[Show abstract][Hide abstract] ABSTRACT: Background:
Facial pain can be a management challenge. Peripheral nerve/field stimulation may be an effective option for refractory cases, but direct muscle stimulation with facial twitching may result. Botulinum toxin injections have been used for blepharospasm and may be effective when facial stimulation results in unacceptable facial muscle twitching due to peripheral stimulation.
A 53-year old female suffered with chronic, refractory facial pain and migraines. Her facial pain began after a root canal of a left upper molar. She was trialed and then permanently implanted with a 1 × 8 sub-compact percutaneous stimulator lead, resulting in improved pain control and reduced medication use. However, she experienced blepharospasm whenever the amplitude was above 2.75 A. Therefore, she was treated with botulinum toxin injections into her bilateral cheek, face, temple and occiput. This treatment provided excellent relief of the facial spasms, allowing her to use her stimulator at high amplitudes, and thereby maximizing her pain relief. She received two subsequent treatments of botulinum toxin injections at 5-month intervals with similar results.
Peripheral nerve/field stimulation is being used for headaches and facial pain. An undesirable side effect of this emerging therapy is direct muscle stimulation. Botulinum toxin injections may be an effective treatment modality when stimulation techniques provide pain relief but also causes muscle twitching.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: Perioperative hydroxy-3-methyl glutaryl coenzyme A reductase
inhibitors (statins) have been shown to decrease morbidity and mortality after
noncardiac surgery. The objective of this study was to assess patient
understanding of the potential benefits of perioperative statins in a select
population already on chronic therapy. A secondary aim was to determine the
frequency with which patients recalled having a discussion with their provider
regarding perioperative statins.
SETTING: Teaching hospital.
PARTICIPANTS: Patients taking daily statins presenting to a preoperative medical
evaluation clinic were offered a 12-question survey that assessed their
understanding of the potential benefit of taking the medication in the
MEASUREMENTS AND MAIN RESULTS: One hundred thirty-two patients completed the
questionnaire. The mean age was 68.3 years (standard deviation, 9.0); 42% were
female. The most frequent surgical referral to the clinic was orthopedics, at
36%. The most common statin prescribed was atorvastatin, in 35% of patients.
Twenty-seven percent of patients (n = 36) recognized that perioperative statins
are beneficial; 44% of these patients (n = 14) cited decreased cholesterol during
the procedure as the reason, representing 12% of the total sampled population.
Twenty-two percent (n = 8) of those recognizing the benefit of perioperative
statins identified a decrease in the risk of heart attack or death as the reason.
This represented only 6% of the total sample. One percent of surgeons mentioned
statins in relation to the planned surgery; 2% of primary or prescribing
physicians mentioned the medication in relation to surgery.
CONCLUSIONS: This study suggested low patient understanding of the potential
importance and reasons for perioperative statins. In addition, this study also
suggested that the information regarding the importance of perioperative statins
is not being relayed to the patient at the level of the surgeon or primary care
physician. All physicians involved in perioperative care can offer improved
patient education to promote compliance with statin therapy in hopes of a
favorable impact on perioperative outcomes.
Full-text · Article · Feb 2015 · Journal of cardiothoracic and vascular anesthesia
[Show abstract][Hide abstract] ABSTRACT: IntroductionAnalyzing hospital naloxone use may assist in identification of areas for quality and safety improvement. Our primary objective is to quantitate the incidence of hospital naloxone use and to assess certain patient populations at risk.Methods
During the years 2008 to 2011, each clinical scenario where naloxone was administered on an in-patient care ward was reviewed. The events were assessed to separate situations where naloxone rescue was effective in reversing opioid-induced intoxication vs. others. Further analysis was conducted to stratify patient populations at greatest risk.ResultsNaloxone was administered for well-defined opioid-induced respiratory depression and oversedation 61% of the time, the remainder used for patient deterioration of other etiology. Surgical populations are at risk with an incidence of 3.8/1,000 hospitalized patients, and this is the greatest within 24 hours of surgery. General surgical patients represent the highest surgical patient risk at 5.5/1,000. Medical patients represent lower risk at 2.0/1,000. Patients with patient-controlled analgesia and epidural opioid infusion are high risk at 12.1 and 13.1/1,000 patients, respectively. Many quality and safety interventions were gradually implemented in response to this data and are summarized. These include nursing and provider education, electronic medical record modification, and more stringent patient monitoring practices.Conclusion
Examination of naloxone use can assist in the identification and stratification of patients at risk for opioid-induced respiratory depression and oversedation and can serve as a driver for improvements in hospital patient safety. This information can also guide other institutions interested in similar improvements.
[Show abstract][Hide abstract] ABSTRACT: Objective
In this study, we analyze device- and procedure-related adverse events (AEs) from a recent prospective, multicenter, double-blinded controlled study that utilized peripheral nerve stimulation (PNS) of occipital nerves for management of chronic migraine.MethodsPNS device characteristics (lead length and spacing), surgical techniques including lead orientation (parallel or perpendicular to the nerve), and implantable pulse generator (IPG) placement (upper buttock, abdomen, infraclavicular, or lower axilla) in 157 patients were analyzed to identify any relationship with the AE incidence rate. Number of prior PNS implants performed (NPPIP) by the implanter and its relationship with different AE categories (hardware-related, biological, and stimulation-related events) and frequently observed device/procedure-related AEs (lead migration/fracture/breakage, persistent pain at the lead/IPG location, unintended/undesirable changes in stimulation, infection) were also evaluated. Three-way ANOVA tests were utilized to evaluate the dependence of AE occurrence on the variables described above.ResultsIPG pocket locations closer to the lead (e.g. infraclavicular region) were associated with a lower AE incidence rate (p < 0.05). Higher NPPIP was related to lower stimulation- and hardware-related AEs (p < 0.05), frequently observed AEs like lead migration, pain, and infection (p < 0.05), and procedure-related additional surgeries (p < 0.05).Conclusion
Implantation of the IPG closer to the lead location was associated with reduced AEs. PNS is a relatively new procedure, and the skill and precision in performing these procedures improves with experience. Our results demonstrate that as the implanter gains more experience with these procedures, a significant reduction in device- and procedure-related AEs may be expected.
[Show abstract][Hide abstract] ABSTRACT: To describe use of bilateral temporal and occipital stimulator leads for a refractory headache disorder.
A 31-year-old female had a 10-year history of chronic, severe occipital and temporal region headaches. The patient underwent permanent implant of an occipital stimulator system that resulted in sustained, compete resolution of her occipital pain. However, she continued to suffer disabling (10/10) temporal region headaches and was bedbound most days of the week. Therefore, bilateral temporal stimulator leads were implanted and tunneled to her internal pulse generator.
At 12-month follow-up, the patient enjoyed sustained improvement in her pain scores (8/10) and marked increase in her level of functioning. Taking into account increased activity level, she rated her overall improvement at 50%. Unfortunately, infection and erosion of her right temporal lead necessitated temporal stimulator removal.
Headache disorders may require stimulation of all painful cephalic regions. However, our success in this case must be considered in light of the technical challenges and expense of placing stimulator leads subcutaneously around the head and neck, including the risk of infection, lead breakage, erosion, and migration.
Full-text · Article · Mar 2014 · Medical Devices: Evidence and Research
[Show abstract][Hide abstract] ABSTRACT: To investigate the sensitivity of MRI of the spine compared with CT myelography (CTM) in detecting CSF leaks.
Between July 1998 and October 2010, 12 patients with orthostatic headache and a CTM-confirmed spinal CSF leak underwent an MRI of the spine with and without contrast. Using CTM as the gold standard, we retrospectively investigated the sensitivity of spinal MRI in detecting a CSF leak.
Eleven of 12 patients with a CSF leak documented by CTM also had extradural fluid collections on spinal MRI (sensitivity 91.7%). Six patients with extradural fluid collections on spinal MRI also had spinal dural enhancement.
When compared with the gold standard of CTM, MRI of the spine appears to be a sensitive and less invasive imaging modality for detecting a spinal CSF leak, suggesting that MRI of the spine should be the imaging modality of first choice for the detection of spinal CSF leaks.
[Show abstract][Hide abstract] ABSTRACT: Objectives:
Patient satisfaction is tied to outcome, but there is scant literature on the relationship of patient perceived outcome and attributes of the pain clinic visit, including the patient interaction with the pain management specialist. The primary purpose of this study is to identify attributes of the patient-provider interaction most strongly associated with patient perceived outcome of their clinic visit. The secondary aim is to correlate patient perceived outcome with patient self-rated overall health.
A patient satisfaction survey conducted via phone approximately 3 weeks after the patient's pain clinic visit.
The response rate was 60.2%; 987 patient surveys collected between 2006 and 2010 were used in the analysis. Four factors were significantly associated with the outcome: (1) Explanations by the physician of the patient's condition and treatment, (2) clear instructions regarding post-appointment activities, (3) knowing the patient as a person, and (4) the patient's self-rated health. In terms of the secondary objective, those who answered very good/excellent regarding their self-rated health had an 87% increased odds of better (very good/excellent) outcome of their pain clinic visit (or 1.87 times the odds of better outcome) compared with those who answered poor/fair/good.
Our results suggest that pain physicians may positively impact patient perceived outcomes of clinic visits by explaining the patient's condition and treatment, providing instructions, and taking the time to understand the patient and their values.
[Show abstract][Hide abstract] ABSTRACT: Objectives:
Patient perception of healthcare quality is of growing interest. It has been shown that patient satisfaction is associated with compliance with medical advice and clinical outcome. The 3-fold purpose of this study was to identify which attributes of the patient-physician interaction most strongly correlated with patients' perceptions of provider quality of care, to identify key drivers that move patients' perception of overall provider quality from "very good" to "excellent," and to identify features of the pain clinic experience that were most important to patients but were simultaneously perceived as lacking.
Randomized patient satisfaction survey conducted via telephone approximately 3 weeks after the patient's pain clinic visit.
A total of 999 patients participated in the survey over 5 years (estimated response rate 60.2%). Thoroughness, listening, and time spent with the provider were the 3 attributes most strongly associated with the patients' perceptions of provider quality of care, while thoroughness, listening, punctuality, and clear instructions were the drivers of "very good" vs. "excellent" patient perceived overall provider quality. Areas identified for clinic improvement include thoroughness, providing adequate explanations and instructions, and including patient preferences in decision making.
These results may guide pain clinic physicians as they seek to improve patient perceptions of their care and ultimately patient outcomes.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To evaluate the efficacy and safety of a novel, continuous intravenous infusion of ketorolac, a powerful nonopioid analgesic, for postoperative pain control. PATIENTS AND METHODS: A prospective, double-blind, randomized, placebo-controlled trial of a continuous infusion of ketorolac tromethamine in 1 L of normal saline vs placebo was performed in 135 patients aged 18 to 75 years after laparoscopic donor nephrectomy or percutaneous nephrolithotomy completed from October 7, 2008, through July 21, 2010. Primary study end points were the 24-hour differences in visual analog pain scores and total narcotic consumption, whereas secondary end points were differences in urine output, serum creatinine level, and hemoglobin level. RESULTS: The study was stopped after randomization of 135 patients (68 in the ketorolac group and 67 in the placebo group) when interim analysis indicated that the difference in mean pain scores between the 2 groups (difference, 0.6) was smaller than the 1-point threshold set forth in the power calculations. No statistically significant change was noted in hemoglobin levels from preoperative to postoperative values (P=.13) or in postoperative serum creatinine levels (P=.13). CONCLUSION: Although continuous infusion of ketorolac produced only a modest decrease in the use of narcotics, it appears to offer a safe therapeutic option for nonnarcotic pain control. TRIAL REGISTRATION: clinicaltrials.gov Identifiers: NCT00765128 and NCT00765232.
Full-text · Article · Oct 2012 · Mayo Clinic Proceedings
[Show abstract][Hide abstract] ABSTRACT: Background:Chronic migraine (CM) is a debilitating neurological disorder with few treatment options. Peripheral nerve stimulation (PNS) of the occipital nerves is a potentially promising therapy for CM patients.Methods:In this randomized, controlled multicenter study, patients diagnosed with CM were implanted with a neurostimulation device near the occipital nerves and randomized 2:1 to active (n = 105) or sham (n = 52) stimulation. The primary endpoint was a difference in the percentage of responders (defined as patients that achieved a ≥50% reduction in mean daily visual analog scale scores) in each group at 12 weeks.Results:There was not a significant difference in the percentage of responders in the Active compared with the Control group (95% lower confidence bound (LCB) of -0.06; p = 0.55). However, there was a significant difference in the percentage of patients that achieved a 30% reduction (p = 0.01). Importantly, compared with sham-treated patients, there were also significant differences in reduction of number of headache days (Active Group = 6.1, baseline = 22.4; Control Group = 3.0, baseline = 20.1; p = 0.008), migraine-related disability (p = 0.001) and direct reports of pain relief (p = 0.001). The most common adverse event was persistent implant site pain.Conclusion:Although this study failed to meet its primary endpoint, this is the first large-scale study of PNS of the occipital nerves in CM patients that showed significant reductions in pain, headache days, and migraine-related disability. Additional controlled studies using endpoints that have recently been identified and accepted as clinically meaningful are warranted in this highly disabled patient population with a large unmet medical need.Trial registration:Clinical trials.gov (NCT00615342).
[Show abstract][Hide abstract] ABSTRACT: The objective of our study was to review the clinical utility of digital subtraction myelography for the diagnosis of spinal CSF leaks in patients with spontaneous intracranial hypotension (SIH) and those with superficial siderosis.
Procedure logs from 2007 to 2011 were reviewed to identify cases in which digital subtraction myelography was performed to diagnose spinal CSF leaks. Electronic medical records were reviewed to obtain information regarding diagnosis and outcome. For patients to be included in the study, preprocedural spinal MRI had to show an extradural fluid collection spanning more than one vertebral level and postmyelographic CT had to confirm the presence of an active CSF leak. If digital subtraction myelography successfully showed the site of the CSF leak, the location was documented.
Eleven patients (seven men and four women; mean age, 49.0 years) underwent digital subtraction myelography during the study period. Six patients had SIH and five patients had superficial siderosis. The extradural fluid collection on spinal MRI averaged a length of 15.5 vertebral levels. Digital subtraction myelography successfully showed the site of the CSF leak in nine of the 11 patients, and all of the dural tears were located in the thoracic spine between T3 and T11.
Digital subtraction myelography is a valuable diagnostic tool for the localization of rapid spinal CSF leaks and should be considered in patients who are clinically suspected to have a dural tear that is accompanied by a longitudinally extensive extradural fluid collection on spinal MRI.
No preview · Article · Sep 2012 · American Journal of Roentgenology
[Show abstract][Hide abstract] ABSTRACT: Robot-assisted cystectomy surgery may be advantageous for patients. The purpose of this study was to compare anesthetic management and outcomes in patients undergoing robot-assisted versus open radical cystectomy. In a retrospective review of 256 cystectomy procedures, procedure duration, blood loss, respiratory parameters, recovery room opiate consumption, pain scores and antiemetic use in the recovery room, and hospital length of stay were compared. After exclusions, 96 robot-assisted and 102 open procedures were analyzed. Anesthesia and surgery duration were significantly longer in the robot-assisted group, while the length of hospital stay was significantly shorter in the robot-assisted group: 7.1 ± 5.8 versus 9.8 ± 5.03 days, p = 0.0005. Estimated blood loss was 601.8 ± 491.4 ml in the open group versus 257.7 ± 164.3 ml in the robot-assisted group, p < 0.0001. Recovery room opiate consumption was significantly less in the robot-assisted group: 9.5 ± 8.9 versus 12.6 ± 9.9 mg (morphine equivalents), p = 0.02. The highest recorded respiratory rate was significantly higher in the robot-assisted group, as was the highest recorded peak airway pressure. Among patients with arterial blood gas data, the highest arterial partial pressure of CO2 was significantly greater in the robot-assisted group than in the open surgery group: 42.6 ± 5.6 versus 37.4 ± 4.8 mmHg CO2, p = 0.0001. Surgeons and anesthesia providers can expect robot-assisted radical cystectomy surgery to last longer than traditional open surgery, but to be associated with less pain and blood loss. Positioning and abdominal insufflation for robot-assisted surgery may contribute to ventilation challenges.
No preview · Article · Sep 2012 · Journal of Robotic Surgery
[Show abstract][Hide abstract] ABSTRACT: Introduction: Occipital nerve stimulation (ONS) may provide relief for refractory headache disorders. However, scant data exist regarding long-term ONS outcomes. Methods: The methods used were retrospective review of the medical records of all (nonindustry study) patients who were trialed and implanted with occipital nerve stimulator systems at our institution, followed by a phone interview. Up to three attempts were made to contact each patient, and those who were contacted were given the opportunity to participate in a brief phone interview regarding their ONS experience. Data for analysis were gleaned from both the phone interview and the patient's medical records. Results: Twenty-nine patients underwent a trial of ONS during the 8.5-year study period. Three patients did not go on to permanent implant, 12 could not be contacted, and 14 participated in the phone interview. Based upon the phone interview (if the patient was contacted) or chart review, ONS was deemed successful in five of the 12 migraine, four of the five cluster headache, and five of the eight miscellaneous headache patients, and therapy was documented as long as 102 months. In one of the 26 patients, success of ONS could not be determined. Among patients deemed to have successful outcomes, headache frequency decreased by 18%, severity by 27%, and migraine disability score by 50%. Fifty-eight percent of patients required at least one lead revision. Discussion: These results, although limited by their retrospective nature, suggest that ONS can be effective long term despite technical challenges. The number of patients within each headache subtype was insufficient to draw conclusions regarding the differential effect of ONS. Conclusions: Randomized controlled long-term studies in specific, intractable, primary headache disorders are indicated.
[Show abstract][Hide abstract] ABSTRACT: Occipital nerve stimulation can be effective therapy for recalcitrant headache disorders. Lead migration remains the primary technical adverse event associated with this therapy. Revision surgery for occipital nerve stimulator leads sometimes requires exposure of all components including internal pulse generator, extension cables, connectors, and leads with multiple incisions. However, minimizing the invasiveness of revision surgery reduces the time, infection risk, and discomfort associated with the procedure. We describe two techniques that attempt to minimize the extent of revision surgery necessary for lead migration.
We describe two minimally invasive revision techniques. One uses a 14-gauge Tuohy needle converted to a slotted needle. The other uses a standard Tuohy needle inserted subcutaneously into the anchor site along the desired course of the lead.
Both techniques allow replacement of a migrated occipital nerve stimulator lead while eliminating the need to access connector or battery sites with multiple incisions. Conclusions: When migration occurs, the techniques described can simplify lead revision while minimizing the invasiveness of the procedure.
[Show abstract][Hide abstract] ABSTRACT: Chronic cluster headache is a severely disabling neurological disorder. Evidence from open-label case series suggest that occipital nerve stimulation may be effective for the treatment of chronic cluster headache.
To evaluate the effectiveness of a microstimulator for chronic cluster headache.
Prospective, observational feasibility study plus medical record review.
Academic medical center.
Four patients with medically refractory chronic cluster headache underwent implantation of a unilateral bion microstimulator. In-person follow-up was conducted for 12 months after implantation, and a prospective follow-up chart review was carried out to assess long term outcome.
Three of the participants returned their headache diaries for evaluation. The mean duration of chronic cluster headache was 14.3 years (range 3 to 29 years). Pain was predominantly or exclusively retroocular/periocular. One participant demonstrated a positive response (> 50% reduction in cluster headache frequency) at 3 months post-implant, while there were 2 responders at 6 months. At least one of the participants continued to show > 60% reduction in headache frequency at 12 months. A chart review showed that at 58-67 months post-implant, all 3 participants reported continued use and benefit from stimulation. No side-shift in attacks was noted in any participant. Adverse events were limited to 2 participants with neck pain and/or cramping with stimulation at high amplitudes; one required revision for a faulty battery.
Small patient population without control group. Not blinded or randomized.
Unilateral occipital nerve stimulation, using a minimally invasive microstimulator, may be effective for the treatment of medically refractory chronic cluster headache. This benefit may occur immediately after implantation, remain sustained up to 5 years after implantation, and occur despite the anterior location of the pain. Prospective, randomized controlled trials of occipital nerve stimulation in chronic cluster headache should proceed.
[Show abstract][Hide abstract] ABSTRACT: To determine patients' opinions regarding the person, method, and timing for disclosure of postoperative visual loss (POVL) associated with high-risk surgery.
On the basis of findings of a pilot study involving 219 patients at Mayo Clinic in Florida, we hypothesized that at least 80% of patients would prefer disclosure of POVL by the surgeon, during a face-to-face discussion, before the day of scheduled surgery. To test the hypothesis, we sent a questionnaire to 437 patients who underwent prolonged prone spinal surgical procedures at Mayo Clinic in Rochester, MN, or Mayo Clinic in Arizona from December 1, 2008, to December 31, 2009.
Among the 184 respondents, 158 patients gave responses supporting the hypothesis vs 26 with at least 1 response not supporting it, for an observed incidence of 86%. The 2-sided 95% confidence interval is 80% to 91%.
At least 80% of patients prefer full disclosure of the risk of POVL, by the surgeon, during a face-to-face discussion before the day of scheduled surgery. This finding supports development of a national patient-driven guideline for disclosing the risk of POVL before prone spinal surgery.
Full-text · Article · Sep 2011 · Mayo Clinic Proceedings