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Li S, Winston P, Mas MF. Spasticity Treatment Beyond Botulinum Toxins. Phys Med Rehabil Clin N Am 2024; 35:399-418. [PMID: 38514226 DOI: 10.1016/j.pmr.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Botulinum toxin (BonT) is the mainstream treatment option for post-stroke spasticity. BoNT therapy may not be adequate in those with severe spasticity. There are a number of emerging treatment options for spasticity management. In this paper, we focus on innovative and revived treatment options that can be alternative or complementary to BoNT therapy, including phenol neurolysis, cryoneurolysis, and extracorporeal shock wave therapy.
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Affiliation(s)
- Sheng Li
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center - Houston, Houston, TX, USA; TIRR Memorial Herman.
| | - Paul Winston
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Victoria, British Columbia, Canada; Canadian Advances in Neuro-Orthopedics for Spasticity Consortium, Victoria, British Columbia, Canada
| | - Manuel F Mas
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Puerto Rico, San Juan, Puerto Rico
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2
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Anderson AB, Rivera JA, McGlone PJ, Saberski ER, Tintle SM, Potter BK. Technical Trick: Cryoneurolysis for Subacute Pain Mitigation in Patients With Limb Loss. J Orthop Trauma 2024; 38:e191-e194. [PMID: 38252476 DOI: 10.1097/bot.0000000000002777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 01/23/2024]
Abstract
SUMMARY Pain after amputation is often managed by target muscle reinnervation (TMR) with the added benefit that TMR also provides improved myoelectric terminal device control. However, as TMR takes several months for the recipient muscles to reliably reinnervate, this technique does not address pain within the subacute postoperative period during which pain chronification, sensitization, and opioid dependence and misuse may occur. Cryoneurolysis, described herein, uses focused, extreme temperatures to essentially "freeze" the nerve, blocking nociception, and improving pain in treated nerves potentially reducing the chances of pain chronification, sensitization, and substance dependence or abuse.
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Affiliation(s)
- Ashley B Anderson
- Uniformed Services University of the Health Sciences, Bethesda, MD
- Division of Orthopaedics, Department of Surgery, Walter Reed National Military Center, Bethesda, MD
| | - Julio A Rivera
- Uniformed Services University of the Health Sciences, Bethesda, MD
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD; and
| | - Patrick J McGlone
- Division of Orthopaedics, Department of Surgery, Walter Reed National Military Center, Bethesda, MD
| | - Ean R Saberski
- Uniformed Services University of the Health Sciences, Bethesda, MD
- Division of Plastics and Reconstructive Surgery, Department of Surgery, Walter Reed National Military Center, Bethesda, MD
| | - Scott M Tintle
- Uniformed Services University of the Health Sciences, Bethesda, MD
- Division of Orthopaedics, Department of Surgery, Walter Reed National Military Center, Bethesda, MD
| | - Benjamin K Potter
- Uniformed Services University of the Health Sciences, Bethesda, MD
- Division of Orthopaedics, Department of Surgery, Walter Reed National Military Center, Bethesda, MD
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Das G, Singam A, Chakole V, Das S, Sharma V. Efficacy and Safety of Cryoablation Compared with Cooled Radiofrequency Ablation of Genicular Nerves in Advanced Osteoarthritis of the Knee: A Study Protocol of Single-Centric, Assessor-Blinded, Randomized, Parallel-Group, Non-inferiority Study. Cardiovasc Intervent Radiol 2024; 47:508-514. [PMID: 38528172 DOI: 10.1007/s00270-024-03703-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 02/29/2024] [Indexed: 03/27/2024]
Abstract
PURPOSE In patients with symptomatic osteoarthritis knee (OAK), cryoneurolysis (CRYO) and cooled radiofrequency ablation (C-RFA) are reported to be effective and safe; however, they have not been compared directly. The objective of this study is to compare CRYO and C-RFA of the genicular nerve (GN) in terms of efficacy and safety profile in patients with Kellgren and Lawrence (KL) grade ≥ 3 OAK. METHODS This single-centric, assessor-blinded, randomized, parallel-group, non-inferiority study will include 80 patients with KL grade ≥ 3 OAK. The patients with ≥ 50% pain relief on diagnostic block of three GNs will be randomized to one of the two groups, i.e., CRYO (n = 40) or C-RFA (n = 40). The three target GNs for the interventions will include: superior medial, superior lateral, and inferior medial. The primary outcome will be efficacy of CRYO or C-RFA at 2, 12, and 24 weeks post-procedure based on the 11-point Numerical Pain Rating Scale. The secondary outcomes will be functional improvement based on 12-item Oxford Knee Score and safety of both the procedures. The study is registered in the Clinical Trials Registry-India. CONCLUSION CRYO and C-RFA provide pain relief and improve functional outcome by preventing transmission of pain signals, though by distinct mechanisms. While C-RFA is an established treatment modality, recent evidence supports CRYO in patients with OAK. This study intends to demonstrate non-inferiority of CRYO against C-RFA, thereby supporting the use of CRYO as an additional treatment modality in patients with KL grade ≥ 3 OAK.
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Affiliation(s)
- Gautam Das
- Department of Pain Medicine, Daradia: The Pain Clinic, Kolkata, West Bengal, 700067, India
| | - Amol Singam
- Department of Anesthesia & Pain Medicine, JNMC, Wardha, Maharashtra, 442005, India
| | - Vivek Chakole
- Department of Anesthesia & Pain Medicine, JNMC, Wardha, Maharashtra, 442005, India
| | - Sushpa Das
- Department of Pain Medicine, Daradia: The Pain Clinic, Kolkata, West Bengal, 700067, India
| | - Vikas Sharma
- Department of Academic Research, Maverick Medicorum®, 601, Shiv Ganga Apartment, Beltarodi, Nagpur, Maharashtra, 440034, India.
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Tidwell CM, DeMarco PJ. Temperature-Mediated Neural Interventions in Knee Osteoarthritis: a Review of Cryoneurolysis and Cooled Radiofrequency Ablation with Ultrasound Guidance. Curr Rheumatol Rep 2024; 26:89-95. [PMID: 38127092 DOI: 10.1007/s11926-023-01127-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE OF REVIEW Knee osteoarthritis is a debilitating chronic disease affecting nearly half of the world's population at some point in their lives. Treatment of pain and loss of function associated with this disease has been limited. In this review, we seek to explore how neural interventions with ultrasound guidance may be an emerging option for non-pharmacologic pain relief in patients with knee osteoarthritis. RECENT FINDINGS Cryoneurolysis techniques have been demonstrated to provide pain relief out to 150 days post-treatment in knee osteoarthritis in select individuals. There have also been studies of cryoneurolysis pre-operatively to total knee replacement providing reduced pain, reduced opioid use post-operatively, and shorter hospital length of stay. Cooled radiofrequency ablation (CRFA) has been demonstrated to significantly reduce pain, improve functionality, and reduce pharmacologic needs in knee osteoarthritis out to 2 years. Both interventions appear to have increased accuracy with ultrasound, and CRFA appears to be associated with improved patient outcomes. The research demonstrates the efficacy of both cryoneurolysis and cooled radiofrequency ablation in the treatment of knee osteoarthritis. Ultrasound guidance in neurolysis provides an additional tool with real-time, high-accuracy nerve localization. These therapies should be considered for certain patients to assist in pain management in the non-operative and post-operative phase of knee osteoarthritis management. Further research is needed to further define the long-term effects and the long-term utility of the techniques in knee pain.
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Affiliation(s)
- Christopher M Tidwell
- National Institutes of Health, National Institute of Arthritis, Musculoskeletal, and Skin Diseases, Building 10, Suite 10N311, 9000 Rockville Pike, Bethesda, Rockville, MD, 20812, USA
| | - Paul J DeMarco
- National Institutes of Health, National Institute of Arthritis, Musculoskeletal, and Skin Diseases, Building 10, Suite 10N311, 9000 Rockville Pike, Bethesda, Rockville, MD, 20812, USA.
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Chang DL, Mirman B, Mehta N, Pak D. Applications of Cryoneurolysis in Chronic Pain Management: a Review of the Current Literature. Curr Pain Headache Rep 2024:10.1007/s11916-024-01222-w. [PMID: 38372950 DOI: 10.1007/s11916-024-01222-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 02/20/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to evaluate and summarize the literature investigating cryoneurolysis in the treatment of various chronic pain pathologies. RECENT FINDINGS There is an increasing amount of interest in the use of cryoneurolysis in chronic pain, and various studies have investigated its use in lumbar facet joint pain, SI joint pain, post-thoracotomy syndrome, temporomandibular joint pain, chronic knee pain, phantom limb pain, neuropathic pain, and abdominal pain. Numerous retrospective studies and a more limited number of prospective, sham-controlled prospective studies suggest the efficacy of cryoneurolysis in managing these chronic pain pathologies with a low complication rate. However, more blinded, controlled, prospective studies comparing cryoneurolysis to other techniques are needed to clarify its relative risks and advantages.
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Affiliation(s)
- David L Chang
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY, 10029, USA.
| | - Benjamin Mirman
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, 1 Gustave L. Levy Place, New York, NY, 10029, USA
| | - Neel Mehta
- Weill Cornell Medical College, Department of Anesthesiology, New York Presbyterian Hospital, New York, NY, USA
| | - Daniel Pak
- Weill Cornell Medical College, Department of Anesthesiology, New York Presbyterian Hospital, New York, NY, USA
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Malik KN, Camp N, Chan J, Ballard M. Interventional Techniques for the Management of Knee Osteoarthritis: A Literature Review. Cureus 2023; 15:e47133. [PMID: 38022320 PMCID: PMC10650933 DOI: 10.7759/cureus.47133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2023] [Indexed: 12/01/2023] Open
Abstract
Osteoarthritis of the knee is a prevalent condition that causes pain, discomfort, and disability that can severely impact the quality of life. This literature review aims to review the various interventional pain management techniques available to treat knee osteoarthritis. It analyzes the efficacy of various interventions such as intra-articular corticosteroids, prolotherapy, viscosupplementation, platelet-rich plasma, and genicular nerve blocks with radiofrequency ablation or cryoneurolysis. We searched databases for studies published in the past 20 years. A total of 37 articles were included. The literature supports the idea that a comprehensive treatment plan consisting of the various aforementioned techniques can provide relief for patients while delaying or avoiding joint replacement surgery.
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Affiliation(s)
- Kashif N Malik
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Nathan Camp
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Justin Chan
- Pain Management, Western University of Health Sciences, Pomona, USA
| | - Matthew Ballard
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
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van der Meulen C, van de Stadt LA, Claassen A, Kroon FPB, Ritt MJPF, Rosendaal FR, Terpstra SES, Vochteloo AJH, Kloppenburg M. Surgical denervation as a treatment strategy for pain in hand osteoarthritis: a systematic literature review. RMD Open 2023; 9:e003134. [PMID: 37532467 PMCID: PMC10401234 DOI: 10.1136/rmdopen-2023-003134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 07/17/2023] [Indexed: 08/04/2023] Open
Abstract
OBJECTIVE Surgical denervation has been proposed as a treatment for pain in hand osteoarthritis (OA). This review aimed to summarise the available evidence and to propose a research agenda. METHODS A systematic literature search was performed up to September 2022. Two investigators independently identified studies that reported on denervation for OA of the proximal interphalangeal, distal interphalangeal, metacarpophalangeal or carpometacarpal joints. Quality of studies was assessed and study characteristics, patient characteristics, details of the surgical technique and outcomes of the surgery were extracted. RESULTS Of 169 references, 17 articles reporting on 384 denervations in 351 patients were selected. Sixteen case series reported positive outcomes with respect to pain, function and patient satisfaction. One non-randomised clinical trial reported no difference in outcome when comparing denervation of the first carpometacarpal (CMC I) joint to trapeziectomy. Adverse events were frequent, with sensory abnormalities occurring the most, followed by the need for revision surgery. All studies had significant risk of bias. CONCLUSION Surgical denervation for pain in hand OA shows some promise, but the available evidence does not allow any conclusions of efficacy and higher-quality research is needed. Techniques should be harmonised and more data regarding how denervation compares to current usual care, other denervation methods or placebo in terms of outcomes and adverse events are needed.
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Affiliation(s)
| | - Lotte A van de Stadt
- Department of Rheumatology, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Aniek Claassen
- Dutch Society for Rheumatology, Utrecht, The Netherlands
| | - Féline P B Kroon
- Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Marco J P F Ritt
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Frits R Rosendaal
- Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Anne J H Vochteloo
- Department of Orthopaedics, OCON Orthopedische kliniek, Hengelo, The Netherlands
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Jennewine BR, Wing CW, Mihalko WM. Body Habitus Impact on Success of Cryoneurolysis for Postoperative Total Knee Arthroplasty Pain Control: A Retrospective Cohort Study. Arthroplast Today 2023; 22:101164. [PMID: 37521741 PMCID: PMC10382622 DOI: 10.1016/j.artd.2023.101164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 03/03/2023] [Accepted: 05/15/2023] [Indexed: 08/01/2023] Open
Abstract
Background Cryoneurolysis utilizes temperatures below -20°C for nonpermanent analgesia to control pain in total knee arthroplasty (TKA). There is concern that body habitus could limit pain control because of accuracy of cryoneurolysis to subcutaneous nerves. This study aimed to determine the relationship between body habitus and effectiveness of cryoneurolysis on postoperative pain control. Methods A retrospective chart review was performed on patients undergoing cryoneurolysis before primary TKA from 2017 to 2019. Included were 114 patients (58 control group and 56 treatment group). Cryoneurolysis patients were divided into 3 groups (small, medium, and large) based on the soft tissue to femoral diaphysis ratio of 7 cm proximal to superior pole of the patella. Postoperative outcome measures were morphine equivalents, numerical rating score for pain, range of motion, and Knee Injury and Osteoarthritis Outcome Score Joint Replacement. Results The small cryoneurolysis group showed decreased opioid consumption at the 2, 6, and 12 weeks compared with control group, with morphine equivalents significantly decreased at 2 weeks for small compared with medium groups (54.3 vs 142.9, P = .0097). Numerical rating score for pain decreased significantly between small and medium groups (3.4 vs 4.0, P = .012) and between medium and large groups (4.0 vs 2.4, P = .012). Range of motion increased at 12 weeks for small group compared with medium group (118 vs 112, P = .042). There were no differences in any outcome measure between small and large groups. Conclusions Body habitus does not appear to affect efficacy of cryoneurolysis in controlling postoperative pain following TKA. Cryoneurolysis remains a useful tool for multimodal pain management.
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Affiliation(s)
| | | | - William M. Mihalko
- Corresponding author. Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA. Tel.: +1 901 759 3273.
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Nemecek Z, Sturm C, Rauen AC, Reisig F, Streitberger K, Harnik MA. Ultrasound-controlled cryoneurolysis for peripheral mononeuropathies: a retrospective cohort study. Pain Manag 2023; 13:363-372. [PMID: 37424263 DOI: 10.2217/pmt-2023-0053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023] Open
Abstract
Aim: Cryoneurolysis is a potential therapy for peripheral mononeuropathies, but randomized studies of its effects on the duration of pain reduction are lacking. Methods: This retrospective cohort study evaluated the analgesic effects of cryoneurolysis on patients with refractory peripheral mononeuropathy. We included 24 patients who underwent ultrasound-guided cryoneurolysis between June 2018 and July 2022. The daily maximum pain level was recorded using a numerical rating scale before and 1, 3 and 6 months after the procedure. Results: At 1 month, 54.2% of patients reported pain reduction of at least 30%. This percentage was significantly lower at 3 and 6 months (13.8 and 9.1%, respectively). Conclusion: Our results suggest that repeated cryoneurolysis may be a viable treatment for refractory mononeuropathy. Further investigations are needed.
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Affiliation(s)
- Zdenek Nemecek
- Department of Anesthesiology & Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Constanze Sturm
- Department of Osteoporosis, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anna C Rauen
- Department of Anesthesiology & Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Reisig
- Department of Anesthesiology & Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Konrad Streitberger
- Department of Anesthesiology & Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael A Harnik
- Department of Anesthesiology & Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Panagopoulos A, Tsiplakos P, Katsanos K, Antzoulas P, Lakoumentas J. Cooled radiofrequency ablation versus cryoneurolysis of the genicular nerves for the symptomatic pain management in knee osteoarthritis: a study protocol of a prospective, randomized, single-blinded clinical trial. J Orthop Surg Res 2023; 18:295. [PMID: 37041607 PMCID: PMC10091842 DOI: 10.1186/s13018-023-03737-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 03/21/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Cooled radiofrequency ablation (CRFA) and cryoneurolysis (CRYO) are two novel methods of genicular neurolysis to relief pain in symptomatic knee osteoarthritis (KOA). In this study, the two methods will be compared, giving us the opportunity to investigate their efficacy, safety and complications. METHODS In this prospective randomized trial 70 patients with KOA will be recruited using a diagnostic block of four genicular nerves. Two groups will be created through software randomization: a CRFA group (35 patients) and a CRYO group (35 patients). The target of the interventions will be four genicular nerves; the superior medial, superior lateral, inferior medial, as well as the medial (retinacular) genicular branch from vastus intermedius. The primary outcome of this clinical trial will be the efficacy of CRFA or CRYO at 2-, 4-, 12-and 24-weeks post-intervention using the Numerical Rating Pain Scale (NRPS). The secondary outcomes are the safety of the two techniques, as well as the clinical evaluation using the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Oxford Knee Score (OKS), and the 7-point scale of Patient Global Impression of Change (PGIC). DISCUSSION These two novel techniques can block pain transmission through genicular nerves in different ways. In contrast to cryoneurolysis, the CRFA method has been well documented in the past. This is the first clinical trial to compare CRFA vs CRYO and draw conclusions about their safety and efficacy. TRIAL REGISTRATION ISRCTN87455770 [ https://doi.org/10.1186/ISRCTN87455770 ]. Registered 29/3/2022, first patient recruited 31/8/2022.
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Affiliation(s)
- A Panagopoulos
- Orthopaedic Department, Patras University Hospital, University of Patras, Patras, Greece.
| | - P Tsiplakos
- Orthopaedic Department, Patras University Hospital, University of Patras, Patras, Greece
| | - K Katsanos
- Department of Interventional Radiology, Patras University Hospital, University of Patras, Patras, Greece
| | - P Antzoulas
- Orthopaedic Department, Patras University Hospital, University of Patras, Patras, Greece
| | - J Lakoumentas
- Department of Medical Physics, School of Medicine, Patras University, Patras, Greece
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Said ET, Marsh-Armstrong BP, Fischer SJ, Suresh PJ, Swisher MW, Trescot AM, Prologo JD, Abdullah B, Ilfeld BM. Relative Effects of Various Factors on Ice Ball Formation and Ablation Zone Size During Ultrasound-Guided Percutaneous Cryoneurolysis: A Laboratory Investigation to Inform Clinical Practice and Future Research. Pain Ther 2023; 12:771-783. [PMID: 37000371 PMCID: PMC10199980 DOI: 10.1007/s40122-023-00497-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 03/02/2023] [Indexed: 04/01/2023] Open
Abstract
INTRODUCTION Ultrasound-guided percutaneous cryoneurolysis provides analgesia using cold temperatures to reversibly ablate peripheral nerves. Cryoneurolysis probes pass a gas through a small internal annulus, rapidly lowering the pressure and temperature, forming an ice ball to envelope the target nerve. Analgesia is compromised if a nerve is inadequately frozen, and laboratory studies suggest that pain may be paradoxically induced with a magnitude and duration in proportion with the incomplete ablation. We therefore investigated the relative effects of various factors that may contribute to the size of the ice ball and the effective cryoneurolysis zone. METHODS A cryoprobe was inserted into a piece of meat, a gas was passed through for 2 min, and the resulting ice ball width (cross-section) and length (axis parallel to the probe) were measured using ultrasound, with the temperature evaluated in nine concentric locations concurrently. RESULTS The factor with the greatest influence on ice ball size was probe gauge: in all probe types, a change from 18 to 14 increased ice ball width, length, and volume by up to 70%, 113%, and 512% respectively, with minimum internal temperature decreasing as much as from -5 to -32 °C. In contrast, alternating the type of meat (chicken, beef, pork) and the shape of the probe tip (straight, coudé) affected ice ball dimensions to a negligible degree. The ice ball dimensions and the zone of adequate temperature drop were not always correlated, and, even within a visualized ice ball, the temperature was often inadequate to induce Wallerian degeneration. CONCLUSIONS Percutaneous probe design can significantly influence the effective cryoneurolysis zone; visualizing a nerve fully encompassed in an ice ball does not guarantee adequate treatment to induce the desired Wallerian degeneration because ice forms at temperatures between 0 and -20 °C, whereas only temperatures below -20 °C induce Wallerian degeneration. The correlation between temperatures in isolated pieces of meat and perfused human tissue remains unknown, and further research to evaluate these findings in situ appears highly warranted.
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Affiliation(s)
- Engy T Said
- Department of Anesthesiology, University of California San Diego, 9500 Gilman Drive, MC 0898, La Jolla, CA, 92093-0898, USA
| | | | - Seth J Fischer
- Department of Anesthesiology, University of California San Diego, 9500 Gilman Drive, MC 0898, La Jolla, CA, 92093-0898, USA
| | - Preetham J Suresh
- Department of Anesthesiology, University of California San Diego, 9500 Gilman Drive, MC 0898, La Jolla, CA, 92093-0898, USA
| | - Matthew W Swisher
- Department of Anesthesiology, University of California San Diego, 9500 Gilman Drive, MC 0898, La Jolla, CA, 92093-0898, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | | | | | - Baharin Abdullah
- Department of Anesthesiology, University of California San Diego, 9500 Gilman Drive, MC 0898, La Jolla, CA, 92093-0898, USA
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, 9500 Gilman Drive, MC 0898, La Jolla, CA, 92093-0898, USA.
- Outcomes Research Consortium, Cleveland, OH, USA.
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Beckwith M, Cushman D, Clark T, Park PK, Burnham T, Burnham R, McCormick ZL, Conger A. Radiofrequency Ablation of the Infrapatellar Branch of the Saphenous Nerve for the Treatment of Chronic Anterior Inferomedial Knee Pain. Pain Med 2023; 24:150-157. [PMID: 35866617 DOI: 10.1093/pm/pnac108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/09/2022] [Accepted: 07/11/2022] [Indexed: 02/06/2023]
Abstract
INTRO Genicular nerve radiofrequency ablation (GNRFA) is an effective treatment for chronic knee pain related to osteoarthritis. It is often utilized when conservative management has failed and patients wish to avoid arthroplasty, are poor surgical candidates due to comorbid medical conditions, or in those suffering from persistent pain after arthroplasty. The classic targets for GNRFA include the superior lateral genicular nerve, superior medial genicular nerve, and inferior medial genicular nerve but multiple anatomic studies have demonstrated additional sensory innervation to the knee. OBJECTIVE In this research article, we propose an image-guided technique that can safely target the infrapatellar branch of the saphenous nerve which also provides sensory innervation to the anterior capsule. PROPOSAL The proposed technique includes variations for conventional bipolar radiofrequency ablation, cooled radiofrequency ablation, dual-tined bipolar radiofrequency ablation, and monopolar radiofrequency ablation using a long axis approach. The described technique is based on updated anatomic studies and takes into account safety concerns such as thermal risk to the skin and/or pes anserine tendons and breaching of the synovial cavity. CONCLUSION Future clinical research should be performed to confirm the safety and effectiveness of this specific approach.
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Affiliation(s)
- Margaret Beckwith
- Division of Physical Medicine and Rehabilitation, Department of Orthopedics, University of Washington St. Louis, St. Louis, Missouri, USA
| | - Daniel Cushman
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Tyler Clark
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Peter K Park
- Division of Physical Medicine and Rehabilitation, Department of Orthopedics, University of Washington St. Louis, St. Louis, Missouri, USA
| | - Taylor Burnham
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Robert Burnham
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Central Alberta Pain and Rehabilitation Institute, Lacombe, Alberta, Canada.,Vivo Cura Health, Calgary, Alberta, Canada
| | - Zachary L McCormick
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Aaron Conger
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Biel E, Aroke EN, Maye J, Zhang SJ. The applications of cryoneurolysis for acute and chronic pain management. Pain Pract 2023; 23:204-215. [PMID: 36370129 PMCID: PMC10107282 DOI: 10.1111/papr.13182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 10/03/2022] [Accepted: 10/11/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cryoneurolysis is a term used to describe the application of extreme cold to targeted nerve tissue. The primary goal of the application of a thermal neurolytic technique is to disrupt the conduction of pain signals from the periphery to the central nervous system and eliminate or diminish the experience of pain. Recent advancements in ultrasound technology coupled with the development and approval of handheld devices specifically designed to deliver cryoneurolysis has expanded the use of this modality in the perioperative setting. APPLICATION Surgical procedures including total knee arthroplasties, shoulder arthroplasties, thoracotomies, and mastectomies have all demonstrated long-term pain relief benefits when cryoneurolysis has been administered days to weeks prior to the planned procedure. In addition, the newly designed handheld device allows for office-based clinical use and has been utilized for various chronic pain conditions including neuropathic and phantom limb pain. CONCLUSION The evidence clearly demonstrates that cryoneurolysis has a low risk profile and when administered appropriately, provides prolonged analgesia without promoting motor blockade. This narrative review article describes the unique mechanism of action of cryoneurolysis for prolonged pain relief and provides emerging evidence to support its applications in both acute and chronic pain management.
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Affiliation(s)
- Emily Biel
- Nurse Anesthesiology ProgramUniversity of South FloridaTampaFloridaUSA
| | - Edwin N. Aroke
- University of Alabama at Birmingham School of NursingBirminghamAlabamaUSA
| | - John Maye
- School of NursingUniversity of South FloridaTampaFloridaUSA
| | - Sarah Jingying Zhang
- School of NursingUniversity of South FloridaTampaFloridaUSA
- University of California San FranciscoSan FranciscoCaliforniaUSA
- Samuel Merritt UniversityOaklandCaliforniaUSA
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14
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Sag AA, Bittman R, Prologo F, Friedberg EB, Nezami N, Ansari S, Prologo JD. Percutaneous Image-guided Cryoneurolysis: Applications and Techniques. Radiographics 2022; 42:1776-1794. [DOI: 10.1148/rg.220082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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15
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Moradi Tuchayi S, Wang Y, Pence IJ, Fast A, Stemmer-Rachamimov A, Evans CL, Anderson RR, Garibyan L. Full Recovery after Multiple Treatments with Injectable Ice Slurry. J Pain Res 2022; 15:2905-2910. [PMID: 36132994 PMCID: PMC9482954 DOI: 10.2147/jpr.s373421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/20/2022] [Indexed: 12/04/2022] Open
Abstract
Background Cryoneurolysis uses tissue cooling as an opioid-sparing, long-lasting treatment for peripheral nerve pain. A nerve-selective method for cryoneurolysis by local injection of ice-slurry was developed to allow cryoneurolysis to be performed with a standard needle and syringe, similar to peripheral nerve blocks. Since the treatment of patients with chronic pain may require repeated injections, we investigated the safety and tolerance of repeated treatments in a rat model. Methods Three repeated ice-slurry treatments, given 6 weeks apart were performed around the rat sciatic nerve. Nerve and surrounding tissues were collected up to 4 months after the third treatment for analysis. Coherent anti-Stokes Raman scattering (CARS) microscopy was used to study effects on myelin sheaths and axon structure. Immunofluorescence (IF) staining was used to study effects on axon density. Hematoxylin and Eosin (H&E) staining was used to examine histologic effects on sciatic nerve and surrounding tissue. Results Histologic and CARS image analysis of nerve tissue collected months after three injections demonstrated recovery of nerve structure, myelin organization and axon density to baseline levels, without any residual inflammation, scarring or neuroma formation. No inflammation or scarring was detected in surrounding skin and muscle tissues. Conclusion Repeated ice-slurry injections cause temporary, nerve-selective and reversible changes in the peripheral nerve. There was no histologic damage to surrounding skin and muscle tissues. Repeated treatments with injectable ice-slurry for cryoneurolysis appear to be safe and well tolerated. Clinical studies for patients with chronic pain are warranted.
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Affiliation(s)
- Sara Moradi Tuchayi
- Wellman Center for Photomedicine, Massachusetts General Hospital, Department of Dermatology, Harvard Medical School, Boston, MA, USA
| | - Ying Wang
- Wellman Center for Photomedicine, Massachusetts General Hospital, Department of Dermatology, Harvard Medical School, Boston, MA, USA
| | - Isaac J Pence
- Wellman Center for Photomedicine, Massachusetts General Hospital, Department of Dermatology, Harvard Medical School, Boston, MA, USA
| | - Alex Fast
- Wellman Center for Photomedicine, Massachusetts General Hospital, Department of Dermatology, Harvard Medical School, Boston, MA, USA
| | - Anat Stemmer-Rachamimov
- Massachusetts General Hospital and Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Conor L Evans
- Wellman Center for Photomedicine, Massachusetts General Hospital, Department of Dermatology, Harvard Medical School, Boston, MA, USA
| | - R Rox Anderson
- Wellman Center for Photomedicine, Massachusetts General Hospital, Department of Dermatology, Harvard Medical School, Boston, MA, USA
| | - Lilit Garibyan
- Wellman Center for Photomedicine, Massachusetts General Hospital, Department of Dermatology, Harvard Medical School, Boston, MA, USA
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16
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Lung BE, Karasavvidis T, Sharma AK, Amirhekmat A, Stepanyan H, Mcmaster W, Yang S, So DH. Cryoneurolysis Is a Safe, Effective Modality to Improve Rehabilitation after Total Knee Arthroplasty. Life (Basel) 2022; 12:1344. [PMID: 36143381 PMCID: PMC9501843 DOI: 10.3390/life12091344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/21/2022] [Accepted: 08/22/2022] [Indexed: 11/28/2022] Open
Abstract
Although long term pain and mobility outcomes in total knee arthroplasties (TKA) are successful, many patients experience significant amount of debilitating pain during the immediate post-operative period that necessitates narcotic use. Percutaneous cryoneurolysis to the infrapatellar saphenous and anterior femoral cutaneous nerves may help to better restore function and rehabilitation after surgery while limiting narcotic consumption. A retrospective chart review of primary TKA patients receiving pre-operative cryoneurolysis from 2019 to 2020 was performed to assess total opioid morphine milligram equivalents (MME) consumed inpatient and at interval follow-up. Demographics and medical comorbidities were compared between cryoneurolysis and age-matched control patients to assess baseline characteristics. Functional rehabilitation outcomes, including knee range of motion (ROM), ambulation distance, and Boston AM-PAC scores, as well as patient reported outcomes using the KOOS JR and SF-12 scores were analyzed using STATA 17 Software. The analysis included 29 cryoneurolysis and 28 age-matched control TKA patients. Baseline demographics and operative technique were not significant between groups. Although not statistically significant, cryoneurolysis patients had a shorter length of stay (2.5 vs. 3.5 days) and overall less inpatient and outpatient MME requirements. Cryoneurolysis patients had statistically significant improved 6-week ROM and 1-year follow-up KOOS JR and SF-12 mental scores compared to the control. There were no differences in complication rates. Cryoneurolysis is a safe, effective treatment modality to improve active functional recovery and patient satisfaction after TKA by reducing MME requirements. Patients who underwent cryoneurolysis had on average fewer MME prescribed during the perioperative period, improved active ROM, and improved patient-reported outcomes with no associated increased risk of infections, deep vein thrombosis, or neurologic complications.
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17
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Stake S, Agarwal AR, Coombs S, Cohen JS, Golladay GJ, Campbell JC, Thakkar SC. Total Knee Arthroplasty After Genicular Nerve Radiofrequency Ablation: Reduction in Prolonged Opioid Use Without Increased Postsurgical Complications. J Am Acad Orthop Surg Glob Res Rev 2022; 6. [PMID: 35960987 PMCID: PMC9377675 DOI: 10.5435/jaaosglobal-d-22-00125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/18/2022]
Abstract
Genicular nerve radiofrequency ablation (GNRFA) is an increasingly used nonsurgical treatment modality for patients with advanced knee osteoarthritis. Previous studies have demonstrated this to be an effective and safe method to decrease pain and increase functionality in this patient population. The purpose of this study was to compare 2-year postoperative complication rates and rates of prolonged postoperative opioid usage between patients undergoing total knee arthroplasty (TKA) after previous GNRFA and those undergoing TKA alone.
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18
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Ng TK, Lam KHS, Allam AE, Nakamoto T. Motor-Sparing Neural Ablation with Modified Techniques for Knee Pain: Case Series on Knee Osteoarthritis and Updated Review of the Underlying Anatomy and Available Techniques. BioMed Research International 2022; 2022:1-13. [PMID: 35686229 PMCID: PMC9173899 DOI: 10.1155/2022/2685898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/13/2022] [Accepted: 05/11/2022] [Indexed: 12/14/2022]
Abstract
Knee osteoarthritis (KOA) is ubiquitous. However, effective pain managements for patients with grades 3 or 4 KOA for whom conservative treatments are unsuccessful, but for whom surgery is not an option, remain lacking. This case series presented two motor-sparing interventional pain treatment modalities for five such patients. Three of the patients with a mean total WOMAC score of 41 underwent thermal radiofrequency (RF) ablation using a modified motor-sparing approach. One-week and four-week post-RF, the total score dropped to 27 (by 34%) and 19 (dropped 53.7%), respectively. Two other similar patients with a mean total WOMAC score 96 underwent chemical neurolysis using a motor-sparing approach with modified landmarks. The WOMAC score dropped to 58.5 (by 39.1%) and 49 (dropped by 49.0%), one-week and four-week postchemical neurolysis, respectively. A narrative review of the currently available approaches is also provided, with the conclusion that neural ablation using the modified landmarks approach may achieve better pain control and preserve the motor functions for patients with severe KOA for whom conservative treatment was unsuccessful and who are not candidates for surgery.
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19
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Perry TA, Segal NA. An open-label, single-arm trial of cryoneurolysis for improvements in pain, Activities of Daily Living and Quality of Life in patients with symptomatic ankle osteoarthritis. Osteoarthritis and Cartilage Open 2022; 4:100272. [DOI: 10.1016/j.ocarto.2022.100272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/13/2022] [Accepted: 05/08/2022] [Indexed: 10/18/2022] Open
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20
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Grigsby E, Radnovich R, Nalamachu S. Efficacy and Safety of Cryoneurolysis for Treatment of Chronic Head Pain Secondary to Occipital Neuralgia: A Pilot Study. Local Reg Anesth 2021; 14:125-132. [PMID: 34557036 PMCID: PMC8455510 DOI: 10.2147/lra.s324527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 09/02/2021] [Indexed: 12/05/2022] Open
Abstract
Purpose Treatment of chronic pain associated with occipital neuralgia (ON) is complex, and no consensus statement or guidelines have been published for ON management. This pilot study evaluated the efficacy and safety of cryoneurolysis for management of ON-associated chronic pain. Patients and Methods The study was a prospective, multicenter, nonrandomized cohort study assessing the degree and duration of clinical effect of cryoneurolysis therapy for reducing pain in patients diagnosed with unilateral or bilateral ON. The primary outcome measure was improvement in pain due to ON from baseline to day 7, measured on an 11-point numeric rating scale for pain. Secondary outcome measures included duration of treatment effects and safety events, including anticipated observations and adverse events. Treatment effect was assessed at days 7, 30, and 56 by asking the patient if they were continuing to experience a treatment effect, with potential responses of “effect,” “no effect,” or “no longer effective.” A posttreatment questionnaire evaluated patient satisfaction. Results Twenty-six patients (9 men, 17 women) with a mean age of 49.1 years enrolled and completed the study. A total of 64% (16/25) of participants reported a clinically important improvement of ≥2 points in numeric rating scale pain scores at day 7; similar results persisted to day 30. Treatment effects were reported by 50% (13/26) of participants at day 30, with a continued effect reported by 35% (9/26) of participants at day 56. Overall, ~70% of participants were satisfied with treatment at 7, 30, and 56 days. No serious anticipated observations, adverse events, or unanticipated adverse device effects were reported. Conclusion Cryoneurolysis provided significant relief from pain associated with ON ≤30 days after treatment and had an acceptable safety profile.
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21
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Urban JA, Dolesh K, Martin E. A Multimodal Pain Management Protocol Including Preoperative Cryoneurolysis for Total Knee Arthroplasty to Reduce Pain, Opioid Consumption, and Length of Stay. Arthroplast Today 2021; 10:87-92. [PMID: 34286056 PMCID: PMC8280475 DOI: 10.1016/j.artd.2021.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 06/01/2021] [Accepted: 06/14/2021] [Indexed: 10/25/2022] Open
Abstract
Background A retrospective analysis was conducted to determine if cryoneurolysis of superficial genicular nerves combined with standard care decreased postoperative opioids and pain after total knee arthroplasty (TKA). Methods Data from patients who underwent TKA at a single center were analyzed. Patients who received standardized cryoneurolysis before TKA were compared with a historical control group including patients who underwent TKA without cryoneurolysis. Both groups received a similar perioperative multimodal pain management protocol. The primary outcome was opioid intake at various time points from hospital stay to 6 weeks after discharge. Additional outcomes included pain, length of stay, and range of motion. Results The analysis included 267 patients (cryoneurolysis group: n = 169; control group: n = 98). During the hospital stay, the cryoneurolysis group had 51% lower daily morphine milligram equivalents (MMEs) (47 vs 97 MMEs; ratio estimate, 0.49 [95% confidence interval (CI), 0.43-0.56]; P < .0001) and 22% lower mean pain score (ratio estimate, 0.78 [95% CI, 0.70-0.88]; P < .0001) vs the control group. The cryoneurolysis group received significantly fewer cumulative MMEs, including discharge prescriptions, than the control group at week 2 (855 vs 1312 MMEs; ratio estimate, 0.65 [95% CI, 0.59-0.73]; P < .0001) and week 6 (894 vs 1406 MMEs; ratio estimate, 0.64 [95% CI, 0.57-0.71]; P < .0001). The cryoneurolysis group had significant 44% reduction in overall length of stay (P < .0001) and greater flexion degree at discharge (P < .0001). Conclusions Addition of preoperative cryoneurolysis to a multimodal pain management protocol reduced opioids and in-hospital pain and optimized outcomes during the 6-week recovery period after TKA.
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22
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Abstract
Introduction: Conventional nerve blocks utilize local anesthetic drugs to provide pain relief for hours or days following surgery or trauma. However, postoperative and trauma pain can last weeks or months. Ultrasound-guided percutaneous cryoneurolysis is an anesthetic modality that offers substantially longer pain relief compared to local anesthetic-based nerve blocks.Areas covered: In this review, we discuss the history, mechanism of action, and use of ultrasound-guided percutaneous cryoneurolysis by anesthesiologists in the setting of acute pain management.Expert opinion: Ultrasound-guided percutaneous cryoneurolysis offers the potential to provide weeks or months of pain relief following surgery or trauma. Compared to continuous local anesthetic-based peripheral nerve blocks, currently the gold standard for providing long duration postoperative analgesia, cryoneurolysis has benefits that include: 1) longer duration measured in weeks or months rather than days; 2) no external reservoir of local anesthetic to be carried by the patient; 3) no risk of infection; and 4) no risk of catheter dislodgement. However, cryoneurolysis can induce a prolonged motor block in addition to the sensory block, decreasing the appropriate indications to those in which potential sensory and motor deficits are acceptable. Additionally, cryoneurolysis of multiple nerves can have a substantial time requirement relative to conventional nerve blocks.
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Affiliation(s)
- John J Finneran Iv
- Outcomes Research Consortium, Cleveland, Ohio, USA.,Department of Anesthesiology, University of California San Diego, San Diego, California, USA
| | - Brian M Ilfeld
- Outcomes Research Consortium, Cleveland, Ohio, USA.,Department of Anesthesiology, University of California San Diego, San Diego, California, USA
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23
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Mihalko WM, Kerkhof AL, Ford MC, Crockarell JR, Harkess JW, Guyton JL. Cryoneurolysis before Total Knee Arthroplasty in Patients With Severe Osteoarthritis for Reduction of Postoperative Pain and Opioid Use in a Single-Center Randomized Controlled Trial. J Arthroplasty 2021; 36:1590-1598. [PMID: 33279353 DOI: 10.1016/j.arth.2020.11.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND We hypothesized that preoperative cryoneurolysis of the superficial genicular nerves in patients with osteoarthritis would decrease postoperative opioid use relative to standard of care (SOC) treatment in patients undergoing total knee arthroplasty (TKA). METHODS Patients received either cryoneurolysis (intent-to-treat [ITT]: n = 62) or SOC (ITT: n = 62). The cryoneurolysis group received cryoneurolysis of the superficial genicular nerves 3-7 days before surgery plus a similar preoperative, intraoperative, and postoperative pain management protocol as the SOC group. The primary end point was cumulative opioid consumption in total daily morphine equivalents from discharge to the 6-week study follow-up assessment. Secondary end points included changes in pain and functional scores. Primary and secondary end points were assessed using ITT and per-protocol (PP) analyses. RESULTS The primary end point was not met in the ITT analysis (4.8 [cryoneurolysis] vs 6.1 [SOC] mg; P = .0841) but was met in the PP analysis (4.2 vs 5.9 mg; P = .0186) after excluding patients with medication deviations or missing follow-up data. Compared with the SOC group, the cryoneurolysis group had improved functional scores and numerical improvements in pain scores across all follow-up assessments, with significant improvements observed in current pain from baseline to the 72-hour and 2-week follow-up assessments and pain in the past week from baseline to the 12-week follow-up assessment. CONCLUSION Findings from the PP analysis suggest that preoperative cryoneurolysis in patients with knee osteoarthritis can reduce opioid consumption and improve functional outcomes after TKA.
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Affiliation(s)
- William M Mihalko
- Department of Orthopedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN
| | - Anita L Kerkhof
- Department of Orthopedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN
| | - Marcus C Ford
- Department of Orthopedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN
| | - John R Crockarell
- Department of Orthopedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN
| | - James W Harkess
- Department of Orthopedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN
| | - James L Guyton
- Department of Orthopedic Surgery & Biomedical Engineering, University of Tennessee Health Science Center, Memphis, TN
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24
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Sahoo RK, Das G, Pathak L, Dutta D, Roy C, Bhatia A. Cryoneurolysis of Innervation to Sacroiliac Joints: Technical Description and Initial Results-A Case Series. A A Pract 2021; 15:e01427. [PMID: 33783380 DOI: 10.1213/xaa.0000000000001427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The sacroiliac joint (SIJ) is a common source of pain in patients with low back pain. Untreated pain from the SIJ can lead to prolonged discomfort and financial burden. Interventional treatments for SIJ-related pain include intraarticular steroid injection and radiofrequency ablation but both procedures provide pain relief for a limited duration. Cryoneurolysis is another neuroablative technique that is effective in various chronic pain conditions. However, there is no clear description of SIJ cryoneurolysis in the published literature. In this report, we present 5 patients with SIJ-related pain and we describe the ultrasound-guided SIJ cryoneurolysis technique and its analgesic efficacy.
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Affiliation(s)
- Rajendra Kumar Sahoo
- From the Department of Anesthesiology and Pain management, Kalinga Institute of Medical Sciences, Bhubaneswar, India
| | - Gautam Das
- Department of Pain Medicine, Daradia Pain Hospital, Kolkata, India
| | - Laxmi Pathak
- Department of Pain Medicine, Daradia Pain Hospital, Kolkata, India
| | - Debjyoti Dutta
- Department of Pain Medicine, Daradia Pain Hospital, Kolkata, India
| | - Chinmoy Roy
- Department of Pain Medicine, Daradia Pain Hospital, Kolkata, India
| | - Anuj Bhatia
- Department of Anesthesia and Pain Management, University Health Network-Toronto Western Hospital, University of Toronto, Toronto, Ontario
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25
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Nygaard NPB, Koch-Jensen C, Vægter HB, Wedderkopp N, Blichfeldt-Eckhardt M, Gram B. Cryoneurolysis for the management of chronic pain in patients with knee osteoarthritis; a double-blinded randomized controlled sham trial. BMC Musculoskelet Disord 2021; 22:228. [PMID: 33637085 PMCID: PMC7913284 DOI: 10.1186/s12891-021-04102-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/19/2021] [Indexed: 01/04/2023] Open
Abstract
Objective Pain is the principal symptom in knee osteoarthritis (OA). Current non-operative treatment options have only moderate effects and often patients experience persistent pain or side-effects. Novel advances in the field of cryoneurolysis applies low temperatures to disrupt nerve signaling at the painful area, providing pain relief. The primary aim of this randomized controlled trial (RCT) is to investigate if cryoneurolysis is superior to sham at decreasing pain intensity 2 weeks after the intervention in patients with knee OA. Secondary aims are to explore effects on pain, quality of life and functional performance over 24 months. Methods This two-arm, parallel-group RCT, approved by the Regional Ethics Committee, will randomly allocate patients (n = 94) to a cryoneurolysis intervention group + standardized education and exercise (CRYO) or a sham group + standardized education and exercise (SHAM) (1:1 ratio). Both groups will be assessed at baseline, 2 weeks post intervention, post education and exercise and at 6, 12 and 24 months after cryoneurolysis. The primary outcome is the NRS knee pain intensity score assessed 2 weeks post the intervention. Secondary outcome measures include functional performance (chair-stand test, 40 m walk, stair test and maximum voluntary contraction of the knee), patient reported outcomes (quality of life (EQ5D), Knee and osteoarthritis outcome scores (KOOS), among others), use of analgesics, and adverse events over 24 months. Impact statement Cryoneurolysis could potentially provide an effective, safe and non-pharmacological therapeutic option to treat pain in OA patients. The potential benefits include increased functional capacity and quality of life as a result of significant pain relief and improved benefits of physical exercise. Trial registration Clinicaltrials.gov, NCT03774121, registered 3 March 2018, http://www.clinicaltrials.gov
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Affiliation(s)
- Niels-Peter Brøchner Nygaard
- Research Unit of Health Science, Hospital of South West Jutland, University Hospital of Southern Denmark, Esbjerg, Denmark. .,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
| | - Carsten Koch-Jensen
- Department of Neurology, Hospital South West Jutland, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Henrik Bjarke Vægter
- Pain Research Group, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Niels Wedderkopp
- Department of Orthopedics, Hospital South West Jutland, University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Morten Blichfeldt-Eckhardt
- Pain Research Group, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Bibi Gram
- Research Unit of Health Science, Hospital of South West Jutland, University Hospital of Southern Denmark, Esbjerg, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Potter BK. From Bench to Bedside: Pain Relief is Cool. Clin Orthop Relat Res 2021; 479:239-241. [PMID: 33428346 PMCID: PMC7899589 DOI: 10.1097/corr.0000000000001614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/25/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Benjamin K Potter
- B. K. Potter, Directorate for Surgical Services, Walter Reed National Military Medical Center & the Uniformed Services University-Walter Reed Department of Surgery, Bethesda, MD, USA
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27
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Filippiadis D, Efthymiou E, Tsochatzis A, Kelekis A, Prologo JD. Percutaneous cryoanalgesia for pain palliation: Current status and future trends. Diagn Interv Imaging 2020; 102:273-278. [PMID: 33281081 DOI: 10.1016/j.diii.2020.11.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022]
Abstract
Cryoanalgesia, otherwise termed cryoneurolysis, refers to application of extreme cold upon peripheral nerves for palliation of pain associated to nerve lesions or biomechanical syndromes of neoplastic and non-neoplastic substrate. Application of cryoanalgesia initiates a cascade of pathophysiologic events interrupting nerve conduction of painful stimuli without irreversible nerve damage. Cryoanalgesia is considered a safe procedure with minimal risk of complications when performed with percutaneous approaches under imaging guidance. In the era of an opioid overdose crisis, cryoanalgesia can be proposed as an alternative aiming at controlling pain and improving life quality. Imaging guidance has substituted open surgical and nerve stimulation approaches in nerve identification, significantly contributing to the minimally invasive character of percutaneous approaches. Ultrasound or computed tomography can serve as low cost, ideal guiding techniques due to their abilities for precise anatomic delineation, high spatial resolution and good tissue contrast. The purpose of this review is to become familiar with the most common imaging guided percutaneous cryoanalgesia indications, to learn about different technical considerations during performance providing the current evidence. Controversies concerning products will be addressed.
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Affiliation(s)
- Dimitrios Filippiadis
- Second Radiology Department, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - E Efthymiou
- Second Radiology Department, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - A Tsochatzis
- Second Radiology Department, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - A Kelekis
- Second Radiology Department, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - J D Prologo
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364, Clifton road NE, 30322 Atlanta, GA, USA
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Abstract
Two regional analgesic modalities currently cleared by the U.S. Food and Drug Administration hold promise to provide postoperative analgesia free of many of the limitations of both opioids and local anesthetic-based techniques. Cryoneurolysis uses exceptionally low temperature to reversibly ablate a peripheral nerve, resulting in temporary analgesia. Where applicable, it offers a unique option given its extended duration of action measured in weeks to months after a single application. Percutaneous peripheral nerve stimulation involves inserting an insulated lead through a needle to lie adjacent to a peripheral nerve. Analgesia is produced by introducing electrical current with an external pulse generator. It is a unique regional analgesic in that it does not induce sensory, motor, or proprioception deficits and is cleared for up to 60 days of use. However, both modalities have limited validation when applied to acute pain, and randomized, controlled trials are required to define both benefits and risks.
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Abstract
The application of advanced imaging guidance and the interventional radiology skill set has expanded the breadth of nerve and nerve plexus targets in the body for potential cryoneurolysis. Advancement of the basic science supporting cryoneurolysis has further solidified proceduralists' confidence and ability to select and manage patients clinically. As these procedures continue to evolve, a structured approach to the wide variety of indications is necessary.
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Affiliation(s)
- J David Prologo
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image Guided Medicine, Emory University School of Medicine, Atlanta, GA.
| | - Faramarz Edalat
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image Guided Medicine, Emory University School of Medicine, Atlanta, GA
| | - Mohamad Moussa
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA
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Kvarstein G, Högström H, Allen SM, Rosland JH. Cryoneurolysis for cervicogenic headache - a double blinded randomized controlled study. Scand J Pain 2020; 20:39-50. [PMID: 31675351 DOI: 10.1515/sjpain-2019-0086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 07/11/2019] [Indexed: 01/15/2023]
Abstract
Background and aims Cervicogenic headache (CEH) is a debilitating condition and analgesics have limited effect. Percutaneous cryoneurolysis is thus still in use although the clinical evidence is lacking. We present a randomized, controlled study to assess the clinical efficacy of cryoneurolysis compared with a corticosteroid combined with a local anaesthetic. Methods In a university-based outpatient pain clinic we performed a randomized, double blinded, comparative study with an 18-week follow-up. After positive diagnostic test blocks 52 eligible patients were randomly allocated in a ratio of 3:2, 31 participants to occipital cryoneurolysis and 21 participants to injections of 1 mL methylprednisolone 40 mg/mL (Depo-Medrol®) combined with 1 mL bupivacaine 5 mg/mL. Results We observed a significant pain reduction of more than 50% in both treatment groups, slightly improved neck function and reduced number of opioid consumers. After 6-7-weeks, however, pain intensity increased gradually, but did not reach baseline within 18 weeks. Although cryoneurolysis provided a more prolonged effect, the group differences did not reach statistical significance. Health related quality of life and psychological distress improved minimally. A large number reported minor and transient side effects, but we found no significant group differences. After 18 weeks, 29% rated the headache as much improved, and 12 (24%) somewhat improved, but a large proportion (78%) reported need for further intervention/treatment. Conclusions Cryoneurolysis provided substantial, but temporary pain relief, and the effect was not significantly different from injections of a corticosteroid combined with a local anaesthetic. Participants were selected by a single test block, and the neurolytic procedure was guided by anatomical landmarks and nerve stimulation. A stricter patient selection and an ultrasound-guided technique might have improved the results. Cryoneurolysis provides temporary pain relief not significantly superior to corticosteroid injection, and the results question the value of occipital cryoneurolysis for a chronic pain condition like CEH. Implications Occipital cryoneurolysis may be considered when non-invasive treatments appear insufficient, but only for patients who have responded substantially to test blocks. A risk of local scar and neuroma formation by repeated cryoneurolysis, leading to neuropathic pain has been discussed by other researchers.
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Affiliation(s)
- Gunnvald Kvarstein
- Department of Pain Management and Research, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.,Department of Clinical Medicine, UIT, The Arctic University of Norway, Tromsø, Norway
| | - Henrik Högström
- Department of Pain Management and Research, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | | | - Jan Henrik Rosland
- Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Behbahani K, Chary A, Patel S, Mitchell JW, Fleishon H, Prologo JD. Percutaneous CT-Guided Cryoablation of the Celiac Plexus: A Retrospective Cohort Comparison with Ethanol. J Vasc Interv Radiol 2020; 31:1216-1220. [DOI: 10.1016/j.jvir.2020.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 12/11/2022] Open
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Prologo JD, Manyapu S, Bercu ZL, Mittal A, Mitchell JW. Percutaneous CT-Guided Cryoablation of the Bilateral Pudendal Nerves for Palliation of Intractable Pain Related to Pelvic Neoplasms. Am J Hosp Palliat Care 2020; 37:619-623. [DOI: 10.1177/1049909119892003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objectives:The purpose of this report is to describe the effect of computed tomography–guided bilateral pudendal nerve cryoablations on pain and time to discharge in the setting of acute hospitalizations secondary to refractory pelvic pain from cancer.Methods:Investigators queried the medical record for patients who underwent pudendal nerve cryoablation using the Category III Current Procedural Technology code assignment 0442T or Category I code 64640 for cases prior to 2015. The resulting list was reviewed, and procedures performed on inpatients for intractable pelvic pain related to neoplasm were selected. The final cohort was then analyzed with regard to patient demographics, procedure details, technical success, safety, pain scores, and time to discharge.Results:Ten patients underwent cryoablation by 3 operators for palliation of painful pelvic neoplasms between June 2014 and January 2019. All probes were satisfactorily positioned and freeze cycles undertaken without difficulty. There were no procedure-related complications or adverse events. The mean difference in pre- and posttreatment worst pain scores was significant (n = 5.20, P = .003). The mean time to discharge following the procedure was 2.3 days.Conclusion:Computed tomography–guided percutaneous cryoablation of the bilateral pudendal nerves may represent a viable option in the setting of acute hospitalization secondary to intractable pain in patients with pelvic neoplasms.
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Affiliation(s)
- John David Prologo
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Sivasai Manyapu
- Department of Interventional Radiology, Emory Johns Creek Hospital, GA, USA
| | - Zachary L. Bercu
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Jason W. Mitchell
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
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McLean BC, Nguyen CD, Newman DP. Cryoablation of the Infrapatellar Branch of the Saphenous Nerve Identified by Non-Invasive Peripheral Nerve Stimulator for the Treatment of Non-Surgical Anterior Knee Pain: A Case Series and Review of the Literature. Cureus 2020; 12:e8747. [PMID: 32714685 PMCID: PMC7377036 DOI: 10.7759/cureus.8747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Chronic, non-surgical, non-specific anterior knee pain is a common source of functionally limiting chronic ailment, especially in a young athletic and active-duty military population. The infrapatellar branch of the saphenous is becoming a common therapeutic target for the diagnosis and treatment of anterior knee pain. It is a nerve commonly injured during knee surgeries and trauma, resulting in neuroma formation and chronic neuropathic pain states, and it can also transmit nociceptive input from patients with non-surgical anterior knee pain of multiple etiologies. Several methods have been employed to treat this condition. After the diagnosis of infrapatellar saphenous neuralgia, the nerve is safely ablated using radiofrequency ablation, neurolytic solutions, and, most recently, cryoablation using the handheld iovera® cryoablation system (Myoscience, Inc. Fremont, CA). Cryoablation is an attractive technique because it is minimally invasive, not permanent, and well tolerated by the patient with only local anesthesia. We have previously described a technique using a non-invasive peripheral nerve stimulator to identify and treat the exact location of the nerve more precisely, thereby optimizing treatment success and procedural simplicity. This case series illustrates our initial use and success with this technique. Further follow-up and randomized sham-controlled trials are also planned.
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Affiliation(s)
- Brian C McLean
- Anesthesiology, Interdisciplinary Pain Management Center, Tripler Army Medical Center, Honolulu, USA
| | - Conner D Nguyen
- Pain Management, Interdisciplinary Pain Management Center, Tripler Army Medical Center, Honolulu, USA
| | - David P Newman
- Pain Management-Physiotherapy, Interdisciplinary Pain Management Center, Tripler Army Medical Center, Honolulu, USA
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Fusco R, Siracusa R, Peritore AF, Gugliandolo E, Genovese T, D’Amico R, Cordaro M, Crupi R, Mandalari G, Impellizzeri D, Cuzzocrea S, Di Paola R. The Role of Cashew ( Anacardium occidentale L.) Nuts on an Experimental Model of Painful Degenerative Joint Disease. Antioxidants (Basel) 2020; 9:antiox9060511. [PMID: 32532064 PMCID: PMC7346149 DOI: 10.3390/antiox9060511] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/08/2020] [Accepted: 06/08/2020] [Indexed: 01/05/2023] Open
Abstract
Osteoarthritis is a progressive joint disease characterized by the activation of different molecular mediators, including proinflammatory cytokines, reactive oxygen species, metalloproteinases and nociceptive mediators. Anacardium occidentale L. is a medicinal plant with anti-oxidative and anti-inflammatory properties. In this study we evaluate the effects of cashew nuts (from Anacardium occidentale L.) oral administration on an experimental model of painful degenerative joint disease. Monosodium iodoacetate (MIA) was intraarticularly injected, and cashew nuts were orally administered three times per week for 21 days, starting the third day after MIA injection. Nociception was evaluated by a Von Frey filament test, and motor function by walking track analysis at 3, 7, 14 and 21 days after osteoarthritis. Histological and biochemical alteration were examined at the end of the experiment. Cashew nuts administration reduced pain-like behavior and showed antioxidant activities, restoring biochemical serum parameters: glutathione (GSH), catalase (CAT) levels, glutathione peroxidase (GPx) activity and lipid peroxidation. Moreover, cashew nuts ameliorated radiographic and histological alteration, resulting in decreased cartilage degradation, pro-inflammatory cytokines and metalloproteinases levels and mast cells recruitment. Our results demonstrated that the oral assumption of cashew nuts counteracts the inflammatory and oxidative process involved in osteoarthritis.
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Affiliation(s)
- Roberta Fusco
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, 98166 Messina, Italy; (R.F.); (R.S.); (A.F.P.); (E.G.); (T.G.); (R.D.); (G.M.); (R.D.P.)
| | - Rosalba Siracusa
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, 98166 Messina, Italy; (R.F.); (R.S.); (A.F.P.); (E.G.); (T.G.); (R.D.); (G.M.); (R.D.P.)
| | - Alesso Filippo Peritore
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, 98166 Messina, Italy; (R.F.); (R.S.); (A.F.P.); (E.G.); (T.G.); (R.D.); (G.M.); (R.D.P.)
| | - Enrico Gugliandolo
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, 98166 Messina, Italy; (R.F.); (R.S.); (A.F.P.); (E.G.); (T.G.); (R.D.); (G.M.); (R.D.P.)
| | - Tiziana Genovese
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, 98166 Messina, Italy; (R.F.); (R.S.); (A.F.P.); (E.G.); (T.G.); (R.D.); (G.M.); (R.D.P.)
| | - Ramona D’Amico
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, 98166 Messina, Italy; (R.F.); (R.S.); (A.F.P.); (E.G.); (T.G.); (R.D.); (G.M.); (R.D.P.)
| | - Marika Cordaro
- Department of Biomedical, Dental and Morphological and Functional Imaging University of Messina, Via Consolare Valeria, 98125 Messina, Italy;
| | - Rosalia Crupi
- Department of Veterinary Sciences, University of Messina, 98168 Messina, Italy;
| | - Giuseppina Mandalari
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, 98166 Messina, Italy; (R.F.); (R.S.); (A.F.P.); (E.G.); (T.G.); (R.D.); (G.M.); (R.D.P.)
| | - Daniela Impellizzeri
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, 98166 Messina, Italy; (R.F.); (R.S.); (A.F.P.); (E.G.); (T.G.); (R.D.); (G.M.); (R.D.P.)
- Correspondence: (D.I.); (S.C.); Tel.: +39-090-676-5208 (D.I. & S.C.)
| | - Salvatore Cuzzocrea
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, 98166 Messina, Italy; (R.F.); (R.S.); (A.F.P.); (E.G.); (T.G.); (R.D.); (G.M.); (R.D.P.)
- Department of Pharmacological and Physiological Science, Saint Louis University School of Medicine, Saint Louis, MO 63104, USA
- Correspondence: (D.I.); (S.C.); Tel.: +39-090-676-5208 (D.I. & S.C.)
| | - Rosanna Di Paola
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, 98166 Messina, Italy; (R.F.); (R.S.); (A.F.P.); (E.G.); (T.G.); (R.D.); (G.M.); (R.D.P.)
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Filippiadis D, Bolotis D, Mazioti A, Tsitskari M, Charalampopoulos G, Vrachliotis T, Kelekis N, Kelekis A. Percutaneous imaging-guided techniques for the treatment of benign neuropathic pain. Diagn Interv Imaging 2020; 102:11-18. [PMID: 32439315 DOI: 10.1016/j.diii.2020.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/22/2020] [Accepted: 05/02/2020] [Indexed: 11/17/2022]
Abstract
To date, conservative management including physical and/or systemic pharmacologic therapy is considered as the first line approach for the management of neuropathic pain syndromes. In the era of an opioid overdose crisis with an increased concern upon the risks and harms arising from the misuse of medicines for pain management, percutaneous minimally invasive techniques such as nerve infiltrations as well as neurolysis or neuromodulation techniques can be proposed to control pain and improve life quality. Computed tomography can serve as an ideal guiding technique due to its specific characteristics including precise anatomic delineation, high spatial resolution and good tissue contrast. The purpose of this review is to make the reader familiar with the most common indications for minimally invasive imaging-guided techniques in patients with neuralgia and provide current evidence regarding technical considerations.
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Affiliation(s)
- D Filippiadis
- 2nd Department of Radiology, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, 1 Rimini street, 12462 Haidari, Athens, Greece.
| | - D Bolotis
- Department of Radiology, Karolinska University Hospital, 14186 Stockholm, Sweden
| | - A Mazioti
- 2nd Department of Radiology, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, 1 Rimini street, 12462 Haidari, Athens, Greece
| | - M Tsitskari
- Department of Radiology, Apollonio Private Hospital, 20 Lefkotheou street, 2054 Strovolos, Nicosia, Cyprus
| | - G Charalampopoulos
- 2nd Department of Radiology, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, 1 Rimini street, 12462 Haidari, Athens, Greece
| | - T Vrachliotis
- Department of Radiology, Henry Dunant Hospital Center, 107 Mesogion Avenue 11525 Athens, Greece
| | - N Kelekis
- 2nd Department of Radiology, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, 1 Rimini street, 12462 Haidari, Athens, Greece
| | - A Kelekis
- 2nd Department of Radiology, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, 1 Rimini street, 12462 Haidari, Athens, Greece
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Billesberger LM, Fisher KM, Qadri YJ, Boortz-Marx RL. Procedural Treatments for Knee Osteoarthritis: A Review of Current Injectable Therapies. Pain Res Manag 2020; 2020:3873098. [PMID: 32148599 DOI: 10.1155/2020/3873098] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 12/18/2019] [Accepted: 01/22/2020] [Indexed: 12/13/2022]
Abstract
Knee osteoarthritis is a common painful degenerative condition affecting the aging Canadian population. In addition to pain and disability, osteoarthritis is associated with depression, comorbid conditions such as diabetes, and increased caregiver burden. It is predicted to cost the Canadian healthcare system $7.6 billion dollars by 2031. Despite its high cost and prevalence, controversy persists in the medical community regarding optimal therapies to treat knee osteoarthritis. A variety of medications like nonsteroidal anti-inflammatories and opioids can cause severe side effects with limited benefits. Total knee arthroplasty, although a definitive management, comes with risk such as postoperative infections, revisions, and chronic pain. Newer injectable therapies are gaining attention as alternatives to medications because of a safer side effect profile and are much less invasive than a joint replacement. Platelet-rich plasma is beginning to replace the more common injectable therapies of intra-articular corticosteroids and hyaluronic acid, but larger trials are needed to confirm this effect. Small studies have examined prolotherapy and stem cell therapy and demonstrate some benefits. Trials involving genicular nerve block procedures have been successful. As treatments evolve, injectable therapies may offer a safe and effective pathway for patients suffering from knee osteoarthritis.
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Abstract
Cryoneurolysis is the deliberate application of cold temperatures to nerves for therapeutic purposes. The idea of treating pain with this technique is thousands of years old and has evolved over time through the application of surgical techniques, nerve stimulation and/or landmark guidance, and through device development. Recent integration of the interventional radiology skill set to this space has unlocked a myriad of opportunities-primarily through a unique ability to percutaneously access deep structures in the body with accuracy and precision, and the capacity to monitor ablation zones. Understanding of the specific neurohistological process that follows targeted cryoneurolysis leads to new options for treating patients in pain without drugs and opens doors for the potential modification of a wide array of disease states.
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Affiliation(s)
- Ross W. Bittman
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Keywan Behbahani
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Felix Gonzalez
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - J. David Prologo
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
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Cahani D, Chacko J, Hahn B. Myonecrosis: A Rare Complication of Cryoneurolysis. J Emerg Med 2019; 57:e73-6. [DOI: 10.1016/j.jemermed.2019.06.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/29/2019] [Accepted: 06/15/2019] [Indexed: 11/24/2022]
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Fonkoue L, Behets CW, Steyaert A, Kouassi JEK, Detrembleur C, De Waroux BLP, Cornu O. Accuracy of fluoroscopic-guided genicular nerve blockade: a need for revisiting anatomical landmarks. Reg Anesth Pain Med 2019; 44:rapm-2019-100451. [PMID: 31451628 DOI: 10.1136/rapm-2019-100451] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 07/23/2019] [Accepted: 08/12/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVES Genicular nerve blockade (GNB) and radiofrequency ablation (RFA) have recently emerged as treatment options for patients with chronic knee pain. However, an increasing number of anatomical studies and systematic reviews concluded that the anatomical basis for needle placement was unclear, incomplete and somewhat inaccurate. This study was designed to assess the accuracy of updated anatomical landmarks for fluoroscopy-guided blockade of the consistent genicular nerves in a cadaveric model. METHODS Based on a comprehensive review of recent anatomical studies and prior dissection of 21 fresh cadaver knees, we defined bony landmarks with high likelihood of successful ablation of the five consistent genicular nerves (GN). We tested the accuracy of GNBs using the above-stated anatomical landmarks in 10 intact fresh cadaveric knees. Needle placement was guided by fluoroscopy and 0.5 mL of 0.1% methylene blue was injected at the site of each nerve. The knees were subsequently dissected to assess the accuracy of the injections. If the nerve was dyed with blue ink, the placement was considered accurate. RESULTS The accuracy of our injections was 100% for the superior medial genicular nerve, inferior medial GN, infrapatellar branch of saphenous nerve and recurrent fibular nerve. The superior lateral GN was dyed in 90% of specimens. CONCLUSION This study provides physicians with precise anatomical landmarks for the five consistent GN for fluoroscopic-guided GNB. Our revised technique, which targets more nerves with increased accuracy, could potentially lead to improved therapeutic benefits on chronic knee pain.
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Affiliation(s)
- Loïc Fonkoue
- Department of Morphology, Experimental and Clinical Research Institute, Universite catholique de Louvain, Brussels, Belgium
- Neuro-Musculo-Skeletal Department (NMSK), Experimental and Clinical Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Catherine Wydemans Behets
- Department of Morphology, Experimental and Clinical Research Institute, Universite catholique de Louvain, Brussels, Belgium
| | - Arnaud Steyaert
- Department of Anesthesia and Pain Medicine, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
- Institute of Neuroscience (IONS), Universite catholique de Louvain, Brussels, Belgium
| | - Jean-Eric Kouame Kouassi
- Neuro-Musculo-Skeletal Department (NMSK), Experimental and Clinical Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Christine Detrembleur
- Neuro-Musculo-Skeletal Department (NMSK), Experimental and Clinical Research Institute, Université catholique de Louvain, Brussels, Belgium
| | | | - Olivier Cornu
- Neuro-Musculo-Skeletal Department (NMSK), Experimental and Clinical Research Institute, Université catholique de Louvain, Brussels, Belgium
- Department of Orthopedics and Trauma, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
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Johnson C, Sisante JF, Alm J, Smith M, Segal NA. Cryoneurolysis for the Treatment of Lateral Femoral Cutaneous Nerve Pain: A Case Report. PM R 2019; 12:423-424. [PMID: 31397972 DOI: 10.1002/pmrj.12234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 07/19/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Ciara Johnson
- Department of Rehabilitation Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Jason-Flor Sisante
- Department of Rehabilitation Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - John Alm
- Department of Rehabilitation Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - McCasey Smith
- Department of Rehabilitation Medicine, The University of Kansas Medical Center, Kansas City, KS
| | - Neil A Segal
- Department of Rehabilitation Medicine, The University of Kansas Medical Center, Kansas City, KS
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Prologo JD, Lin E, Horesh Bergquist S, Knight J, Matta H, Brummer M, Singh A, Patel Y, Corn D. Percutaneous CT-Guided Cryovagotomy in Patients with Class I or Class II Obesity: A Pilot Trial. Obesity (Silver Spring) 2019; 27:1255-1265. [PMID: 31339003 DOI: 10.1002/oby.22523] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 04/13/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This study evaluated the safety of percutaneous CT-guided cryoablation of the vagus nerve (percutaneous cryovagotomy) in participants with class I or class II obesity. METHODS The study was an open-label, single-group, prospective pilot investigation designed around safety-related stopping criteria. Twenty participants with 30 > BMI > 37 underwent percutaneous cryovagotomy with follow-up visits at day 7, 45, 90, and 180. Data related to adverse events, technical success, weight loss, quality of life, dietary intake, global impressions of hunger change, activity, and body composition were analyzed. RESULTS The procedural technical success rate was 100%. There were no adverse events in 19 participants who completed the trial. Ninety-five percent of patients reported decreased appetite following the procedure, and reductions in mean absolute weight and BMI were observed at all time points. The mean quality of life and activity scores improved from baseline to 6 months post procedure, and mean caloric intake and overall body fat decreased over the same period. CONCLUSIONS Percutaneous CT-guided cryovagotomy is feasible and was tolerated without complications or adverse events in this cohort. Quantitative preliminary data from this pilot investigation inform the design of a larger prospective randomized clinical trial.
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Affiliation(s)
- J David Prologo
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Edward Lin
- Division of General and Gastrointestinal Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Jackie Knight
- Department of Radiology and Imaging Sciences, Emory Healthcare, Atlanta, Georgia, USA
| | - Hazem Matta
- Radiology Regional Center, Fort Myers, Florida, USA
| | - Marjin Brummer
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arvinpal Singh
- Division of Bariatric Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Yogi Patel
- Department of Bioengineering and Neuroengineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - David Corn
- Department of Periodontics and Endodontics, The State University of New York, Buffalo, New York, USA
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Fonkoué L, Behets C, Kouassi JÉK, Coyette M, Detrembleur C, Thienpont E, Cornu O. Distribution of sensory nerves supplying the knee joint capsule and implications for genicular blockade and radiofrequency ablation: an anatomical study. Surg Radiol Anat 2019; 41:1461-1471. [DOI: 10.1007/s00276-019-02291-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 07/15/2019] [Indexed: 11/24/2022]
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Gabriel RA, Ilfeld BM. Peripheral nerve blocks for postoperative analgesia: From traditional unencapsulated local anesthetic to liposomes, cryoneurolysis and peripheral nerve stimulation. Best Pract Res Clin Anaesthesiol 2019; 33:293-302. [PMID: 31785715 DOI: 10.1016/j.bpa.2019.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/19/2019] [Accepted: 06/24/2019] [Indexed: 02/01/2023]
Abstract
Peripheral nerve blocks (PNBs) using local anesthetics either via single injection or continuous perineural catheter have been the mainstay for regional anesthesia and are a vital component of postoperative multimodal opioid-sparing pain management. There are some limitations to PNBs, however, mainly its limited duration of action, but also risk of catheter-associated infection and dislodgements. Furthermore, local anesthetic-based blocks can induce sensory deficits and motor weakness, possibly increasing the risk of falling and/or decreasing the ability to participate in postoperative rehabilitation. In this review, we first discuss various local anesthetic-based PNB techniques for major surgery and then review newer modalities, including liposome bupivacaine, cryoanalgesia, and peripheral nerve stimulation; all of which may offer advantages over single and continuous local anesthetic-based PNBs.
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Affiliation(s)
- Rodney A Gabriel
- Department of Anesthesiology, University of California, 200 West Arbor Dr, MC 8770, San Diego, CA 92103, USA.
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California, 200 West Arbor Dr, MC 8770, San Diego, CA 92103, USA.
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Lee KM, Wason J, Stallard N. To add or not to add a new treatment arm to a multiarm study: A decision-theoretic framework. Stat Med 2019; 38:3305-3321. [PMID: 31115078 PMCID: PMC6619445 DOI: 10.1002/sim.8194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/05/2019] [Accepted: 04/17/2019] [Indexed: 12/16/2022]
Abstract
Multiarm clinical trials, which compare several experimental treatments against control, are frequently recommended due to their efficiency gain. In practise, all potential treatments may not be ready to be tested in a phase II/III trial at the same time. It has become appealing to allow new treatment arms to be added into on‐going clinical trials using a “platform” trial approach. To the best of our knowledge, many aspects of when to add arms to an existing trial have not been explored in the literature. Most works on adding arm(s) assume that a new arm is opened whenever a new treatment becomes available. This strategy may prolong the overall duration of a study or cause reduction in marginal power for each hypothesis if the adaptation is not well accommodated. Within a two‐stage trial setting, we propose a decision‐theoretic framework to investigate when to add or not to add a new treatment arm based on the observed stage one treatment responses. To account for different prospect of multiarm studies, we define utility in two different ways; one for a trial that aims to maximise the number of rejected hypotheses; the other for a trial that would declare a success when at least one hypothesis is rejected from the study. Our framework shows that it is not always optimal to add a new treatment arm to an existing trial. We illustrate a case study by considering a completed trial on knee osteoarthritis.
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Affiliation(s)
- Kim May Lee
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - James Wason
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK.,Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Nigel Stallard
- WMS - Statistics and Epidemiology, University of Warwick, Coventry, UK
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Abstract
The infrapatellar branch of the saphenous is becoming a common therapeutic target for the diagnosis and treatment of anterior knee pain. It is a nerve commonly injured during knee surgeries, resulting in neuroma formation and chronic neuropathic pain states, and can also transmit nociceptive input in patients with non-surgical anterior knee pain of multiple etiologies. After diagnosing infrapatellar saphenous neuralgia, the nerve is safely ablated using radiofrequency ablation, neurolytic solutions, and, most recently, cryoablation using the handheld iovera® cryoablation system (Myoscience, Inc. Fremont, CA). The iovera® technology benefits from procedural simplicity in that the nerve doesn't specifically need to be identified and the described technique involves treating a long line over which the infrapatellar branch of the saphenous nerve is expected to course. However, there is significant variability in the course of the nerve and much of the area treated misses the actual location of the nerve, wasting time and potentially increasing patient discomfort and risk of complications. To address these limitations we endeavored to identify a way to more precisely treat the specific location of the nerve thereby optimizing treatment success and procedural simplicity. Using a MiniStim® peripheral nerve stimulator (Halyard Health, Inc., Georgia, US) to scan for the nerve along the previously described treatment line, we have been able to identify a more precise location of the nerve and optimize the treatment target area. This non-invasive identification technique has, to our knowledge, not been previously described.
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Affiliation(s)
- Brian McLean
- Pain Department and Interdisciplinary Pain Management Center, Tripler Army Medical Center, Kaneohe, USA
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McCumber TL, Cassidy KM, Latacha KS, Simet SM, Vilburn MJ, Urban ND, Vogt CM, Urban JA. Accuracy of ultrasound-guided localization of the peripatellar plexus for knee pain management. J Clin Anesth 2019; 58:1-2. [PMID: 31004974 DOI: 10.1016/j.jclinane.2019.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/18/2019] [Accepted: 04/02/2019] [Indexed: 11/16/2022]
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Filippiadis D, Charalampopoulos G, Mazioti A, Alexopoulou E, Vrachliotis T, Brountzos E, Kelekis N, Kelekis A. Interventional radiology techniques for pain reduction and mobility improvement in patients with knee osteoarthritis. Diagn Interv Imaging 2019; 100:391-400. [PMID: 30935863 DOI: 10.1016/j.diii.2019.02.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/10/2019] [Accepted: 02/17/2019] [Indexed: 02/06/2023]
Abstract
Osteoarthritis of the knee is the most common cause of chronic knee pain being more prevalent in middle-aged and elderly patients. Symptomatic patients complain of pain and mobility impairment. Therapeutic armamentarium includes physical therapy, oral pharmacologic therapy, intra-articular injections, nerve ablation or modulation, trans-catheter arterial embolization, minimally invasive arthroscopic treatment and partial or total knee arthroplasty. Interventional radiology therapies for knee osteoarthritis include intra-articular injections, neurotomy and neuromodulation techniques as well as transcatheter intra-arterial therapies. These therapies aim to control pain and inflammation, improve mobility and function whilst the novel cell-based therapies have the potential for bone and cartilage regenerative repair facilitating the delay to surgery. The purpose of this review is to illustrate the technical aspects, the indications and the methodology of local therapies for knee osteoarthritis performed by interventional radiologists and provide current evidence.
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Affiliation(s)
- D Filippiadis
- 2(nd) Department of Radiology, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, Athens, Greece.
| | - G Charalampopoulos
- 2(nd) Department of Radiology, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - A Mazioti
- 2(nd) Department of Radiology, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - E Alexopoulou
- 2(nd) Department of Radiology, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - T Vrachliotis
- 2(nd) Department of Radiology, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - E Brountzos
- 2(nd) Department of Radiology, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - N Kelekis
- 2(nd) Department of Radiology, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - A Kelekis
- 2(nd) Department of Radiology, University General Hospital "ATTIKON", Medical School, National and Kapodistrian University of Athens, Athens, Greece
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Abstract
Triamcinolone acetonide extended-release (ER) 32 mg (Zilretta®) is approved in the USA for the management of osteoarthritis (OA) pain of the knee and is administered as a single, 5 mL intra-articular (IA) injection. Although the therapeutic effects from IA corticosteroids are typically short-lived, triamcinolone acetonide ER is formulated in poly (lactic-co-glycolic acid) (PLGA) microspheres that slowly release triamcinolone acetonide in the synovium, enabling their prolonged presence in the joint. This reduces systemic exposure and lessens corticosteroid-related systemic adverse reactions, such as blood glucose elevations. In a 24-week, randomized, phase III clinical trial, triamcinolone acetonide ER 32 mg significantly improved mean average daily pain intensity in patients with knee OA relative to placebo, and pain, stiffness and physical function (according to WOMAC criteria) relative to placebo and triamcinolone acetonide crystalline suspension (CS). Triamcinolone acetonide ER was generally well tolerated, with a tolerability profile similar to that of triamcinolone acetonide CS and placebo. Findings from a single-arm phase IIIb study indicated that a repeat administration of triamcinolone acetonide ER may be similarly efficacious to an initial injection without having deleterious effects on cartilage or other aspects of joint structure. Thus, triamcinolone acetonide ER expands the treatment options available for the management of OA pain of the knee.
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Affiliation(s)
- Julia Paik
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
| | - Sean T Duggan
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand
| | - Susan J Keam
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand
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Huang D, Liu YQ, Liang LS, Lin XW, Song T, Zhuang ZG, Wang SL, Bao HG, Wang L, Zhang XW, Cheng ZG, Duan BL, Qiu WD, Xiong YC, Liu JF. The Diagnosis and Therapy of Degenerative Knee Joint Disease: Expert Consensus from the Chinese Pain Medicine Panel. Pain Res Manag 2018; 2018:2010129. [PMID: 30651899 DOI: 10.1155/2018/2010129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/19/2018] [Indexed: 01/07/2023]
Abstract
At present, there are many constantly updated guidelines and consensuses on the diagnosis and treatment of osteoarthritis both at home and abroad. The recommendations established using methods of evidence-based medicine has experienced strict research on controlling bias and promoting reproduction rate. As a result, the previous evidence was reevaluated, and a lot of changes were provoked in the diagnosis and treatment concept of osteoarthritis. However, several methods not recommended by foreign guidelines are still in use in the current clinical practice in China. On the one hand, Chinese experts have not reached extensive consensus on whether it is necessary to make changes according to foreign guidelines. On the other hand, almost all the current relevant guidelines are on osteoarthritis, but the lesions around knee joints which, as a whole, bear the largest weight in human body, cannot be ignored. For this purpose, Chinese Association for the Study of Pain (CASP) organized some leading experts to formulate this Chinese Pain Specialist Consensus on the diagnosis and treatment of degenerative knee osteoarthritis (DKOA) in combination with the guidelines in foreign countries and the expert experience of clinical practice in China. The consensus, which includes the definition, pathophysiology, epidemiology, clinical manifestation, diagnostic criteria, and treatments of DKOA, is intended to be used by first-line doctors, including pain physicians to manage patients with DKOA.
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Abstract
Maximizing analgesia is critical following joint arthroplasty because postoperative pain is a major barrier to adequate physical therapy. Continuous peripheral nerve blocks have been the mainstay for acute pain management in this population; however, this and similar techniques are limited by their duration of action. Cryoneurolysis and peripheral nerve stimulation are two methodologies used for decades to treat chronic pain. With the advent of portable ultrasound devices and percutaneous administration equipment, both procedures may now be suitable for treatment of acute pain. This article reviews these two modalities and their application to joint arthroplasty.
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Affiliation(s)
- Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, 200 West Arbor Drive, MC 8770, San Diego, CA 92103, USA
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California, San Diego, 200 West Arbor Drive, MC 8770, San Diego, CA 92103, USA.
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