Sympathetic blocks for complex regional pain syndrome: a survey of pain physicians.

BACKGROUND: Sympathetic blocks (SB) are commonly used to treat pain from complex regional pain syndrome (CRPS). However, there are currently no guidelines to assist pain physicians in determining the best practices when using and performing these procedures. METHODS: A 32-question survey was developed on how SBs are used and performed to treat CRPS. The survey was conducted online via SurveyMonkey. The responses were statistically analyzed using descriptive statistics, and comparing academic versus non-academic, and fellowship versus non-fellowship-trained physicians. RESULTS: A total of 248 pain physicians responded with a response rate of 37%. Forty-four percent of respondents schedule the first SB at the first clinic visit; 73% perform one to three consecutive blocks; over 50% will repeat the block if a patient receives at least 50% pain relief from the previous one lasting 1-7 days.Fifty-four percent of respondents perform stellate ganglion blocks (SGB) at the C6 vertebral level, 41% at C7; 53% perform lumbar sympathetic blocks (LSB) at L3 level, 39% at L2; 50% use fluoroscopy to guide SGB, 47% use ultrasound. More respondents from academic than non-academic centers use ultrasound for SGB. About 75% of respondents use a total volume of 5-10 mL for SGB and 10-20 mL for LSB. The most commonly used local anesthetic is 0.25% bupivacaine. About 50% of respondents add other medications, mostly steroids, for these blocks. CONCLUSION: Our study showed a wide variation in current practice among pain physicians in treating CRPS with SBs. There is a clear need for evidence-based guidelines on when and how to perform SBs for CRPS.

A review and survey of policies utilized for interventional pain procedures: a need for consensus.

BACKGROUND: Other than the newly published anticoagulation guidelines, there are currently few recommendations to assist pain medicine physicians in determining the safety parameters to follow when performing interventional pain procedures. Little information exists regarding policies for oral intake, cumulative steroid dose limits, driving restrictions with and without sedation, and routine medication use for interventional procedures. METHODS: A 16-question survey was developed on common policies currently in use for interventional pain procedures. The questionnaire was distributed through the American Society of Regional Anesthesia and Pain Medicine and American Academy of Pain Medicine. We sought to statistically analyze the range of policies being used by pain medicine physicians and to determine if there are any commonly accepted standards. RESULTS: A total of 337 physicians out of 4037 members responded to our survey with a response rate of 8.4%. A total of 82% of these respondents used a sedative agent while performing an interventional pain procedure. The majority of respondents required drivers after procedures, except after trigger points. A total of 47% indicated that they have an nil per os (NPO) policy for procedures without sedation. A total of 98% reported that they had an anticoagulation policy before an interventional procedure. A total of 17% indicated that the interval between steroid doses was <2 weeks, while 53% indicated that they waited 2-4 weeks between steroid doses. CONCLUSION: Our study has clearly demonstrated a wide variation in the current practice among physicians regarding sedation, NPO status, steroid administration, and the need for designated drivers. There was much higher endorsement of policies regarding anticoagulation. There is an obvious need for evidence-based guidelines for these aspects of interventional pain care to improve patient safety and minimize the risk of adverse events.

Addition of objective data to identify risk for medication misuse and abuse: the inconsistency score.

OBJECTIVE: To identify and quantify the rate of aberrant drug-taking behaviors using objective data. DESIGN: Institutional Review Board-approved anonymous, voluntary, quality improvement project. SETTING: University-based, multidisciplinary pain management center. SUBJECTS: Consecutive initial visit patients. METHODS: Patients were interviewed, asked to provide a urine sample, and filled out a brief questionnaire about recent prescription, over-the-counter, and illicit drug use. Discrepancies between patient report (PQ), the Virginia State prescription monitoring program (PMP), referring physician records (MRs), and the point-of-care urine drug screen (POC UDS) results were scored from 0 (none) to a maximum of 2 points (2+ discrepancies) for each potential comparator between data sets. Maximum potential inconsistency score (IS) was 16 points. RESULTS: Two hundred nine patients were interviewed to yield 118 specimens. Mean age of participants was 48.2 years (22-83 year); 65.3% were female. IS scores ranged from 1 to 11, and 52.5% of the patients had an IS ≥ 3. Higher IS scores correlated with higher numbers of pharmacies, prescribing physicians, prescriptions on the PMP, and presence of illicit substances in the urine. Addition of either POC UDS or PMP to PQ and MR increased identification of inconsistencies by >400%, and PMP plus UDS by >900%. CONCLUSIONS: Patient report and the medical record are inadequate to screen for aberrant drug-related behaviors. Addition of PMP and POC UDS contribute significantly to identification of inconsistencies through higher IS scores and differentiate patients at higher risk of medication misuse, abuse, or diversion. Comparison of multiple sources of objective information provides better insight into inconsistencies of report and behavior, and may assist in more appropriate and safer prescribing decisions.

Cervicogenic headache in patients with presumed migraine: missed diagnosis or misdiagnosis?

UNLABELLED: The differential diagnosis of headache is often challenging, with significant clinical and socioeconomic consequences of incomplete or inaccurate diagnosis. Overlapping symptoms contribute to the diagnostic challenge. Four female patients, ages 26 to 69 with standing diagnoses of migraine, were evaluated and treated for complaints of chronic, severe headaches. All had obtained limited relief from migraine therapies. On physical examination, all had occipital nerve tenderness or positive Tinel sign over the occipital nerve. All responded well to occipital nerve blocks with local anesthetic, achieving complete or substantial pain relief lasting up to 2 months. We conclude that accurate diagnosis of occipital neuralgia or cervicogenic headache as contributing factors can lead to substantial headache relief through occipital nerve blocks in patients with coexisting or misdiagnosed migraine. PERSPECTIVE: The pathophysiology of many types of chronic headaches is not well understood. Mixed mechanisms such as neurovascular, neuropathic, myofascial, and cervicogenic may all contribute. Our four patients with chronic headaches responded well to occipital nerve blocks. The neuroanatomical relationship between the trigeminocervical nucleus and occipital nerve may serve as the basis of efficacy for these blocks.

Electronic pain questionnaires: a randomized, crossover comparison with paper questionnaires for chronic pain assessment.

Electronic questionnaires for pain assessment are becoming increasingly popular. There have been no published reports to establish the equivalence or psychometric properties of common pain questionnaires administered via desktop computers. This study compared responses to paper (P) and touch screen electronic (E) versions of the Short-Form McGill Pain Questionnaire (SF-MPQ) and Pain Disability Index (PDI), while examining the role of computer anxiety and experience, and evaluating patient acceptance. In a randomized, crossover design 189 chronic pain patients completed P and E versions of the SF-MPQ and PDI, and self-ratings of anxiety, experience, relative ease and preference. Psychometric properties were highly similar for P and E questionnaires. For the SF-MPQ, 60% or more of subjects gave equivalent responses on individual descriptors and PPI scale, with 80% rating within +/-1 point for an 11-point VAS. Correlations for the SF-MPQ scales ranged from 0.68 to 0.84. For the PDI, 60% or more of subjects responded within +/-1 point on individual questions, and the total score correlation was 0.67. Comparison of mean difference scores revealed no significant differences between modes for any of the questionnaire items or scores. Anxiety and experience scores showed no significant associations through correlations and high/low comparisons. Although nearly half of subjects reported no computer training, anxiety ratings were low, and considerably more subjects rated the E questionnaires as easier and preferred. Findings are consistent with test-retest reliability data, and support the validity and acceptance of electronic versions of the SF-MPQ and PDI.

Evaluation of audiologic impairment in critically ill patients: results of a screening protocol.

OBJECTIVE: To assess hearing impairment in adults admitted to a university surgical intensive care unit in order to identify patients at risk for impaired receptive communication. DESIGN: Prospective, clinical, observational study within the continuing quality improvement program. SETTING: Ten-bed adult surgical intensive care unit at a university hospital. PATIENTS: Patients were 442 adult patients admitted to the surgical intensive care unit for trauma, a critical illness, or postoperative monitoring. INTERVENTIONS: As part of a continuing quality improvement protocol, adults admitted to the surgical intensive care unit were screened for hearing loss. Screening included otoscopy, tympanometry, and distortion product otoacoustic emissions as near the time of admission as was possible. Testing was available only on weekdays. MEASUREMENTS AND MAIN RESULTS: Audiologic testing was performed on day 1.7 +/- 3.0 and took 9.3 mins (range, 5-17 min). The women studied (n = 177, 56.2 +/- 18.2 yrs) were significantly older than the men (n = 265, 51.2 +/- 17.8 yrs, p <.0001). We found that 71.4% of patients had normal otoscopy. Only 42.5% of patients passed tympanometry. True failures accounted for 37.3% of patients and technical failures for 20.2%. Distortion product otoacoustic emission (DPOAE) testing was performed on 97.4% of ears. Only 36.2% of patients passed; 58.4% of ears failed, suggesting clinically significant auditory impairment. DPOAE results correlated with age. The pass rate was approximately 60% for patients <40 yrs of age but declined steadily by decade to <7% in patients >80 yrs. The mean age of passed DPOAE (44.2 +/- 16.2 yrs) was significantly younger than patients who failed DPOAE (60.0 +/- 16.6 yrs, p <.0001). CONCLUSIONS: Adult patients admitted to the surgical intensive care unit for trauma, postoperative monitoring, or critical illness are at significant risk of impaired auditory reception. Almost two thirds of patients studied failed the screening protocol. Risk of failure increases with age and male gender. Screening with otoscopy, tympanometry, and DPOAE is an efficient and sensitive way to identify patients at risk for impaired auditory acuity.