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PhD Jacob Patijn MD,
Nagy Mekhail MD, PhD, FIPP,
Salim Hayek MD, PhD, FIPP,
Arno Lataster MSc,
Maarten van Kleef MD, PhD, FIPP,
Jan Van Zundert MD, PhD, FIPP,
Jacob Patijn,
Nagy Mekhail, Salim Hayek,
Arno Lataster,
Maarten van Kleef,
Jan Van Zundert
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ABSTRACT: Meralgia paresthetica (MP) is a neurological disorder of the nervus cutaneous femoris lateralis (lateral femoral cutaneous nerve) (LFCN) characterized by a localized area of paresthesia and numbness on the anterolateral aspect of the thigh. Medical history and neurological examination are essential in making the diagnosis. However, red flags such as tumor and lumbar disc herniations must be ruled out. While the diagnosis of MP is essentially a clinical diagnosis, sensory nerve conduction velocity studies are a useful additional diagnostic tool.The first choice in management of MP is, besides treating the underlying cause, always a conservative approach. Simple measures such as losing weight and not wearing tight belts and/or trousers can be advised. Pharmacological therapy consists mainly of antineuropathic medication.Anatomical variants of the LFCN occur in a quarter of patients and may be the reason for negative response to diagnostic blocks. For interventional treatment of MP, such as local injection with anesthetics and corticosteroids or pulsed radiofrequency treatment of the LFCN, the evidence is limited. In particular, pulsed radiofrequency treatment of the LFCN should only take place in a study context.
Pain Practice 04/2011; 11(3):302 - 308. · 2.21 Impact Factor
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ABSTRACT: Meralgia paresthetica (MP) is a neurological disorder of the nervus cutaneous femoris lateralis (lateral femoral cutaneous nerve) (LFCN) characterized by a localized area of paresthesia and numbness on the anterolateral aspect of the thigh. Medical history and neurological examination are essential in making the diagnosis. However, red flags such as tumor and lumbar disc herniations must be ruled out. While the diagnosis of MP is essentially a clinical diagnosis, sensory nerve conduction velocity studies are a useful additional diagnostic tool.The first choice in management of MP is, besides treating the underlying cause, always a conservative approach. Simple measures such as losing weight and not wearing tight belts and ⁄ or trousers can be advised. Pharmacological therapy consists mainly of antineuropathic medication.Anatomical variants of the LFCN occur in a quarter of patients and may be the reason for negative response to diagnostic blocks. For interventional treatment of MP, such as local injection with anesthetics and corticosteroids or pulsed radiofrequency treatment of the LFCN, the evidence is limited. In particular, pulsed radiofrequency treatment of the LFCN should only take place in a study context.
Pain Practice 03/2011; 11(3):302-8. · 2.21 Impact Factor
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PhD Leonardo Kapural MD,
Timothy Deer MD,
Alexandar Yakovlev MD,
Toula Bensitel MD,
PhD Salim Hayek MD,
Stephen Pyles MD,
Yasin Khan MD,
Alberta Kapural MD,
Dondre Cooper,
Lisa Stearns MD,
Paulina Zovkic,
Leonardo Kapural,
Timothy Deer,
Alexandar Yakovlev,
Toula Bensitel, Salim Hayek,
Stephen Pyles,
Yasin Khan,
Alberta Kapural,
Lisa Stearns
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ABSTRACT: Background, Objectives, and Methods. A few recent reports suggested that spinal cord stimulation (SCS) effectively suppresses chronic abdominal pain. However, there is no consensus on patient selection or technical aspects of SCS for such pain. That is why we conducted national survey and collected 76 case reports. There were six incompletely filled reports, so we analyzed 70 cases.Results. There were 43 female and 27 male patients. SCS was trialed in an average of 4.7 days (median of 4 days). In most patients, the leads were positioned for the SCS trial with their tips at the level of the T5 vertebral body (26 patients) or T6 vertebral body (15 patients).Four patients failed SCS trial: their average baseline visual analog scale (VAS) pain score was 7 ± 2.4 cm and did not improve at the conclusion of the trial (6.5 ± 1.9 cm; P = 0.759). Pain relief exceeded 50% in 66 of 70 patients reported. Among those, VAS pain score before the trial averaged 7.9 ± 1.8 cm. During the trial VAS pain scores decreased to 2.45 ± 1.45 cm (P < 0.001). The opioid use decreased from 128 ± 159 mg of morphine sulfate equivalents a day to 79 ± 112 mg (P < 0.017).During permanent implantation most of the physicians used two octrode leads and were positioned midline at T5-6 levels. The average patient follow-up was 84 weeks. VAS pain scores before an implant were 8 ± 1.9 cm, while after the implant 2.49 ± 1.9 cm. The opioid use before an implant was 158 ± 160 mg and at the last office visit after the implant 36 ± 49 mg.Conclusion. In conclusion, it seems that the SCS for the treatment of the abdominal visceral pain may provide a positive patient long-term experience, significant improvements in pain scores and a decrease in opioid use.
Pain Medicine 04/2010; 11(5):685 - 691. · 2.35 Impact Factor
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Leonardo Kapural,
Timothy Deer,
Alexandar Yakovlev,
Toula Bensitel, Salim Hayek,
Stephen Pyles,
Yasin Khan,
Alberta Kapural,
Dondre Cooper,
Lisa Stearns,
Paulina Zovkic
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND, OBJECTIVES, AND METHODS: A few recent reports suggested that spinal cord stimulation (SCS) effectively suppresses chronic abdominal pain. However, there is no consensus on patient selection or technical aspects of SCS for such pain. That is why we conducted national survey and collected 76 case reports. There were six incompletely filled reports, so we analyzed 70 cases. RESULTS: There were 43 female and 27 male patients. SCS was trialed in an average of 4.7 days (median of 4 days). In most patients, the leads were positioned for the SCS trial with their tips at the level of the T5 vertebral body (26 patients) or T6 vertebral body (15 patients). Four patients failed SCS trial: their average baseline visual analog scale (VAS) pain score was 7 +/- 2.4 cm and did not improve at the conclusion of the trial (6.5 +/- 1.9 cm; P = 0.759). Pain relief exceeded 50% in 66 of 70 patients reported. Among those, VAS pain score before the trial averaged 7.9 +/- 1.8 cm. During the trial VAS pain scores decreased to 2.45 +/- 1.45 cm (P < 0.001). The opioid use decreased from 128 +/- 159 mg of morphine sulfate equivalents a day to 79 +/- 112 mg (P < 0.017). During permanent implantation most of the physicians used two octrode leads and were positioned midline at T5-6 levels. The average patient follow-up was 84 weeks. VAS pain scores before an implant were 8 +/- 1.9 cm, while after the implant 2.49 +/- 1.9 cm. The opioid use before an implant was 158 +/- 160 mg and at the last office visit after the implant 36 +/- 49 mg. CONCLUSION: In conclusion, it seems that the SCS for the treatment of the abdominal visceral pain may provide a positive patient long-term experience, significant improvements in pain scores and a decrease in opioid use.
Pain Medicine 03/2010; 11(5):685-91. · 2.35 Impact Factor
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Anesthesiology 03/2009; 110(3):681-4. · 5.36 Impact Factor
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ABSTRACT: Post lumbar surgery syndrome or failed back surgery syndrome with persistent pain continues to increase over the years. The speculated causes of post lumbar laminectomy syndrome include acquired stenosis, epidural fibrosis, arachnoiditis, radiculopathy, and recurrent disc herniation. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome. Percutaneous epidural adhesiolysis has been employed in interventional pain management in the treatment of chronic, refractory low back and lower extremity pain after back surgery.
A systematic review of randomized trials and observational studies.
To evaluate the effectiveness of percutaneous adhesiolysis in managing chronic low back and lower extremity pain due to post lumbar surgery syndrome.
A comprehensive literature search was conducted utilizing electronic databases, as well as systematic reviews and cross references from 1966 through December 2008. The quality of individual articles used in this analysis was assessed by modified Cochrane review criteria for randomized trials and the Agency for Healthcare Research and Quality (AHRQ) criteria for assessment of observational studies. Clinical relevance was evaluated using 5 questions according to the criteria recommended by the Cochrane Review Back Group. Analysis was conducted using 5 levels of evidence, ranging from Level I to III, with 3 subcategories in Level II.
The primary outcome measure was pain relief (short-term relief of at least 6 months and long-term relief of more than 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and change in opioid intake.
Of the 13 studies considered for inclusion, 3 randomized trials and 4 observational studies met the inclusion criteria for methodologic quality assessment and evidence synthesis based on methodologic quality scores of 50 or more. Evidence of percutaneous adhesiolysis in the management of chronic low back pain in post-lumbar surgery syndrome is Level I to Level II-1, with evidence derived from 3 randomized trials.
There is a paucity of efficacy and pragmatic trials. No trials have been published after 2006.
The indicated level of evidence for percutaneous adhesiolysis is Level I or II-1 based on the US Preventative Services Task Force (USPSTF) criteria.
Pain physician 12(2):361-78. · 10.72 Impact Factor
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ABSTRACT: Disability, societal, and health impact of chronic intractable pain secondary to various failed therapies is a major issue. As advanced therapy, implantable therapies, which include intrathecal devices and spinal cord stimulation systems, are frequently used in managing chronic intractable pain. Thus, continuous infusion of intrathecal medication is one of the methods used for the control of chronic, refractory, cancer, and non-cancer pain. However, despite the high costs of chronic non-cancer pain, it has been claimed that there is a lack of evidence for intrathecal infusion systems and the cost effectiveness of these systems has been questioned in improving pain and function.
A systematic review of intrathecal infusion devices for chronic non-cancer pain.
To determine the efficacy, utilization, safety, and complications associated with the use of intrathecal infusion devices for long-term management of chronic non-cancer pain.
Literature search was performed through EMBASE, Medline, Cochrane databases, and systematic reviews identified from 1966 to December 2008. Studies were then reviewed and assessed using the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies and the Cochrane Musculoskeletal Review Group criteria for randomized trials. The level of evidence was determined using 5 levels of evidence, ranging from Level I to III with 3 subcategories in Level II, based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF).
The primary outcome measure was pain relief (short-term relief < or = one-year and long-term > one-year). Secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake were also utilized.
The level of evidence for intrathecal infusion systems indicated either Level II-3 or Level III (limited) based on U.S. Preventive Services Task Force (USPSTF) criteria.
The limitations of this study include the paucity of literature, lack of quality evidence, and lack of randomized trials.
This systematic review illustrates Level II-3 or Level III (limited) evidence for intrathecal infusion systems for long-term relief in chronic non-cancer pain.
Pain physician 12(2):345-60. · 10.72 Impact Factor
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ABSTRACT: Post lumbar surgery syndrome with persistent chronic low back and lower extremity pain is common in the United States. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome (FBSS). Percutaneous adhesiolysis with a catheter or direct visualization of the spinal canal and the contents with an endoscope are techniques employed in resistant cases when patients fail to respond to conservative modalities of treatment, including fluoroscopically directed epidural injections. Some patients failing to respond to percutaneous adhesiolysis are candidates for spinal endoscopic adhesiolysis. However, literature evaluating the effectiveness of spinal endoscopic adhesiolysis is sparse and discussions continue about its effectiveness, utility, and complications.
A systematic review of the available literature.
To evaluate the effectiveness and safety of spinal endoscopic adhesiolysis in the management of chronic low back and lower extremity pain in post surgical patients with chronic recalcitrant pain, non-responsive to conservative modalities of management and fluoroscopically directed epidural injections.
A search of relevant resources (PubMed, EMBASE, and the Cochrane database) was accomplished and the resulting publications were examined based on the inclusion/exclusion criteria set forth. Randomized controlled trials and observational studies were included in the search. Two reviewers assessed the studies' methodologies and outcomes. Randomized clinical trials were assessed and scored based on the criteria established by the Cochrane methodological assessment criteria of randomized clinical trials and the observational studies were assessed and scored based on the Agency for Healthcare Research and Quality (AHRQ) criteria. Clinical relevance was evaluated utilizing Cochrane review criteria. Analysis was conducted using 5 levels of evidence, ranging from Level I to III, with 3 subcategories in Level II.
The primary outcome measure was pain relief (> or = 50%) in follow-up for at least 6 months. Pain relief for longer than 6 months was considered long-term and 6 months or less was considered short-term. The secondary outcome measures were functional and psychological status, return to work, patient satisfaction, and opioid intake.
Of the 13 studies considered for inclusion, one randomized trial and 5 observational studies met inclusion criteria for evidence synthesis based on the inclusion criteria and methodologic quality scores of 50 or more. The indicated level of evidence for endoscopic adhesiolysis is Level II-1 or II-2 evidence for short- and long-term relief based on the U.S. Preventive Services Task Force (USPSTF) criteria.
There was a paucity of literature for randomized trials.
Spinal endoscopic adhesiolysis may be used as an effective treatment modality for chronic refractory low back pain and radiculopathy that is related to epidural adhesions.
Pain physician 12(2):419-35. · 10.72 Impact Factor
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ABSTRACT: Chronic, recurrent neck pain is common and is associated with high pain intensity and disability, which is seen in 14% of the adult general population. Controlled studies have supported the existence of cervical facet or zygapophysial joint pain in 36% to 67% of these patients. However, these studies also have shown false-positive results in 27% to 63% of the patients with a single diagnostic block. There is also a paucity of literature investigating therapeutic interventions of cervical facet joint pain.
A systematic review of cervical facet joint interventions.
To evaluate the accuracy of diagnostic facet joint nerve blocks and the effectiveness of cervical facet joint interventions.
Medical databases and journals were searched to locate all relevant literature from 1966 through December 2008 in the English language. A review of the literature of the utility of facet joint interventions in diagnosing and managing facet joint pain was performed according to the Agency for Healthcare Research and Quality (AHRQ) criteria for diagnostic studies and observational studies and the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials.
The level of evidence was defined as Level I, II, or III based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF).
For diagnostic interventions, studies must have been performed utilizing controlled local anesthetic blocks which achieve at minimum 80% relief of pain and the ability to perform previously painful movements. For therapeutic interventions, the primary outcome measure was pain relief (short-term relief up to 6 months and long-term relief greater than 6 months) with secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake.
Based on the utilization of controlled comparative local anesthetic blocks, the evidence for the diagnosis of cervical facet joint pain is Level I or II-1. The indicated evidence for therapeutic cervical medial branch blocks is Level II-1. The indicated evidence for radiofrequency neurotomy in the cervical spine is Level II-1 or II-2, whereas the evidence is lacking for intraarticular injections.
A systematic review of cervical facet joint interventions is hindered by the paucity of published literature and lack of literature for intraarticular cervical facet joint injections.
The evidence for diagnosis of cervical facet joint pain with controlled comparative local anesthetic blocks is Level I or II-1. The indicated evidence for therapeutic facet joint interventions is Level II-1 for medial branch blocks, and Level II-1 or II-2 for radiofrequency neurotomy.
Pain physician 12(2):323-44. · 10.72 Impact Factor
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ABSTRACT: Lumbar facet joints are a well recognized source of low back pain and referred pain in the lower extremity in patients with chronic low back pain. Conventional clinical features and other non-invasive diagnostic modalities are unreliable in diagnosing lumbar zygapophysial joint pain. Controlled diagnostic studies have shown the prevalence of lumbar facet joint pain in 27% to 40% of the patients with chronic low back pain without disc displacement or radiculitis, with a false-positive rate of 27% to 47% with a single diagnostic block.
A systematic review of diagnostic and therapeutic lumbar facet joint interventions.
To determine the clinical utility of diagnostic and therapeutic lumbar facet joint interventions in managing chronic low back pain of facet joint origin.
Review of the literature for clinical studies on efficacy and utility of facet joint interventions in diagnosing and managing facet joint pain was performed according to the Agency for Healthcare Research and Quality (AHRQ) criteria for diagnostic studies and observational studies and the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials. Data sources included relevant literature of the English language identified through searches of Medline and EMBASE from 1966 to December 2008 and manual searches of bibliographies of known primary and review articles. Analysis results were performed for diagnostic and therapeutic interventions separately.
The level of evidence was defined as Level I, II, or III with 3 subcategories in Level II based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF) for therapeutic interventions.
For diagnostic interventions, studies must have been performed utilizing controlled local anesthetic blocks. Pain relief was categorized as at least 80% pain relief from baseline pain and ability to perform previously painful movements. For therapeutic interventions, the primary outcome measure was pain relief with secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake. For therapeutic interventions, short-term pain relief was defined as relief lasting 6 months or less and long-term relief as longer than 6 months.
Based on USPSTF criteria, evidence showed Level I or II-1 for diagnostic facet joint nerve blocks. Based on the review of included therapeutic studies, Level II-1 to II-2 evidence was indicated for lumbar facet joint nerve blocks with indicated level of evidence of Level II-2 to II-3 for lumbar radiofrequency neurotomy.
The shortcoming of this systematic review of lumbar facet joint interventions is the paucity of published literature.
The evidence for diagnosis of lumbar facet joint pain with controlled local anesthetic blocks is Level I or II-1. The indicated level of evidence for therapeutic lumbar facet joint interventions is Level II-1 or II-2 for lumbar facet joint nerve blocks, Level II-2 or II-3 evidence for radiofrequency neurotomy, and Level III (limited) evidence for intraarticular injections.
Pain physician 12(2):437-60. · 10.72 Impact Factor
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ABSTRACT: Two minimally invasive techniques have been used more recently as a possible treatment for painful internal disk disruption (IDD). Intradiscal thermal annuloplasty (IDTA), known as IDET, has already shown promising results in pain reduction and functional restoration. The second technique, radiofrequency posterior annuloplasty (RFA), is used in many interventional pain practices, although studies on the technique's efficacy are lacking. This study compares the effectiveness of those two methods.
We matched 42 patients (21 had IDTA and 21 radiofrequency annuloplasty) for age, sex, weight, smoking history, manual labor, and number of intervertebral disks treated. Enrolled patients completed pain disability index (PDI) questionnaires before receiving either IDTA or RFA; at 2 weeks; and 2, 3, 6, 9, and 12 months following either treatment.
From the third to the twelfth month after the procedure, the IDTA group had significantly lower mean pain scores than the RFA group. Visual analog scale (VAS) pain scores decreased from 6.6 +/- 2.0 before to 4.4 +/- 2.4 at 1 year after radiofrequency annuloplasty (P = 0.001), while in the IDTA group the average VAS pain score decreased from 7.4 +/- 1.9 before IDTA to 1.4 +/- 1.9 at 1 year follow-up. Similarly, PDI scores in the IDTA group had a significantly larger improvement than those for patients who received radiofrequency annuloplasty.
This study shows significant improvement in pain scores and patients' PDI following IDTA but not after RFA of the intervertebral disks. IDTA appears to be more efficacious than RFA based on PDI and VAS scores measured at 1 year following procedure.
Pain Medicine 6(6):425-31. · 2.35 Impact Factor
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ABSTRACT: Coccygodynia is painful condition localized in the region of the coccyx. In most cases a traumatic etiology is present. In the idiopathic form other causes such as infections and tumor have to be excluded. Coccygodynia can also be the result of pain referred from visceral structures due to conditions such as disorders of the rectum, the colon sigmoideum, and the urogenital system. In case of a traumatic etiology the diagnosis is made based on the typical medical history whereby the pain is provoked by prolonged sitting and cycling. Lateral images of the coccyx are always indicated. The same is true for manual examination of the coccyx. In case of absence of provocation of the coccygeal pain by prolonged sitting and manual examination neurological causes such as lumbar disc hernias are a possible reason for the coccygodynia. In the acute phase the first choice of treatment are NSAIDs. Treatment for patients with severe pain in the chronic phase consists of manual therapy and/or a local injection of local anesthetic and corticosteroid into the painful segment (2 C+). Other interventional treatments such as intradiscal injections, ganglion impar block, radiofrequency treatment and caudal block are advised only under study conditions (0). Coccygectomy is not recommended because of long-term moderate results and the chance of major complications.
Pain Practice 10(6):554-9. · 2.21 Impact Factor
