Factors Associated With Same Day Discharge Post-Spinal Cord Stimulator Placement

BACKGROUND

Spinal cord stimulator (SCS) surgeries, whether performed using the open or percutaneous approach, are becoming increasingly common for a range of neuropathic pain conditions, including post-laminectomy syndrome and complex regional pain syndrome. However, there is limited knowledge regarding the factors linked to same-day discharge patterns following SCS.

OBJECTIVE

The purpose of this study was to identify factors associated with same-day discharge after SCS placement. The primary outcome was same-day discharge.

STUDY DESIGN

Retrospective, cohort study using a nationwide database.

METHODS

Inclusion criteria included patients who underwent percutaneous or open SCS from January 1, 2014 through December 31, 2021. Exclusion criteria included patients with missing data (n = 178) and those with SCS implants for unlisted indications (n = 1,817). A multivariable analysis was conducted on the outcome data and co-variates associated with same-day discharge after SCS.

RESULTS

After applying inclusion and exclusion criteria, a total of 18,058 patients remained in the final data set, including 7,339 patients who underwent percutaneous SCS and 10,719 patients who underwent open SCS procedures. After analysis, factors associated with increased rates of same-day discharge after SCS included men (odds ratio [OR] 1.16; 95% CI, 1.09 -1.24;  P < 0.001), patients on Medicaid (OR 1.64; 95% CI, 0.1.34 - 2.01; P < 0.001), and hospitals in the US Midwest (OR 1.66; 95% CI, 1.45 - 1.90; P < 0.001) and hospitals in the US West (OR 1.32; 95% CI, 1.20 - 1.46; P < 0.001). Factors associated with decreased rates of same-day discharge after SCS included the open approach (OR 0.21; 95% CI, 0.19 - 0.23; P < 0.001), Hispanic ethnicity (OR 0.61; 95% CI, 0.54 - 0.69; P < 0.001) and increased age (OR 0.99; 95% CI, 0.98 - 0.99; P < 0.001).

LIMITATIONS

Since our study is retrospective, the data are subject to various biases, including variable confounding, human error in data entry, and generalizability of the results.

CONCLUSION

These results can be used to help determine hospital bed needs post-SCS surgery. Future research should focus on identifying the specific reasons certain demographic and geographic factors might influence same-day discharge rates. Our study provides important insights into the factors associated with same-day discharge rates post open and percutaneous SCS implant and highlights the need for patient-centered, evidence-based approaches to health care delivery.

Endoscopic Versus Microscopic Microvascular Decompression for Trigeminal Neuralgia: A Prospective Controlled Study

BACKGROUND

Several studies have suggested favorable results with endoscope-assisted microvascular decompression (EA-MVD) for treating patients with trigeminal neuralgia (TN); however, supporting evidence is limited.

OBJECTIVES

This study aimed to compare the efficacy and safety of EA-MVD with microscopic microvascular decompression (M-MVD).

STUDY DESIGN

Prospective controlled study.

SETTING

We performed a prospective controlled clinical study that included 52 patients with TN (36, [69.2%] women; 16, [30.8%] men), from June 2021 through January 2022.

METHODS

Patients were assigned to receive either EA-MVD (n = 23) or M-MVD (n = 29). The primary outcome was pain intensity relief, measured using the Visual Analog Scale (VAS) and the Barrow Neurological Institute grading scale. The secondary outcomes were the detection of multiple offending vessels, endoscopic use, operation time, hospital stay length, and complications. All patients were followed-up for >= 12 months.

RESULTS

At 12 months, both treatment groups showed similar improvements in pain intensity (P = 0.099). The mean VAS score was 3.5 ± 1.6 and 2.9 ± 1.7 in the EA-MVD and M-MVD groups, respectively. Overall, most patients in both groups reached a pain-free status or had nearly pain-free relief (EA-MVD: 21/23, 91.3%; M-MVD: 27/29, 93.1%). The incidence of multiple offending vessels was higher in the EA-MVD group than in the M-MVD group (52.2% vs 17.2%, P = 0.038). The mean operating time in the EA-MVD group (158 ± 27 minutes) was longer and the hospital stay (6 ± 1 days) was shorter than those of the M-MVD group (144 ± 25 minutes and 8 ± 4 days). No mortality or endoscope-related serious adverse events were noted, with the exception of an intracranial infection case in the M-MVD group.

LIMITATIONS

The mean follow-up time was relatively short and a single-center study and a small patient population, which might bring some clinical bias.

CONCLUSIONS

M-MVD and EA-MVD achieved similar analgesic effects for TN; however, EA-MVD allowed observation of more probable offending vessels with good flexible operative visualization.

Nomogram for Predicting the Recurrence Rate in Selective Radiofrequency Thermocoagulation of the Trigeminal Nerve Based on Regression via Least Absolute Shrinkage and Selection Operator

BACKGROUND

Computed tomography-guided percutaneous selective radiofrequency thermocoagulation (RFT) of the trigeminal nerve is a novel, minimally invasive technique for the treatment of trigeminal neuralgia, but the high recurrence rate after surgery might pose a serious problem.

OBJECTIVES

The purpose of this study was to explore the risk factors affecting the recurrence rate after RFT and to predict the recurrence rate and provide evidence for the early prediction.

STUDY DESIGN

A single-center retrospective study.

SETTING

This study was carried out in the Affiliated Hospital of Jiaxing University in China.

METHODS

One hundred thirty-nine patients were included in this study. The cumulative survival rates according to temperature and type of pain were estimated by the Kaplan-Meier analysis. The least absolute shrinkage and selection operator Cox regression model was used to build the nomogram. Time-independent receiver operating characteristic curve analysis confirmed the signature's predictive capacity. A calibration curve was generated to judge the accuracy of absolute risk predictions, and Brier scores were used to quantitatively evaluate the calibration. Decision curve analysis was applied to comprehensively evaluate the clinical effectiveness of the model. A multiparameter nomogram was used to analyze the scores and predict the risk of relapse.

RESULTS

Three predictors were screened by multivariate Cox regression analysis. Pain grade (refit hazard ratio [HR]: 1.6807; 95% confidence interval [CI]: 1.1963-2.3613) and type of pain (HR: 6.2802; 95% CI: 3.3705-11.7021) were considered to be risk factors affecting the recurrence rate after RFT, while temperature (HR: 0.5203; 95% CI: 0.2859-0.9468) was identified as a protective factor. The recurrence rate within 2 years in 85°C group was 51.09%, while that in 95°C group was 29.79%. The nomogram exhibited good discrimination and calibration. Compared with the preoperative period, all of the patients' postoperative Numeric Rating Scale scores (NRS-11)decreased significantly (P < 0.05). The main postoperative complication was numbness, with a gradual decrease in the Barrow Neurological Institute score over time. Autonomic symptoms and decrease of masticatory muscle function were the secondary postoperative complications, and no other adverse events were observed. Overall patient satisfaction at 2 years postoperatively was 7.83 ± 1.93.

LIMITATIONS

This study contains a small sample size from a single center and the conclusion of randomized controlled trials will be more convincing.

CONCLUSIONS

Increasing temperature can effectively reduce the recurrence rate after RF, and the combination of atypical pain and higher NRS-11s could be a risk factor increasing the recurrence rate. The novel nomogram exhibited favorable survival stratification accuracy and shown a great potential for screening high-risk groups and evaluating the risk of recurrence rate.

Dorsal Root Ganglion Stimulation for the Management of Phantom Limb Pain: A Scoping Review

BACKGROUND

Amputees commonly feel an intermittent tingling, piercing, or burning sensation in the region of the missing portion of the amputated limb, a phenomenon known as phantom limb pain. Current treatment modalities include medications, mirror therapy, transcutaneous electrical nerve stimulation, and more recently neuromodulation through spinal cord stimulation and dorsal root ganglion (DRG) stimulation.

OBJECTIVES

The aim of this review is to examine the existing literature to identify and analyze evidence for the use of DRG stimulation as a pain relief modality for phantom limb pain.

STUDY DESIGN

Scoping Review.

METHODS

A literature search was conducted using relevant search terms. PubMed, Web of Science, Cochrane, and CINAHL databases were used, and reference lists of selected articles were searched for additional relevant literature.

RESULTS

Most studies analyzed had low to moderate bias in all categories assessed. There are case reports and case series indicating that DRG stimulation could be an effective treatment method for phantom limb pain. Fifteen of 25 patients across 5 studies achieved satisfactory levels of pain relief and significant improvements were reported by all patients evaluated for quality of life. Patient selection and proper targeting of stimulation are important factors in limiting large variability in results while determining effectiveness of this pain relief modality.

LIMITATIONS

The studies included in this scoping review are limited by the number of cases and by the length of follow-up. Also, there are no randomized control trials or observational studies with large sample sizes that allow for adequate power. Many of these studies do not have a standardized methodology of quantifying pain relief from DRG stimulation.

CONCLUSIONS

The cumulative evidence at present suggests DRG stimulation may be a potentially effective treatment for phantom limb pain, however, a powered prospective randomized controlled trial is needed to assess the long-term benefits of this treatment modality. Given the increasing population of military veterans who are living with limb amputations, finding a modality for adequate long-term pain control is crucial.

Exercise Facilitates the M1-to-M2 Polarization of Microglia by Enhancing Autophagy via the BDNF/AKT/mTOR Pathway in Neuropathic Pain

BACKGROUND

In neuropathic pain following peripheral nerve injury, microglia are rapidly activated and accumulated in the spinal cord. Physical exercise can alleviate neuropathic pain. However, the exact mechanism underlying this analgesic effect is not fully understood.

OBJECTIVES

We aimed to investigate the molecular mechanisms by which exercise alleviates neuropathic pain in relation to brain-derived neurotrophic factor (BDNF), microglia polarization, and autophagy.

STUDY DESIGN

A randomized controlled animal study divided into 2 stages. The first stage comprised 4 groups each with 6 mice, and the second stage comprised 6 groups, 3 with 18 mice and 3 with 12 mice.

SETTING

Department of Anesthesiology, Lanzhou University Second Hospital, Orthopaedics Key Laboratory of Gansu Province, Lanzhou University.

METHODS

Von Frey filaments, Western blotting, immunofluorescence, and transmission electron microscopy analyses were conducted to detect relevant markers.

RESULTS

After peripheral nerve injury, exercise training downregulated BDNF expression and reversed microglial activation, as indicated by the increased expression of the M2 marker CD206 and decreased expression of the M1 marker CD86 in the spinal dorsal horn of mice. Autophagy flux was enhanced after exercise training, as suggested by the increased expression of the autophagy markers LC3-II/LC3-I and Beclin1 and decreased expression of the autophagy adaptor protein p62. Furthermore, autophagy inhibition by 3-methyladenine aggravated M1 polarization and hyperalgesia, whereas autophagy induced by rapamycin promoted M2 polarization and reduced hyperalgesia. Intrathecal injection of BDNF significantly upregulated BDNF expression, inhibited autophagy, triggered M1 polarization of spinal microglia, and aggravated hyperalgesia. Furthermore, BDNF regulated autophagy through the AKT/mTOR pathway, thereby participating in exercise training-mediated polarization of microglia after nerve injury.

LIMITATIONS

The effect of exercise on autophagy and pain cannot be assessed in an in vitro model. The influence of intrathecal injection of BDNF on the metabolic changes in other neuronal cells and the subsequent effects on pain should be investigated. Further studies on how exercise training modulates microglial autophagy to alleviate neuropathic pain are needed.

CONCLUSIONS

Exercise training promoted the recovery of sciatic nerve injury in mice, possibly by regulating microglial polarization through BDNF/AKT/mTOR signaling-mediated autophagy flux. We confirmed the efficacy of exercise training in alleviating neuropathic pain and suggest a new therapeutic target for neuropathic pain.

Comparison of Efficacy and Safety of CT-Guided Radiofrequency Thermocoagulation Through Foramen Rotundum Versus Foramen Ovale for V2 Primary Trigeminal Neuralgia

BACKGROUND

Primary trigeminal neuralgia (TN) is one of the most severe facial pain syndromes. TN affects patients' quality of life and, when severe, can lead to depression and increase social burden.

OBJECTIVES

This retrospective study aimed to compare efficacy and safety of computed tomographic (CT)-guided percutaneous radiofrequency thermocoagulation (RFT) through the foramen rotundum (FR) versus through the foramen ovale (FO) for treatment of maxillary division (V2) TN.

STUDY DESIGN

A prospective study.

SETTING

Shengjing Hospital of China Medical University.

METHODS

Seventy patients with V2 TN were randomly assigned to 2 groups: RFT-FR group (n = 35) and RFT-FO group (n = 35). Visual Analog Scale (VAS), the Medical Outcomes Study 36-Item Short-Form Health Survey, the total efficacy, complications, and recurrence rate were assessed before and after surgery at different time points.

RESULTS

Compared with the preoperative VAS, the postoperative VAS in the RFT-FR and RFT-FO groups both decreased significantly (P < 0.05). There was no significant difference in VAS between the 2 groups (P > 0.05); in both groups quality of life improved to varying degrees after RFT. In the RFT-FO group, the physical component summary (PCS) and mental component summary (MCS) were significantly lower than in the RFT-FR group at 1 week, 2 weeks and 1 month (P < 0.05). After 3 months, the PCS and MCS of the RFT-FO group gradually increased, so the 2 groups no longer differed significantly (P > 0.05). The total incidence of complications in the RFT-FR and RFT-FO groups was 20.0% (7/35) and 62.9% (22/35), respectively, and differed significantly (P < 0.05).

LIMITATIONS

This study cohort size is small, but we will gradually increase the number of patients later. Second, there may be acquiescence bias or response bias. Third, the punctures under the more commonly used C-arm imaging guidance deserve to be evaluated in the future.

CONCLUSIONS

CT-guided RFT through the FR and FO are both an effective, minimally invasive treatments for V2 TN that can relieve pain effectively.