Pain medicine fellow neuromodulation surgical skill assessment tool: a pilot.

OBJECTIVE: Spinal cord stimulation (SCS) is an evidence-based therapy for the treatment of refractory pain. Current American College of Graduate Medical Education requirements for pain medicine fellowship graduation include observation of five neuromodulation cases. Matriculating fellows have varying degrees of technical skill, training, and experience. The purpose of this study was to use an innovative skill-based assessment tool using the validated Zwisch scale to evaluate fellow surgical performance during SCS cases. DESIGN: Cross-sectional survey SETTING: Mayo Clinic, Rochester, Minnesota. SUBJECTS: Consultant faculty (10) in the Division of Pain Medicine and pain medicine fellows (5). METHODS: A list of faculty-driven neuromodulation surgical objectives was formed and a rubric was created that focused on technical approach, imaging, epidural access and wound closure. Consultants who perform surgical cases were instructed to use the Zwisch scale as a guide to evaluate fellow surgical performance during a neuromodulation case. Faculty and fellows were surveyed before and after implementation of the tool to determine their satisfaction with use of the skill assessment tool. RESULTS: The consultants reported they were more satisfied, consistent, and efficient with feedback provided to the trainee on every aspect of neuromodulation surgical cases. The improvement was most significant during the fellows' intraoperative skill assessment. The fellows indicated increased satisfaction, improved communication, and increased efficiency of feedback when the tool was utilized. The fellows reported greater intraoperative skill assessment and consistency of feedback provided. CONCLUSIONS: The diverse nature of primary specialty backgrounds observed in pain medicine fellowship training offers a unique opportunity to assess and improve fellow skill and surgical competence in the field of neuromodulation. Both faculty and fellows reported improved satisfaction, consistency and efficiency with feedback provided. Importantly, this pilot project observed that implementation of a skill assessment tool was beneficial for both the faculty and fellow as the feedback received was viewed as strongly beneficial to the educational experience.

Epidural Hematoma Following Interlaminar Epidural Injection in Patient Taking Aspirin.

OBJECTIVE: We present a case report of a patient who developed an epidural hematoma following an interlaminar epidural steroid injection with no risk factors aside from old age and aspirin use for secondary prevention. CASE REPORT: A 79-year-old man developed an epidural hematoma requiring surgical treatment following an uncomplicated interlaminar epidural steroid injection performed for neurogenic claudication. In the periprocedural period, he continued aspirin for secondary prophylaxis following a myocardial infarction. CONCLUSIONS: For patients taking aspirin for primary or secondary prophylaxis, the American Society of Regional Anesthesia and Pain Medicine antiplatelet and anticoagulation guidelines for spine and pain procedures recommend a shared assessment and risk stratification when deciding to hold the medication for intermediate-risk neuraxial procedures. Cases such as this serve to highlight the importance of giving careful consideration to medical optimization of a patient even when a low- or intermediate-risk procedure is planned.

Utilization of Leads After Permanent Implant in Spinal Cord Stimulator Systems.

OBJECTIVE: The goal of this study was to determine the frequency and clinical indications associated with implantation of single vs. dual percutaneous lead spinal cord stimulator (SCS) systems and to look further into how these leads are utilized for treatment. MATERIALS AND METHODS: A retrospective cohort analysis of all patients undergoing SCS implantation between January 2001 and December 2013 with a minimum of 2 years of clinical follow-up was performed. Number of trial leads and implanted leads was recorded. For patients with dual-lead systems, it was noted if and when the second lead was used, along with the clinical indication for lead activation. RESULTS: In the 259-patient cohort, 15.8% (n = 41) patients underwent placement of a single-lead system, 83.0% (n = 215) underwent placement of a dual-lead system, and 1.2% (n = 3) underwent placement of 3-lead systems. Placement of dual-lead systems was similar among all indication groups. Of those patients with a dual-lead system in place, 88.1% utilized both leads and average time to programming of the second lead was 2.3 months. The most common reason to activate the second lead was inadequate stimulation coverage. Five of the 41 patients with single-lead systems underwent an additional surgery to implant a second lead due to inadequate stimulation with 1 lead. CONCLUSIONS: To our knowledge this is the first descriptive analysis of the frequency of single- and dual-lead SCS systems. This report indicates that dual-lead systems are most often placed and both leads are required for optimal patient therapy.

Outcomes of C1-2 joint injections.

OBJECTIVE: Intra-articular injections of the C1-2 joint are an effective therapeutic option for pain generated from degenerative and inflammatory conditions affecting the joint. Limited information exists about the adverse events (AEs) associated with these injections. The primary aim of this study is to describe the frequency and type of AEs associated with C1-2 joint injections. The secondary aim is to identify clinical factors associated with the occurrence of AEs of C1-2 joint injections. DESIGN/METHODS: A retrospective chart review was conducted on all C1-2 joint injections performed at the Mayo Pain Medicine Clinic in Rochester, MN, from January 1, 2005 through July 31, 2015. AE data were extracted from procedural and post-procedural clinical notes. Analysis was conducted to determine correlations between any AE and demographic and clinical characteristics. Using univariate and multivariate logistic regression analyses, associations were determined. RESULTS: From January 1, 2005 to July 31, 2015, 135 C1-2 injections were performed on 72 patients. Overall, at least 1 AE was reported in 18.5% of the injections. The most common AEs were post-procedural increase in pain and procedural vascular contrast uptake. There was a significant association between AE occurrence and greater pre-procedural maximum pain score. CONCLUSIONS: AEs from C1-2 joint injections occurred commonly, but there were no persistent or serious AEs associated with these injections. The data also demonstrate that patients with higher pre-procedural maximum pain scores are more likely to experience an AE.

Patient Outcomes and Spinal Cord Stimulation: A Retrospective Case Series Evaluating Patient Satisfaction, Pain Scores, and Opioid Requirements.

INTRODUCTION: Spinal cord stimulators (SCS) are used to treat various chronic pain states. Establishing patient outcomes in terms of pain control, opioid medication use, and overall satisfaction is vital in maintaining SCS's role in clinical practice. METHODS: All patients who underwent SCS implantation between January 2001 and December 2011 at a tertiary academic pain medicine center were included if he or she underwent permanent cervical or thoracolumbar dorsal column SCS implantation and age was 18 or greater. For the 199 patients who met inclusion criteria, data were collected retrospectively. Preimplant information included indication for implantation, Numeric Rating Scale (NRS) score, and dose in oral morphine equivalents (OME). Postimplant NRS score was recorded at 6 months and 1 year. OME requirement and patient satisfaction were determined at 1 year postimplantation. RESULTS: This data set showed an overall decrease in OME requirements and NRS scores at both 6 months and 1 year. These differences were statistically significant (P < 0.01) compared to preimplantation values. Additionally, 84.27% of patients were satisfied with their implants at 1 year. Patient outcomes were analyzed further in respect to implant indication; groups included failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS), angina, and other. For all groups, there were statistically significant (P < 0.01) decreases in NRS scores at 6 months and 1 year. In the FBSS and CRPS groups, statistically significant (P < 0.02) decreases in OME usage existed. CONCLUSION: Retrospective review of patients with spinal cord stimulators revealed OME reduction at 1 year for those patients in the FBSS and CRPS groups; patient satisfaction at 1 year and NRS score reduction at 6 months and 1 year were statistically significant for all groups.

Spinal cord stimulator explantation for magnetic resonance imaging: a case series.

INTRODUCTION: Spinal cord stimulator (SCS) systems are implanted to treat pain conditions such as neuropathic, radicular, and ischemic pain syndromes. Prior to July 2013, SCS systems were not magnetic resonance imaging (MRI) compatible due to the risk of thermal injury at the site of the leads and generator. Although there are some case reports of patients undergoing MRI studies with SCS systems in place, these stimulators are frequently explanted when clinical care has necessitated an MRI. The purpose of this case series is to discuss the role of SCS explantation in order to acquire an MRI. METHODS: This study was performed at a tertiary academic pain medicine clinic. After exempt status was obtained via the institutional review board, patients were identified via the use of Common Procedural Terminology codes for implantable devices. A chart review was performed to identify all patients >18 years of age who had a lumbar or thoracic dorsal column SCS implanted during January 2001-December 2011. The charts were then followed to identify any patients who underwent a surgery for explantation of the device. Data collection included the total number of patients undergoing permanent SCS implantation, the total number of explantation of these devices, patient demographic factors, indication for SCS implantation, incidence of revisions and the indication, duration between implantation and explant of the device, and indication for explantation. RESULTS: During the time between 2001 and 2011, 199 patients were identified who underwent a thoracic or lumbar SCS implant after a successful trial. Among 199 implants, 33 devices were explanted, and of these, four were explanted due to the primary need for an MRI scan.