Interventional Pain Procedures: A Narrative Review Focusing On Safety and Complications. PART 2 Interventional Procedures For Back Pain.

In patients where conservative approaches have failed to relieve from chronic pain, interventional procedures may be an option in well selected patients. In recent years there has been an increase in the use and development of invasive procedures. Concomitantly, there has also been an increase in the complications associated with these procedures. Taken this into consideration, it is important for healthcare providers to take a cautious and vigilant approach, with a focus on patient safety, in order to minimize the risk of adverse events and ensure the best possible outcome for the patient. This may include careful selection of patients for procedures, use of proper techniques and equipment, and close monitoring and follow-up after the procedure. The aim of this narrative review is to summarize the primary complications associated with commonly performed image-guided (fluoroscopy or ultrasound-guided) interventional procedures and provide strategies to reduce the risk of these complications. We conclude that although complications from interventional pain procedures can be mitigated to a certain degree, they cannot be eliminated altogether. In order to avoid adverse events, patient safety should be given considerable attention and physicians should be constantly aware of the possibility of developing complications.

The Dorsomedian Ligamentous Strand: An Evaluation In Vivo with Epiduroscopy.

Several anatomical studies have described the morphology of the spinal space; however, researchers do not all agree on the presence of the dorsomedian ligamentous strand (DLS), which divides the epidural space. The possible existence of this structure still influences some clinical practice, such as locoregional anesthesia and pain therapy. Since the number of procedures occurring inside the epidural space have increased, this study's primary objective was to describe the composition of this space through epiduroscopy. We conducted a retrospective analysis of video recorded during epiduroscopy. Two independent doctors performed blind analyses of morphological aspects of peridural space visualized during the procedure in each patient for the maximum possible extension depending on the underlying pathology in the tract from S1 to L1. We enrolled 106 patients who underwent epiduroscopy; 100% of patients presented no medial longitudinal segmentation dividing the epidural channel at any level of the spinal tract investigated, including in the epidural space with pathological fibrotic scars and in those with no adherence. The main finding of our study was the visual absence of any anatomical structure dividing the epidural channel. We report that in vivo, in our experience, with direct epiduroscopy, the DLS is not visible.

24-Month Effectiveness of Periduoscopic Adhesiolysis in Reducing the Use of Spinal Cord Stimulation in Patient With Chronic Lumbar Pain: A Possible Therapeutic Regimen?

Objectives Epiduroscopy is a minimally invasive procedure that is used in pain therapy to treat lumbar and root pain that is resistant to medical and infiltrative therapies. The indications for periduroscopy are partly shared with those of spinal cord stimulation (SCS): failed back surgery syndrome (FBSS) and stenosis of the vertebral canal in particular. The costs and risks of periduroscopy are considerably lower than those of SCS. The purpose of this study is to evaluate the clinical and economic advantages of integrating periduroscopy as a step prior to SCS for patients with severe lumbar or radicular pain that is unresponsive to pharmacological and infiltrative treatments. Materials and Methods Patients were enrolled if they had FBSS and spinal stenosis with indications for SCS and accepted periduroscopy treatment before the possible SCS trial. Patients were followed up for 24 months with evaluations of clinical data on the day after the procedure and at one and 24 months. The pain trend, satisfaction with the periduroscopy procedure, and the incidence of SCS implants in the study period were analyzed. Results A total of 106 patients were enrolled. Immediately after the procedure and in the first month, the reduction of pain and the level of patient satisfaction were high, but they were drastically reduced at 24 months with a progressive reappearance of symptoms that substantially overlapped with the pre-surgery levels. At 24 months, 48% of the patients underwent a neurostimulation trial, and a significant percentage of them were able to avoid the implantation of an SCS. Conclusions Periduroscopy appears to be rational as a step prior to SCS in terms of the improvement of pain symptoms in the short term, the definitive results in a significant percentage of patients, and the significant economic savings for the health system.

Prevalence of Low Back and Cervical Back Pain in Military Helicopter Crews: An Underestimated Italian Problem.

BACKGROUND: Studies have highlighted the incidence and prevalence of chronic pain, which is an epidemic problem in all career sectors, as well as estimated the economic loss that follows its pathology. Several studies have indicated a high incidence of chronic osteoarticular pain in military service members, particularly in flight personnel. To date, no studies have estimated the incidence of pain pathology in the Italian military population, despite the implications related to flight qualification. METHODS: A survey was conducted on helicopter flight personnel undergoing periodic annual evaluation. RESULTS: A statistically significantly higher incidence of pain pathology than that reported in the global civilian population was demonstrated. More than 80% of the interviewed population reported moderate-to-severe back pain (45% in the lumbar tract and 38% in the cervical tract). Further, it was found that most staff with chronic pain do not use drugs or other treatments for severe pain because of concerns that such treatment approaches may compromise flight qualifications. DISCUSSION: The present study observed a high incidence of pain in Italian military flight personnel and examined the degree to which this problem is undertreated in these individuals. To address this problem, further in-depth and larger investigations that include therapeutic protocols to resolve such pain pathologies should be conducted. Such investigations could help to reduce pain experienced by flight personnel and enhance the productivity of the Italian military forces while considering the pharmacologic limitations related to the task. CONCLUSION: Chronic lumbar and neck pain is more common in military helicopter crews than in the civilian population. The true figure is frequently underestimated because of staff concerns regarding the potential influence of therapies on work activity.

Ultrasound Block of the Medial Branch: Learning the Technique Using CUSUM Curves.

Background: Blocking the medial branch of the lumbar facet joints plays a fundamental diagnostic and therapeutic role in the treatment of lumbar pain. Attempts to replace the typical guided X-ray techniques with ultrasound-guided techniques have also involved treating the lumbar medial branches. By applying the cumulative sum control chart (CUSUM method), we sought to evaluate the learning curve associated with ultrasound-guided block of the lumbar medial branches in operators experienced in locoregional anesthesia but without expertise in pain therapy. Aim: This study aimed to use a repeatable method to identify the learning curve of the ultrasound-guided medial branch block. Settings and Design: This study was a prospective application of over forty consecutive procedures of ultrasound lumbar medial branch block. Materials and Methods: The ultrasound medial branch blocks were performed under ultrasound guidance with confirmation of correct positioning using fluoroscopy on a population of patients with low back pain with any body mass index (BMI). Statistical Analysis: The operator's performance was assessed using the learning curve cumulative summation test (LS-CUSUM). Results and Conclusions: The correct target was reached in 29 procedures out of a total of 40 (72.5%) and in 29 out of 36 procedures performed on patients with BMI <30 (80.5%). According to the CUSUM algorithm, 11 further consecutive successes would have been necessary (47 procedures in total) to achieve a proven learning of the technique in the group with only patients with a BMI <30, with a further 22 consecutive successes (62 procedures in total) in the general group. Ultrasound-guided block of the lumbar medial branch appears not to be optimal for training beginner/intermediate operators seeking to replace guided X-ray procedures with guided ultrasound.

Complication of epiduroscopy: a brief review and case report.

Epiduroscopy is defined as a percutaneous, minimally invasive endoscopic investigation of the epidural space. Periduroscopy is currently used mainly as a diagnostic tool to directly visualize epidural adhesions in patients with failed back surgery syndrome (FBSS), and as a therapeutic action in patients with low back pain by accurately administering drugs, releasing inflammation, washing the epidural space, and mechanically releasing the scars displayed. Considering epiduroscopy a minimally invasive technique should not lead to underestimating its potential complications. The purpose of this review is to summarize and explain the mechanisms of the side effects strictly related to the technique itself, leaving aside complications considered typical for any kind of extradural procedure (e.g. adverse reactions due to the administration of drugs or bleeding) and not fitting the usual concept of epiduroscopy for which the data on its real usefulness are still lacking. The most frequent complications and side effects of epiduroscopy can be summarized as non-persistent post-procedural low back and/or leg discomfort/pain, transient neurological symptoms (headache, hearing impairment, paresthesia), dural puncture with or without post dural puncture headache (PDPH), post-procedural visual impairment with retinal hemorrhage, encephalopathy resulting in rhabdomyolysis due to a dural tear, intradural cyst, as well as neurogenic bladder and seizures. We also report for first time, to our knowledge, a case of symptomatic pneumocephalus after epiduroscopy, and try to explain the reason for this event and the precautions to avoid this complication.

Second edition of SIMPAR's "Feed Your Destiny" workshop: the role of lifestyle in improving pain management.

This review is aimed to summarize the latest data regarding pain and nutrition, which have emerged during the second edition of Feed Your Destiny (FYD). Theme presentations and interactive discussions were held at a workshop on March 30, 2017, in Florence, Italy, during the 9th Annual Meeting of Study in Multidisciplinary Pain Research, where an international faculty, including recognized experts in nutrition and pain, reported the scientific evidence on this topic from various perspectives. Presentations were divided into two sections. In the initial sessions, we analyzed the outcome variables and methods of measurement for health claims pertaining to pain proposed under Regulation EC No 1924/2006 of the European Parliament and of the Council of 20 December 2006 on nutrition and health claims made on foods. Moreover, we evaluated how the Mediterranean diet can have a potential impact on pain, gastrointestinal disorders, obesity, cancer, and aging. Second, we discussed the evidence regarding vitamin D as a nutraceutical that may contribute to pain control, evaluating the interindividual variability of pain nature and nurture, and the role of micro-RNAs (miRNAs), polyunsaturated omega 3 fatty acids, and phenolic compounds, with a final revision of the clinical role of nutrition in tailoring pain therapy. The key take-home message provided by the FYD workshop was that a balanced, personalized nutritional regimen might play a role as a synergic strategy that can improve management of chronic pain through a precision medicine approach.

Plasma N-glycome composition associates with chronic low back pain.

BACKGROUND: Low back pain (LBP) is the symptom of a group of syndromes with heterogeneous underlying mechanisms and molecular pathologies, making treatment selection and patient prognosis very challenging. Moreover, symptoms and prognosis of LBP are influenced by age, gender, occupation, habits, and psychological factors. LBP may be characterized by an underlying inflammatory process. Previous studies indicated a connection between inflammatory response and total plasma N-glycosylation. We wanted to identify potential changes in total plasma N-glycosylation pattern connected with chronic low back pain (CLBP), which could give an insight into the pathogenic mechanisms of the disease. METHODS: Plasma samples of 1128 CLBP patients and 760 healthy controls were collected in clinical centers in Italy, Belgium and Croatia and used for N-glycosylation profiling by hydrophilic interaction ultra-performance liquid chromatography (HILIC-UPLC) after N-glycans release, fluorescent labeling and clean-up. Observed N-glycosylation profiles have been compared with a cohort of 126 patients with acute inflammation that underwent abdominal surgery. RESULTS: We have found a statistically significant increase in the relative amount of high-branched (tri-antennary and tetra-antennary) N-glycan structures on CLBP patients' plasma glycoproteins compared to healthy controls. Furthermore, relative amounts of disialylated and trisialylated glycan structures were increased, while high-mannose and glycans containing bisecting N-acetylglucosamine decreased in CLBP. CONCLUSIONS: Observed changes in CLBP on the plasma N-glycome level are consistent with N-glycosylation changes usually seen in chronic inflammation. GENERAL SIGNIFICANCE: To our knowledge, this is a first large clinical study on CLBP patients and plasma N-glycome providing a new glycomics perspective on potential disease pathology.

Transversus Abdominis Plane Block for the Diagnosis and Treatment of Chronic Abdominal Wall Pain Following Surgery: A Case Series.

OBJECTIVE: The transversus abdominis plane (TAP) block is a relatively simple regional anesthesia technique which entails the injection of local anesthetics (LA) into the interfascial plane between the internal oblique and transversus abdominis muscles, where nerves supplying the anterolateral abdominal wall course. It is widely used for acute pain management following abdominal surgical procedures. We describe a series of cases in which TAP blocks were used to aid in the diagnosis and treatment of chronic abdominal wall pain (CAWP). DESIGN: Consecutive case series of 5 patients presenting with CAWP. SETTING: Regional referral Center for Pain Medicine of the academic tertiary hospital of Parma, Italy. RESULTS: Five patients received TAP blocks with LA and steroid. Four patients reported ≥50% pain relief within hours of the procedure, and 2 of them maintained low pain intensities at 6- and 12-month follow-up calls. CONCLUSIONS: Transversus abdominis plane blocks are a valuable addition to the diagnostic armamentarium of pain physicians confronted with abdominal pain of unclear origin. Although most patients responded to the LA injection, the varying degrees of response duration may have been influenced by the different etiologies underlying each condition and the variable expressions of placebo responses. Once the abdominal wall and/or its nerves are identified as pain generators, the optimal therapeutic management remains to be determined. Available literature as well as our case series shows that long-term benefit may be obtained with 1 or more injections, but we speculate that this may only be the case for pain with predominantly neuropathic components.

Sex differences in the daily rhythmicity of morphine consumption after major abdominal surgery.

OBJECTIVE: The sex of the patients has been shown to affect postoperative pain and morphine consumption; still a clear understanding able to explain the reasons behind this difference struggles to emerge. Our research aimed to investigate one specific aspect of the variability in morphine consumption between sexes. Previous studies have shown that circadian rhythm can influence opioid consumption. Furthermore, circadian rhythm is different between female and male. Our analysis investigated the presence of differences in daily rhythmicity of morphine consumption between males and females. DESIGN: This is a secondary analysis of data collected during 2 years long multicenter clinical trial (NCT01233752). SETTINGS: Clinical data were collected in two Italian hospitals: IRCCS Foundation Policlinico S. Matteo (Pavia) and San Gerardo Hospital (Monza). PATIENTS: The authors recorded data about morphine consumption in 157 patients who underwent major abdominal surgery, who received morphine intravenous patient-controlled analgesia (IV-PCA) as postoperative analgesia. INTERVENTIONS: The authors analyzed the daily periodicity of effective boluses delivered by morphine IV-PCA with Poisson multilevel models, adjusted by the time of start for each pump. An effective bolus was defined as a correctly delivered bolus of 1 mg of morphine. The authors also evaluated the interactions among the time of the day and sex, age (

Conventional (Simplicity III) and Cooled (SInergy) Radiofrequency for Sacroiliac Joint Denervation: One-Year Retrospective Study Comparing Two Devices.

OBJECTIVE: To compare two radiofrequency (RF) devices, Simplicity III (conventional RF), and SInergy (cooled RF), which are specifically designed to denervate the sacroiliac joint (SIJ). DESIGN: Retrospective observational study. SETTING: Italian National Health Service Public Hospital. SUBJECTS: Forty-three patients with SIJ-derived pain refractory to conservative treatment; 21 and 22 patients, respectively, received Simplicity III or SInergy to denervate the SIJ. METHODS: Mean numerical rating scale (NRS) and Oswestry Disability Index (ODI) scores were determined for each study group up to 12 months postprocedure. Secondary outcomes included the average amount of time required to complete each RF procedure and the adverse events associated with each technique. RESULTS: Average SInergy group NRS and ODI scores were consistently less than those in the Simplicity III cohort at each post-RF denervation follow-up, and such differences were statistically significant at six and 12 months. The Simplicity III procedure was completed approximately 2.5 times faster than the SInergy procedure, and one minor adverse event was reported in the SInergy group. CONCLUSIONS: The study results suggest that SInergy safely afforded patients with greater and more durable analgesia and disability relief than Simplicity III for SIJ-derived pain. The Simplicity III procedure may be more conducive than SInergy for bilateral procedures and for patients who have limited tolerance to be in an RF procedure-required prone position. Randomized controlled trials are needed to confirm the implication made in this study that SInergy is the preferred RF denervation option for treating SIJ-derived pain and the disability associated with it.

Mechanisms of low back pain: a guide for diagnosis and therapy.

Chronic low back pain (CLBP) is a chronic pain syndrome in the lower back region, lasting for at least 3 months. CLBP represents the second leading cause of disability worldwide being a major welfare and economic problem. The prevalence of CLBP in adults has increased more than 100% in the last decade and continues to increase dramatically in the aging population, affecting both men and women in all ethnic groups, with a significant impact on functional capacity and occupational activities. It can also be influenced by psychological factors, such as stress, depression and/or anxiety. Given this complexity, the diagnostic evaluation of patients with CLBP can be very challenging and requires complex clinical decision-making. Answering the question "what is the pain generator" among the several structures potentially involved in CLBP is a key factor in the management of these patients, since a mis-diagnosis can generate therapeutical mistakes. Traditionally, the notion that the etiology of 80% to 90% of LBP cases is unknown has been mistaken perpetuated across decades. In most cases, low back pain can be attributed to specific pain generator, with its own characteristics and with different therapeutical opportunity. Here we discuss about radicular pain, facet Joint pain, sacro-iliac pain, pain related to lumbar stenosis, discogenic pain. Our article aims to offer to the clinicians a simple guidance to identify pain generators in a safer and faster way, relying a correct diagnosis and further therapeutical approach.

Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach.

ERAS approach (Enhanced Recovery After Surgery) is a multimodal, perioperative pathway designed to achieve early recovery after surgery. ERAS has shown documented efficacy in elective surgery, and the concept of "multimodal" and "multidisciplinary" approach seems still to be of higher importance than each single item within ERAS protocols. New perspectives include the use of ERAS in emergency surgery, where efficacy and safety on outcome have been documented, and flexibility of traditional items may add benefits for traditionally high-risk patients. Obstetric surgery, as well, may open wide horizons for future research, since extremely poor data are currently available, and ERAS benefits may translate even on the baby. Finally, the concept of "outcome" may be extended when considering the specific setting of cancer surgery, in which variables like cancer recurrence, early access to adjuvant therapies, and, finally, long-term survival are as important as the reduced perioperative complications. In this perspective, different items within ERAS protocols should be reinterpreted and eventually integrated towards "protective" techniques, to develop cancer-specific ERAS approaches keeping pace with the specific aims of oncologic surgery.