L5 primary dorsal rami and S1-S3 lateral branch radiofrequency denervation using cooling-probe technology after a local anesthetic block, and 14 patients received the local anesthetic block followed by placebo denervation. Patients who did not respond to placebo injections crossed over and were treated with radiofrequency denervation using conventional technology.Results: One, 3, and 6 months after the procedure, 11 (79%), 9 (64%), and 8 (57%) radiofrequency-treated patients experienced pain relief of 50% or greater and significant functional improvement. In contrast, only 2 patients (14%) in the placebo group experienced significant improvement at their 1-month follow-up, and none experienced benefit 3 months after the procedure. In the crossover group (n = 11), 7 (64%), 6 (55%), and 4 (36%) experienced improvement 1, 3, and 6 months after the procedure. One year after treatment, only 2 patients (14%) in the treatment group continued to demonstrate persistent pain relief.Conclusions: These results provide preliminary evidence that L4 and L5 primary dorsal rami and S1-S3 lateral branch radiofrequency denervation may provide intermediate-term pain relief and functional benefit in selected patients with suspected sacroiliac joint pain. Larger studies are needed to confirm these results and to determine the optimal candidates and treatment parameters for this poorly understood disorder. [ABSTRACT FROM AUTHOR]

Background and Objectives: The concept of opioid-induced hyperalgesia has recently gained prominence as a contributing factor for opioid tolerance and long-term treatment failure. But whereas the preclinical data for this phenomenon are strong, the mixed clinical data derive primarily from experimental pain models conducted in volunteers and heroin addicts, and nonstandardized clinical stimuli, e.g., surgery. The primary objective of this study is to delineate the effect of opioid dose and treatment duration on pain intensity and unpleasantness ratings following a standardized clinical pain stimulus.Methods: Three hundred and fifty-five patients, on a steady regimen of analgesic medications and scheduled for an interventional procedure, received a standardized subcutaneous injection of lidocaine prior to a full dose of local anesthetic. Before and immediately following the injection, subjects were asked to rate pain and unpleasantness intensity on a 0 to 10 numerical rating scale. Subjects were stratified into 6 groups based on opioid dosage. A control group of 27 volunteers who had no pain and were taking no analgesics were also injected.Results: Both opioid dose and duration of treatment directly correlated with pain intensity and unpleasantness scores. Baseline pain intensity was also positively associated with both outcome variables. Gender was found to be associated with pain intensity and unpleasantness, with females scoring higher in both categories than males. Compared with patients not receiving opioid treatment, patients receiving opioid therapy were more likely to rate the standardized pain stimulus as being more unpleasant than painful.Conclusions: The results of this study bolster preclinical and experimental pain models demonstrating enhanced pain perception in subjects receiving opioid therapy. This simple clinical model may provide a useful tool in examining opioid-induced hyperalgesia. [ABSTRACT FROM AUTHOR]

Background and Objectives: The concept of radiofrequency denervation has recently come under question in light of several studies showing minimal to no benefit. One possibility proposed for these negative outcomes is poor selection criteria. Unlike virtually all other spine interventions, the factors associated with success and failure for cervical facet denervation have yet to be determined. The purpose of this study is to determine which demographic, clinical and treatment factors are associated with cervical facet radiofrequency denervation outcomes.Methods: Data were garnered from 3 academic medical centers on 92 patients with chronic neck pain who underwent radiofrequency denervation after a positive response to diagnostic local anesthetic blocks. Success was defined as at least 50% pain relief lasting at least 6 months. Variables evaluated for their association with outcome included age, sex, duration of pain, opioid use, pain referral pattern, paraspinal tenderness, pain exacerbated by extension/rotation, magnetic resonance image abnormalities, diabetes, smoking, scoliosis, obesity, prior surgery, and levels treated.Results: The only clinical variable associated with success was paraspinal tenderness. Factors associated with treatment failure included radiation to the head, opioid use, and pain exacerbated by neck extension and/or rotation.Conclusions: Selecting patients based on key clinical variables may increase the chance of treatment success for cervical facet radiofrequency denervation. [ABSTRACT FROM AUTHOR]

Background and Objectives: Since its advent more than 50 years ago, the use of discography has been mired in controversy. The purpose of this review is to provide a clinical overview of lumbar discography and discogenic back pain, with special emphasis on determining the accuracy of discography and whether or not the procedure improves outcomes for surgery.Methods: Material for this review was obtained from a MEDLINE search conducted from 1951 thru September 2004, bibliographic references, book chapters, and conference proceedings.Results: Based on a large number of comparative studies, plain discography is less accurate than magnetic resonance imaging in diagnosing lumbar herniated nucleus pulposus and comparable or slightly more sensitive in detecting degenerative disc disease. For disc degeneration, CT discography remains the gold standard for diagnosis. There are very few studies comparing surgical outcomes between patients who have undergone preoperative provocative discography and those who have not. What little evidence exists is conflicting. Before disc replacement surgery, approximately half the studies have used preoperative discography. A comparison of outcomes did not reveal any significant difference between the 2 groups but none of the studies was controlled, and they used different outcome measures, follow-up periods, and surgical techniques. Because all intradiscal electrothermal therapy (IDET) studies have used discography before surgery, no conclusions can be drawn regarding its effects on outcome.Conclusions: Although discography, especially combined with CT scanning, may be more accurate than other radiologic studies in detecting degenerative disc disease, its ability to improve surgical outcomes has yet to be proven. In the United States and Europe, there are inconsistencies in the use of lumbar discography such that it is routinely used before IDET, yet only occasionally used before spinal fusion. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to determine the factors associated with false-positive medial branch blocks (MBB), the nerve blocks used to diagnose facet arthropathy, in soldiers and retirees.Methods: The study subjects were 78 patients with chronic low back pain who underwent diagnostic MBB to determine whether or not the facet joints were pain generators. Radiofrequency denervation of these nerves was performed in all patients with positive responses. Patients who failed to obtain pain relief after the blocks (negative blocks) and those who obtained temporary pain relief after MBB but failed radiofrequency denervation (false-positive blocks) then proceeded to undergo discography. Based on patients' responses to diagnostic blocks, discography results, the presence of radicular pain, and previous back surgery, the data were analyzed to determine whether any of these variables correlated with false-positive MBB.Results: The presence of discogenic or radicular pain was not associated with a higher false-positive response rate to MBB. Conversely, the absence of discogenic pain was associated with a higher percentage of false-positive blocks. There was also a trend for patients with previous back surgery to have a higher false-positive rate than those who had not undergone previous surgery.Conclusions: Although a high incidence of epidural and foraminal spread occurs during the performance of MBB, this is unlikely to be a significant cause of false-positive blocks. [ABSTRACT FROM AUTHOR]

Trauma is a major cause of mortality throughout the world. In recent years, major advances have been made in the management of trauma, the end result of which has been reduced mortality and enhanced function. One of these areas is pain control. Improved pain management has not only led to increased comfort in trauma patients, but has also been shown to reduce morbidity and improve long-term outcomes. This review focuses on the treatment of pain in the setting of acute injury and on pain management in trauma patients who go on to develop chronic pain. Emphasis is placed on pharmacologic interventions, invasive and noninvasive pain management techniques, analgesia in challenging patients, and pain control in commonly encountered trauma conditions. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: A bi-institutional, retrospective clinical data analysis. OBJECTIVES: To determine risk factors for failure and complications of intradiscal electrothermal therapy, a treatment for discogenic back pain. SUMMARY OF THE BACKGROUND DATA: Intradiscal electrothermal therapy is a relatively new treatment for discogenic back pain. Though previous studies have shown it to be an effective treatment, there are few published studies examining complications and none examining risk factors for failure. METHODS: The authors treated 79 patients with discogenic back pain using intradiscal electrothermal therapy. Complications were assessed by patient report and, when indicated, further diagnostic testing. Success or failure was determined by visual analogue pain scores at 6-month follow-up. Variables examined for their relationship to failure and complications were age, sex, duration of pain, number of levels heated, smoking history, diabetes, obesity, leg pain, and previous back surgery. RESULTS: Forty-eight percent of patients reported more than 50% pain relief at their 6-month follow-up. There were eight complications (10%), most of which were self-limited and transient. The only risk factor associated with intradiscal electrothermal therapy failure was obesity (P = 0.01). Whereas 54% of nonobese patients reported good pain relief at 6 months, only one out of 10 obese patients had successful intradiscal electrothermal therapy. The obese patients in our study were more likely to have a complication from intradiscal electrothermal therapy than they were to obtain pain relief. CONCLUSION: The only risk factor found to be associated with IDET outcome was obesity, which was a strong predictor of failure. Obesity should be considered a relative contraindication to performing IDET. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To shed light on nebulized morphine, a new treatment for dyspnea in children with terminal lung disease. METHODS: A clinical case study was conducted on a patient in a tertiary care medical center. RESULTS: Nebulized morphine was administered in incremental doses ranging from 2.5 mg to 12.5 mg in a 10-year-old, 20-kg boy with end-stage cystic fibrosis. Before the nebulized morphine treatments were started, a dose of nebulized lidocaine failed to provide the patient with any relief. After each dose of morphine, the following parameters were recorded: visual analog 'dyspnea' scores, vital signs, venous blood gases, and blood levels of morphine. The nebulized morphine was found to have a modest effect on the patient's dyspnea, with no significant differences found between the varying doses. Venous carbon dioxide tension levels increased <4 mm Hg for all doses except 12.5 mg, for which there was a 9-mm Hg increase. Systemic blood levels of morphine were <10 ng/mL at all doses. The nebulized morphine did not cause any significant changes in blood pressure or heart rate for doses <12.5 mg. CONCLUSIONS: Inhaled morphine was associated with a mild, beneficial effect on dyspnea, with minimal differences found between the lowest and highest doses. This 'ceiling' effect may be the result of saturation of opioid receptors in the lung, the variable bioavailability of inhaled morphine, or a placebo response. More studies are needed to determine what, if any, the optimum dose of nebulized morphine is for children. [Abstract for this article also available on page 614 of printed version. Full article available at http://www.pediatrics.org/cgi/content/full/110/3/e38] [ABSTRACT FROM AUTHOR]