Contact Heat in Magnetoencephalography: A Systematic Review.

BACKGROUND: Contact heat is commonly used in experimental research to evoke brain activity, most frequently acquired with electroencephalography (EEG). Although magnetoencephalography (MEG) improves spatial resolution, using some contact heat stimulators with MEG can present methodological challenges. This systematic review assesses studies that utilise contact heat in MEG, their findings and possible directions for further research. METHODS: Eight electronic databases were searched for relevant studies, in addition to the selected papers' reference lists, citations and ConnectedPapers maps. Best practice recommendations for systematic reviews were followed. Papers met inclusion criteria if they used MEG to record brain activity in conjunction with contact heat, regardless of stimulator equipment or paradigm. RESULTS: Of 646 search results, seven studies met the inclusion criteria. Studies demonstrated effective electromagnetic artefact removal from MEG data, the ability to elicit affective anticipation and differences in deep brain stimulation responders. We identify contact heat stimulus parameters that should be reported in publications to ensure comparisons between data outcomes are consistent. CONCLUSIONS: Contact heat is a viable alternative to laser or electrical stimulation in experimental research, and methods exist to successfully mitigate any electromagnetic noise generated by PATHWAY CHEPS equipment - though there is a dearth of literature exploring the post-stimulus time window.

Biologic Drugs as Analgesics for the Management of Low Back Pain and Sciatica.

OBJECTIVE: To discuss the current knowledge on the impact of commonly used biologic agents (i.e., anti-tumor necrosis factor-alpha [anti-TNF-α] and anti-nerve growth factor [anti-NGF]) in the management of low back pain with or without sciatica. METHODS: A narrative literature review of studies investigating the use of biologic agents for the management of low back pain and sciatica was conducted. We searched MEDLINE and EMBASE for English language publications. A hand-search of reference lists of relevant studies was also performed. RESULTS: Although some observational studies showed that inhibition of TNF-α reduced pain and improved function, randomized controlled trials and a meta-analysis failed to demonstrate the superiority of anti-TNF-α over placebo in this regard. Anti-TNF-α, however, reduced the risk of having invasive procedures such as discectomy and radicular block in cases of sciatica. Conversely, controlled studies showed moderate pain reduction and mild functional improvement with anti-NGF administration, but the side effect profile of anti-NGF was unfavorable compared with placebo. CONCLUSIONS: Overall, anticytokine treatments have limited efficacy in patients with chronic low back pain with or without sciatica. However, larger and better-designed studies may need to be performed in specific patient subpopulations. Low back pain is particularly disabling in younger patients. This group therefore represents a potential target population for investigating the effectiveness of anticytokine therapies, especially where other pharmacological and nonpharmacological management strategies have failed.

Intrathecal Drug Delivery Systems for the Management of Chronic Noncancer Pain: A Systematic Review of Economic Evaluations.

BACKGROUND: Intrathecal drug delivery (ITDD) systems are one of a limited number of management options for chronic noncancer pain, cancer pain, and spasticity. Concerns over their effectiveness and high initial costs led National Health Service (NHS) England to decommission ITDD for patients with chronic noncancer pain. However, the extent to which this decision is in line with existing economic evidence is unclear. The aim of this systematic review was to identify and review the existing evidence on the cost effectiveness of ITDD for chronic noncancer pain. METHODS: Full and partial economic evaluations on ITDD were identified through systematic searches in MEDLINE, Embase, Web of Science, and the NHS for Reviews and Dissemination databases. Database searches were complemented by hand searching of reference lists of relevant studies and searches of grey literature. Study selection was carried out by 2 assessors, independently. Study quality assessment was performed to inform critical appraisal of health economics studies. Data were extracted using a data extraction form developed for the purposes of this study. RESULTS: Four thousand four hundred and sixty-four unique studies were identified, of which 7 met the inclusion criteria. With the exception of 1 study, the studies found ITDD to be either cost saving or cost effective compared to conventional medical management. ITDD became cost ineffective in 1 further study following price year adjustment to 2016. CONCLUSIONS: Study findings showed ITDD to be not cost effective only in extremely conservative scenarios. There is limited evidence on the effectiveness of ITDD in noncancer pain; however, the available economic evidence controverts arguments to refute the treatment on economic grounds.

An overview of treatment approaches for chronic pain management.

Pain which persists after healing is expected to have taken place, or which exists in the absence of tissue damage, is termed chronic pain. By definition chronic pain cannot be treated and cured in the conventional biomedical sense; rather, the patient who is suffering from the pain must be given the tools with which their long-term pain can be managed to an acceptable level. This article will provide an overview of treatment approaches available for the management of persistent non-malignant pain. As well as attempting to provide relief from the physical aspects of pain through the judicious use of analgesics, interventions, stimulations, and irritations, it is important to pay equal attention to the psychosocial complaints which almost always accompany long-term pain. The pain clinic offers a biopsychosocial approach to treatment with the multidisciplinary pain management programme; encouraging patients to take control of their pain problem and lead a fulfilling life in spite of the pain.

Comparison of the Effects of Intermittent Boluses to Simple Continuous Infusion on Patients' Global Perceived Effect in Intrathecal Therapy for Pain: A Randomized Double-Blind Crossover Study.

Objective: Intrathecal drug delivery (ITDD) is commonly used for intractable pain management. A paucity of good-quality studies in chronic noncancer patients and concerns over increased dosages have focused interest on different modes of administration. The aim of this international multicenter randomized double-blind crossover trial was to compare the efficacy of the same daily dose of drugs administered by intermittent boluses vs simple continuous infusion. Methods: Eligible patients implanted with a programmable ITDD device were randomized to receive two weeks of either intermittent boluses or a simple continuous flow in period 1, followed by a crossover to the alternative mode of administration. The primary outcome measure was the Patients' Global Impression of Change (PGIC) scale. Results: The mean proportion of positive responders (at least "minimally improved") was 38.4% in the continuous condition vs 37.3% in the bolus (difference in proportions = 1.1%, 95% confidence interval [CI] = -21.8-24.0%, P = 0.93). The mean PGIC in the continuous condition was 3.8 vs 3.9 in the bolus (mean difference = -0.1, -0.6-0.4, P = 0.72). Exploratory analyses revealed a tendency for the mean proportion of positive responders to be higher at low vs high flow rates for both bolus and continuous administrations. Two patients were withdrawn from the study due to adverse events during the bolus phase, both with symptoms of increased pain, and one patient with additional symptoms of numbness and urinary retention. Conclusion: The mean PGIC and proportion of positive responders was not substantially different after intermittent bolus vs continuous administration.

Intrathecal drug delivery systems for the management of chronic non-cancer pain: protocol for a systematic review of economic evaluations.

INTRODUCTION: Intrathecal drug delivery (ITDD) systems are an option for the management of patients with chronic non-cancer pain, cancer pain and spasticity. Concerns over their invasiveness and high initial costs have led National Health Service (NHS) England to decommission ITDD for patients with chronic non-cancer pain. However, the extent to which this decision is in line with existing economic evidence is unclear. To address this question, we will carry out a systematic review to identify and evaluate the existing evidence on the cost-effectiveness of ITDD for chronic non-cancer pain. METHODS AND ANALYSIS: A high-sensitivity search strategy will be employed in Cochrane Library, MEDLINE, EMBASE, Web of Science, NHS EED, DARE and HTA. Database searches will be complemented by additional searching techniques. Screening of the results will be performed by 2 reviewers independently using predetermined inclusion and exclusion criteria. Full and partial economic evaluations will be included. Data extraction will be carried out using a form created for the purposes of this review. Quality assessment of all included studies will be performed using recommended checklists. ETHICS AND DISSEMINATION: Ethical approval is not required as primary data will not be collected. Findings will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42016035266.

Electroencephalographic evoked pain response is suppressed by spinal cord stimulation in complex regional pain syndrome: a case report.

Pain is a subjective response that limits assessment. The purpose of this case report was to explore how the objectivity of the electroencephalographic response to thermal stimuli would be affected by concurrent spinal cord stimulation. A patient had been implanted with a spinal cord stimulator for the management of complex regional pain syndrome of both hands for 8 years. Following ethical approval and written informed consent we induced thermal stimuli using the Medoc PATHWAY Pain & Sensory Evaluation System on the right hand of the patient with the spinal cord stimulator switched off and with the spinal cord stimulator switched on. The patient reported a clinically significant reduction in thermal induced pain using the numerical rating scale (71.4 % reduction) with spinal cord stimulator switched on. Analysis of electroencephalogram recordings indicated the occurrence of contact heat evoked potentials (N2-P2) with spinal cord stimulator off, but not with spinal cord stimulator on. This case report suggests that thermal pain can be reduced in complex regional pain syndrome patients with the use of spinal cord stimulation and offers objective validation of the reported outcomes with this treatment.

Attrition with spinal cord stimulation.

The aim of this prospective study was to investigate whether spinal cord stimulation (SCS) significantly reduces pain intensity for up to 18-month follow-up in patients with chronic neuropathic pain. Forty-eight patients were recruited. Patients rated their pain using a Visual analog scale (VAS) and pain-related disability using the Oswestry Disability Index (ODI) at baseline (1 week prior to SCS surgery) and at 6-, 12-, and 18-month follow-up. Pain intensity significantly decreased from baseline to all 3 time points [F (3,135) = 16.264, p < 0.001]. The greatest difference in the reduction of pain intensity was observed between baseline (M = 7.20, SD = 1.34) and 6-month follow-up (M = 4.60, SD = 2.20), [t(47) = 6.741, p < 0.001]. However, when looking at differences between the 6-month follow-up and subsequent assessments, statistically significant increases in pain intensity from the 6-month to the 12-month follow-up [t(47) = -2.788, p = 0.008], and from the 6-month to the 18-month follow-up [t(47) = -3.339, p = 0.002] could be observed. Statistically significant changes were also observed for clinical changes in pain scores [F (2,94) = 4.972, p = 0.009. There was a significant decrease in the percentage of clinical change obtained from the 6-month (M = 33.19, SD = 35.63) to the 12-month follow-up (M = 23.76, SD = 33.62), [t(47) = 2.347, p = 0.025], and from the 6-month to the 18-month follow-up (M = 18.34, SD = 33.51), [t(47) = 3.072, p = 0.004]. A number of patients also reported higher levels of pain intensity at the 12-and 18-month follow-up than at baseline. Pain-related disability scores significantly decreased from baseline (M = 55.04, SD = 16.43) to the 6-month follow up (M = 46.98, SD = 19.05), [t(47) = 3.464, p = 0.001] and from baseline to the 12-month follow up (M = 48.49, SD = 20.94), [t(47) = 2.918, p = 0.005], but not during the 18-month follow up (M = 51.75, SD = 20.92), [t(47) = 1.330, p = .190]. There was a significant increase in pain-related disability between the 6- and the 18-month follow up [t(47) = -2.188. p = 0.034]. These findings suggest that the beneficial effect of SCS on pain intensity may diminish over time, and that the 6-month follow-up scores may reflect a placebo effect.

Analysis of psychological characteristics impacting spinal cord stimulation treatment outcomes: a prospective assessment.

BACKGROUND: Psychological factors are recognised as influencing the outcome of spinal cord stimulation (SCS) although there is currently no consensus as to which factors impact upon SCS efficacy. OBJECTIVE: To identify psychological characteristics that may impact the efficacy of SCS. STUDY DESIGN: Prospective evaluation. SETTING: Single secondary care center in Dudley, United Kingdom. PATIENTS: Seventy-five patients were initially recruited and 56 patients (31 women and 25 men) were followed-up for 12-months. INTERVENTION: SCS for the management of chronic non-cancer pain. MAIN OUTCOME MEASURES: Outcome measures assessed at baseline, 6 months, and 12 months following SCS implantation included the visual analogue scale (VAS), Oswestry disability index (ODI), hospital anxiety and depression (HAD) scale, and the pain coping strategies questionnaire (PCSQ). RESULTS: Statistically significant improvements were observed for the VAS (P < 0.001), ODI (P = 0.011), anxiety (P = 0.042), and depression (P = 0.010) in the HAD scale and for the subscales reinterpreting pain sensation (P = 0.018), control over pain (P = 0.001), and ability to decrease pain (P < 0.001) of the PCSQ. We observed that depression and autonomous coping (control over pain, ability to reduce pain, and catastrophizing) may impact sensory aspects such as pain intensity and disability scores affecting the outcome of SCS treatment. Age at time of implant and duration of pain prior to implant were also found to impact SCS efficacy. LIMITATIONS: It has been reported that loss of analgesia may be experienced within 12 to 24 months following SCS implantation and therefore, it would be of interest to follow patients over a longer period. CONCLUSIONS: This study demonstrates that psychological aspects such as depression and autonomous coping may impact SCS treatment. Addressing these issues prior to SCS implantation may improve SCS long-term outcome.

Neuropathic pain in osteoarthritis: a review of pathophysiological mechanisms and implications for treatment.

OBJECTIVES: Osteoarthritis (OA) is the leading cause of musculoskeletal pain and functional disability worldwide, affecting a growing number of individuals in the western society. Despite various conservative and interventional treatment approaches, the overall management of the condition is problematic, and pain-the major clinical problem of the disease-remains sub-optimally controlled. The objectives of this review are to present the pathophysiologic mechanisms underlying the complexity of pain in OA and to discuss the challenges for new treatment strategies aiming to translate experimental findings into daily clinical practice. METHODS: A narrative literature review of studies investigating the existence of a neuropathic component in OA pain was conducted. We searched PubMed, Embase and Scopus for English language publications. A hand-search of reference lists of relevant studies was also performed. RESULTS: Recent advances have shed additional light on the pathophysiology of osteoarthritic pain, highlighting the contribution of central pain pathways together with the sensitisation of peripheral joint receptors and changes of the nociceptive process induced by local joint inflammation and structural bone tissue changes. Thus, a neuropathic pain component may be predominant in individuals with minor joint changes but with high levels of pain refractory to analgesic treatment, providing an alternative explanation for osteoarthritic pain perception. CONCLUSION: A growing amount of evidence suggests that the pain in OA has a neuropathic component in some patients. The deeper understanding of multiple mechanisms of OA pain has led to the use of centrally acting medicines that may have a benefit on alleviating osteoarthritic pain. The ineffective pain management and the increasing rates of disability associated with OA mandate for change in our treatment paradigm.

Osteoarthritis pain has a significant neuropathic component: an exploratory in vivo patient model.

Osteoarthritis is the most common form of arthritis and includes manifestations of both nociceptive and neuropathic mechanisms. Intravenous lignocaine, a sodium channel blocker and neuronal membrane stabiliser, has been shown in controlled trials to be effective in neuropathic pain; however, the outcome of intravenous lignocaine in osteoarthritis patients has not been assessed yet. The existence of a neuropathic component to the pain of osteoarthritis was investigated by examining possible benefits upon sensory aspects of pain in osteoarthritis patients receiving intravenous lignocaine therapy. Retrospective observational study was carried out using health data routinely collected for non-research purposes. Patients with generalised osteoarthritis who had not responded to more conservative treatments were recruited sequentially and scheduled for intravenous lignocaine therapy either in the rheumatology or pain relief departments. Assessment of efficacy was carried out through a questionnaire including sensory, psychological and social aspects of pain. The sample consisted of 17 women (60.7%) and 11 men (39.3%) with an average age at the time of treatment of 59 ± 11 years. The average pain relief calculated from the NRS scores was 30.2 ± 21.4%, and the mean duration of pain relief was 10 ± 6 weeks. Pain intensity (p < 0.001), pain relief (p < 0.003) and mobility (p < 0.003) were all significantly improved after administration of lignocaine intravenous infusion therapy. Pain was significantly reduced in a group of osteoarthritis patients after administration of intravenous lignocaine. This suggests that part of the pain mechanism in this patient group may be neuropathic, appears to contribute significantly to the patients' pain, and requires further investigation in studies designed specifically for the purpose.

Randomised, double-blind controlled trial by dose reduction of implanted intrathecal morphine delivery in chronic non-cancer pain.

OBJECTIVE: This study aimed to investigate the efficacy of intrathecal morphine in the long term by hypothesising that a reduction of the intrathecal opioid dose following long-term administration would increase the level of pain intensity. DESIGN: Randomised, double-blind, controlled, parallel group trial. SETTING: Department of Pain Management, Russells Hall Hospital, Dudley, UK. PARTICIPANTS: 24 patients with non-cancer pain implanted with morphine reservoirs were assessed for eligibility. INTERVENTIONS: Participants were randomly allocated to one of two parallel groups in which one of the groups had no change in morphine dose and the other group had a small reduction (20%) in dosage every week during a 10-week follow-up. OUTCOME: Primary outcomes were visual analogue scale (VAS) pain score change and withdrawal from the study due to lack of efficacy. RESULTS: 9 of the patients assessed for eligibility declined to participate in the study. 15 patients were randomised to control (n=5) or intervention (n=10) and included in an intention-to-treat analysis. Owing to worsening of pain, seven patients withdrew from the study prematurely. None knew prior to withdrawal which arm of the study they were in, but all turned out to be in the dose-reduction arm. The calculation of dropout rates between groups indicated a significant statistical difference (p=0.026) and recruitment was ceased. The VAS change between baseline and the last observation was smaller in the control group (median, Mdn=11) than in the intervention group (Mdn=30.5), although not statistically significant, Z=-1.839, p=0.070; r=-0.47. Within groups, VAS was significantly lower at baseline (Mdn=49.5) than at the last observation (Mdn=77.5) for the reduction group, Z=-2.805, p=0.002; r=-0.627 but not for the control group (p=0.188). CONCLUSIONS: This double-blind randomised controlled trial of chronic intrathecal morphine administration suggests the effectiveness of this therapy for the management of chronic non-cancer pain. However, owing to the small number of patients completing the study (n=8), further studies are warranted. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Centre (ISRCTN 33733462).

A narrative review of the impact of disbelief in chronic pain.

Although the experience of being believed is frequently alluded to in chronic pain literature, few studies have specifically explored this phenomenon and even fewer reviews have been offered. This narrative review sought to explore the wider social context in which individuals with chronic pain may experience disbelief toward their pain. Articles were obtained through a search of eight databases and a hand search of the references of full-text papers. Key results within the articles were noted and integrated to form three main themes: stigma, the experience of isolation, and the experience of emotional distress. The experience of stigma can occur in a number of ways. It may be through actual or perceived encounters with others; it can be through the use of psychologic explanations of pain; it can come through a perceived challenge to one's integrity and subsequently affect an individual's identity; and such stigma may be influenced by negative female stereotypes. The loss of relationships associated with being disbelieved can lead to the experience of isolation. This may be self-initiated, particularly when an individual has been given a contested diagnosis. Finally, disbelief can lead to emotional distress. This can take the form of guilt, depression, and anger. Throughout the article, implications for health care professionals, working with individuals living with chronic pain, are discussed.

Hypogonadism and low bone mineral density in patients on long-term intrathecal opioid delivery therapy.

OBJECTIVES: This study aimed to investigate the hypothalamic-pituitary-gonadal axis in a sample of male patients undertaking intrathecal opioid delivery for the management of chronic non-malignant pain and the presence of osteopaenia and/or osteoporosis in those diagnosed with hypogonadism. DESIGN: Observational study using health data routinely collected for non-research purposes. SETTING: Department of Pain Management, Russells Hall Hospital, Dudley, UK. PATIENTS: Twenty consecutive male patients attending follow-up clinics for intrathecal opioid therapy had the gonadal axis evaluated by measuring their serum luteinising hormone, follicle stimulating hormone, total testosterone, sex hormone binding globulin and calculating the free testosterone level. Bone mineral density was measured by DEXA scanning in those patients diagnosed with hypogonadism. RESULTS: Based on the calculated free testosterone concentrations, 17 (85%) patients had biochemical hypogonadism with 15 patients (75%) having free testosterone <180 pmol/L and 2 patients (10%) between 180 and 250 pmol/L. Bone mineral density was assessed in 14 of the 17 patients after the exclusion of 3 patients. Osteoporosis (defined as a T score ≤-2.5 SD) was detected in three patients (21.4%) and osteopaenia (defined as a T score between -1.0 and -2.5 SD) was observed in seven patients (50%). Five of the 14 patients (35.7%) were at or above the intervention threshold for hip fracture. CONCLUSIONS: This study suggests an association between hypogonadism and low bone mass density in patients undertaking intrathecal opioid delivery for the management of chronic non-malignant pain. Surveillance of hypogonadism and the bone mineral density levels followed by appropriate treatment may be of paramount importance to reduce the risk of osteoporosis development and prevention of fractures in this group of patients.

Prevalence and influence of diagnostic criteria in the assessment of hypogonadism in intrathecal opioid therapy patients.

BACKGROUND: Hypogonadism is frequently diagnosed based on total testosterone (TT) levels alone. However, 99% of testosterone is bound to the sex hormone-binding globulin (SHBG) with only 1% free testosterone. Alternative assessment methods consist of assay of free testosterone (FT) or bioavailable testosterone (BT) by equilibrium dialysis, calculation of FT and BT through the Vermeulen equations, and calculation of the free androgen index (FAI). OBJECTIVES: The aim of this study was to investigate the prevalence of hypogonadism in male chronic non-cancer pain patients undertaking long-term intrathecal opioid therapy and the existence of diagnostic discrepancies according to the criteria used. STUDY DESIGN: Prospective observational study. SETTING: Department of Pain Management, Russells Hall Hospital, Dudley, United Kingdom. METHODS: Twenty consecutive male patients undertaking long-term intrathecal opioid therapy had the gonadal axis evaluated by assays of luteinising hormone (LH), follicle stimulating hormone (FSH), TT, SHBG and by calculating the FT, BT and FAI. RESULTS: Hypogonadism was present in 17 (85%) of the patients based on TT; 17 (85%) according to FT and BT calculations; and 14 (70%) when calculating FAI. Based on either TT or FT being low or borderline/low, 19 (95%) of the investigated patients were biochemically hypogonadal. Significant differences were observed between diagnosis based on FT and FAI (P < 0.05). No significant differences were observed between diagnosis based on TT and FT (P = 0.40) or TT and FAI (P = 0.20). CONCLUSION: Hypogonadism is common in patients undertaking intrathecal opioid therapy for the management of chronic non-malignant pain; however, diagnostic criteria can influence the diagnosis of this side effect. The assessment of the hypothalamic-pituitary-gonadal axis should include evaluation of total serum testosterone, free testosterone, or bioavailable testosterone.

A predictive model for intrathecal opioid dose escalation for chronic non-cancer pain.

BACKGROUND: Tolerance is defined as a phenomenon in which exposure to a drug results in a decrease of an effect or the requirement of a higher dose to maintain an effect. The fear of a patient developing opioid tolerance contributes regularly to the stigmatization and withholding of intrathecal opioid therapy for chronic pain of non-cancer origin. OBJECTIVES: The aim of this study was to describe the intrathecal opioid dose escalation throughout the years in chronic non-cancer pain patients. A secondary objective was the development of an intrathecal opioid dose predictive model. STUDY DESIGN: Retrospective assessment of medical records. SETTING: Department of Pain Management, Russells Hall Hospital, Dudley, United Kingdom. METHODS: Medical records were reviewed and pump refill notes screened from the date of implant through November 2010 for 31 patients undertaking continuous intrathecal opioid therapy. All the patients included had undertaken a minimum of 6 years of intrathecal therapy when the data were collected. RESULTS: Significant increases in the intrathecal morphine dose were verified between follow-up at one year and all subsequent observations, F (2.075, 62.238) = 13.858, 0 < 0.001, but ceased to be significant from year 3 onwards, indicating stability of the morphine dose, F (3, 90) = 2.516, P = 0.63. A model that accounts for 76% of the variability of morphine doses at year 6 based on year 2 assessment combined with duration of pain prior to initiation of intrathecal therapy was developed: year 6 dose = -0.509 + (1.296 x [year 2 dose]) + (0.061 x [duration of pain]). LIMITATIONS: Retrospective study. CONCLUSION: The opioid dose escalation observed throughout the years was modest and not significant following year 3 of therapy. The model developed has the potential to assist the physician in the identification of a need for alternative treatment strategies. Furthermore, since many of the pump replacements are performed prior to year 6, it can also assist in the informed decision of the benefits and risks of the maintenance of this therapy.

Qualitative exploration of psychological factors associated with spinal cord stimulation outcome.

BACKGROUND AND AIM: Spinal cord stimulation (SCS) is a last resort treatment for chronic pain consisting of an implantable pulse generator connected to leads placed in the epidural space of the spinal cord. Effective in reducing chronic pain, however, efficacy has been found to decrease over time. Psychological factors affecting outcome of SCS have been investigated through quantitative methods, but these have failed to provide confident predictors. We aimed to investigate via a qualitative approach, the experience of SCS following 1 year of therapy. METHODS: Thirteen chronic non-cancer pain participants were interviewed. All participants had been trialled with SCS. The majority had gone on to full implantation with varying degrees of pain relief. Thematic analysis was employed to analyse the data from the interviews. RESULTS: Interviews resulted in findings that previous quantitative studies had failed to uncover. Two emergent core themes surfaced: 'coping with pain' and 'SCS treatment'. The effect of emotion upon coping was recurrent. Participants divided the SCS experience into information provision, independence and unexpected experiences. CONCLUSION: The findings provide context for the patients' experience of SCS. This research suggests that improved preparation prior to SCS including information provision, CBT and contact with expert patients may be of value.

Long-term intrathecal drug administration for chronic nonmalignant pain.

BACKGROUND: Chronic pain of nonmalignant origin requires effective long-term treatments, as for many patients pain management will be necessary throughout the rest of their lives. Intrathecal drug delivery systems (IDDS) have become a recognized therapy for the management of severe and otherwise intractable chronic pain. However, it is still not clear whether this treatment can be effective for periods up to 10 years or longer, given the paucity of long-term follow-up. This study sought to examine the effectiveness of IDDS following an average of 13 years postimplantation. METHODS: Twenty patients participated in a longitudinal study with an average follow-up of 13.5 years (range: 10.4 to 17.9) after IDDS implantation. Investigation was carried out by means of a questionnaire before IDDS and after an average of 4 and 13 years of IDDS therapy. Assessment of pharmacological data and complications/side effects was performed. RESULTS: Statistically significant improvements between baseline and 4-year assessment were observed for the following sensory and psychosocial variables: pain intensity, pain relief, coping, self-efficacy, depression, quality of life, housework, mobility, sleep, and social life (all P<0.001). No statistically significant changes were detected between assessments at averages of 4 and 13.5 years. CONCLUSIONS: This study, with one of the longest follow-up intervals reported in the IDDS literature, shows that IDDS has the potential to be a life-long pain management solution in appropriately selected patients with chronic nonmalignant pain.

Type of interventional pain procedure, body weight, and presence of spinal pathology are determinants of the level of radiation exposure for fluoroscopically guided pain procedures.

In the recent years new technology has led to the development of a bewildering array of imaging procedures. Yet, conventional radiography remains one of the most used tools to diagnose and to aid procedural interventions. Fluoroscopy guidance facilitates targeted drug delivery or radiofrequency directly to the area of pathology, a benefit that has to be balanced against the risks of radiation exposure. In this prospective observational survey of routine practice, dose area product (DAP) and screening time (ST) were recorded in 127 consecutive patients undergoing fluoroscopically guided spinal procedures along with other probable measures of potentially greater radiation exposure such as weight, type of spinal pathology, the ease of recognition of the anatomical landmarks, and the radiographic quality of the image in terms of contrast and graininess. The mean ST was 34±27 seconds (range, 3 to 218 seconds), the mean DAP was 1.18±1.08 Gy cm(2) (range, 0.023 to 6.82 seconds). A correlation between weight and DAP was confirmed (r=0.230, P<0.05, Spearman's correlation coefficient). Patients with spinal pathology (n=33) had higher radiation exposure than those without (DAP median=0.85, U=978.00, P<0.005, r=-0.28, Mann-Whitney test). The DAP values obtained compare favourably with the recommended doses for radiographs and other procedures, although they generally exceed the values for a chest X-ray.