On the therapeutic viability of peripheral nerve stimulation for ilioinguinal neuralgia: putative mechanisms and possible utility.

Injury to the ilioinguinal nerve commonly follows during lower abdominal and pelvic surgery, especially with inguinal hernia repair, appendectomy, and hysterectomy. Other potential causes include low abdominal blunt trauma, iliac crest bone graft, psoas abscess, Pott's disease, and prolonged wearing of abdominally constrictive clothing. The actual incidence of ilioinguinal neuralgia is uncertain, as reported percentage ranges between 12% and 62%. Prompt and accurate diagnosis is critical, and appropriate treatments range from conservative pharmacologic management with nonopioid (eg, gabapentin, topiramate) as well as opioid agents, to surgical neurectomy of the proximal portion of the ilioinguinal nerve. Pharmacological treatment is frequently unsuccessful (particularly if delayed) and while surgery is successful in approximately 73% of cases, it can result in problematic paresthesias, and pain may continue to persist in some patients. Thus, minimally invasive techniques, such as peripheral nerve stimulation, may be viable in those patients who are refractory to pharmacological management, as an option to surgery, and who have not gained satisfactory pain relief through surgical intervention. We present three cases of successful pain control of ilioinguinal neuralgia with peripheral nerve stimulation. These cases demonstrate the potential benefits of neurostimulation including durable effective pain relief and decreased use of medication. Putative mechanisms of effect(s) and caveats for continued research to inform prudent employment of this technique are presented.

[Lumbar discogenic pain. Disk degeneration and minimally invasive interventional therapies]. / Lumbaler diskogener Schmerz. Bandscheibendegeneration und minimalinvasive Therapie.

Discogenic pain has been responsible for a countless number of missed workdays and millions if not billions of dollars of lost revenue. Minimally invasive interventional therapies of the discogenic back pain gained significant acceptance among the proceduralists. The centuries old dilemma of discogenic low back pain has by no means been answered. We know today that discogenic low back pain has a multitude of causes. The leaking "chemical soup" within the nucleus pulposus is certainly responsible for causing inflammation and thus pain. However, neuropeptides released from peripheral endings of nociceptive afferents are also inflammatory mediators and pain generators. The nerves innervating the discs have been identified and in many cases denervated with good results. These nerves from posterior to anterior include the sinuvertebral nerve, the rami communicantes, and the sympathetic trunk. Diagnosing discogenic low back pain is the key to successful treatment. Classically this should be a low back pain in a "band-like" distribution without radiculopathy that is worse in the morning, worse with Valsalva, and aggravated by standing in flexion. Provocative discography with manometric monitoring is essential in aiding the diagnosis. Once the diagnosis is confirmed, a multitude of invasive therapy may be offered including: L2 root sleeve blocks, intradiscal RFTC, RFTC of the rami communicantes, or Comparative data on the effectiveness of the above-mentioned procedures is lacking and may in fact be an excellent topic for future discussion.

Feasibility of spinal cord stimulation in a patient with a cardiac pacemaker.

OBJECTIVE: To report about the safe use of a spinal cord stimulator (SCS) and a permanent cardiac pacemaker (PPM). DESIGN: Open-label case report. CASE DESCRIPTION: A 75-year-old male with a history of diabetic polyneuropathy and a permanent pacemaker was followed for 6 months after implantation of a SCS. CONCLUSION: The simultaneous use of bipolar SCS in a patient with a PPM is not contraindicated. However, because false inhibition of a cardiac pacemaker may potentially lead to serious events, individual testing is mandatory to ascertain safety in each patient.

Pulsed radiofrequency for the treatment of ilioinguinal neuralgia after inguinal herniorrhaphy.

BACKGROUND AND PURPOSE: Ilioinguinal neuralgia secondary to inguinal hernia repair is frequently a chronic, debilitating pain. It is most often due to destruction or entrapment of nerve tissue from staples, sutures, or direct surgical trauma. Treatment modalities, including oral analgesics, nerve blocks, mesh excision, and surgical neurectomy, have varied success rates. Pulsed radiofrequency (PRF) has recently been described as a successful method of treating chronic groin pain. Unlike conventional radiofrequency, PRF is non-neurodestructive and therefore less painful and without the potential complications of neuritis-like reactions and neuroma formation. Although the mechanism is unknown, it appears that the interaction of an electromagnetic field and c-fos proteins may alter normal transmission of painful impulses. Our study examines five patients treated with PRF for ilioinguinal neuralgia secondary to inguinal herniorrhaphy. METHOD: Five patients were diagnosed with chronic ilioinguinal neuralgia secondary to inguinal hernia repair at our institution. Each patient was treated at vertebral T12, L1, and L2 with root PRF at 42 degrees C for 120 seconds per level. RESULTS: Four out of five patients reported pain relief lasting from four to nine months on follow-up visits. Only one patient reported no pain relief whatsoever. CONCLUSION: Ilioinguinal neuralgia is challenging to treat. We have demonstrated the successful use of PRF for four out of five patients seen in our office.

Pulsed radiofrequency of lumbar nerve roots for treatment of chronic inguinal herniorraphy pain.

BACKGROUND: Inguinal hernia repairs are commonly performed and although not seen in a majority of patients, chronic inguinal pain can be a debilitating state resulting after inguinal hernia repairs. Treatment options exist, including pharmacological and surgical management, but with associated risks and side effects. METHODS: In this case series report, five patients with chronic inguinal pain were selected. After initial positive response to T12, L1 and L2 nerve root blocks, pulse radiofrequency (PRF) was performed. RESULTS: All patients reported 75% to 100% pain relief lasting from six to nine months. DISCUSSION: Several hypotheses have been proposed, including selective delta and c-nerve fiber destruction, upregulation of intermediate early gene expression (IEG) and increase in c-fos protein that modulated pain transmission. CONCLUSION: The mechanism of action of pulsed radiofrequency remains unclear. This case study demonstrates the effectiveness of minimally invasive neurodestruction of T12, L1 and L2 nerve roots utilizing Pulse Radiofrequency fields.

Treatment of tension-type headache with botox: a review of the literature.

Botulinum toxin has been shown to effectively treat several types of neurological disorders. It has recently been evaluated for the treatment of tension-type headaches in patients who are unable to tolerate or cannot benefit from standard therapies. Most of the open design studies seem to present positive results. However, the randomized, double-blind, placebo-controlled studies present contradictory results for the efficacy of botulinum toxin. Based on these data, further controlled trials of botulinum toxin are needed to evaluate its effects on tension headaches and to determine optimal injection sites, doses, and frequency of treatments.

Perioperative management of opioid-tolerant chronic pain patients.

Opioids occupy a position of unsurpassed clinical utility in the treatment of many types of painful conditions. In recent years there has been a noticeable shift regarding the use of opioids for the treatment of both benign and malignancy-related pain. As acceptance of the prescribing of opioids for chronically painful conditions has grown, many more opioid-tolerant patients are presenting for surgical procedures. It is therefore imperative that practicing anesthesiologists become familiar with currently available opioid formulations, including data regarding drug interactions and side effects, in order to better plan for patients' perioperative anesthetic needs and management. Unfortunately, there is a lack of scientifically rigorous studies in this important area, and most information must be derived from anecdotal reports and the personal experience of anesthesiologists working in this field. In this review, we shall discuss current chronic pain management and the impact of opioid use and tolerance on perioperative anesthetic management.

Intradiscal electrothermal coagulation and percutaneous neuromodulation therapy in the treatment of discogenic low back pain.

Low back pain (LBP) is a major physical and socioeconomic entity. A significant percentage of LBP is attributable to internal disc disruption. The management of internal disc disruption has traditionally been limited to either conservative treatment or spinal fusion. Intradiscal electrothermal coagulation (IDET) and percutaneous neuromodulation therapy (PNT) are now being performed as an alternative to these therapies. Scientific data regarding the pathophysiology, biologic effects, and clinical results are relatively scarce. Early biomechanical and histologic investigations into the effects of IDET are conflicting. However, in early prospective human trials, IDET seems to provide some benefit with little risk. PNT represents a new less invasive technique for the treatment of discogenic pain, but limited research is available to determine long-term clinical efficacy. IDET and PNT are potentially beneficial treatments for internal disc disruption in carefully selected patients as an alternative to spinal fusion. More basic science and clinical research with long-term follow-up evaluation is necessary.

Coadministration of an opioid agonist and antagonist for pain control.

The increased use of opioids in the treatment of chronic pain encourages the search for drugs with low abuse and tolerance potential but with potent analgesic activity. Opioid agonist-antagonists and partial agonists have less abuse potential than do mu opioid receptor agonists such as morphine, and have been used for many years for their analgesic affects. Recently they have been approved for treatment of opioid addiction. As a guard against abuse, an opioid antagonist, such as naloxone, is added to some opioid formulations. Doctors are often hesitant to prescribe agonist-antagonists and partial agonists to opioid-tolerant patients, fearing that these drugs may precipitate withdrawal. Can drugs being used safely for addiction treatment also safely replace opioid agonists to provide analgesia in chronic pain patients who are opioid-tolerant?

Perioperative and intraoperative pain and anesthetic care of the chronic pain and cancer pain patient receiving chronic opioid therapy.

The expanding role of the anesthesiologist as a "perioperative physician" places ever-increasing demands upon his or her clinical skills and knowledge. One area of growing concern for the anesthesiologist involves the perioperative assessment and management of the opioid-tolerant chronic pain patient. Opioids occupy a position of unsurpassed clinical utility for the treatment of many types of painful conditions. Coupled with noticeable shifts in physician attitudes that have occurred in recent years regarding the use of opioids for the treatment of benign and malignancy-related pain, many more patients are presenting for surgical procedures who are opioid tolerant. It is important therefore that the practicing anesthesiologist become familiar with the currently available opioid formulations, including drug interactions and side effects, in order to better plan the patient's perioperative anesthetic needs and management. Unfortunately, there is a lack of scientifically rigorous studies in this important area, and most of the information must be derived from anecdotal reports and personal experience of anesthesiologists working in this field. In this review, we shall discuss some aspects of current chronic pain management, the newer forms of opioid administration which may be unfamiliar to the anesthesiologist, as well as clinical aspects of opioid use and tolerance including the impact it may have on perioperative anesthetic management.