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Canós-Verdecho Á, Robledo R, Izquierdo R, Bermejo A, Gallach E, Abejón D, Argente P, Peraita-Costa I, Morales-Suárez-Varela M. Confirmatory study of the usefulness of quantum molecular resonance and microdissectomy for the treatment of lumbar radiculopathy in a prospective cohort at 6 months follow-up. Scand J Pain 2024; 24:sjpain-2023-0077. [PMID: 38447036 DOI: 10.1515/sjpain-2023-0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 12/07/2023] [Indexed: 03/08/2024]
Abstract
OBJECTIVES Low back pain is a common musculoskeletal complaint and while prognosis is usually favorable, some patients experience persistent pain despite conservative treatment and invasive treatment to target the root cause of the pain may be necessary. The aim of this study is to evaluate patient outcomes after treatment of lumbar radiculopathy (LR) with quantum molecular resonance radiofrequency coblation disc decompression and percutaneous microdiscectomy with grasper forceps (QMRG). METHODS This prospective cohort study was carried out in two Spanish hospitals on 58 patients with LR secondary to a contained hydrated lumbar disc hernia or lumbar disc protrusion of more than 6 months of evolution, which persisted despite conservative treatment with analgesia, rehabilitation, and physiotherapy, and/or epidural block, in the previous 2 years. Patients were treated with QMRG and the outcomes were measured mainly using the Douleur Neuropathique en 4 Questions, Numeric Rating Scale, Oswestry Disability Index, SF12: Short Form 12 Health Survey, Patient Global Impression of Improvement, Clinical Global Impression of Improvement, and Medical Outcomes Study Sleep Scale. RESULTS Patients who received QMRG showed significant improvement in their baseline scores at 6 months post-treatment. The minimal clinically important difference (MCID) threshold was met by 26-98% of patients, depending on the outcome measure, for non-sleep-related outcomes, and between 17 and 62% for sleep-related outcome measures. Of the 14 outcome measures studied, at least 50% of the patients met the MCID threshold in 8 of them. CONCLUSION Treatment of LR with QMRG appears to be effective at 6 months post-intervention.
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Affiliation(s)
- Ángeles Canós-Verdecho
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Av. de Fernando Abril Martorell, 106, 46026 Valencia, Spain
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Av. de Fernando Abril Martorell, 106, 46026 Valencia, Spain
| | - Ruth Robledo
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Av. de Fernando Abril Martorell, 106, 46026 Valencia, Spain
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Av. de Fernando Abril Martorell, 106, 46026 Valencia, Spain
| | - Rosa Izquierdo
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Av. de Fernando Abril Martorell, 106, 46026 Valencia, Spain
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Av. de Fernando Abril Martorell, 106, 46026 Valencia, Spain
| | - Ara Bermejo
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Av. de Fernando Abril Martorell, 106, 46026 Valencia, Spain
| | - Elisa Gallach
- Multidisciplinary Pain Management Unit, Hospital Universitari i Politècnic La Fe, Av. de Fernando Abril Martorell, 106, 46026 Valencia, Spain
- Psychiatry Department, Hospital Universitari i Politècnic La Fe, Av. de Fernando Abril Martorell, 106, 46026 Valencia, Spain
| | - David Abejón
- Multidisciplinary Pain Management Unit, Hospital Universitario Quirónsalud, Calle Diego de Velázquez, 1, 28223 Pozuelo de Alarcón, Madrid, Spain
| | - Pilar Argente
- Anaesthesiology Department, Hospital Universitari i Politècnic La Fe, Av. de Fernando Abril Martorell, 106, 46026 Valencia, Spain
- Surgical Specialities Department, Hospital Universitari i Politècnic La Fe, Av. de Fernando Abril Martorell, 106, 46026 Valencia, Spain
| | - Isabel Peraita-Costa
- Unit of Preventive Medicine and Public Health, Department of Preventive Medicine and Public Health, Food Sciencs, Toxicology and Forensic Medicine, Universitat de València, Av. Vicent Andrés Estellés s/n, 46100 Burjassot, Valencia, Spain
- CIBER Epidemiology and Public Health (CIBERESP), The Institute of Health Carlos III (ISCIII), Av. Monforte de Lemos, 3-5, Pabellón 11, Planta 0, 28029 Madrid, Spain
| | - María Morales-Suárez-Varela
- Unit of Preventive Medicine and Public Health, Department of Preventive Medicine and Public Health, Food Sciencs, Toxicology and Forensic Medicine, Universitat de València, Av. Vicent Andrés Estellés s/n, 46100 Burjassot, Valencia, Spain
- CIBER Epidemiology and Public Health (CIBERESP), The Institute of Health Carlos III (ISCIII), Av. Monforte de Lemos, 3-5, Pabellón 11, Planta 0, 28029 Madrid, Spain
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Sayed D, Grider J, Strand N, Hagedorn JM, Falowski S, Lam CM, Tieppo Francio V, Beall DP, Tomycz ND, Davanzo JR, Aiyer R, Lee DW, Kalia H, Sheen S, Malinowski MN, Verdolin M, Vodapally S, Carayannopoulos A, Jain S, Azeem N, Tolba R, Chang Chien GC, Ghosh P, Mazzola AJ, Amirdelfan K, Chakravarthy K, Petersen E, Schatman ME, Deer T. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res 2022; 15:3729-3832. [PMID: 36510616 PMCID: PMC9739111 DOI: 10.2147/jpr.s386879] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. Objective The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. Methods The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. Results After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. Conclusion The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA,Correspondence: Dawood Sayed, The University of Kansas Health System, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA, Tel +1 913-588-5521, Email
| | - Jay Grider
- University of Kentucky, Lexington, KY, USA
| | - Natalie Strand
- Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Steven Falowski
- Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Christopher M Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nestor D Tomycz
- AHN Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry, Henry Ford Health System, Detroit, MI, USA
| | - David W Lee
- Physical Medicine & Rehabilitation and Pain Medicine, Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | - Hemant Kalia
- Rochester Regional Health System, Rochester, NY, USA,Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Soun Sheen
- Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Mark N Malinowski
- Adena Spine Center, Adena Health System, Chillicothe, OH, USA,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Michael Verdolin
- Anesthesiology and Pain Medicine, Pain Consultants of San Diego, San Diego, CA, USA
| | - Shashank Vodapally
- Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA
| | - Alexios Carayannopoulos
- Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Newport Hospital, Lifespan Physician Group, Providence, RI, USA,Comprehensive Spine Center at Rhode Island Hospital, Newport Hospital, Providence, RI, USA,Neurosurgery, Brown University, Providence, RI, USA
| | - Sameer Jain
- Interventional Pain Management, Pain Treatment Centers of America, Little Rock, AR, USA
| | - Nomen Azeem
- Department of Neurology, University of South Florida, Tampa, FL, USA,Florida Spine & Pain Specialists, Riverview, FL, USA
| | - Reda Tolba
- Pain Management, Cleveland Clinic, Abu Dhabi, United Arab Emirates,Anesthesiology, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - George C Chang Chien
- Pain Management, Ventura County Medical Center, Ventura, CA, USA,Center for Regenerative Medicine, University Southern California, Los Angeles, CA, USA
| | | | | | | | - Krishnan Chakravarthy
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA,Va San Diego Healthcare, San Diego, CA, USA
| | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA,Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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Daniels AH, Durand WM, Steinbaum AJ, Lafage R, Hamilton DK, Passias PG, Kim HJ, Protopsaltis T, Lafage V, Smith JS, Shaffrey C, Gupta M, Klineberg EO, Schwab F, Gum JL, Mundis G, Eastlack R, Kebaish K, Soroceanu A, Hostin RA, Burton D, Bess S, Ames C, Hart RA. Examination of Adult Spinal Deformity Patients Undergoing Surgery with Implanted Spinal Cord Stimulators and Intrathecal Pumps. Spine (Phila Pa 1976) 2022; 47:227-233. [PMID: 34310536 DOI: 10.1097/brs.0000000000004176] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study of a prospectively collected multi-center database of adult spinal deformity (ASD) patients. OBJECTIVE We hypothesized that patients undergoing ASD surgery with and without previous spinal cord stimulators (SCS)/ intrathecal medication pumps (ITP) would exhibit increased complication rates but comparable improvement in health-related quality of life. SUMMARY OF BACKGROUND DATA ASD patients sometimes seek pain management with SCS or ITP before spinal deformity correction. Few studies have examined outcomes in this patient population. METHODS Patients undergoing ASD surgery and eligible for 2-year follow-up were included. Preoperative radiographs were reviewed for the presence of SCS/ITP. Outcomes included complications, Oswestry Disability Index (ODI), Short Form-36 Mental Component Score, and SRS-22r. Propensity score matching was utilized. RESULTS In total, of 1034 eligible ASD patients, a propensity score-matched cohort of 60 patients (30 with SCS/ITP, 30 controls) was developed. SCS/ITP were removed intraoperatively in most patients (56.7%, n = 17). The overall complication rate was 80.0% versus 76.7% for SCS/ITP versus control (P > 0.2), with similarly nonsignificant differences for intraoperative and infection complications (all P > 0.2). ODI was significantly higher among patients with SCS/ITP at baseline (59.2 vs. 47.6, P = 0.0057) and at 2-year follow-up (44.4 vs. 27.7, P = 0.0295). The magnitude of improvement, however, did not significantly differ (P = 0.45). Similar results were observed for SRS-22r pain domain. Satisfaction did not differ between groups at either baseline or follow-up (P > 0.2). No significant difference was observed in the proportion of patients with SCS/ITP versus control reaching minimal clinically important difference in ODI (47.6% vs. 60.9%, P = 0.38). Narcotic usage was more common among patients with SCS/ITP at both baseline and follow-up (P < 0.05). CONCLUSION ASD patients undergoing surgery with SCS/ITP exhibited worse preoperative and postoperative ODI and SRS-22r pain domain; however, the mean improvement in outcome scores was not significantly different from patients without stimulators or pumps. No significant differences in complications were observed between patients with versus without SCS/ITP.Level of Evidence: 3.
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Affiliation(s)
- Alan H Daniels
- Department of Orthopedics, Warren Alpert Medical School, Brown University, Providence, RI
| | - Wesley M Durand
- Warren Alpert Medical School, Brown University, Providence, RI
| | | | | | | | - Peter G Passias
- Department of Orthopedics, NYU Langone Orthopedic Hospital, New York, NY
| | - Han Jo Kim
- Hospital for Special Surgery, New York, NY
| | | | | | - Justin S Smith
- University of Virginia Health System, Charlottes-ville, VA
| | | | | | | | | | | | | | | | | | - Alex Soroceanu
- University of Calgary Spine Program, University of Calgary, Alberta, Canada
| | - Richard A Hostin
- Department of Orthopedic Surgery, Baylor Scoliosis Center, Dallas, TX
| | - Doug Burton
- University of Kansas Hospital, Kansas City, KS
| | - Shay Bess
- Denver International Spine Center, Denver, CO
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4
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Role of neuraxial drug delivery in cancer pain therapy. FUTURE DRUG DISCOVERY 2020. [DOI: 10.4155/fdd-2019-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Opioids have long been the mainstay of cancer pain treatment and have been used without any consideration for their effect on cancer growth and long-term prognosis. There is now growing evidence that the continued use of opioids for this indication should be reviewed and even reconsidered. Although current evidence and literature covering this subject is mixed and does not yet allow for a clear determination to be made about safety, there is enough data to support the search for new treatment paradigms, beginning with anesthesia for oncologic surgery and management of cancer pain over the disease course.
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5
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Genov PG, Timerbaev VK, Dolgasheva NS, Efanov AA, Grin' AA, Rebrova OY. [The effect of various multimodal analgesia regimens during surgical treatment of patients with spinal stenosis on the rate of failed back surgery syndrome]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2019; 83:71-79. [PMID: 31166320 DOI: 10.17116/neiro20198302171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the effect of various methods of perioperative analgesia on the rate of failed back surgery syndrome in patients operated on for spinal stenosis. MATERIAL AND METHODS A total of 122 patients were operated on for spinal stenosis in 2010-2016. The patients were assigned to groups according to the type of received analgesia: Group K (n=19) underwent analgesia on-demand. Patients in the PMA group (n=21) received preventive multimodal analgesia (PMA) with ketoprofen, paracetamol and morphine. Patients in the PMA+PG (n=20) and PMA+N (n=20) groups additionally received pregabalin and nefopam, respectively. Patients in the PMA+E group (n=22) received continuous epidural analgesia with a combination of ropivacaine and morphine. In patients in the PMA+I group (n=20), the wound was infiltrated with ropivacaine and ketorolac. RESULTS AND CONCLUSION In Group K, analgesia was not adequate during five postoperative days. Analgesia with PMA resulted in significant pain reduction during three postoperative days compared to Group K. Wound infiltration in addition to PMA was followed by more significant pain relief during six postoperative hours (compared to the PMA group). Administration of pregabalin or nefopam, as well as epidural analgesia, did not improve quality of postoperative analgesia. Five to seven months after the surgery, 66% (57; 75%) of patients had low back and/or leg pain; 41% (32; 50%) of patients had leg pain. Among patients suffering from pain, 32-41% patients had the severe chronic pain syndrome that resulted in sleep disorder, disability and significant deterioration of quality of life. The rate of failed back surgery syndrome did not depend on the perioperative analgesia regimen.
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Affiliation(s)
- P G Genov
- Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department, Moscow, Russia
| | - V Kh Timerbaev
- Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department, Moscow, Russia
| | - N S Dolgasheva
- Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department, Moscow, Russia
| | - A A Efanov
- Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department, Moscow, Russia
| | - A A Grin'
- Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department, Moscow, Russia
| | - O Yu Rebrova
- Pirogov Russian National Research Medical University, Ministry of Health of the Russia, Moscow, Russia
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6
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Shirvalkar P, Poree LR, Krames ES. The Development of Algorithms for Pain Care Including Neuromodulation Therapies. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00047-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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7
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Duarte RV, Lambe T, Raphael JH, Eldabe S, Andronis L. Intrathecal Drug Delivery Systems for the Management of Chronic Noncancer Pain: A Systematic Review of Economic Evaluations. Pain Pract 2017; 18:666-686. [DOI: 10.1111/papr.12650] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 09/08/2017] [Accepted: 10/16/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Rui V. Duarte
- Liverpool Reviews and Implementation Group; Department of Health Services Research; University of Liverpool; Liverpool U.K
| | - Tosin Lambe
- Health Economics Unit; Institute of Applied Health Research; University of Birmingham; Birmingham U.K
| | - Jon H. Raphael
- Faculty of Health; Birmingham City University; Birmingham U.K
- Department of Pain Management; Russells Hall Hospital; Dudley U.K
| | - Sam Eldabe
- Department of Pain and Anaesthesia; The James Cook University Hospital; Middlesbrough U.K
| | - Lazaros Andronis
- Health Economics Unit; Institute of Applied Health Research; University of Birmingham; Birmingham U.K
- Populations; Evidence and Technologies Group; Division of Health Sciences; University of Warwick; Coventry U.K
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Abstract
Neuropathic pain after spinal surgery, the so-called failed back surgery syndrome (FBSS), is a frequently observed troublesome disease entity. Although medications may be effective to some degree, many patients continue experiencing intolerable pain and functional disability. Only gabapentin has been proven effective in patients with FBSS. No relevant studies regarding manipulation or physiotherapy for FBSS have been published. Spinal cord stimulation (SCS) has been widely investigated as a treatment option for chronic neuropathic pain, including FBSS. SCS was generally accepted to improve chronic back and leg pain, physical function, and sleep quality. Although the cost effectiveness of SCS has been proved in many studies, its routine application is limited considering that it is invasive and is associated with safety issues. Percutaneous epidural adhesiolysis has also shown good clinical outcomes; however, its effects persisted for only a short period. Because none of the current methods provide absolute superiority in terms of clinical outcomes, a multidisciplinary approach is required to manage this complex disease. Further studies concerning the etiology, diagnosis, treatment, and cost effectiveness of FBSS are warranted to deepen our understanding of this condition.
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Faour M, Anderson JT, Haas AR, Percy R, Woods ST, Ahn UM, Ahn NU. Neck Pain, Preoperative Opioids, and Functionality After Cervical Fusion. Orthopedics 2017; 40:25-32. [PMID: 27755643 DOI: 10.3928/01477447-20161013-02] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 08/23/2016] [Indexed: 02/03/2023]
Abstract
The use of opioids among patients with workers' compensation claims is associated with tremendous costs, especially for patients who undergo spinal surgery. This study compared return-to-work rates after single-level cervical fusion for degenerative disk disease between patients who received opioids before surgery and patients who underwent fusion with no previous opioid use. All study subjects qualified for workers' compensation benefits for injuries sustained at work between 1993 and 2011. The study population included 281 subjects who underwent single-level cervical fusion for degenerative disk disease with International Classification of Diseases, Ninth Revision, and Current Procedural Terminology code algorithms. The opioid group included 77 subjects who received opioids preoperatively. The control group included 204 subjects who had surgery with no previous opioid use. The primary outcome was meeting return-to-work criteria within 3 years of follow-up after fusion. Secondary outcome measures after surgery, surgical details, and presurgical characteristics for each cohort also were collected. In 36.4% of the opioid group, return-to-work criteria were met compared with 56.4% of the control group. Patients who took opioids were less likely to meet return-to-work criteria compared with the control group (odds ratio, 0.44; 95% confidence interval, 0.26-0.76; P=.0028). Return-to-work rates within the first year after fusion were 24.7% for the opioid group and 45.6% for the control group (P=.0014). Patients who used opioids were absent from work for 255 more days compared with the control group (P=.0001). The use of opioids for management of diskogenic neck pain, with the possibility of surgical intervention, is a negative predictor of successful return to work after fusion in a workers' compensation population. [Orthopedics. 2017; 40(1):25-32.].
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Abstract
Failed back surgery syndrome (FBSS) is a generalised disorder that is characterised by chronic pain in the lower back and/or legs that persists or recurs following anatomically successful spinal surgery. This paper aims to (1) assess the burden of failed back surgery in terms of its epidemiology, impact on health outcomes and costs and (2) summarise the evidence base for the cost-effectiveness of interventions for the management of FBSS. A narrative review based on a search of MEDLINE (PubMed) up to August 2012 was undertaken. Despite advances in technology and surgical techniques and increasing rates of spine surgery, a proportion of individuals continue to suffer from FBSS. Estimates from randomised controlled trials indicate that 5-50% of patients may have an unsuccessful outcome following lumbar spinal surgery. The understanding of the epidemiology and burden of FBSS remains poor and further research is needed in this area. The impact of FBSS on an individual's health-related quality of life and its economic cost to society are considerable and more disabling than other common chronic pain and chronic medical conditions, such as heart failure and motor neuron disease. There is a substantive body of evidence in FBSS patients showing spinal cord stimulation (SCS) to be cost-effective (<£10,000 per quality-adjusted life year). In 2008, the National Institute for Health and Clinical Excellence recommended SCS as a treatment option for FBSS, either as an alternative to further lumbar surgery or as an adjunct to conservative medical management. The clinical and cost-effectiveness of SCS in the subgroup of those with FBSS receiving workers' compensation remains less clear. Intrathecal morphine pumps may also be a potentially cost-effective strategy for FBSS. The findings of this review emphasise the importance of identifying strategies to prevent the development of FBSS and effective guidelines for the management of established FBSS. The continued development and application of new neuromodulation therapies and technological innovations in the field of FBSS need to be accompanied by the collection of clinical and economic data in order to demonstrate to healthcare policy makers and payers that such innovations provide benefit to the patient at good value for money.
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Affiliation(s)
- Rod S Taylor
- Peninsula Medical School, University of Exeter, Exeter, UK
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11
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Micheli L, Di Cesare Mannelli L, Rizzi A, Guerrini R, Trapella C, Calò G, Ghelardini C. Intrathecal administration of nociceptin/orphanin FQ receptor agonists in rats: A strategy to relieve chemotherapy-induced neuropathic hypersensitivity. Eur J Pharmacol 2015; 766:155-62. [PMID: 26450087 DOI: 10.1016/j.ejphar.2015.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 09/15/2015] [Accepted: 10/02/2015] [Indexed: 12/14/2022]
Abstract
Oxaliplatin and paclitaxel are considered central components in the treatment of colorectal and breast cancer, respectively. The development of neuropathy during chronic treatment represents the major dose-limiting side effect that leads to discontinuation or interruption of therapies. The management of neuropathy is a challenge to individuate innovative therapeutic strategies based on new targets and correct routes of administration. We evaluated the hypersensitivity reliever effect of different opioid receptor agonists in rat models of oxaliplatin and paclitaxel-induced neuropathy. Compounds were spinally infused by intrathecal catheter. In oxaliplatin-treated rats, 0.3 nmol morphine induced the reversion of the mechanical hypersensitivity (Paw-pressure test), nociceptin/orphanin FQ (N/OFQ; 0.3-3 nmol) significantly increased the pain threshold without reaching the values of the control animals. The N/OFQ peptide (NOP) receptor full agonist UFP-112 reverted pain threshold alterations at lower dosage (0.1 nmol) vs morphine and N/OFQ, the partial agonist UFP-113 (0.1-1 nmol) was similar to N/OFQ. The higher efficacy of morphine vs N/OFQ was highlighted also in paclitaxel-treated rats. The mechanical hypersensitivity was fully reverted by 0.1 nmol UFP-112 and UFP-113. In conclusion, intrathecal μ opioid peptide (MOP) and NOP receptor agonists relieved chemotherapy-induced neuropathic pain. The synthetic peptides showed valuable potency and efficacy suggesting the NOP system as an exploitable target.
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Affiliation(s)
- Laura Micheli
- Department of Neuroscience, Psychology, Drug Research and Child Health - Neurofarba, Pharmacology and Toxicology Section, University of Florence, Florence, Italy
| | - Lorenzo Di Cesare Mannelli
- Department of Neuroscience, Psychology, Drug Research and Child Health - Neurofarba, Pharmacology and Toxicology Section, University of Florence, Florence, Italy.
| | - Anna Rizzi
- Department of Medical Sciences, Section of Pharmacology and National Institute of Neuroscience, University of Ferrara, Italy
| | - Remo Guerrini
- Department of Chemical and Pharmaceutical Sciences and LTTA, University of Ferrara, Ferrara, Italy
| | - Claudio Trapella
- Department of Chemical and Pharmaceutical Sciences and LTTA, University of Ferrara, Ferrara, Italy
| | - Girolamo Calò
- Department of Medical Sciences, Section of Pharmacology and National Institute of Neuroscience, University of Ferrara, Italy
| | - Carla Ghelardini
- Department of Neuroscience, Psychology, Drug Research and Child Health - Neurofarba, Pharmacology and Toxicology Section, University of Florence, Florence, Italy
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12
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Veizi E, Hayek S. Interventional therapies for chronic low back pain. Neuromodulation 2015; 17 Suppl 2:31-45. [PMID: 25395115 DOI: 10.1111/ner.12250] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 08/28/2014] [Accepted: 08/31/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Low back pain (LBP) is a highly prevalent condition and one of the leading causes of lost productivity and health-care costs. The objective of this review is to discuss the role of interventional pain procedures and evidence of their effectiveness in treatment of chronic LBP. METHODS This is a narrative review examining published studies on interventional procedures for LBP. The rationales, indications, technique, evidence, and complications for the interventional procedures are discussed. RESULTS Interventional pain procedures are used extensively in diagnosis and treatment of chronic pain. LBP is multifactorial, and while significant progress has been made in understanding its pathophysiology, this has not resulted in a proportional improvement of functional outcomes. For certain procedures, such as spinal cord stimulation, medical branch blocks and radiofrequency ablations, and epidural steroid injections for radiculopathy, safety, efficacy, and cost-effectiveness in treating LBP have been well studied. For others, such as interventions for discogenic pain, treatment successes have been modest at best. CONCLUSIONS Implementation of interventional pain procedures in the treatment framework of LBP has resulted in improvement of pain intensity in at least the short and medium terms, but equivocal results have been observed in functional improvement.
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Affiliation(s)
- Elias Veizi
- Department of Anesthesiology, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA; Pain Medicine & Spine Care, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
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Micheli L, Di Cesare Mannelli L, Guerrini R, Trapella C, Zanardelli M, Ciccocioppo R, Rizzi A, Ghelardini C, Calò G. Acute and subchronic antinociceptive effects of nociceptin/orphanin FQ receptor agonists infused by intrathecal route in rats. Eur J Pharmacol 2015; 754:73-81. [PMID: 25704616 DOI: 10.1016/j.ejphar.2015.02.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 02/06/2015] [Accepted: 02/11/2015] [Indexed: 12/11/2022]
Abstract
Severe pain occurs in the context of many diseases and conditions and is a leading cause of disability. Nociceptin/orphanin FQ (N/OFQ) is the endogenous ligand of the N/OFQ peptide (NOP) receptor. This peptidergic system controls pain transmission and in particular spinally administered N/OFQ has robust antinociceptive properties. The aim of this study was to investigate the spinal antinociceptive properties of NOP peptide agonists after acute and subchronic treatment in rats. Doses unable to alter motor coordination were selected. UFP-112 (full NOP agonist) and UFP-113 (partial NOP agonist) were administered intrathecally (i.t.) by spinal catheterization. Acute injection of UFP-112 induced antinociceptive response at lower dosages (0.03-1nmol i.t.) compared to morphine and similar to N/OFQ. UFP-113 was effective in a 0.001-1nmol i.t. dose range. The antinociceptive effects of NOP ligands were no longer evident in rats knockout for the NOP gene, while those of morphine were maintained. The continuous spinal infusion (by osmotic pumps) of 0.1nmol/h UFP-112 and UFP-113 showed antinociceptive action comparable to 1-3nmol/h morphine or N/OFQ. The antinociceptive effect of morphine progressively decreased and was no longer significant after 6 days of treatment. Similar results were obtained with N/OFQ, UFP-112, and UFP-113. The acute i.t. injection of morphine in animals tolerant to N/OFQ and UFP-112 evoked analgesic effects. Neither morphine nor N/OFQ induced antinociceptive effects in morphine- and UFP-113-tolerant rats. In conclusion this study highlights the analgesic efficacy and potency of UFP-112 and UFP-113 underlining the relevance of NOP system in analgesia.
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Affiliation(s)
- Laura Micheli
- Department of Neuroscience, Psychology, Drug Research and Child Health - Neurofarba - Pharmacology and Toxicology Section, University of Florence, Florence, Italy
| | - Lorenzo Di Cesare Mannelli
- Department of Neuroscience, Psychology, Drug Research and Child Health - Neurofarba - Pharmacology and Toxicology Section, University of Florence, Florence, Italy.
| | - Remo Guerrini
- Department of Chemical and Pharmaceutical Sciences and LTTA, University of Ferrara, Ferrara, Italy
| | - Claudio Trapella
- Department of Chemical and Pharmaceutical Sciences and LTTA, University of Ferrara, Ferrara, Italy
| | - Matteo Zanardelli
- Department of Neuroscience, Psychology, Drug Research and Child Health - Neurofarba - Pharmacology and Toxicology Section, University of Florence, Florence, Italy
| | - Roberto Ciccocioppo
- School of Pharmacy, Pharmacology Unit, University of Camerino, Camerino, Italy
| | - Anna Rizzi
- Department of Medical Sciences, Section of Pharmacology and National Institute of Neuroscience, University of Ferrara, Italy
| | - Carla Ghelardini
- Department of Neuroscience, Psychology, Drug Research and Child Health - Neurofarba - Pharmacology and Toxicology Section, University of Florence, Florence, Italy
| | - Girolamo Calò
- Department of Medical Sciences, Section of Pharmacology and National Institute of Neuroscience, University of Ferrara, Italy
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Saulino M, Kim PS, Shaw E. Practical considerations and patient selection for intrathecal drug delivery in the management of chronic pain. J Pain Res 2014; 7:627-38. [PMID: 25419158 PMCID: PMC4234284 DOI: 10.2147/jpr.s65441] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Chronic pain continues to pose substantial and growing challenges for patients, caregivers, health care professionals, and health care systems. By the time a patient with severe refractory pain sees a pain specialist for evaluation and management, that patient has likely tried and failed several nonpharmacologic and pharmacologic approaches to pain treatment. Although relegated to one of the interventions of "last resort", intrathecal drug delivery can be useful for improving pain control, optimizing patient functionality, and minimizing the use of systemic pain medications in appropriately selected patients. Due to its clinical and logistical requirements, however, intrathecal drug delivery may fit poorly into the classic pain clinic/interventional model and may be perceived as a "critical mass" intervention that is feasible only for large practices that have specialized staff and appropriate office resources. Potentially, intrathecal drug delivery may be more readily adopted into larger practices that can commit the necessary staff and resources to support patients' needs through the trialing, initiation, monitoring, maintenance, and troubleshooting phases of this therapy. Currently, two agents - morphine and ziconotide - are approved by the United States Food and Drug Administration for long-term intrathecal delivery. The efficacy and safety profiles of morphine have been assessed in long-term, open-label, and retrospective studies of >400 patients with chronic cancer and noncancer pain types. The efficacy and safety profiles of ziconotide have been assessed in three double-blind, placebo-controlled trials of 457 patients, and safety has been assessed in 1,254 patients overall, with severe chronic cancer, noncancer, and acquired immunodeficiency syndrome pain types. Both agents are highlighted as first-line intrathecal therapy for the management of neuropathic or nociceptive pain. The purpose of this review is to discuss practical considerations for intrathecal drug delivery, delineate criteria for the identification and selection of candidates for intrathecal drug delivery, and consider which agent may be more appropriate for individual patients.
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Affiliation(s)
- Michael Saulino
- MossRehab, Elkins Park, PA, USA ; Department of Rehabilitation Medicine, Jefferson Medical College, Philadelphia, PA, USA
| | - Philip S Kim
- Helen F Graham Cancer Center, Christiana Care Health System, Newark, DE, USA ; Center for Interventional Pain Spine, LLC., Bryn Mawr, PA, USA
| | - Erik Shaw
- Shepherd Pain Institute, Shepherd Center, Atlanta, GA, USA
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Abstract
Advances in intrathecal analgesia and intrathecal drug delivery systems have allowed for a range of medications to be used in the control of pain and spasticity. This technique allows for reduced medication doses that can decrease the side effects typically associated with oral or parenteral drug delivery. Recent expert panel consensus guidelines have provided care paths in the treatment of nociceptive, neuropathic, and mixed pain syndromes. While the data for pain relief, adverse effect reduction, and cost-effectiveness with cancer pain control are compelling, the evidence is less clear for noncancer pain, other than spasticity. Physicians should be aware of mechanical, pharmacological, surgical, and patient-specific complications, including possible granuloma formation. Newer intrathecal drug delivery systems may allow for better safety and quality of life outcomes.
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Affiliation(s)
- Michael M Bottros
- Division of Pain Medicine, Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, USA
| | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Bolash R, Udeh B, Saweris Y, Guirguis M, Dalton JE, Makarova N, Mekhail N. Longevity and cost of implantable intrathecal drug delivery systems for chronic pain management: a retrospective analysis of 365 patients. Neuromodulation 2014; 18:150-5; discussion 155-6. [PMID: 25250852 DOI: 10.1111/ner.12235] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 05/29/2014] [Accepted: 07/09/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Intrathecal drug delivery systems represent an important component of interventional strategies for refractory chronic pain syndromes. Continuous intrathecal administration of opioids results in higher subarachnoid drug concentrations, improved pain scores, and less frequent side effects when compared with systemic opioid administration. Substantial costs arise at the time of surgical implantation and at revision for battery depletion or treatment of a complication. Despite current widespread use, the real-world longevity and cost of implanted intrathecal pumps (ITP) has not been fully quantified. MATERIALS AND METHODS Patients with an ITP implanted at Cleveland Clinic Pain Management Center between January 1998 and December 2012 were included. ITP longevity was calculated as the time between implant and explant for depletion of the system's battery. Using the 2013 fee schedule of the Centers for Medicare & Medicaid Services, the daily cost of having a functioning ITP was calculated. The costs of office visits for pump refills and the cost of intrathecal medications were not included, nor were the possible savings due to decreased utilization of alternate medical services. RESULTS Three hundred sixty-five patients had 559 pumps implanted. Postlaminectomy syndrome was the most common indication (40%). The median system longevity for all pumps was 5.4 years (97.5% confidence interval: [5.0, 5.8]), including pumps extracted prematurely, as well as those that reached the elective replacement interval. The median ITP longevity was 5.9 years (95% confidence interval: [5.6, 6.1]) for pumps explanted for end of battery life. The median system cost per day was $10.46. The median cost per day of pumps explanted for end of battery life was $9.26, versus $44.59 for pumps explanted prematurely due to complications. CONCLUSIONS Overall, the cohort experienced an increased incidence of pump-related complications and a device longevity that was within the range of the manufacturer's anticipated lifespan. Increasing the lifespan of the ITP and improving patient selection have the potential to significantly improve the cost-effectiveness of intrathecal therapy.
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Affiliation(s)
- Robert Bolash
- Department of Pain Management, Cleveland Clinic, Cleveland, OH, USA
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Bolash R, Mekhail N. Intrathecal pain pumps: indications, patient selection, techniques, and outcomes. Neurosurg Clin N Am 2014; 25:735-42. [PMID: 25240660 DOI: 10.1016/j.nec.2014.06.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Intrathecal drug delivery represents an advanced modality for refractory chronic pain patients as well as intractable spasticity. This article reviews the advantages and indications for intrathecal therapy, as well as recommendations for proper patient selection using a multidisciplinary team to provide a global assessment of the impact of chronic pain on the patient's well-being. The goals and expectations of trialing are discussed alongside advantages and disadvantages of several trialing techniques. A discussion of outcomes is presented for patients with chronic pain due to both malignant and nonmalignant causes.
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Affiliation(s)
- Robert Bolash
- Department of Pain Management, Cleveland Clinic, 9500 Euclid Avenue/C25, Cleveland, OH 44195, USA
| | - Nagy Mekhail
- Evidence Based Pain Medicine Research, Department of Pain Management, Cleveland Clinic, 9500 Euclid Avenue/C25, Cleveland, OH 44195, USA.
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Krames E, Poree L, Deer T, Levy R. Implementing the SAFE Principles for the Development of Pain Medicine Therapeutic Algorithms That Include Neuromodulation Techniques. Neuromodulation 2013; 12:104-13. [PMID: 22151283 DOI: 10.1111/j.1525-1403.2009.00197.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Currently accepted chronic pain treatment algorithms have positioned therapies according to levels of invasiveness and up-front costs. After reviewing updated literature on efficacy and cost outcomes of care for patients with chronic pain that include interventional implantable technologies, we offer a new model of thinking when formulating algorithms of care that might include more invasive and costly interventions such as spinal cord stimulation, the SAFE principles. These SAFE principles include "safety,""appropriateness,""fiscal neutrality," and "efficacy."
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Affiliation(s)
- Elliot Krames
- Pacific Pain Treatment Centers, San Francisco, CA, USA; Pain Clinic of Monterey Bay, Aptos, CA, USA; Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA; Center for Pain Relief Inc., Charleston, WV, USA; West Virginia University School of Medicine, Morgantown, WV, USA; Departments of Neurologic Surgery and Physiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Kumar K, Rizvi S, Bishop S, Tang W. Cost Impact of Intrathecal Polyanalgesia. PAIN MEDICINE 2013; 14:1569-84. [DOI: 10.1111/pme.12204] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Chodakiewitz YG, Bicalho GVC, Chodakiewitz JW. Multi-target neurostimulation for adequate long-term relief of neuropathic and nociceptive chronic pain components. Surg Neurol Int 2013; 4:S170-5. [PMID: 23682344 PMCID: PMC3654775 DOI: 10.4103/2152-7806.110676] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 02/11/2013] [Indexed: 11/16/2022] Open
Abstract
Successful treatment of chronic pain for patients with failed back surgery syndrome can be extremely complicated. These patients require careful and individualized clinical assessment, as they often present with mixed pain syndromes that involve both neuropathic and nociceptive components. The distinct types of pain involved in such cases may require combined treatments from individual interventions that are analgesically independent and specific for each type of pain involved. Neuromodulation by electric stimulation at appropriately chosen targets and combinations may be an important option to consider for such patients. We present a case of combined debilitating axial nociceptive spinal pain and bilateral neuropathic leg pain in a patient after 14 failed back operations. A combination of spinal cord stimulation (SCS) and deep brain stimulation in the periventricular gray (PVG) have successfully provided the patient with complete relief of both components of his chronic pain condition, after all other pain management options had been exhausted. By alternating activation of each implanted stimulator separately and in conjunction, we were able to demonstrate a clinically independent analgesic character for each stimulation system, each specific to a particular type of pain. The SCS provided complete relief of the neuropathic pain component, without affecting the nociceptive component at all. The PVG stimulation provided complete relief of the nociceptive component, without affecting the neuropathic component at all. In combination, there was complete relief of the total chronic pain condition. There appeared to be no overlapping or synergistic effect between the two neuromodulation systems in the patient. The patient has had prolonged complete relief from his chronic pain condition with the combined neuromodulation intervention over 22 years of follow-up.
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Guillemette S, Witzke S, Leier J, Hinnenthal J, Prager JP. Medical Cost Impact of Intrathecal Drug Delivery for Noncancer Pain. PAIN MEDICINE 2013; 14:504-15. [DOI: 10.1111/j.1526-4637.2013.01398.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Poree L, Krames E, Pope J, Deer TR, Levy R, Schultz L. Spinal cord stimulation as treatment for complex regional pain syndrome should be considered earlier than last resort therapy. Neuromodulation 2013; 16:125-41. [PMID: 23441988 DOI: 10.1111/ner.12035] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 10/30/2012] [Accepted: 11/26/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND Spinal cord stimulation (SCS), by virtue of its historically described up-front costs and level of invasiveness, has been relegated by several complex regional pain syndrome (CRPS) treatment algorithms to a therapy of last resort. Newer information regarding safety, cost, and efficacy leads us to believe that SCS for the treatment of CRPS should be implemented earlier in a treatment algorithm using a more comprehensive approach. METHODS We reviewed the literature on pain care algorithmic thinking and applied the safety, appropriateness, fiscal or cost neutrality, and efficacy (S.A.F.E.) principles to establish an appropriate position for SCS in an algorithm of pain care. RESULTS AND CONCLUSION Based on literature-contingent considerations of safety, efficacy, cost efficacy, and cost neutrality, we conclude that SCS should not be considered a therapy of last resort for CRPS but rather should be applied earlier (e.g., three months) as soon as more conservative therapies have failed.
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Affiliation(s)
- Lawrence Poree
- Department of Anesthesiology, University of California San Francisco, San Francisco, CA, USA
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Cost Effectiveness of Intrathecal Drug Therapy in Management of Chronic Nonmalignant Pain. Clin J Pain 2013; 29:138-45. [DOI: 10.1097/ajp.0b013e31824b5fc9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Deer T, Winkelmüller W, Erdine S, Bedder M, Burchiel K. Intrathecal therapy for cancer and nonmalignant pain: patient selection and patient management. Neuromodulation 2012; 2:55-66. [PMID: 22151109 DOI: 10.1046/j.1525-1403.1999.00055.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Intrathecal drug delivery improves pain relief, reduces suffering, and enhances quality of life in the small proportion of patients who do not respond well to oral analgesics, including oral morphine. Although morphine is the "gold standard," and the only drug approved for intrathecal pain therapy in the United States, off-label use of alternative agents appears promising, particularly in patients with neuropathic pain. Careful patient selection and management are significant determinants of successful treatment outcomes. Patient selection criteria for cancer and nonmalignant pain are similar; however, a more comprehensive psychological and social assessment is required for patients with nonmalignant pain. In addition, all patients (those with cancer or nonmalignant pain) must exhibit a positive response to an epidural or intrathecal screening test. A multidisciplinary team approach, involving psychologists, nurses, physical therapists, social workers, and spiritual leaders should be used to manage patients. Current practices for patient selection and management, screening tests, and dosing guidelines for intrathecal drug delivery systems are discussed.
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Affiliation(s)
- T Deer
- The Center for Pain Relief, Charleston, West Virginia, USA; Gemeinschaftspraxis für Neurochirurgie, Hannover, Germany; Department of Algology, Medical Faculty of Istanbul, Istanbul, Turkey; Advanced Pain Management Group, Inc., Portland, Oregon, USA; Oregon Health Sciences University, Portland, Oregon, USA
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Hamza M, Doleys D, Wells M, Weisbein J, Hoff J, Martin M, Soteropoulos C, Barreto J, Deschner S, Ketchum J. Prospective Study of 3-Year Follow-Up of Low-Dose Intrathecal Opioids in the Management of Chronic Nonmalignant Pain. PAIN MEDICINE 2012; 13:1304-13. [DOI: 10.1111/j.1526-4637.2012.01451.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Krames ES, Monis S, Poree L, Deer T, Levy R. Using the SAFE Principles When Evaluating Electrical Stimulation Therapies for the Pain of Failed Back Surgery Syndrome. Neuromodulation 2011; 14:299-311; discussion 311. [DOI: 10.1111/j.1525-1403.2011.00373.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Affiliation(s)
- Chin-wern Chan
- Wasser Pain Management Center, Mount Sinai Hospital, Toronto, Ontario, Canada
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Biggs SA, Duarte RV, Raphael JH, Ashford RL. Influence of a latent period in QALY anaylsis: Pilot study of intrathecal drug delivery systems for chronic non-malignant pain. Br J Neurosurg 2011; 25:401-6. [DOI: 10.3109/02688697.2010.551676] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Schuchard M, Lanning R, North R, Reig E, Krames E. Neurologic Sequelae of Intraspinal Drug Delivery Systems: Results of a Survey of American Implanters of Implantable Drug Delivery Systems. Neuromodulation 2010; 1:137-48. [DOI: 10.1111/j.1525-1403.1998.tb00007.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Whitfill T, Haggard R, Bierner SM, Pransky G, Hassett RG, Gatchel RJ. Early intervention options for acute low back pain patients: a randomized clinical trial with one-year follow-up outcomes. JOURNAL OF OCCUPATIONAL REHABILITATION 2010; 20:256-63. [PMID: 20369277 DOI: 10.1007/s10926-010-9238-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
INTRODUCTION In an earlier study, Gatchel et al. (J Occup Rehabil 13:1-9, 2003) demonstrated that participants at high risk for developing chronic low back pain disability (CLBPD), who received a biopsychosocial early intervention treatment program, displayed significantly more symptom improvement, as well as cost savings, relative to participants receiving standard care. The purpose of the present study was to expand on these results by examining whether the addition of a work-transition component would further strengthen the effectiveness of this early intervention treatment. METHODS Using an existing algorithm, participants were identified as being high-risk (HR) or low-risk (LR) for developing CLBPD. HR participants were then randomly assigned to one of three groups: early intervention (EI); early intervention with work transition (EI/WT); or standard care (SC). Participants provided information regarding pain, disability, work status, and psychosocial functioning at baseline, periodically during treatment, and again 1 year following completion of treatment. RESULTS At 1-year follow-up, no significant differences were found between the EI and EI/WT groups in terms of occupational status, self-reports of pain and disability, coping ability or psychosocial functioning. However, significant differences in all these outcomes were found comparing these groups to standard care. CONCLUSION The addition of a work transition component to an early intervention program for the treatment of ALBP did not significantly contribute to improved work outcomes. However, results further support the effectiveness of early intervention for high-risk ALBP patients.
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Affiliation(s)
- Travis Whitfill
- Division of Clinical Psychology, The University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.
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Dewilde S, Verdian L, Maclaine GDH. Cost-effectiveness of ziconotide in intrathecal pain management for severe chronic pain patients in the UK. Curr Med Res Opin 2009; 25:2007-19. [PMID: 19563256 DOI: 10.1185/03007990903090849] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To examine the cost-effectiveness of using intrathecal ziconotide in the treatment of severe chronic pain compared to best supportive care for patients with intractable chronic pain in the United Kingdom. METHODS Using a simulation model, the analysis evaluated the cost and health economic consequences of using ziconotide as a treatment for severe chronic pain. The modelled population and clinical data were based on a randomised controlled trial in which the main outcome was reduction in pain as measured by the visual analogue scale of pain intensity (VASPI). Resource use data were elicited using a modified Delphi panel and costed using published sources. Utility values were derived from a separate research study. The main outcome measure was the cost per quality-adjusted life-year (QALY). Extensive scenario analysis was conducted to evaluate parameter uncertainty. RESULTS Overall, findings were robust to most assumptions. The cost-effectiveness of ziconotide compared to best supportive care (BSC) was pound 27,443 per QALY (95% CI pound 18,304-38,504). Scenarios were investigated in which discount rates, the time horizon, the threshold for qualifying as a responder, pump-related assumptions, utilities, ziconotide drug dose, and the patient discontinuation rate with ziconotide were varied. The most sensitive parameter was the dosage of ziconotide: using the lower and upper bounds of the average ziconotide dosage observed in the long-term open-label study changed the incremental cost-effectiveness ratio (ICER) to pound 15,500 [pound 8206-25,405] and pound 44,700 [pound 30,541-62, 670]. CONCLUSIONS Ziconotide may offer an economically feasible alternative solution for patients for whom current treatment is inappropriate or ineffective. The main study limitation is that some model inputs, mainly related to resource use, are based on assumptions or expert interviews.
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Affiliation(s)
- S Dewilde
- Services in Health Economics, 1000 Brussels, Belgium.
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Intrathecal Analgesics, Choice of System. Neuromodulation 2009. [DOI: 10.1016/b978-0-12-374248-3.00035-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Krames E, Poree LR, Deer T, Levy R. Rethinking Algorithms of Pain Care: The Use of the S.A.F.E. Principles. PAIN MEDICINE 2009; 10:1-5. [DOI: 10.1111/j.1526-4637.2008.00550.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Cancer pain is prevalent and often multifactorial. For a segment of the cancer pain population, pain control remains inadequate despite full compliance with the WHO analgesic guidelines including use of co-analgesics. The failure to obtain acceptable pain or symptom relief prompted the inclusion of a fourth step to the WHO analgesic ladder, which includes advanced interventional approaches. Interventional pain-relieving therapies can be indispensable allies in the quest for pain reduction among cancer patients suffering from refractory pain. There are a variety of techniques used by interventional pain physicians, which may be grossly divided into modalities affecting the spinal canal (e.g., intrathecal or epidural space), called neuraxial techniques and those that target individual nerves or nerve bundles, termed neurolytic techniques. An array of intrathecal medications are infused into the cerebrospinal fluid in an attempt to relieve refractory cancer pain, reduce disabling adverse effects of systemic analgesics, and promote a higher quality of life. These intrathecal medications include opioids, local anesthetics, clonidine, and ziconotide. Intrathecal and epidural infusions can serve as useful methods of delivering analgesics quickly and safely. Spinal delivery of drugs for the treatment of chronic pain by means of an implantable drug delivery system (IDDS) began in the 1980s. Both intrathecal and epidural neurolysis can be effective in managing intractable cancer-related pain. There are several sites for neurolytic blockade of the sympathetic nervous system for the treatment of cancer pain. The more common sites include the celiac plexus, superior hypogastric plexus, and ganglion impar. Today, interventional pain-relieving approaches should be considered a critical component of a multifaceted therapeutic program of cancer pain relief.
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Affiliation(s)
- Paul J Christo
- Department of Anesthesiology & Critical Care Medicine, Division of Pain Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Staats P, Whitworth M, Barakat M, Anderson W, Lilienfeld S. The Use of Implanted Programmable Infusion Pumps in the Management of Nonmalignant, Chronic Low-Back Pain. Neuromodulation 2007; 10:376-80. [DOI: 10.1111/j.1525-1403.2007.00127.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rainov NG, Heidecke V. Management of chronic back and leg pain by intrathecal drug delivery. ACTA NEUROCHIRURGICA. SUPPLEMENT 2007; 97:49-56. [PMID: 17691356 DOI: 10.1007/978-3-211-33079-1_6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Intrathecal delivery of analgesic drugs by implantable pump systems has been recognized as a treatment option for patients with chronic pain of benign or malignant origin that is resistant to oral or parenteral medication. Patients with chronic back and leg pain (CBLP), a benign but severely disabling condition of the lumbar spine with multifactorial genesis, have been demonstrated in a number of retrospective and in some prospective clinical studies to benefit from intrathecal delivery of opioid and/or non-opioid substances, either as single drugs or in combinations. In addition, intrathecal therapy for CBLP has been proven safe and less expensive that conventional medical therapy. This chapter summarizes the clinical and experimental evidence and the personal experience of the authors with long-term intrathecal infusion therapy for CBLP. It discusses important clinical issues such as drug selection, drug combinations, and side effects and complications of intrathecal infusion. It is concluded that further clinical research is needed in order to provide stronger evidence for the usefulness of a number of drugs currently used for intrathecal therapy on a mostly empirical basis.
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Affiliation(s)
- N G Rainov
- Department of Neurosurgery, Central Clinic Augsburg, Augsburg, Germany.
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North RB, Kidd D, Shipley J, Taylor RS. Spinal Cord Stimulation versus Reoperation for Failed Back Surgery Syndrome: A Cost Effectiveness and Cost Utility Analysis Based on a Randomized, Controlled Trial. Neurosurgery 2007; 61:361-8; discussion 368-9. [PMID: 17762749 DOI: 10.1227/01.neu.0000255522.42579.ea] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE:
We analyzed the cost-effectiveness and cost–utility of treating failed back–surgery syndrome using spinal cord stimulation (SCS) versus reoperation.
MATERIALS AND METHODS
A disinterested third party collected charge data for the first 42 patients in a randomized controlled crossover trial. We computed the difference in cost with regard to success (cost–effectiveness) and mean quality–adjusted life years (cost–utility). We analyzed the patient–charge data with respect to intention to treat (costs and outcomes as a randomized group), treated as intended (costs as randomized; crossover failure assigned to a randomized group), and final treatment costs and outcomes.
RESULTS:
By our mean 3.1–year follow–up, 13 of 21 patients (62%) crossed to reoperation versus 5 of 19 patients (26%) who crossed to SCS (P < 0.025). The mean cost per success was US $117,901 for crossovers to SCS. No crossovers to reoperation achieved success despite a mean per-patient expenditure of US $260,584. The mean per-patient costs were US $31,530 for SCS versus US $38,160 for reoperation (intention to treat), US $48,357 for SCS versus US $105,928 for reoperation (treated as intended), and US $34,371 for SCS versus US $36,341 for reoperation (final treatment). SCS was dominant (more effective and less expensive) in the incremental cost–effectiveness ratios and incremental cost–utility ratios. A bootstrapped simulation for incremental costs and quality–adjusted life years confirmed SCS's dominance, with approximately 72% of the cost results occurring below US policymakers' “maximum willingness to pay” threshold.
CONCLUSION:
SCS was less expensive and more effective than reoperation in selected failed back–surgery syndrome patients, and should be the initial therapy of choice. SCS is most cost–effective when patients forego repeat operation. Should SCS fail, reoperation is unlikely to succeed.
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Affiliation(s)
- Richard B North
- Department of Neurosurgery, The Johns Hopkins University, Baltimore, Maryland 21287, USA.
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Gatchel RJ, Okifuji A. Evidence-Based Scientific Data Documenting the Treatment and Cost-Effectiveness of Comprehensive Pain Programs for Chronic Nonmalignant Pain. THE JOURNAL OF PAIN 2006; 7:779-93. [PMID: 17074616 DOI: 10.1016/j.jpain.2006.08.005] [Citation(s) in RCA: 249] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2006] [Revised: 07/19/2006] [Accepted: 08/11/2006] [Indexed: 11/20/2022]
Abstract
UNLABELLED Chronic pain is one of the most prevalent and costly problems in the United States today. Traditional medical treatments for it, though, have not been consistently efficacious or cost-effective. In contrast, more recent comprehensive pain programs (CPPs) have been shown to be both therapeutically efficacious and cost-effective. The present study reviews available evidence demonstrating the therapeutic efficacy and cost-effectiveness of CPPs, relative to conventional medical treatment. Searches of the chronic pain treatment literature during the past decade were conducted for this purpose, using MEDLINE and PSYCHLIT. Studies reporting treatment outcome results for patients with chronic pain were selected, and data on the major outcome variables of self-reported pain, function, healthcare utilization and cost, medication use, work factors, and insurance claims were evaluated. When available, conventional medical treatments were used as the benchmark against which CPPs were evaluated. This review clearly demonstrates that CPPs offer the most efficacious and cost-effective, evidence-based treatment for persons with chronic pain. Unfortunately, such programs are not being taken advantage of because of short-sighted cost-containment policies of third-party payers. PERSPECTIVE A comprehensive review was conducted of all studies in the scientific literature reporting treatment outcomes for patients with chronic pain. This review clearly revealed that CPPs offer the most efficacious and cost-effective treatment for persons with chronic pain, relative to a host of widely used conventional medical treatment.
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Affiliation(s)
- Robert J Gatchel
- Department of Psychology, College of Science, The University of Texas at Arlington, Arlington, Texas, USA.
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New Onset Lumbar Radicular Pain After Implantation of an Intrathecal Drug Delivery System. Reg Anesth Pain Med 2006. [DOI: 10.1097/00115550-200607000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Intrathecal drug delivery (IDD) is a proven and effective treatment alternative in carefully selected patients with chronic pain that cannot be controlled by a well-tailored drug regime and/or spinal cord stimulation (SCS), and may be specifically trialed in patients who fail to respond to SCS. While the lack of randomized controlled trials is often perceived as a limitation of IDD, many studies attest to the efficacy of this therapy, and a number are large-scale and with follow-up periods of up to five years. Good to excellent pain relief is achieved in many patients who have failed more conservative therapies, and there is often a reduced need for analgesia. The advent of patient-controlled analgesia allows flexibility of dosing according to the patient's needs. Consequently, quality of life improves in many patients and the majority express satisfaction with treatment. Some patients are able to return to work. The benefits of IDD (including a potent analgesic response with a more stable therapeutic drug level, decreased latency, increased duration of action, and decreased pharmacological complications) mean that side effects such as nausea, vomiting, sedation, and constipation are reduced. In addition, IDD demonstrates long-term cost-effectiveness when compared to conventional pain therapies, addressing a concern that affects many physicians in clinical practice today.
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Affiliation(s)
- Serdar Erdine
- Department of Algology, Medical Faculty of Istanbul University, Istanbul, Turkey.
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Mavrocordatos P, Cahana A. Minimally invasive procedures for the treatment of failed back surgery syndrome. Adv Tech Stand Neurosurg 2006; 31:221-52. [PMID: 16768306 DOI: 10.1007/3-211-32234-5_5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Failed back surgery syndrome has become unfortunately a common clinical entity. FBSS does not have one specific treatment because it does not have one specific cause. Some features are shared with chronic low back pain (CLBP) and some pathological processes are specific. Both pathologies are leading causes of disability in the industrialized world and costly medical and surgical treatments are continuously used despite their limited efficacy. Nonetheless, evidence based practice guidelines are systematically developed. In this chapter we cautiously review the vast, complex and at times contradictory literature regarding the treatment of FBSS. Interventional Pain literature suggests that there is moderate evidence (small randomized or non randomized or single group or matched case controlled studies) for medial branch neurotomy and limited evidence (non experimental one or more center studies) for intra-discal treatments in mechanical low back pain. There is moderate evidence for the use of transforaminal epidural steroid injections, lumbar percutaneous adhesiolysis and spinal endoscopy for painful lumbar radiculopathy and spinal cord stimulation and intrathecal pumps mostly after spinal surgery. In reality there is no gold standard for the treatment of FBSS but, these results seem promising.
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Affiliation(s)
- P Mavrocordatos
- Department of Anesthesiology, Pharmacology and Intensive Care, Geneva, Switzerland
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Taylor RJ, Taylor RS. Spinal cord stimulation for failed back surgery syndrome: A decision-analytic model and cost-effectiveness analysis. Int J Technol Assess Health Care 2005; 21:351-8. [PMID: 16110715 DOI: 10.1017/s0266462305050464] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Objectives:The aim of this study was to develop a decision-analytic model to assess the cost-effectiveness of spinal cord stimulation (SCS), relative to nonsurgical conventional medical management (CMM), for patients with failed back surgery syndrome (FBSS).Methods:A decision tree and Markov model were developed to synthesize evidence on both health-care costs and outcomes for patients with FBSS. Outcome data of SCS and CMM were sourced from 2-year follow-up data of two randomized controlled trials (RCTs). Treatment effects were measured as levels of pain relief. Short- and long-term health-care costs were obtained from a detailed Canadian costing study in FBSS patients. Results are presented as incremental cost per quality adjusted life year (QALY) and expressed in 2003 Euros. Costs were discounted at 6 percent and outcomes at 1.5 percent.Results:Over the lifetime of the patient, SCS was dominant (i.e., SCS is cost-saving and gives more health gain relative to CMM); a finding that was robust across sensitivity analyses. At a 2-year time horizon, SCS gave more health gain but at an increased cost relative to CMM. Given the uncertainty in effectiveness and cost parameters, the 2-year cost-effectiveness of SCS ranged from €30,370 in the base case to €63,511 in the worst-case scenario.Conclusions:SCS was found to be both more effective and less costly than CMM, over the lifetime of a patient. In the short-term, although SCS is potentially cost-effective, the model results are highly sensitive to the choice of input parameters. Further empirical data are required to improve the precision in the estimation of short-term cost-effectiveness.
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Turk DC, Burwinkle TM. Clinical Outcomes, Cost-Effectiveness, and the Role of Psychology in Treatments for Chronic Pain Sufferers. ACTA ACUST UNITED AC 2005. [DOI: 10.1037/0735-7028.36.6.602] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Burton AW, Rajagopal A, Shah HN, Mendoza T, Cleeland C, Hassenbusch SJ, Arens JF. Epidural and intrathecal analgesia is effective in treating refractory cancer pain. PAIN MEDICINE 2004; 5:239-47. [PMID: 15367301 DOI: 10.1111/j.1526-4637.2004.04037.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The use of neuraxial (intrathecal and epidural) analgesia has been suggested in treatment guidelines put forth for the treatment of refractory cancer pain. We review the literature and present our algorithm for using neuraxial analgesia. We also present our outcomes using this algorithm over a 28-month period. We used neuraxial analgesia in 87 of 4,107 patients, approximately 2% of those seen for pain consultation. Evaluation of those patients at an 8-week follow-up revealed improved pain control. After institution of neuraxial analgesia, there was a significant reduction in the proportion of patients with severe pain (defined as a "pain worst" score in the severe range of 7-10), from 86% to 17%, noted to be highly statistically significant. At follow-up, numerical pain scores decreased significantly from 7.9 +/- 1.6 to 4.1 +/- 2.3. No difference was noted between the intrathecal and epidural groups. Oral opioid intake after instituting neuraxial analgesia revealed a significant decrease from 588 mg/day oral morphine equivalents to 294 mg/day. At follow-up, self-reported drowsiness and mental clouding (0-10) also significantly decreased from 6.2 +/- 3.0 and 5.4 +/- 3.4 to 3.2 +/- 3.0 and 3.1 +/- 3.0, respectively. This retrospective review shows promising efficacy of neuraxial analgesia in the context of failing medical management.
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Affiliation(s)
- Allen W Burton
- Department of Anesthesiology, University of Texas M.D.Anderson Cancer Center, Houston, Texas 77030, USA.
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Nguyen H, Hassenbusch SJ. Cost-effectiveness of intraspinal drug delivery for chronic pain. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/j.spmd.2004.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Affiliation(s)
- Christine Colella
- University of Cinncinati and St. Elizabeth's Hospital for Independent Anesthesiology, Inc., OH, USA
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Abstract
The evaluation of the complex chronic pain patient should be different than for the patient with a simple pain problem. The former requires a team approach. It is important that the neurosurgeon contemplating a pain-relieving operation get the best information that is likely to have an impact on outcome. This should include the following: 1. Some way to extract the appropriate information contained in the patient's medical records. 2. Physical factors that have a negative impact on prognosis. 3. Psychologic information, including return-to-work decisions, medication use issues, meaning of prior successes, negative environmental factors, codependency issues, secondary gains and their impact, presence of pain games, negatively acting financial considerations, impact of depression, presence of poor role models, impact of pain on general functioning, and the patient's future plans. Consider that just like a successful operation is a symphony of relatively simple harmonious parts, so, too, is the assessment of the complex chronic pain patient. The complexity of the patient and her or his predicament should not impair your ability to understand her or his real needs. The appropriate assessment of the patient requires that issues other than the pain itself be factored into the decisions about interventions. In the end, it is not appropriate to suggest afterward that psychosocial factors were the major cause for a poor result when nothing had been done about the same factors that had been present before the procedure.
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Affiliation(s)
- Joel L Seres
- Department of Neurosurgery L-427, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97201, USA.
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