Combining Procedural and Behavioral Treatments for Chronic Low Back Pain: A Pilot Feasibility Randomized Controlled Trial.

Individual treatments for chronic low back pain (CLBP) have small magnitude effects. Combining different types of treatments may produce larger effects. This study used a 2×2 factorial randomized controlled trial (RCT) design to combine procedural and behavioral treatments for CLBP. The study aims were to: (1) assess feasibility of conducting a factorial RCT of these treatments; and (2) estimate individual and combined treatment effects of (a) lumbar radiofrequency ablation (LRFA) of the dorsal ramus medial branch nerves (vs. a simulated LRFA control procedure) and (b) Activity Tracker-Informed Video-Enabled Cognitive Behavioral Therapy program for CLBP (AcTIVE-CBT) (vs. an educational control treatment) on back-related disability at 3 months post-randomization. Participants (n=13) were randomized in a 1:1:1:1 ratio. Feasibility goals included an enrollment proportion ≥30%, a randomization proportion ≥80%, and a ≥80% proportion of randomized participants completing the 3-month Roland-Morris Disability Questionnaire (RMDQ) primary outcome endpoint. An intent-to-treat analysis was used. The enrollment proportion was 62%, the randomization proportion was 81%, and all randomized participants completed the primary outcome. Though not statistically significant, there was a beneficial, moderate-magnitude effect of LRFA vs. control on 3-month RMDQ (-3.25 RMDQ points; 95% CI: -10.18, 3.67). There was a significant, beneficial, large-magnitude effect of AcTIVECBT vs. control (-6.29, 95% CI: -10.97, -1.60). Though not statistically significant, there was a beneficial, large effect of LRFA+AcTIVE-CBT vs. control (-8.37; 95% CI: -21.47, 4.74). We conclude that it is feasible to conduct an RCT combining procedural and behavioral treatments for CLBP.

Corticosteroid-Induced Psychosis After a Single Transforaminal Epidural Steroid Injection.

INTRODUCTION: Neuropsychiatric symptoms are a well-described side effect of systemic corticosteroid therapy and can range from mild to severe. CASE PRESENTATION: We describe a case of substance-induced psychosis following epidural injection of 10 mg dexamethasone. Three days after the procedure, the patient developed symptoms including anger, hostility, insomnia, paranoia, and delusions. Symptoms resolved between 7 and 17 days. DISCUSSION: In the past 50 years, there have been several case reports of severe neuropsychiatric effects following intraarticular or other interventional pain injections with various corticosteroids. More recent reviews have identified possible risk factors, including corticosteroid dose, patient age, sex, and history of neuropsychiatric disorder, among others, although these conclusions are not duplicated across all studies. CONCLUSION: Recommendations for practice include patient and family education on possible adverse effects of corticosteroid administration, utilization of minimum effective doses for interventional procedures, and the consideration of close follow-up and multidisciplinary coordination, especially in high-risk patients.

Chemotherapy-induced peripheral neuropathy: a review of recent findings.

PURPOSE OF REVIEW: Chemotherapy-induced peripheral neuropathy (CIPN) is a common, frequently chronic condition characterized by pain and decreased function. Given the growing number of cancer survivors and an increasing recognition of opioid therapy limitations, there is a need for critical analysis of the literature in directing an informed and thoughtful approach for the management of painful CIPN. RECENT FINDINGS: A PubMed search for 'chemotherapy-induced peripheral neuropathy AND pain' identifies 259 publications between 1 January 2016 and 31 March 2017. Based on review of this literature, we aim to present a clinically relevant update of painful CIPN. Notably, the use of duloxetine as a first-line agent in treatment of CIPN is confirmed. Moreover, clinical trials focus on nonpharmacologic strategies for managing painful CIPN. SUMMARY: Despite the volume of recent publications, there are limited preventive or therapeutic strategies for CIPN supported by high-level evidence. Duloxetine remains the only pharmacologic agent with demonstrated benefit; its clinical use should be routinely considered. Moving forward, nonopioid analgesic therapies will likely play an increasing role in CIPN treatment, but further research is necessary to confirm their utility. Promising therapies include vitamin B12 supplementation, physical therapy, and various forms of neuromodulation.

Anesthesia Residents Preferentially Request Operating Room Case Assignments with Complex Cases.

Self-directed learning is associated with knowledge and performance improvements, increased identification and amelioration of knowledge gaps, and heightened critical appraisal of available evidence. We developed and implemented a decision support system that could support self-directed learning for anesthesia residents by soliciting resident input in case selection. We hypothesized that residents would utilize this system to request complex cases, and that more advanced residents would request more complex cases. Prospective, observational study involving 101 anesthesiology residents. We used a web-based interface, RHINOS [Residents Helping in Navigating Operating Room (OR) Scheduling], which allowed residents to share their rank-ordered preferences for OR assignment. Number of cases per OR, anesthesia base units, time units, and proportion of inpatient cases were used as proxies for case complexity. Data were analyzed using a mixed linear model. Residents requested rooms with fewer cases [F(3,22,350) = 194.0; p < 0.001], more base units [F(3,19,158) = 291.4; p < 0.001], more time units [F(3,19,744) = 186.4; p < 0.001], and a greater proportion of cases requiring inpatient preoperative evaluation [F(3,51,929) = 11.3; p < 0.001]. In most cases, these differences were greater for more advanced residents. As hypothesized, residents requested ORs with higher case complexity, and these cases more often required inpatient preoperative evaluation. More advanced residents exhibited a stronger preference for more educational cases than junior residents.