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Abd-Elsayed A. Wireless Peripheral Nerve Stimulation at C2 and C3 to Treat Persistent Daily Headaches and Occipital Neuralgia. PAIN MEDICINE CASE REPORTS 2021; 5:409-411. [DOI: 10.36076/pmcr.2021.5.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND: Headache is a very challenging condition to treat. We are presenting a unique approach for treating headache and occipital neuralgia that involves placing a wireless peripheral nerve stimulation system at the C2 and C3 levels. CASE REPORT: A 39-year-old man with a history of headache and occipital neuralgia resistant to several treatment modalities was treated with occipital nerve stimulation at the levels of C2 and C3. CONCLUSION: Peripheral nerve stimulation at the C2 and C3 levels is a unique approach for treating resistant headache and occipital neuralgia. KEY WORDS: C2, C3, headache, occipital neuralgia, peripheral nerve stimulation
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Gyorfi M, Abd-Elsayed A. Peripheral Nerve Stimulator for Treating Sural and Posterior Tibial Neuralgias – Case Report. PAIN MEDICINE CASE REPORTS 2021; 5:413-416. [DOI: 10.36076/pmcr.2021.5.413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND: Sural neuralgia is persistent pain in the distribution of the sural nerve that provides sensation to the lateral posterior corner of the leg, lateral foot, and fifth toe. Sural neuralgia is a rare condition, but can be challenging to treat and cause significant limitations. Posterior tibial neuralgia, also known as tarsal tunnel syndrome, is an injury or stretch affecting the tibial nerve at the medial border of the ankle and heel. We present one case of sural neuralgia complicated by superimposed posterior tibial neuralgia resistant to conservative management that were effectively treated with a peripheral nerve stimulator placement. CASE REPORT: A 60-year-old man developed sural and posterior tibial neuralgias after a motorcycle accident resulting in severe injury of his left lower extremity. He underwent surgery for his open left distal tibia fracture. The patient continued to have pain which was not alleviated with physical therapy and conservative management. Six years after the initial injury and failing conservative management, he underwent successful sural and posterior tibial nerve blocks followed by placement of a peripheral nerve stimulator with improvement in pain and daily function. CONCLUSIONS: Peripheral nerve stimulators may be a safe and effective treatment for both sural and posterior tibial neuralgias that do not respond to conservative therapy. However, large scale studies are needed to elucidate its effectiveness and safety profile. KEY WORDS: Peripheral nerve stimulator, posterior tibial neuralgia, sural neuralgia
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Grabnar M, Abd-Elsayed A, Kim C. Videoconferencing during COVID-19: strategies for a successful fellowship interview. ADVANCES IN CLINICAL MEDICAL RESEARCH AND HEALTHCARE DELIVERY 2021; 1. [DOI: 10.53785/2769-2779.1041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Peck J, Slovek A, Miro P, Vij N, Traube B, Lee C, Berger AA, Kassem H, Kaye AD, Sherman WF, Abd-Elsayed A. A Comprehensive Review of Viscosupplementation in Osteoarthritis of the Knee. Orthop Rev (Pavia) 2021; 13:25549. [PMID: 34745480 DOI: 10.52965/001c.25549] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/03/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose of Review The purpose of this systematic review is to discuss emerging evidence in the field of viscosupplementation for chronic knee pain secondary to Osteoarthritis (OA). This review focuses on types of viscosupplementation that are clinically available currently, evidence to support their use, contraindications, and adverse events. Recent Findings OA, also known as degenerative joint disease, is the most common form of arthritis in the United States, affecting 54.4 million, or 22.7% of the adult population. The knee is the most common joint affected in OA, with up to 41% involvement, 30% in the hands, and 19% in the hips. The pathophysiology of OA is complex, with contributing factors including mechanical stress to the joint, as well as many person-specific factors such as genetic susceptibility, ethnicity, nutrition, and sex. Treatment modalities include weight control, exercise, non-steroidal and steroidal anti-inflammatory drugs, opioids, intra-articular platelet-rich plasma, placebo, corticosteroid injection, intra-articular viscosupplementation, and surgery. Viscosupplementation consists of injection of hyaluronic acid (HA) into affected joints, intending to restore the physiologic viscoelasticity in the synovial fluid (SF) in the absence of inflammation. HA has also been shown to downregulate pro-inflammatory factors, such as PGE2 and NFkB, and proteases and proteinases known to break down the joint matrix.The contraindications for HA injection are similar to any other injection therapy, and adverse events are usually mild, local, and transient. Viscosupplementation (VS) is effective over placebo and more effective than NSAIDs and corticosteroids in pain reduction and improved functionality; however, guidelines recommend neither for nor against its use, demonstrating variability in the existing evidence base.Current VS options divide primarily into native vs. cross-linked and low-molecular-weight vs. high-molecular-weight. Current treatment options include Hylan g-f-20, Sodium Hyaluronate preparations (Suparts Fx, Euflexxa, Gelsyn-3, Durolane, Hyalgen), single-use agents (Gel-One, Synvisc-One, Monovisc), and Hyaluronan (Orthovisc, Monovisc, Hymovic). They share a common safety profile, and all have evidence supporting their efficacy. Their specific details are reviewed here. Summary OA is the most common form of arthritis. It is a chronic, debilitating illness with a high impact on the functionality and quality of life of a significant part of the population in the western world. Treatments include medical management, physical therapy, activity modification, injection, and surgery. VS effectively reduces pain, increases functionality, and delays surgery in the knee to treat osteoarthritis. While previous studies have demonstrated variable results, more evidence is becoming available generally supportive of the benefit of VS in the treatment of knee OA.
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Orhurhu V, Huang L, Quispe RC, Khan F, Karri J, Urits I, Hasoon J, Viswanath O, Kaye AD, Abd-Elsayed A. Use of Radiofrequency Ablation for the Management of Headache: A Systematic Review. Pain Physician 2021; 24:E973-E987. [PMID: 34704708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Headache is a very common condition that affects 5-9% of men and 12-25% of women in North America and Europe. Globally, the prevalence of active headaches among adults is 47%. The most common type of headache is tension headaches (38% of adults), followed by migraines (10%), and chronic headaches (3%). While the majority of headaches are benign, the disorder can severely negatively influence a patients' quality of life, which is directly reflected in societal costs. OBJECTIVE The objective of this review was to summarize available evidence behind radiofrequency ablation (RFA) for headache, including pain outcome measures, secondary outcomes, and complications. STUDY DESIGN Systematic review. SETTING This systematic review examined studies that applied the use of RFA for management of headache. METHODS This systematic review was reported following the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Two reviewers independently scored the methodological quality of the selected studies. Due to heterogeneity of studies, a best-evidence synthesis of the available prognostic factors was provided. RESULTS In the present investigation, we evaluated 18 studies composed of 6 randomized controlled trials (RCTs), 6 prospective studies, and 6 retrospective studies. All the studies assessed pain improvement with RFA in patients with headache. Most studies targeted the occipital nerve for treatment. Complications were mostly mild and self-limiting, including eyelid swelling, rash, superficial infection of the procedural site, and worsening of headache. LIMITATIONS A large variability in definitions of trigeminal neuralgia, radiofrequency technique, and patient selection bias was observed in our selected cohort of studies. In addition, there is a paucity of strong longitudinal RCTs and prospective studies. CONCLUSION Our review discusses several studies that suggest the efficacy of RFA in the treatment of headaches. Outcomes varied based on the difference in approaches regarding continuous radiofrequency versus pulsed radiofrequency, temperature, and duration of administration. The majority of the studies discussed in this review indicate a therapeutic benefit of RFA for headaches over a short-term period. Pain outcomes beyond one year are understudied and further studies are needed to determine the long-term effects of RFA for headaches.
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Abd-Elsayed A, Hussain N, Stanley G. Combining Virtual Reality and Behavioral Health to Promote Pain Resiliency: Analysis of a Novel BioPsychoSocial Modality for Solving Pain in the Workplace. Pain Ther 2021; 10:1731-1740. [PMID: 34657235 PMCID: PMC8520463 DOI: 10.1007/s40122-021-00333-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 09/28/2021] [Indexed: 11/30/2022] Open
Abstract
Background The use of virtual reality in treating pain symptoms is a new and emerging modality that has gained more traction, especially in light of the COVID-19 pandemic, which has led to a rise in the remote care of patients. Our study tested the effectiveness of a home-based pain relief program that utilized virtual reality and behavioral health for treating acute and chronic pain. Study Design Retrospective Cohort Study. Methods Due to the remote nature of the pain clinic during the COVID-19 pandemic, patients with work-related injuries were considered for inclusion in a 90-day Harvard MedTech Vx Pain Relief Program, which consisted of home-based virtual reality therapy (VRT) and tailored behavioral therapy that was conducted through phone consultations. Both the VRT and behavioral therapy focused on the specific workplace injury and centered around setting three personal goals for each patient that were considered meaningful to them. The progress towards achieving these goals was then tracked. The primary outcome of the retrospective analysis was pain scores after completion of home-based VRT. Secondary outcomes included: change in opioid therapy (opioid consumption), psychological awareness/perception of pain, level of immersion, and overall improvement/achievement in patient goals. Results A total of 36 patients (16 male and 20 female) with acute and chronic pain secondary to workplace injuries were included; these injuries severely limited their activities of daily living and reduced their quality of life. During the course of VRT and after completion of the 90-day program, patients experienced a substantial immediate and legacy pain relief. Specifically, patients reported an average 40% reduction in pain while utilizing the program and an additional 2.8 h of continued pain relief at the conclusion of 90 days. Further, 69% of patients also reported either a decrease in opioid use or complete cessation after VRT. The majority of patients also reported reduced depression, fatigue, and sleep disturbance. Conclusions The Harvard MedTech Vx Therapy appears to be an effective tool in the treatment of pain and the psycho-social issues associated with pain. This translates into a greater degree of pain resiliency and an overall improvement in general wellness and improved workplace functionality.
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Michaud K, Cooper P, Abd-Elsayed A, Kohan L. Review of Radiofrequency Ablation for Peripheral Nerves. Curr Pain Headache Rep 2021; 25:63. [PMID: 34622328 DOI: 10.1007/s11916-021-00981-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Radiofrequency ablation (RFA) has become an increasingly widespread treatment tool for various chronic pain syndromes within the last two decades with the majority of publications on the topic coming after 2006. Not only are clinicians using RFA to treat more peripheral nerve pain syndromes but the technology itself is evolving quickly to the point that it is nearly impossible to stay abreast on the complexity of such a diversely utilized instrument. This review summarizes studies that focus on the use of RFA for peripheral nerve neurotomy and anatomical studies regarding RFA published between 2015 and 2020. RECENT FINDINGS Topics in this review include anatomical regions or nerves of the body published since 2015. Significant findings are summarized in each section. Peripheral nerve RFA is rapidly changing. Many studies have been performed over the last 5 years showing the usefulness of RFA.
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Engle AM, Abd-Elsayed A, Pope JE, Fishman M. The Impact of Clinical Setting on Evaluating Patients Using the PROMIS-29 Baseline Measures in the COVID Era: A Retrospective Multicenter Quantitative Analysis. Pain Ther 2021; 10:1663-1672. [PMID: 34599754 PMCID: PMC8487233 DOI: 10.1007/s40122-021-00323-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 09/01/2021] [Indexed: 11/29/2022] Open
Abstract
Background Multidimensional patient-reported outcomes are a critical part of assessing patients to better understand their well-being during treatment. The PROMIS-29 assessment tool is utilized as a component of assessing multidimensional pain scales. It includes patient-reported measures of pain, mood, sleep, social participation, and function. Currently, there are no data on whether a patient’s immediate environment (remote versus in person) influences the reported patient outcomes measurement of a multidimensional tool represented as PROMIS-29 data. Methods Retrospective analysis of prospectively collected data was performed. Subjects were identified and consecutively enrolled upon entry into a chronic pain or spine center in the United States. The PROMIS-29 v2.1 was recorded. Statistical differences were assessed among age groups and across the seven domains of the assessment. Results A total of 25,187 distinct patients were enrolled in the study from August 2018 to December 2020 with a presenting baseline measurement of PROMIS-29. The PROMIS-29 v2.1 was evaluated across the seven domains, and subgroup age analysis was performed for patients completing surveys in the clinical setting (non-remote group) and those completing the survey in the remote setting (remote group) during entry into spine and pain practices across the United States. For mental health scores, those less than 40 years of age and those over 80 years of age showed significant differences in ratings of anxiety and depression in the remote versus non-remote setting. Regarding physical health scores, those aged 60–79 showed a significant difference in the remote versus non-remote ratings for pain interference (p = 0.005; 63.9 vs. 64.4), physical function (p = 0.000; 36.4 vs. 35.7), and fatigue (p = 0.020; 57.2 vs. 57.7), while subjects over 80 years of age showed a statistical difference between the remote versus non-remote setting only in rating physical function (p = 0.025; 33.0 vs. 34). Notably, the rating of sleep disturbance in the remote versus non-remote setting was the only significant variable in the 40–59 age category (p = 0.000; 60.0 vs. 59.1). Those less than 40 years of age also reported a significant difference in the remote versus non-remote setting when rating sleep disturbance (p = 0.000; 60.5 vs. 58.9). With regard to social function, only those older than 80 years showed a significant difference in rating of ability in the remote compared to the non-remote setting (p = 0.031; 39.6 vs. 40.7). Conclusions This data set is the first published data describing the influence of environment (remote versus in person) on PROMIS-29 outcome measurements in the chronic pain population.
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Singh M, Karri J, Orhurhu V, Lachman L, Abd-Elsayed A. Radiofrequency Ablation for Thoracic and Abdominal Chronic Pain Syndromes. Phys Med Rehabil Clin N Am 2021; 32:647-666. [PMID: 34593134 DOI: 10.1016/j.pmr.2021.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Chronic thoracic pain and chronic abdominal pain are common conditions that can significantly affect quality of life. Pain syndromes encompassing a variety of causes, including cancer pain, neuritis, and postsurgical pain, are traditionally managed by the use of pharmacologic therapy; however, many cases are refractory to these conservative methods. Radiofrequency ablation (RFA) has been increasingly used as a tool to treat resistant, chronic pain of both thoracic and abdominal origin. Multiple cases and trials have been reported that show the efficacy of RFA in the treatment of these chronic pain conditions.
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Fiala K, Martens J, Abd-Elsayed A. Preoperative considerations. SACROILIAC JOINT PAIN 2021:185-192. [DOI: 10.1093/med/9780197607947.003.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Sacroiliac joint fusion surgery is an option for patients whose sacroiliac joint pain has been refractory to conservative pain management. A good candidate for fusion surgery is one who has completed all appropriate nonsurgical management efforts, including physical therapy, intraarticular sacroiliac steroid injections, oral analgesics, and radiofrequency ablation of sacral nerve roots, without experiencing any improvement in pain. This chapter covers candidate selection, the two main surgical approaches used for this fusion surgery (open and minimally invasive), anticoagulation guidelines, and the risk of infection and complications. Before surgery it is very important to make sure the patient understands the risks of the surgery as well as the potential for success.
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Ferguson K, Abd-Elsayed A. Peripheral nerve stimulation trial and implantation. SACROILIAC JOINT PAIN 2021:135-146. [DOI: 10.1093/med/9780197607947.003.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
This chapter will detail the surgical recommendations and step-by-step approaches for both trial stimulation and permanent implantation of peripheral nerve stimulation to treat sacroiliac joint pain. It also provides a brief history of this procedure, which has evolved from being a procedure that required careful, open dissection of the target nerve to a sleek treatment requiring only image guidance and a minimally invasive percutaneous approach. A trial stimulation period typically ranges from 7 to 14 days; steps for the trial simulation procedure include preparation, target point identification, and lead insertion. Additional topics for the permanent implantation procedure include tunneling and pocket dissection.
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Hughes MC, Abd-Elsayed A. Complications of peripheral nerve stimulation for sacroiliac pain. SACROILIAC JOINT PAIN 2021:161-166. [DOI: 10.1093/med/9780197607947.003.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
This chapter will look at complications of peripheral nerve stimulation (PNS) by stratifying them into three distinct categories: hardware-related complications (lead migration or fracture, connection issues, and premature battery depletion), biologic complications (infection), and programming or therapy-related complications. Today, the complications related to current PNS procedures are rare and minor. Hospital admission is exceedingly unlikely. Every new device on the market is working not only to improve performance but also to mitigate risks such as lead migration and infection. Also included in this chapter is background information about how the procedure and the hardware have evolved over the years, leading to improved performance and fewer complications.
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Abd-elsayed A, Sayed D. Sacroiliac Joint Pain. 2021. [DOI: 10.1093/med/9780197607947.001.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Lower back pain attributed to the sacroiliac joint (SIJ) is prevalent but historically has been frequently underdiagnosed. Even when the SIJ is properly identified as a source of lower back pain, individuals suffering from SIJ dysfunction are often not treated effectively. Improved educational resources for clinicians based on effective evidence-based treatments for SIJ dysfunction are critical in improving the current gap in diagnosis and treatment. Several established and emerging treatments exist for patients with SIJ dysfunction, but prior to this text, no comprehensive resource has existed that addressed management of SIJ dysfunction. This text presents a full and up-to-date review of all the available treatments for SIJ dysfunction, with the aim of providing clinicians with a single comprehensive resource for treatment of their patients.
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Janapala RN, Manchikanti L, Sanapati MR, Thota S, Abd-Elsayed A, Kaye AD, Hirsch JA. Efficacy of Radiofrequency Neurotomy in Chronic Low Back Pain: A Systematic Review and Meta-Analysis. J Pain Res 2021; 14:2859-2891. [PMID: 34531682 PMCID: PMC8439627 DOI: 10.2147/jpr.s323362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/03/2021] [Indexed: 12/23/2022] Open
Abstract
Purpose The objective of the systematic review and meta-analysis is to evaluate the efficacy of radiofrequency neurotomy as a therapeutic lumbar facet joint intervention. Patients and Methods Utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, a systematic review and meta-analysis was performed. A comprehensive literature search of multiple data sources from 1966 to September 2020 including manual searches of bibliography of known review articles was performed. The inclusion criteria were based on the selection of patients with chronic low back pain with diagnosis confirmed based on controlled diagnostic blocks and with the publication of at least 6 months of results of appropriate outcome parameters. Quality assessment of the trials was performed with Cochrane review criteria and interventional pain management techniques-quality appraisal of reliability and risk of bias assessment (IPM-QRB). The level of evidence of effectiveness is classified at five levels ranging from Level I to Level V. The primary outcome measure was a significant reduction in pain, eg, short term (up to 6 months) and long term (more than 6 months). The secondary outcome measure was an improvement in functional status. Results A total of 12 randomized controlled trials (RCTs) met the inclusion criteria for evaluating the efficacy of lumbar radiofrequency neurotomy. Radiofrequency neurotomy showed Level II evidence for efficacy for both the short term and long term. Conclusion This systematic review of the assessment of the efficacy of radiofrequency neurotomy in managing chronic low back pain was based on the inclusion of 12 RCTs with a diagnostic block and at least 6 months of follow-up results that showed Level II evidence for both short-term and long-term improvement.
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Kenfield M, Zacharias N, Abd-Elsayed A. Intrathecal Drug Delivery for the Treatment of Cancer-Associated Chronic Pain in Children. Neuromodulation 2021:S1094-7159(22)00576-1. [PMID: 34520605 DOI: 10.1111/ner.13535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/27/2021] [Accepted: 08/16/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Management of refractory cancer-associated pain can be particularly challenging. Regional anesthesia is an alternative modality to treat acute and chronic refractory pain. Intrathecal (IT) drug delivery of opioids and other adjuncts has been used to treat refractory cancer-associated pain. This method has been shown to be relatively safe and effective, often associated with fewer systemic side effects when compared to oral or IV opioid administration. While intrathecal drug delivery systems (IDDS) are regularly used in the adult cancer population for the treatment of refractory, chronic pain, there is limited evidence of similar use in the pediatric setting. MATERIALS AND METHODS We performed a systematic review using conventional Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology to identify studies reporting IT drug delivery for the treatment of pediatric cancer-related pain. The primary outcome was satisfaction with analgesia categorized as "satisfactory" or "unsatisfactory." Functional benefits, previous systemic pharmaceutical interventions, previous non-IT regional interventions, indication for IT drug delivery, IT drugs used, and method of delivery were collected. RESULTS A total of 11 studies were identified, describing 16 patients with cancer-related pain treated with IT drug delivery. The average age of the cohort was 12.25 years, with ages ranging from 3 to 19 years. Most patients were adolescent (10/16). All patients had cancer diagnoses, with most patients suffering from solid tumor pain (14/16). Nearly all patients achieved satisfactory analgesia through IT drug delivery (15/16) and most reported functional benefits in addition to analgesia (13/16). Majority received IT drugs via external catheters (9/16). One severe complication of respiratory depression was reported, which resolved following naloxone administration. CONCLUSIONS There exist children with cancer whose pain is refractory to the standard approaches and may benefit from IT drug delivery. The existing data, although limited and of low tier evidence, suggest that IT drug delivery has been effective in the pediatric cancer population.
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Manchikanti L, Knezevic E, Knezevic NN, Vangala BP, Sanapati MR, Thota S, Abdi S, Abd-Elsayed A, Kaye AD, Hirsch JA. A Comparative Systematic Review and Meta-Analysis of 3 Routes of Administration of Epidural Injections in Lumbar Disc Herniation. Pain Physician 2021; 24:425-440. [PMID: 34554683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND The Best Practices in Pain Management from the U.S. Department of Health and Human Services (HHS) describes interventional techniques as part of a continuum. Epidural injections are commonly utilized modalities in managing low back and lower extremity pain. Epidural injections were initially administered in 1901 where the first descriptions of caudal epidural with local anesthetic for low back pain appeared. Since then, multiple developments have occurred. Currently, epidural injections are provided by caudal, interlaminar, and transforaminal approaches. The comparative effectiveness of each modality has been studied. However, comparative assessment has been sparse. OBJECTIVES To assess the efficacy of 3 routes of administration of epidural injections for lumbar disc herniation. STUDY DESIGN A systematic review and meta-analysis of randomized controlled trials (RCTs) of transforaminal, interlaminar and caudal epidural injections in managing chronic low back and lower extremity pain due to lumbar disc herniation. METHODS RCTs with a placebo control or an active control design, performed under fluoroscopic guidance, with at least 6 months of follow-up are included. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Data extraction and methodological quality assessment were performed. Evidence was summarized utilizing principles of best evidence synthesis. RESULTS A total of 21 trials were included. Of these, 7 studied caudal epidural injections, whereas transforaminal epidural injections were studied in 12 trials, and lumbar interlaminar epidural injections were studied in 10 trials, which all met inclusion criteria. Based on qualitative and quantitative analysis, which included conventional dual-arm and single-arm analysis for interlaminar epidural injections, and single-arm analysis for caudal and transforaminal epidural injections, and the approach to the epidural space, there is Level I evidence for local anesthetic and steroids, Level II for local anesthetic alone for transforaminal and interlaminar approaches, and Level II for the caudal approach with steroids or local anesthetic alone for short- and long-term relief. LIMITATIONS There is a paucity of literature with intermediate or long-term relief of at least 6 months with appropriate outcome parameters. Conventional dual-arm meta-analysis was feasible only for interlaminar epidural injections. CONCLUSION Epidural injections with local anesthetic and steroids showed Level I evidence for transforaminal and interlaminar approaches, whereas with local anesthetic alone Level II evidence was demonstrated. In contrast, caudal epidural injections showed Level II evidence with local anesthetic with steroids or local anesthetic alone.
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Eells A, Shumsky P, Freeman J, Wie C, Abd-Elsayed A, Strand N. Treatment of Intracranial Hypertension-Related Headache Causing Low Cerebrospinal Fluid Pressure Requiring Epidural Blood Patch. PAIN MEDICINE CASE REPORTS 2021; 5:305-307. [DOI: 10.36076/pmcr.2021.5.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND: Patients can have a lumbar puncture for numerous reasons, including therapeutic cerebrospinal fluid (CSF) drainage in patients with idiopathic intracranial hypertension (IIH). Aggressive CSF drainage to alleviate the IIH headache can inadvertently cause a low-pressure postdural puncture headache (PDPH). CASE REPORT: We report the novel case of a patient with an IIH headache, which was treated with CSF drainage resulting in a PDPH and subsequent return of the IIH headache. Physical examination findings of papilledema and the nonpositional character after the epidural blood patch (EBP), and improvement of symptoms with topiramate and dexamethasone, show that IIH was the likely cause of her post-EBP headaches. CONCLUSIONS: The best-case scenario is to prevent severe cases of PDPH in this patient population. The authors recommend targeting intracranial pressure (ICP) after the treatment of IIH to the high-normal range to prevent PDPH. If IIH headache symptoms arise after EBP, conservative measures to reduce ICP can be utilized, such as acetazolamide, topiramate, and dexamethasone. KEY WORDS: Epidural blood patch, idiopathic intracranial hypertension, lumbar puncture, postdural puncture headache
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Abd-Elsayed A. The Evolution of Wireless Peripheral Nerve Stimulation. ASRA NEWS 2021; 46. [DOI: 10.52211/asra080121.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Manchikanti L, Knezevic E, Knezevic NN, Sanapati MR, Thota S, Abd-Elsayed A, Hirsch JA. Epidural Injections for Lumbar Radiculopathy or Sciatica: A Comparative Systematic Review and Meta-Analysis of Cochrane Review. Pain Physician 2021; 24:E539-E554. [PMID: 34323441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Epidural injections are one of the commonly performed procedures in managing low back and lower extremity pain. In the past, Pinto et al and Chou et al performed systematic reviews and meta-analyses with a recent update from Oliveira et al showing lack of effectiveness of epidural steroid injections in managing lumbar radiculopathy. In contrast, multiple other systematic reviews and meta-analyses have supported the efficacy and use of epidural injections utilizing fluoroscopic guidance. STUDY DESIGN A systematic review and meta-analysis of randomized controlled trials (RCTs) of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy. OBJECTIVES To assess the efficacy of 3 categories of epidural injections for lumbar radiculopathy or sciatica performed utilizing saline with steroids, local anesthetic alone, or steroids with local anesthetic. METHODS In this systematic review and meta-analysis, RCTs with a placebo control or an active control design, performed under fluoroscopic guidance, with at least 6 months of followed-up were included. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Literature search was performed through January 2021. Methodological quality assessments were performed. Evidence was summarized utilizing principles of best evidence synthesis. RESULTS In this analysis, a total of 21 RCTs were utilized with at least 6 months of follow-up and performed under fluoroscopic guidance. However, only 6 of 25 trials from Cochrane review met inclusion criteria for this review. Based on qualitative analysis, of the 21 trials included in the present analysis, there was only one placebo-controlled trial found to be negative. With conventional meta-analysis, there was no significant difference among the studies because all of the studies were active control with local anesthetic or local anesthetic and steroids. Further, with single-arm analysis, of the 5 trials included in that portion of the study, significant improvement was seen with local anesthetic alone compared to local anesthetic and steroids. There was a tendency for better improvement with steroids in terms of both pain relief and functional status. The level of evidence is Level I or strong for local anesthetic with steroids and Level I to II or moderate to strong for local anesthetic as a single agent based on multiple relevant high quality RCTs. LIMITATIONS Despite multiple trials available, there is a paucity of true RCTs performed under fluoroscopic guidance with any of the approaches. CONCLUSION Epidural injections with or without steroids for radiculopathy showed significant effectiveness with Level I or strong evidence for local anesthetic with steroids and Level II to I or moderate to strong evidence with local anesthetic alone.
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Mathias K, Amarnani A, Pal N, Karri J, Arkfeld D, Hagedorn JM, Abd-Elsayed A. Chronic Pain in Patients with Rheumatoid Arthritis. Curr Pain Headache Rep 2021; 25:59. [PMID: 34269913 DOI: 10.1007/s11916-021-00973-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2021] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Chronic pain is highly prevalent in patients with rheumatoid arthritis (RA) and can cause various physical and psychological impairments. Unfortunately, the appropriate diagnosis of chronic pain syndromes in this population can be challenging because pain may be primary to RA-specific inflammation and/or secondary to other conditions, typically osteoarthritis (OA) and fibromyalgia (FM). This disparity further poses a clinical challenge, given that chronic pain can often be discordant or undetected with standard RA-specific surveillance strategies, including serological markers and imaging studies. In this review, we provide a robust exploration of chronic pain in the RA population with emphasis on epidemiology, mechanisms, and management strategies. RECENT FINDINGS Chronic pain associated with RA typically occurs in patients with anxiety, female sex, and elevated inflammatory status. Up to 50% of these patients are thought to have chronic pain despite appropriate inflammatory suppression, typically due to peripheral and central sensitization as well as secondary OA and FM. In addition to the standard-of-care management for OA and FM, patients with RA and chronic pain benefit from behavioral and psychological treatment options. Moreover, early and multimodal therapies, including non-pharmacological, pharmacological, interventional, and surgical strategies, exist, albeit with varying efficacy, to help suppress inflammation, provide necessary analgesia, and optimize functional outcomes. Overall, chronic pain in RA is a difficult entity for both patients and providers. Early diagnosis, improved understanding of its mechanisms, and initiation of early, targeted approaches to pain control may help to improve outcomes in this population.
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Abd-Elsayed A, Karri J. A Response to: Letter to the Editor Regarding Radiofrequency Treatment-Newer Modes and Long-Term Effects. Pain Ther 2021; 10:1777-1778. [PMID: 34216362 PMCID: PMC8586322 DOI: 10.1007/s40122-021-00285-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 06/17/2021] [Indexed: 10/27/2022] Open
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Abd-Elsayed A, Cui C, Eckmann MS. Cooled Radiofrequency Ablation of the Trochanteric Branch of the Nervus Femoralis to Treat Greater Trochanteric Pain Syndrome. PAIN MEDICINE 2021; 23:1375-1378. [PMID: 34175957 DOI: 10.1093/pm/pnab207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Greater trochanteric pain syndrome is a common cause of lateral hip pain. Corticosteroid injections are commonly utilized as non-surgical interventions, however they are not effective for all patients. This technical case report describes a method for treating greater trochanteric pain syndrome by utilizing cooled radiofrequency ablation. METHODS The trochanteric branch of the nervus femoralis is identified as providing sensory innervation to the greater trochanter and its surrounding structures. We have identified fluoroscopic targets to block the nerve and perform cooled radiofrequency ablation. We present two patient cases which demonstrated significant pain relief of greater trochanteric pain syndrome with this treatment. CONCLUSIONS Cooled radiofrequency ablation of the trochanteric branch of the nervus femoralis is a potential treatment for greater trochanteric pain syndrome. This procedure provides a potential steroid-sparing interventional treatment based on reproducible fluoroscopic landmarks.
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Schultz D, Abd-Elsayed A. Response to: "Adverse Events and Complications Associated With Intrathecal Drug Delivery Systems: Insights From the Manufacturer and User Facility Device Experience (MAUDE) Database". Neuromodulation 2021; 24:796-797. [PMID: 34160875 DOI: 10.1111/ner.13417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Latimer D, Stocker MD, Sayers K, Green J, Kaye AM, Abd-Elsayed A, Cornett EM, Kaye AD, Varrassi G, Viswanath O, Urits I. MDMA to Treat PTSD in Adults. PSYCHOPHARMACOLOGY BULLETIN 2021; 51:125-149. [PMID: 34421149 PMCID: PMC8374929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Post-traumatic stress disorder (PTSD) has become one of the most common psychiatric diagnosis in the United States specifically within the veteran population. The current treatment options for this debilitating diagnosis include trauma-focused psychotherapies along with selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI).1 MDMA has recently been shown as a novel therapeutic agent with promisingly results in the treatment of PTSD. MDMA is a psychoactive compound traditionally categorized as a psychedelic amphetamine that deemed a Schedule I controlled substance in the 1980s. Prior to its status as a controlled substance, it was used by psychotherapists for an array of psychiatric issues. In more recent times, MDMA has resurfaced as a potential therapy for PTSD and the data produced from randomized, controlled trials back the desire for MDMA to be utilized as an effective pharmacologic therapy in conjunction with psychotherapy.2.
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Strand NH, Abd-Elsayed A, Shumsky PM, Freeman JA, Kukulski ML, Wie CS. Epidural Blood Patch Procedure in Patients with Lymphoma or Leukemia: Is There a Risk of Cancer Seeding? PAIN MEDICINE 2021; 22:1236-1237. [PMID: 32918480 DOI: 10.1093/pm/pnaa285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Gupta M, Knezevic NN, Abd-Elsayed A, Ray M, Patel K, Chowdhury B. Treatment of Painful Diabetic Neuropathy-A Narrative Review of Pharmacological and Interventional Approaches. Biomedicines 2021; 9:biomedicines9050573. [PMID: 34069494 PMCID: PMC8161066 DOI: 10.3390/biomedicines9050573] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/01/2021] [Accepted: 05/06/2021] [Indexed: 12/11/2022] Open
Abstract
Painful diabetic neuropathy (PDN) is a common complication of diabetes mellitus that is associated with a significant decline in quality of life. Like other painful neuropathic conditions, PDN is difficult to manage clinically, and a variety of pharmacological and non-pharmacological options are available for this condition. Recommended pharmacotherapies include anticonvulsive agents, antidepressant drugs, and topical capsaicin; and tapentadol, which combines opioid agonism and norepinephrine reuptake inhibition, has also recently been approved for use. Additionally, several neuromodulation therapies have been successfully used for pain relief in PDN, including intrathecal therapy, transcutaneous electrical nerve stimulation (TENS), and spinal cord stimulation (SCS). Recently, 10 kHz SCS has been shown to provide clinically meaningful pain relief for patients refractory to conventional medical management, with a subset of patients demonstrating improvement in neurological function. This literature review is intended to discuss the dosage and prospective data associated with pain management therapies for PDN.
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Abd-Elsayed A. Liposomal bupivacaine versus bupivacaine hydrochloride: are we changing the outcomes? Reg Anesth Pain Med 2021; 46:499. [PMID: 33837137 DOI: 10.1136/rapm-2021-102683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 03/27/2021] [Accepted: 03/30/2021] [Indexed: 11/04/2022]
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Abd-Elsayed A, Tang T, Karri J, Hughes M, Urits I, Gupta M, Pasqualucci A, Myrcik D, Varrassi G, Viswanath O. Neuromodulation for Pain Management in the Inpatient Setting: A Narrative Review. Cureus 2021; 13:e13892. [PMID: 33880248 PMCID: PMC8046682 DOI: 10.7759/cureus.13892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 03/15/2021] [Indexed: 12/14/2022] Open
Abstract
Pain is highly prevalent and pharmacological therapy is not always efficacious. There are a few pathophysiological reasons to believe that neuromodulation would increase the rate of success of pain management. This review article is focused on that aspect, discussing non-invasive or minimally invasive neuromodulation techniques in both the inpatient and outpatient setting. This article provides an in-depth discussion of the multiple neuromodulation techniques available over time to be suitable and effective when used as analgesic therapies for chronic pain. We reviewed the literature and discussed all available neuromodulation options that were tested in the inpatient and outpatient setting. Neuromodulation plays a very important role in treating chronic pain in both inpatient and outpatient setting.
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Abd-Elsayed A. Radiation safety and knowledge: what do we know? Reg Anesth Pain Med 2021; 46:477. [PMID: 33688037 DOI: 10.1136/rapm-2021-102574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 11/04/2022]
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Karri J, Lachman L, Hanania A, Marathe A, Singh M, Zacharias N, Orhurhu V, Gulati A, Abd-Elsayed A. Radiotherapy-Specific Chronic Pain Syndromes in the Cancer Population: An Evidence-Based Narrative Review. Adv Ther 2021; 38:1425-1446. [PMID: 33570737 DOI: 10.1007/s12325-021-01640-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 01/27/2021] [Indexed: 12/25/2022]
Abstract
While radiation therapy is increasingly utilized in the treatment paradigm of many solid cancers, the chronic effects of radiation therapies are poorly characterized. Notably, understanding radiation-specific chronic pain syndromes is paramount given that the diagnosis and management of these conditions can serve to prevent long-standing functional impairments, optimize quality of life, and even allow for continued radiotherapy candidacy. These radiation-specific chronic pain phenomena include dermatitis, mucositis, enteritis, connective tissue fibrosis, lymphedema, and neuropathic pain syndromes. It is necessary to maintain a low threshold of suspicion for appropriately diagnosing these conditions as there exists a variance in when these symptoms arise after radiation. However, we present key epidemiological data delineating vulnerable cancer populations for each pain syndrome along with the available evidence for the management for each specific condition.
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Xu J, Sun Z, Wu J, Rana M, Garza J, Zhu AC, Chakravarthy KV, Abd-Elsayed A, Rosenquist E, Basi H, Christo P, Cheng J. Peripheral Nerve Stimulation in Pain Management: A Systematic Review. Pain Physician 2021; 24:E131-E152. [PMID: 33740342 PMCID: PMC8897810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Peripheral nerve stimulation (PNS) has been increasingly used to manage acute and chronic pain. However, the level of clinical evidence to support its use is not clear. OBJECTIVES To assess the clinical evidence of PNS in the treatment of acute or chronic pain. STUDY DESIGN A systematic review of the efficacy and safety of PNS in managing acute or chronic pain. METHODS Data sources were PubMed, Cochrane Library, Scopus, CINAHL Plus, Google Scholar, and reference lists. The literature search was performed up to December 2019. Study selection included randomized trials, observational studies, and case reports of PNS in acute or chronic pain. Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR). The evidence was summarized utilizing principles of best evidence synthesis on a scale of 1 to 5. Data syntheses: 227 studies met inclusion criteria and were included in qualitative synthesis. RESULTS Evidence synthesis based on randomized controlled trials (RCTs) and observational studies showed Level I and II evidence of PNS in chronic migraine headache; Level II evidence in cluster headache, postamputation pain, chronic pelvic pain, chronic low back and lower extremity pain; and Level IV evidence in peripheral neuropathic pain, and postsurgical pain. Peripheral field stimulation has Level II evidence in chronic low back pain, and Level IV evidence in cranial pain. LIMITATIONS Lack of high-quality RCTs. Meta-analysis was not possible due to wide variations in experimental design, research protocol, and heterogeneity of study population. CONCLUSIONS The findings of this systematic review suggest that PNS may be effective in managing chronic headaches, postamputation pain, chronic pelvic pain, and chronic low back and lower extremity pain, with variable levels of evidence in favor of this technique.
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Hanna R, Abd-Elsayed A. Review of the Safety of Bipolar Radiofrequency Ablation in Patients with Chronic Pain with Implantable Cardiac Rhythm Management Devices. Pain Physician 2021; 24:E169-E176. [PMID: 33740350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Chronic pain, especially low back pain and hip pain, has been a growing public health concern that affects over 100 million Americans annually. Radiofrequency ablation (RFA) has distinct advantages over other chronic pain management modalities and its use has been increasing over the past decade. Among the growing population with comorbid conduction disorders and persistent pain, RFA and its potential interference with implantable cardiac devices is of concern.RFA is becoming a foundational element of persistent pain management and has been shown to be effective in a multitude of chronic pain syndromes. Cardiac implantable electronic devices (CIED), such as cardiac pacemakers or implantable cardioverter defibrillators, have been used in the treatment of cardiac conduction diseases for a number of decades. With our aging population, these diseases have increased in both incidence and prevalence. Chronic pain and cardiac conduction diseases are both common in our increasingly aging population. OBJECTIVES This study aims to determine if the literature supports the hypothesis that patients with CIEDs can safely use RFA with minimal to no interaction. STUDY DESIGN Systematic assessment of literature with a modified approach with bipolar RFA. METHODS A narrative review with systematic assessment of the literature was carried out. In this review, we included randomized controlled trials (RCTs), open non-randomized control studies, prospective studies, retrospective studies, case series, and case reports. All types of radiofrequency utilized for pain management including pulsed and conventional were included. Outcome measures included interactions between the cardiovascular implantable electronic device (CIED) and radiofrequency ablation (RFA), adverse events, RFA efficacy in treating the pain using pain scores, and other complications. RESULTS Our search criteria yielded 4 studies for inclusion, with inclusion of 33 patients and 71 bipolar radiofrequency for treatments. No adverse events or interactions occurred between the bipolar radiofrequency device and the implanted cardiac devices in any of these patients. Bipolar radiofrequency was utilized in all patients (n = 33). Overall there were no complications or malfunctions. LIMITATIONS Small sample size, narrative review. CONCLUSIONS This study provides evidence that bipolar RFA can be safely used in patients with CIEDs for chronic pain provided that proper precautions are employed. Considerations for safe use are provided.
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Abd-Elsayed A. Burnout among chronic pain anesthesiologists. Reg Anesth Pain Med 2021; 46:388. [PMID: 33574157 DOI: 10.1136/rapm-2021-102530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/04/2022]
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Karri J, Palmer JS, Charnay A, Garcia C, Orhurhu V, Shah S, Abd-Elsayed A. Utility of Electrical Neuromodulation for Treating Chronic Pain Syndromes in the Pediatric Setting: A Systematic Review. Neuromodulation 2021; 25:671-679. [PMID: 33556220 DOI: 10.1111/ner.13365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/08/2020] [Accepted: 01/05/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Chronic pain syndromes in children can carry significant threats to psychological well-being, opioid overuse, functional impairments, and severe disability. While several high-level studies, almost exclusively in adults, have demonstrated the utility of implantable electrical neuromodulation systems for treating various chronic pain syndromes, there exists a paucity of pediatric-specific evidence. Unfortunately, evidence and practice patterns established from adults may not be fully translatable to children given differences in disease manifestations and anatomical variances. MATERIALS AND METHODS We performed a systematic review using conventional PRISMA methodology to identify studies reporting use of implantable electrical neuromodulation systems in children. The primary outcome parameters collected were analgesic relief and functional benefits. Additionally, previous interventions attempted, neuromodulation parameters, and limitations were collected as reported. RESULTS A total of 11 studies was identified, which described 19 patients who were refractory to multidisciplinary pain management strategies. The cohort was mostly adolescent (18/19), suffered from CRPS (14/19), and received SCS (17/19). Nearly all patients, both those with CRPS (13/14) and non-CRPS conditions (4/4), reported significant pain relief and functional recovery following neuromodulation. There were no severe complications reported; limitations included suboptimal benefit or loss of analgesia (3/19), lead or device revision (3/19), and subcutaneous infection (1/19), all of which were congruent with adult outcomes. CONCLUSION There exist children with chronic pain refractory to standard of care approaches who could be considered for neuromodulation interventions. The existing data, which was limited and from a low tier of evidence, suggest that these interventions are relatively safe and provide meaningful pain reduction and functional improvements. While not previously reported, we recommend careful consideration of the pubertal growth spurt prior to device lead placement-if reasonable and appropriate-given the possibility of inferior lead migration with physiologic growth in patients with SCS devices or foraminal extrusion in patients with dorsal root ganglion stimulation devices.
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Abd-Elsayed A. Liposomal bupivacaine for surgical site infiltration. (Is it superior to plain bupivacaine?). Reg Anesth Pain Med 2021; 46:362. [PMID: 33547089 DOI: 10.1136/rapm-2020-102446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 11/04/2022]
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Helm Ii S, Harmon PC, Noe C, Calodney AK, Abd-Elsayed A, Knezevic NN, Racz GB. Transforaminal Epidural Steroid Injections: A Systematic Review and Meta-Analysis of Efficacy and Safety. Pain Physician 2021. [PMID: 33492919 DOI: 10.36076/ppj.2021.24.s209-s232] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Transforaminal epidural injections have been used since the late 1990s to treat lumbar radicular pain. They have been the subject of considerable attention, with varying conclusions from systematic reviews as to their efficacy. Transforaminal injections have been associated with rare but major complications. Further, the use of transforaminal injections has increased since the passage of the Affordable Care Act. Finally, with the SARS-CoV-2 pandemic, there has been heightened concern regarding the risk associated with steroid injections. OBJECTIVES To evaluate and update the effectiveness of transforaminal injections for 4 indications: radicular pain; from spinal stenosis; from failed back surgery syndrome; and for axial low back pain; and to evaluate the safety of the procedure. STUDY DESIGN A systematic review and meta-analysis of the efficacy of transforaminal injections. METHODS The available literature on transforaminal injections was reviewed and the quality assessed. The level of evidence was classified on a 5-point scale based on the quality of evidence developed by the US Preventive Services Task Force (USPSTF) and modified by the American Society of Interventional Pain Physicians (ASIPP). Data sources included relevant literature from 1966 to April 2020, and manual searches of the bibliographies of known primary and review articles. Pain relief and functional improvement were the primary outcome measures. A minimum of 6 months pain relief follow-up was required. RESULTS For this systematic review, 66 studies were identified. Eighteen randomized controlled trials met the inclusion criteria. No observational studies were included. Eleven randomized controlled trials dealt with various aspects of transforaminal injections for radicular pain owing to disc herniation. Based on these studies, there is Level 1 evidence supporting the use of transforaminal injections for radicular pain owing to disc herniation. A meta-analysis showed that at both 3 and 6 months, there was highly statistically significant improvement in both pain and function with both particulate and nonparticulate steroids. For radicular pain from central stenosis there is one moderate quality study, with Level IV evidence. For radicular pain caused by failed back surgery syndrome there is one moderate quality study, with Level IV evidence. For radicular pain from foraminal stenosis and for axial pain there is Level V evidence, opinion-based/consensus, supporting the use of transforaminal injections. Transforaminal injections are generally safe. However, they have been associated with major neurologic complications related to cord infarct. Causes other than intraluminal injection of particulates appear to be at play. The use of an infraneural approach and of blunt needles appear to offer the greatest patient safety. Because of concern over the role of particulate steroids, multiple other injectates have been evaluated, including nonparticulate steroids, tumor necrosis factor alpha (TNF-a) inhibitors, and local anesthetics without steroids. No injectate has been proven superior. If there is concern about immunosuppression because of risk of COVID-19 infection, either the lowest possible dose of steroid or no steroid should be used. LIMITATIONS The study was limited by the paucity of literature for some indications. CONCLUSIONS There is Level I evidence for the use of transforaminal injections for radicular pain from disc herniations.
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Abd-Elsayed A. Novel device for sealing perforations following dural puncture. Reg Anesth Pain Med 2021; 46:397. [PMID: 33504474 DOI: 10.1136/rapm-2020-102423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 11/03/2022]
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Stelter B, Karri J, Marathe A, Abd-Elsayed A. Dorsal Root Ganglion Stimulation for the Treatment of Non-Complex Regional Pain Syndrome Related Chronic Pain Syndromes: A Systematic Review. Neuromodulation 2021; 24:622-633. [PMID: 33501749 DOI: 10.1111/ner.13361] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/08/2020] [Accepted: 12/21/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND While the majority of indications and approvals for dorsal root ganglion stimulation (DRGS) are for the refractory management of complex regional pain syndrome (CRPS), emerging evidence has suggested that DRGS may be favorably used for a plethora of other chronic pain phenomena. Consequently, we aimed to characterize the use and efficacy of DRGS for these non-CRPS-related chronic pain syndromes. MATERIALS AND METHODS A systematic review of clinical studies demonstrating the use of DRGS for non-CRPS-related chronic pain syndromes. The literature search was performed using PubMed, Cochrane Library, and CINAHL plus across August and September 2020. RESULTS A total of 28 reports comprising 354 total patients were included in the analysis. Of the chronic pain syndromes presented, axial low back pain, chronic pelvic and groin pain, other peripheral neuropathies, and studies with multiple concomitant pain syndromes, a majority demonstrated >50% mean pain reduction at the time of last follow-up following DRGS. Physical function, quality of life (QOL), and lesser pain medication usage also were repeatedly reported to be significantly improved. CONCLUSIONS DRGS continues to lack supportive evidence from well designed, high level studies and recommendations from consensus committee experts. However, we present repeated and consistent evidence from lower level studies showing success with the use of DRGS for various non-CRPS chronic pain syndromes in reducing pain along with increasing function and QOL from one week to three years. Due to such low-level, high bias evidence, we strongly encourage the continuation of high-level studies in order to provide a stronger foundation for the use of DRGS in non-CRPS chronic pain patients. However, it may be reasonable and appropriate to evaluate patients for DRGS candidacy on a case-by-case basis particularly if they manifest focal pain syndromes refractory to noninterventional measures and may not be ideal candidates for other forms of neuromodulation.
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Urits I, Li N, Berger AA, Walker P, Wesp B, Zamarripa AM, An D, Cornett EM, Abd-Elsayed A, Kaye AD. Treatment and Management of Loin Pain Hematuria Syndrome. Curr Pain Headache Rep 2021; 25:6. [PMID: 33495883 DOI: 10.1007/s11916-020-00925-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW Loin pain hematuria syndrome (LPHS) is rare and seldom diagnosed, yet it has a particularly significant impact on those affected. This is a review of the latest and seminal evidence of the pathophysiology and diagnosis of LPHS and presents the typical clinical presentation and treatment options available. RECENT FINDINGS LPHS is typically found in young women with characteristic symptoms, including severe recurrent flank pain and gross or microscopic hematuria. The majority of patients will experience crippling pain for many years without effective therapy, often requiring frequent use of narcotic medication. However, the lack of conclusive pathophysiology, in conjunction with the rarity of LPHS, has prohibited the development and trial of definitive treatment options. Nevertheless, in order to combat this rare but severe disease, management strategies have continued to evolve, ranging from conservative measures to invasive procedures. This review presents an overview of the current hypotheses on the pathophysiology of LPHS in addition to summarizing the management strategies that have been utilized. Only 30% of LPHS patients will experience spontaneous resolution, whereas the majority will continue to face chronic, crippling pain. Several methods of treatment, including invasive and non-invasive, may provide an improved outcome to these patients. Treatment should be individually tailored and multi-disciplinary in nature. Further research is required to further elucidate the pathophysiology and develop new, specific, treatment options.
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Abd-Elsayed A, Schwenk ES. Weaning down opioids in the inherited patients on high-dose opioids. Reg Anesth Pain Med 2021; 46:537. [PMID: 33452204 DOI: 10.1136/rapm-2020-102375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/17/2020] [Accepted: 12/20/2020] [Indexed: 11/03/2022]
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Visnjevac O, Ma F, Abd-Elsayed A. A Literature Review of Dorsal Root Entry Zone Complex (DREZC) Lesions: Integration of Translational Data for an Evolution to More Accurate Nomenclature. J Pain Res 2021; 14:1-12. [PMID: 33442287 PMCID: PMC7800708 DOI: 10.2147/jpr.s255726] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 11/30/2020] [Indexed: 12/18/2022] Open
Abstract
The purpose of this translational review was to provide evidence to support the natural evolution of the nomenclature of neuromodulatory and neuroablative radiofrequency lesions for pain management from lesions of individualized components of the linear dorsal afferent pathway to “Dorsal Root Entry Zone Complex (DREZC) lesions.” Literature review was performed to collate anatomic and procedural data and correlate these data to clinical outcomes. There is ample evidence that the individual components of the DREZC (the dorsal rami and its branches, the dorsal root ganglia, the dorsal rootlets, and the dorsal root entry zone) vary dramatically between vertebral levels and individual patients. Procedurally, fluoroscopy, the most commonly utilized technology is a 2-dimensional x-ray-based technology without the ability to accurately locate any one component of the DREZC dorsal afferent pathway, which results in clinical inaccuracies when naming each lesion. Despite the inherent anatomic variability and these procedural limitations, the expected poor clinical outcomes that might follow such nomenclature inaccuracies have not been shown to be prominent, likely because these are all lesions of the same anatomically linear sensory pathway, the DREZC, whereby a lesion in any one part of the pathway would be expected to interrupt sensory transmission of pain to all subsequent more proximal segments. Given that the common clinically available tools (fluoroscopy) are inaccurate to localize each component of the DREZC, it would be inappropriate to continue to erroneously refer to these lesions as lesions of individual components, when the more accurate “DREZC lesions” designation can be utilized. Hence, to avoid inaccuracies in nomenclature and until more accurate imaging technology is commonly utilized, the evidence herein supports the proposed change to this more sensitive and inclusive nomenclature, “DREZC lesions.” ![]()
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Abd-Elsayed A. Simultaneous versus staged bilateral knee arthroplasty: do we impact chronic opioid use? Reg Anesth Pain Med 2021; 46:404. [PMID: 33408160 DOI: 10.1136/rapm-2020-102294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 11/04/2022]
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Kalia H, Viswanath O, Abd-Elsayed A. Epidemiology. TRIGEMINAL NERVE PAIN 2021:17-21. [DOI: 10.1007/978-3-030-60687-9_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Roychoudhury P, Romero AR, Raslan A, Abd-Elsayed A. Peripheral Neurectomy for Treatment of Trigeminal Neuralgia. TRIGEMINAL NERVE PAIN 2021:207-214. [DOI: 10.1007/978-3-030-60687-9_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Garcia AJ, Okeagu CN, Kaye AD, Abd-Elsayed A. Metabolism, Pathophysiology, and Clinical Considerations of Iron Overload, a Comprehensive Review. ESSENTIALS OF BLOOD PRODUCT MANAGEMENT IN ANESTHESIA PRACTICE 2021:289-299. [DOI: 10.1007/978-3-030-59295-0_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Day M, Abd-Elsayed A, Ashworth B. Algorithms for Management Recommendations. TRIGEMINAL NERVE PAIN 2021:229-242. [DOI: 10.1007/978-3-030-60687-9_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Jiang Y, Karri J, Mathias K, Abd-Elsayed A. The Effects of Perioperative Transfusion of Allogenic Blood Products of Cancer Recurrence. ESSENTIALS OF BLOOD PRODUCT MANAGEMENT IN ANESTHESIA PRACTICE 2021:397-403. [DOI: 10.1007/978-3-030-59295-0_41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Manchikanti L, Atluri S, Boswell MV, Calodney AK, Diwan S, Gupta S, Kaye AD, Knezevic NN, Candido KD, Abd-Elsayed A, Pappolla MA, Racz GB, Sachdeva H, Sanapati MR, Shah S, Singh V, Soin A, Hirsch JA. Methodology for Evidence Synthesis and Development of Comprehensive Evidence-Based Guidelines for Interventional Techniques in Chronic Spinal Pain. Pain Physician 2021; 24:S1-S26. [PMID: 33492917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND The re-engineered definition of clinical guidelines in 2011 from the IOM (Institute of Medicine) states, "clinical practice guidelines are statements that include recommendations intended to optimize patient care that is informed by a systematic review of evidence and an assessment of the benefit and harms of alternative care options." The revised definition distinguishes between the term "clinical practice guideline" and other forms of clinical guidance derived from widely disparate development processes, such as consensus statements, expert advice, and appropriate use criteria. OBJECTIVE To assess the literature and develop methodology for evidence synthesis and development of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. METHODS A systematic review of the literature including methodology of guideline development encompassing GRADE approach for guidance on evidence synthesis with recommendations. RESULTS Some of the many factors described in 2011 continue as of 2020 and impede the development of clinical practice guidelines. These impediments include biases due to a variety of conflicts and confluence of interest, inappropriate and poor methodological quality, poor writing and ambiguous presentation, projecting a view that these are not applicable to individual patients or too restrictive with the elimination of clinician autonomy, and overzealous and inappropriate recommendations, either positive, negative, or non-committal. Thus, ideally, a knowledgeable, multidisciplinary panel of experts with true lack of bias and confluence of interest must develop guidelines based on a systematic review of the existing evidence. This manuscript describes evidence synthesis from observational studies, various types of randomized controlled trials (RCTs), and, finally, methodological and reporting quality of systematic reviews. The manuscript also describes various methods utilized in the assessment of the quality of observational studies, diagnostic accuracy studies, RCTs, and systematic reviews. LIMITATIONS Paucity of publications with appropriate evidence synthesis methodology in reference to interventional techniques. CONCLUSION This review described comprehensive evidence synthesis derived from systematic reviews, including methodologic quality and bias measurement. The manuscript described various methods utilized in the assessment of the quality of the systematic reviews, RCTs, diagnostic accuracy studies, and observational studies.
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Manchikanti L, Knezevic NN, Navani A, Christo PJ, Limerick G, Calodney AK, Grider J, Harned ME, Cintron L, Gharibo CG, Shah S, Nampiaparampil DE, Candido KD, Soin A, Kaye AD, Kosanovic R, Magee TR, Beall DP, Atluri S, Gupta M, Helm Ii S, Wargo BW, Diwan S, Aydin SM, Boswell MV, Haney BW, Albers SL, Latchaw R, Abd-Elsayed A, Conn A, Hansen H, Simopoulos TT, Swicegood JR, Bryce DA, Singh V, Abdi S, Bakshi S, Buenaventura RM, Cabaret JA, Jameson J, Jha S, Kaye AM, Pasupuleti R, Rajput K, Sanapati MR, Sehgal N, Trescot AM, Racz GB, Gupta S, Sharma ML, Grami V, Parr AT, Knezevic E, Datta S, Patel KG, Tracy DH, Cordner HJ, Snook LT, Benyamin RM, Hirsch JA. Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines. Pain Physician 2021; 24:S27-S208. [PMID: 33492918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and recommendations were provided. RESULTS In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives.The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness.Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness.The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations.
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Roychoudhury P, Di Grazia V, Orhurhu V, Abd-Elsayed A. Balloon Compression of the Trigeminal Nerve. TRIGEMINAL NERVE PAIN 2021:177-186. [DOI: 10.1007/978-3-030-60687-9_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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