A Prospective, Randomized Single-Blind Crossover Study Comparing High-Frequency 10,000 Hz and Burst Spinal Cord Stimulation.

OBJECTIVES: Although both high-frequency and burst spinal cord stimulation (SCS) have shown improved efficacy and patient satisfaction compared with conventional tonic stimulation, there are limited data directly comparing the two. This study aimed to compare both high-frequency 10,000 Hz and burst SCS in the same patients in terms of pain relief and satisfaction in those with axial back pain with or without leg pain. MATERIALS AND METHODS: This prospective, single-blind, randomized controlled trial was conducted at an outpatient pain clinic within an academic medical center. Participants were randomly allocated to one of two groups in which they trialed either burst or high-frequency 10,000 Hz SCS over five days, followed by a 24- to 48-hour washout period with no stimulation, and the alternative therapy over the remaining four days. Visual analog scale (VAS) scores were collected immediately before and after both therapy trials. Secondary end points included percentage change in VAS score and patient preference. RESULTS: Of 25 participants, those receiving burst followed by high-frequency SCS (n = 11) had a mean VAS difference of 4.73 after the first trial period and 2.86 after the second. Of those receiving high-frequency followed by burst SCS (n = 14), mean VAS difference after the first trial period was 4.00 and 1.93 after the second trial period. Four participants were withdrawn owing to lead migration. Both therapies showed statistically significant differences in pre- minus post-VAS scores and percent relief. There were no significant differences in carryover or treatment effects between the two groups. There was a statistically significant association between trial sequence and stimulator type implanted because the first stimulator trialed was more likely to be chosen. CONCLUSIONS: There were no observed differences in VAS pain score decrease when comparing burst and high-frequency 10,000 Hz SCS programming therapies. Patient preference followed an order effect, favoring the first programming therapy in the trial sequence.

The Impact of Isolation During COVID-19 on Chronic Musculoskeletal Pain in the Geriatric Population: A Narrative Review.

BACKGROUND: During the COVID-19 pandemic, social distancing has been employed to decrease the spread of COVID-19, especially within the geriatric population; however, the resulting loneliness and isolation carry their own detrimental effects. Loneliness resulting from the COVID-19 pandemic may also have negative implications on those with chronic musculoskeletal pain. OBJECTIVES: The aim of this review was to identify the role of loneliness specific to the recent COVID-19 pandemic as it relates to the prevalence and severity of chronic pain in the geriatric population and to provide an overview for clinicians. STUDY DESIGN: Narrative review. METHODS: A literature search was conducted using combinations of relevant search terms. Databases included PubMed and relevant grey literature sources. Reference lists of selected articles were also searched for additional relevant literature. RESULTS: Recent literature supports that social isolation and loneliness stemming from the COVID-19 pandemic have negative implications on chronic musculoskeletal pain. Loneliness has been well documented to have deleterious effects on physical and mental health, and it is increasingly linked to worsening debility and pain interference for those with chronic musculoskeletal pain. This has been found to be most prominent in the geriatric population, who are at the greatest risk for social decline and loneliness. Loneliness has also been found to have negative effects on cardiovascular disease, infectious disease, and mental health, as well as cognitive decline. LIMITATIONS: Potential selection bias due to the narrative review design. Some included studies required the use of online questionnaires, which may not be accessible for the geriatric population, those without technology literacy, or low socioeconomic status populations. Future studies should emphasize screening patients for access to technological devices and reliable internet while partnering with community programs focused on digital literacy and resource access. CONCLUSIONS: A myriad of deleterious effects stemming from social isolation and loneliness have been documented, of which geriatric populations are especially susceptible. Both early identification of at-risk patients and safe interventions are essential to mitigate loneliness and stop the progression of debility. Further resources and research are necessary to illuminate how best to proceed, both in the setting of the ongoing pandemic and how interventions can be applied to alleviate suffering in those with limited ability to receive hospital or clinic-based care.

Antitumor necrosis factor alpha and an epidural abscess during a spinal cord stimulator trial: A case report.

Spinal cord stimulation (SCS) is commonly utilized for treatment and management of chronic intractable low back and lower extremity pain. Although SCS is an overall low-risk procedure, there are potential life-threatening complications, including surgical site infections, such as an epidural abscess. Immunosuppression, a risk factor for epidural abscess, is becoming more common as an increasing number of patients are being treated with biologics for a multitude of autoimmune disorders. One class of commonly utilized biologics is antitumor necrosis factor (anti-TNF) alpha. Whereas these drugs can provide tremendous benefit for treatment and management of autoimmune disorders, there is no clear understanding of the degree to which these medications increase a patient's risk for surgical site infection, including those associated with SCS-related procedures. We present a case of an epidural abscess that developed immediately following an SCS trial in a patient with multiple undisclosed risk factors, including the use of an anti-TNF alpha agent to treat ankylosing spondylitis. For an epidural abscess, early diagnosis is key to preventing devastating complications and the need for surgical intervention. Immunosuppression can be the result of multiple issues including cancer, HIV, and biologic agents, such as anti-TNF alpha for the management of autoimmune diseases. There is limited evidence pertaining to the development of epidural abscesses in patients on anti-TNF alpha medications who undergo SCS. Studies focused on infections in patients undergoing SCS trials and permanent implants while on anti-TNF alpha agents could provide recommendations and guidance.

Physician and executive collaboration on rapid development of pandemic needs response to support physicians and medical staff during the COVID-19 pandemic in an academic medical center: a descriptive review.

Dialogue on physician well-being was concerning even prior to onset of the COVID-19 pandemic, which introduced additional unprecedented strain on healthcare workers compounded by increased personal and family stress. This paper describes our process for a rapid needs assessment and creation of a pandemic resiliency and well-being support infrastructure for physicians and healthcare staff at an academic medical center. In March 2020, executive leadership from our health system and physician group created a Resiliency and Support Steering Committee (RSSC) for rapid development of a pandemic needs response for our healthcare providers. RSSC identified key priorities: psychological care, medical care, basic care, and communication. A brief pandemic-focused needs survey was designed and distributed to healthcare professionals and targeted efforts focused on initiatives prioritized by respondents. A shared drive database allowed initiatives and outcomes to be communicated in real time. A wellness webpage was rapidly built and disseminated. Psychological support initiatives included proactive and reactive support. Providers were offered rapid access scheduling for primary medical care. Vetted resources were shared for regional grab-and-go food, grocery delivery, laundry services, and childcare. Additional resources included personal protective equipment (PPE) supply chain information, PPE guideline updates and training and access to scrubs/scrub laundering. Our pandemic support will fold into ongoing wellness initiatives that will be tailored and intentionally communicated. Multimodal and intentional communication processes will continue with a focus on enhancing bidirectional platform functionality. Cultural awareness of the importance of mitigating distress and supporting well-being will be prioritized through partnership with frontline members and leadership.

Spinal Radiofrequency Ablation Combined with Cement Augmentation for Painful Spinal Vertebral Metastasis: A Single-Center Prospective Study.

BACKGROUND: The spine is the most common site of skeletal metastatic disease. Vertebral body metastases (VBM) can cause crippling pain, fractures, and spinal cord compression. Radiofrequency ablation (RFA) is a minimally invasive technique that has proven to be a safe method of targeted tissue destruction. Studies have shown that RFA combined with cement vertebral augmentation is safe and effective and has been associated with significant improvements in pain and quality of life. OBJECTIVES: The purpose of this study was continued evaluation of the safety and efficacy of this technique. STUDY DESIGN: Prospective cohort. SETTING: A single academic medical center. METHODS: Patients undergoing RFA with cement vertebral augmentation for a painful thoracic or lumbar VBM were eligible for inclusion. Additional inclusion criteria included pain concordant with a metastatic lesion on cross-sectional imaging, aged 18 years or older, and considered candidates for spinal tumor ablation by the operating physician. Patients with vertebral metastatic disease in the cervical spine or patients with spinal cord compression from posterior tumor extension were excluded. Ablation within each VBM was performed using a bipolar radiofrequency probe with an extensible electrode and available articulation, permitting vertebral body navigation percutaneously. Patients were evaluated at baseline, 3 days, one week, one month, and 3 months using the Numeric Rating Scale (NRS-11) and Functional Assessment of Cancer Therapy-General 7 (FACT-G7) to assess pain and quality-of-life, respectively. A one-sample t test was performed, and 95% confidence intervals were calculated to assess changes in average NRS-11 and FACT-G7 scores. RESULTS: A total of 30 patients met inclusion criteria and underwent RFA of one or more VBM. Patients with 13 different primary cancers types underwent treatment. Patients received RFA to either one (n = 26; 87%) or 2 vertebral body levels (n = 4; 13%). Of the 34 levels, 13 were thoracic vertebra (38%) and 21 were lumbar vertebra (62%). Average NRS-11 scores decreased from a baseline of 5.77 to 4.65 (3 days; P = 0.16), 3.33 (one week; P < 0.01), 2.64 (one month; P < 0.01), and 2.61 (3 months; P < 0.01). FACT-G7 increased from a baseline average of 13.0 to 14.7 (3 days; P = 0.13), 14.69 (one week; P = 0.15), 14.04 (one month; P = 0.35), and 15.11 (3 months; P = 0.07). No major adverse events were reported. LIMITATIONS: A heterogeneous patient population, small sample size, and potential confounders of concurrent variable adjuvant therapies were limitations. Additionally, most patients received both cement augmentation and targeted RFA, making it difficult to distinguish independent analgesic benefits of the therapies. CONCLUSIONS: This study demonstrates that minimally invasive targeted RFA with cement augmentation of spinal metastatic lesions is an effective treatment for patients with VBM. KEY WORDS: Cancer, cancer pain, spinal metastasis, radiofrequency ablation, tumor ablation, cement augmentation.

The Prevalence of Post-Traumatic Stress Disorder Symptoms in Chronic Pain Patients in a Tertiary Care Setting: A Cross-Sectional Study.

BACKGROUND: There is limited research regarding the prevalence of post-traumatic stress disorder (PTSD) in civilian multidisciplinary pain clinics. Controlled studies have only examined specific patient populations, such as those with motor vehicle accidents, war veterans, work-related injuries, back pain, and headache. OBJECTIVE: The purpose of this study was to estimate the prevalence of PTSD symptoms in patients with chronic pain at a large multidisciplinary pain clinic. METHODS: Three hundred consecutive new or newly referred patients with a self-reported history of chronic pain were recruited to complete an in-person screen for PTSD symptoms, which included the Brief Trauma Questionnaire and the PTSD Symptom-Scale Self-Report. Two hundred and sixty-five were eligible for the study. RESULTS: Seventy-four (28%) screened positive for PTSD symptoms, a value higher than the lifetime prevalence of PTSD in the general population (6.8%). Those who screened positive for PTSD symptoms were significantly younger (p = 0.007) and had higher levels of pain intensity (p = 0.0005) compared to those who screened negative for PTSD symptoms. CONCLUSIONS: The prevalence of PTSD symptoms in our chronic pain population (28%) exceeded the prevalence of PTSD in the general population (7%). Patients with chronic pain who screened positive for PTSD reported higher pain severity and were younger. This emphasizes the need for PTSD screening in the chronic pain population, as early identification and treatment may be effective in reducing the mounting health care costs and disease burden of comorbid chronic pain and PTSD.

Retrospective Analysis of Intrathecal Drug Delivery: Outcomes, Efficacy, and Risk for Cancer-Related Pain at a High Volume Academic Medical Center.

OBJECTIVES: Cancer pain is common and difficult to treat, as conservative medical management fails in approximately 20% of patients for reasons such as intolerable side-effects or failure to control pain. Intrathecal drug delivery systems (IDDS), while underutilized, can be effective tools to treat intractable cancer pain. This study aims to determine the degree of pain relief, efficacy, and safety of patients who underwent IDDS implantation at a multidisciplinary pain clinic. MATERIALS AND METHODS: A retrospective review was conducted of patients with an intrathecal pain pump implanted for malignant pain. Charts were reviewed for demographics, cancer type, pain scores before and after implantation, and intrathecal drugs utilized. A Wilcoxon Signed-Rank test was conducted on the paired differences of pain scores before and after implant. A regression analysis was conducted using a linear model to assess effects of demographic variables on change in pain scores. RESULTS: 160 patients were included in analysis. The median pain score was 7.1 at time of implantation and 5.0 at one-month postimplantation. For patients with both baseline and one-month pain scores available, the median decrease in pain was 2.5 (p < 0.0001). Pain scores three-month postimplantation did not significantly differ from one-month postimplantation. Median longevity was 65 days. Five patients had pumps explanted due to infection with a median time to pump extraction of 28 days. CONCLUSIONS: IDDS has the potential to improve cancer pain in a variety of patients and should be strongly considered as an option for those with cancer pain intractable to conservative medical management.

Reducing Radiation Exposure in Lumbar Transforaminal Epidural Steroid Injections with Pulsed Fluoroscopy: A Randomized, Double-blind, Controlled Clinical Trial.

BACKGROUND: Fluoroscopy-guided lumbar transforaminal epidural steroid injections (L-TFESI) result in radiation exposure that carries risks to patients, physicians, and procedural staff. OBJECTIVE: We aim to evaluate the feasibility of using pulsed fluoroscopy to safely reduce radiation exposure during L-TFESI. STUDY DESIGN: This is a prospective, double-blind, randomized controlled trial. SETTING: This study took place in a single-center, academic, outpatient interventional pain management clinic. METHODS: Patients undergoing L-TFESI were randomly assigned to either continuous mode fluoroscopy (high-dose), pulsed fluoroscopy with 8 pulses per second (medium-dose), or pulsed fluoroscopy with one pulse per second (low-dose). Data on radiation doses and other clinical and demographic factors were also collected. RESULTS: In total, 231 cases were analyzed in the high-dose group (n = 81), medium-dose group (n = 72), and low-dose group (n = 78). Mean radiation effective dose (µSv) was 121 in the high-dose group, 57.9 in the medium-dose group, and 34.8 in the low-dose group (P < 0.001). The incidence of inadequate image quality in the pulsed groups was 6% (9/150). The body mass index (BMI, mean ± SD) was significantly higher in patients with inadequate image quality (37.3 ± 7.2) than with adequate quality (30.5 ± 7.2, P = 0.005). LIMITATIONS: Radiation doses were measured using the meter on C-arm fluoroscopes rather than by direct measurement. CONCLUSIONS: The use of pulsed fluoroscopy during L-TFESI resulted in radiation dose reduction of up to 72.1% without causing any significant adverse events. Pulsed fluoroscopy should be considered as an initial fluoroscopic setting for L-TFESI to reduce radiation exposure. KEY WORDS: Radiation, epidural, fluoroscopy, injection, exposure, pulse.

Perioperative Factors Affecting Ambulatory Outcomes Following Laparoscopic-Adjustable Gastric Banding.

OBJECTIVE: Morbidly obese patients are traditionally hospitalised following bariatric surgery. However, laparoscopic-adjustable gastric banding (LAGB) is amenable for ambulatory care. We hypothesised that the majority of patients can receive an ambulatory LAGB and that both surgical and anaesthetic perioperative factors will significantly affect non-ambulatory LAGB outcomes. METHODS: Medical records of 201 consecutive LAGB patients performed at the University of Kansas Medical Centre during a 3-y period were reviewed. Demographic, medical, laboratory, anaesthetic, intraoperative and postoperative data were collected. Factors associated with non-ambulatory outcomes were identified and analysed using logistic regression, and a classification tree analysis was used to rank the descriptive model factor to the non-ambulatory outcome. RESULTS: Average patient age was 43.4±11.4 years, and average body mass index was 48.2±10.3 kg m2-1. A total of 155 patients (77.1%; 95% confidence interval, 71%-83%; p<0.0001) were discharged home within 2-3 hours of surgery, whereas 36 stayed for 23 hours and 10 required hospital admission for 1-2 days. Increased surgical port numbers (p=0.007), ≥50% of total intraoperative fentanyl administered in the recovery room (post-anaesthesia care unit) for the treatment of postoperative pain (p=0.007) and a lack of prophylactic beta-blockade (p=0.001) were three factors associated with non-ambulatory outcomes. Obstructive sleep apnoea was not associated with a non-ambulatory outcome (p=0.83). CONCLUSION: The majority of patients received an ambulatory LAGB. Meticulous laparoscopic surgical technique with the least feasible number of access ports and multimodal analgesic technique aimed at reduction of postoperative opioid consumption are the most important factors for a successful ambulatory LAGB outcome.

Novel use of a noninvasive hemodynamic monitor in a personalized, active learning simulation.

The present study furthered the concept of simulation-based medical education by applying a personalized active learning component. We tested this novel approach utilizing a noninvasive hemodynamic monitor with the capability to measure and display in real time numerous hemodynamic parameters in the exercising participant. Changes in medical knowledge concerning physiology were examined with a pre-and posttest. Simply by observation of one's own hemodynamic variables, the understanding of complex physiological concepts was significantly enhanced.