The opioid crisis has plagued the United States. The widespread and growing use of illicit drugs ... more The opioid crisis has plagued the United States. The widespread and growing use of illicit drugs is claiming tens of thousands of lives annually [1]. At the same time, patients with pain and their care providers have been concerned by the ever-growing challenges to pain care. The Centers for Disease Control and Prevention (CDC) estimated that 50 million American adults have chronic daily pain and 19.6 million have high-impact chronic pain that interferes with work and daily living [2]. Chronic pain alone costs our nation $560 to $635 billion annually [3]. Likewise, millions of people suffer from unnecessary acute pain, resulting in profound physical, emotional, and societal cost.
Complex Regional Pain Syndrome (CRPS) is a chronic pain disorder characterized by a diverse array... more Complex Regional Pain Syndrome (CRPS) is a chronic pain disorder characterized by a diverse array of symptoms, including pain that is disproportionate to the initial triggering event, accompanied by autonomic, sensory, motor, and sudomotor disturbances. The primary pathology of both types of CRPS (Type I, also known as reflex sympathetic dystrophy, RSD; Type II, also known as causalgia) is featured by allodynia, edema, changes in skin color and temperature, and dystrophy, predominantly affecting extremities. Recent studies started to unravel the complex pathogenic mechanisms of CRPS, particularly from an autoimmune and neuroimmune interaction perspective. CRPS is now recognized as a systemic disease that stems from a complex interplay of inflammatory, immunologic, neurogenic, genetic, and psychologic factors. The relative contributions of these factors may vary among patients and even within a single patient over time. Key mechanisms underlying clinical manifestations include peripheral and central sensitization, sympathetic dysregulation, and alterations in somatosensory processing. Enhanced understanding of the mechanisms of CRPS is crucial for the development of effective therapeutic interventions. While our mechanistic understanding of CRPS remains incomplete, this article updates recent research advancements and sheds light on the etiology, pathogenesis, and molecular underpinnings of CRPS.
The conventional conservative management that consists of physical therapy, activity modification... more The conventional conservative management that consists of physical therapy, activity modification, medication such as NSAIDs, muscle relaxants, anticonvulsants, and antidepressants may not be sufficient to provide satisfactory pain relief. There is a dearth of literature regarding interventional approaches to the management of patients with low back pain associated with Bertolotti's syndrome [8,10]. In this report, we describe five patients with Bertolotti's syndrome who
Interventional therapies are critical and integral parts of a multipronged strategy for pain reli... more Interventional therapies are critical and integral parts of a multipronged strategy for pain relief and rehabilitation in patients with complex regional pain syndrome (CRPS). These therapies include intravenous drug infusion to a specific limb or as a systemic drug delivery route, sympathetic blocks, and neuromodulation modalities, such as peripheral nerve stimulation, dorsal root ganglion stimulation, spinal cord stimulation, and intrathecal drug delivery. This chapter focuses on the clinical evidence of efficacy of the interventional therapies for CRPS, as well as the essential skills in clinical practice of these interventions. There is level I evidence to support neuromodulation via dorsal root ganglion and spinal cord stimulation; level II evidence to support intrathecal drug therapy and sympathetic blocks; and substantial yet variable evidence to support peripheral nerve stimulation and intravenous therapies. It is imperative that interventional treatment is individualized, with an emphasis placed on improving quality of life and function.
BACKGROUND: Peripheral nerve stimulation (PNS) has been increasingly used to manage acute and chr... more BACKGROUND: Peripheral nerve stimulation (PNS) has been increasingly used to manage acute and chronic pain. However, the level of clinical evidence to support its use is not clear. OBJECTIVES: To assess the clinical evidence of PNS in the treatment of acute or chronic pain. STUDY DESIGN: A systematic review of the efficacy and safety of PNS in managing acute or chronic pain. METHODS: Data sources were PubMed, Cochrane Library, Scopus, CINAHL Plus, Google Scholar, and reference lists. The literature search was performed up to December 2019. Study selection included randomized trials, observational studies, and case reports of PNS in acute or chronic pain. Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) and Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of...
Access to full text and tables of contents, including tentative ones for forthcoming issues: www.... more Access to full text and tables of contents, including tentative ones for forthcoming issues: www.karger.com/crd_issues
Background:Painful diabetic neuropathy (PDN) is one of the major complications of diabetes mellit... more Background:Painful diabetic neuropathy (PDN) is one of the major complications of diabetes mellitus. It is often debilitating and refractory to pharmaceutical therapies. Our goal was to systematically review and evaluate the strength of evidence of interventional management options for PDN and make evidence-based recommendations for clinical practice.Methods:We searched PubMed, Scopus, Google Scholar, and Cochrane library and systematically reviewed all types of clinical studies on interventional management modalities for PDN.Results:We identified and analyzed 10 relevant randomized clinical trials (RCTs), 8 systematic reviews/meta-analyses, and 5 observational studies of interventional modalities for PDN using pain as primary outcome. We assessed the risk of bias in grading of evidence and found that there is moderate to strong evidence to support the use of dorsal column spinal cord stimulation (SCS) in treating PDN in the lower extremities (Evidence level: 1B+), while studies investigating its efficacy in the upper extremities are lacking. Evidence exists that acupuncture and injection of Botulinum toxin -A provide relief in pain or muscle cramps due to PDN with minimal side effects (2B+/1B+). Similar level of evidence supports surgical decompression of lower limb peripheral nerves in patients with intractable PDN and superimposed nerve compression (2B±/1B+). Evidence for sympathetic blocks or neurolysis and dorsal root ganglion (DRG) stimulation is limited to case series (2C+).Conclusion:Moderate to strong evidence exists to support the use of SCS in managing lower extremity pain in patients who have failed conventional medical management for PDN. Acupuncture or injection of Botulinum toxin -A can be considered as an adjunctive therapy for PDN. Surgical decompression of peripheral nerves may be considered in patients with PDN superimposed with nerve compression. High quality studies are warranted to further evaluate the safety, efficacy, and cost-effectiveness of interventional therapies for PDN.
Appropriate patient selection and minimizing complications are critical for successful spinal cor... more Appropriate patient selection and minimizing complications are critical for successful spinal cord stimulation (SCS) therapy in managing intractable pain. We thus reviewed electronic medical records of 707 consecutive cases of patients who received SCS therapy in the Cleveland Clinic from 2000 to 2005 with an emphasis on indications and complications. SCS was used to treat complex regional pain syndrome (CRPS) (345 cases), failed back surgery syndrome (235 cases), peripheral vascular disease (20 cases), visceral pain in the chest, abdomen, and pelvis (37 cases), and peripheral neuropathy (70 cases). CRPS and failed back surgery syndrome accounted for 82% of the cases. The implant-totrial ratio was 75% on average, with the highest for CRPS type 2 (83%) and the lowest for peripheral vascular diseases (65%). The only documented complication associated with SCS trials was lead migration in 5 of 707 patients (0.7%). There were no permanent neurological deficits or deaths as a result of SCS implant or its complications. Hardware-related complications were common (38%) and included lead migration (22.6%), lead connection failure (9.5%), and lead breakage (6%). Revisions or replacements were required in these cases. Biologically related complications included pain at the generator site (12%) and clinical infection (4.5%; 2.5% with positive culture). The rates of infection varied among the different diagnoses with the highest in failed back surgery syndrome (6.3%). Patients with diabetes had an infection rate of 9%, over the 4% in non-diabetics. Infections were managed successfully with explantation and antibiotic therapy without permanent sequela.
BackgroundKetamine infusions are frequently employed for refractory complex regional pain syndrom... more BackgroundKetamine infusions are frequently employed for refractory complex regional pain syndrome (CRPS), but there are limited data on factors associated with treatment response. Sympathetic blocks are also commonly employed in CRPS for diagnostic and therapeutic purposes and generally precede ketamine infusions.ObjectivesWe sought to determine whether demographic and clinical factors, and technical and psychophysical characteristics of sympathetic blocks are associated with response to ketamine infusion.MethodsIn this multi-center retrospective study, 71 patients who underwent sympathetic blocks followed by ketamine infusions at 4 hospitals were evaluated. Sympathetically maintained pain (SMP) was defined as ≥ 50% immediate pain relief after sympathetic block and a positive response to ketamine was defined as ≥ 30% pain relief lasting over 3 weeks.ResultsFactors associated with a positive response to ketamine in univariable analysis were the presence of SMP (61.0% success rate vs...
Occipital neuralgia is a primary headache disorder characterized by intermittent, sharp stabbing ... more Occipital neuralgia is a primary headache disorder characterized by intermittent, sharp stabbing occipital pain. Diagnosis is made by history, clinical examination, and positive response to anesthetic block of the greater occipital nerve. Occipital neuralgia should be differentiated from cervicogenic headache, migraines, and other causes of headaches as some of them may manifest with similar symptoms, including occipital pain and allodynia, and may also respond to occipital nerve block. Conservative treatment with physical therapy and low-dose antiepileptics or tricyclic antidepressants can be effective. Refractory cases may respond to occipital nerve block, Botox injection, pulse radiofrequency, or occipital nerve stimulation.
The opioid crisis has plagued the United States. The widespread and growing use of illicit drugs ... more The opioid crisis has plagued the United States. The widespread and growing use of illicit drugs is claiming tens of thousands of lives annually [1]. At the same time, patients with pain and their care providers have been concerned by the ever-growing challenges to pain care. The Centers for Disease Control and Prevention (CDC) estimated that 50 million American adults have chronic daily pain and 19.6 million have high-impact chronic pain that interferes with work and daily living [2]. Chronic pain alone costs our nation $560 to $635 billion annually [3]. Likewise, millions of people suffer from unnecessary acute pain, resulting in profound physical, emotional, and societal cost.
Complex Regional Pain Syndrome (CRPS) is a chronic pain disorder characterized by a diverse array... more Complex Regional Pain Syndrome (CRPS) is a chronic pain disorder characterized by a diverse array of symptoms, including pain that is disproportionate to the initial triggering event, accompanied by autonomic, sensory, motor, and sudomotor disturbances. The primary pathology of both types of CRPS (Type I, also known as reflex sympathetic dystrophy, RSD; Type II, also known as causalgia) is featured by allodynia, edema, changes in skin color and temperature, and dystrophy, predominantly affecting extremities. Recent studies started to unravel the complex pathogenic mechanisms of CRPS, particularly from an autoimmune and neuroimmune interaction perspective. CRPS is now recognized as a systemic disease that stems from a complex interplay of inflammatory, immunologic, neurogenic, genetic, and psychologic factors. The relative contributions of these factors may vary among patients and even within a single patient over time. Key mechanisms underlying clinical manifestations include peripheral and central sensitization, sympathetic dysregulation, and alterations in somatosensory processing. Enhanced understanding of the mechanisms of CRPS is crucial for the development of effective therapeutic interventions. While our mechanistic understanding of CRPS remains incomplete, this article updates recent research advancements and sheds light on the etiology, pathogenesis, and molecular underpinnings of CRPS.
The conventional conservative management that consists of physical therapy, activity modification... more The conventional conservative management that consists of physical therapy, activity modification, medication such as NSAIDs, muscle relaxants, anticonvulsants, and antidepressants may not be sufficient to provide satisfactory pain relief. There is a dearth of literature regarding interventional approaches to the management of patients with low back pain associated with Bertolotti's syndrome [8,10]. In this report, we describe five patients with Bertolotti's syndrome who
Interventional therapies are critical and integral parts of a multipronged strategy for pain reli... more Interventional therapies are critical and integral parts of a multipronged strategy for pain relief and rehabilitation in patients with complex regional pain syndrome (CRPS). These therapies include intravenous drug infusion to a specific limb or as a systemic drug delivery route, sympathetic blocks, and neuromodulation modalities, such as peripheral nerve stimulation, dorsal root ganglion stimulation, spinal cord stimulation, and intrathecal drug delivery. This chapter focuses on the clinical evidence of efficacy of the interventional therapies for CRPS, as well as the essential skills in clinical practice of these interventions. There is level I evidence to support neuromodulation via dorsal root ganglion and spinal cord stimulation; level II evidence to support intrathecal drug therapy and sympathetic blocks; and substantial yet variable evidence to support peripheral nerve stimulation and intravenous therapies. It is imperative that interventional treatment is individualized, with an emphasis placed on improving quality of life and function.
BACKGROUND: Peripheral nerve stimulation (PNS) has been increasingly used to manage acute and chr... more BACKGROUND: Peripheral nerve stimulation (PNS) has been increasingly used to manage acute and chronic pain. However, the level of clinical evidence to support its use is not clear. OBJECTIVES: To assess the clinical evidence of PNS in the treatment of acute or chronic pain. STUDY DESIGN: A systematic review of the efficacy and safety of PNS in managing acute or chronic pain. METHODS: Data sources were PubMed, Cochrane Library, Scopus, CINAHL Plus, Google Scholar, and reference lists. The literature search was performed up to December 2019. Study selection included randomized trials, observational studies, and case reports of PNS in acute or chronic pain. Data extraction and methodological quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) and Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of...
Access to full text and tables of contents, including tentative ones for forthcoming issues: www.... more Access to full text and tables of contents, including tentative ones for forthcoming issues: www.karger.com/crd_issues
Background:Painful diabetic neuropathy (PDN) is one of the major complications of diabetes mellit... more Background:Painful diabetic neuropathy (PDN) is one of the major complications of diabetes mellitus. It is often debilitating and refractory to pharmaceutical therapies. Our goal was to systematically review and evaluate the strength of evidence of interventional management options for PDN and make evidence-based recommendations for clinical practice.Methods:We searched PubMed, Scopus, Google Scholar, and Cochrane library and systematically reviewed all types of clinical studies on interventional management modalities for PDN.Results:We identified and analyzed 10 relevant randomized clinical trials (RCTs), 8 systematic reviews/meta-analyses, and 5 observational studies of interventional modalities for PDN using pain as primary outcome. We assessed the risk of bias in grading of evidence and found that there is moderate to strong evidence to support the use of dorsal column spinal cord stimulation (SCS) in treating PDN in the lower extremities (Evidence level: 1B+), while studies investigating its efficacy in the upper extremities are lacking. Evidence exists that acupuncture and injection of Botulinum toxin -A provide relief in pain or muscle cramps due to PDN with minimal side effects (2B+/1B+). Similar level of evidence supports surgical decompression of lower limb peripheral nerves in patients with intractable PDN and superimposed nerve compression (2B±/1B+). Evidence for sympathetic blocks or neurolysis and dorsal root ganglion (DRG) stimulation is limited to case series (2C+).Conclusion:Moderate to strong evidence exists to support the use of SCS in managing lower extremity pain in patients who have failed conventional medical management for PDN. Acupuncture or injection of Botulinum toxin -A can be considered as an adjunctive therapy for PDN. Surgical decompression of peripheral nerves may be considered in patients with PDN superimposed with nerve compression. High quality studies are warranted to further evaluate the safety, efficacy, and cost-effectiveness of interventional therapies for PDN.
Appropriate patient selection and minimizing complications are critical for successful spinal cor... more Appropriate patient selection and minimizing complications are critical for successful spinal cord stimulation (SCS) therapy in managing intractable pain. We thus reviewed electronic medical records of 707 consecutive cases of patients who received SCS therapy in the Cleveland Clinic from 2000 to 2005 with an emphasis on indications and complications. SCS was used to treat complex regional pain syndrome (CRPS) (345 cases), failed back surgery syndrome (235 cases), peripheral vascular disease (20 cases), visceral pain in the chest, abdomen, and pelvis (37 cases), and peripheral neuropathy (70 cases). CRPS and failed back surgery syndrome accounted for 82% of the cases. The implant-totrial ratio was 75% on average, with the highest for CRPS type 2 (83%) and the lowest for peripheral vascular diseases (65%). The only documented complication associated with SCS trials was lead migration in 5 of 707 patients (0.7%). There were no permanent neurological deficits or deaths as a result of SCS implant or its complications. Hardware-related complications were common (38%) and included lead migration (22.6%), lead connection failure (9.5%), and lead breakage (6%). Revisions or replacements were required in these cases. Biologically related complications included pain at the generator site (12%) and clinical infection (4.5%; 2.5% with positive culture). The rates of infection varied among the different diagnoses with the highest in failed back surgery syndrome (6.3%). Patients with diabetes had an infection rate of 9%, over the 4% in non-diabetics. Infections were managed successfully with explantation and antibiotic therapy without permanent sequela.
BackgroundKetamine infusions are frequently employed for refractory complex regional pain syndrom... more BackgroundKetamine infusions are frequently employed for refractory complex regional pain syndrome (CRPS), but there are limited data on factors associated with treatment response. Sympathetic blocks are also commonly employed in CRPS for diagnostic and therapeutic purposes and generally precede ketamine infusions.ObjectivesWe sought to determine whether demographic and clinical factors, and technical and psychophysical characteristics of sympathetic blocks are associated with response to ketamine infusion.MethodsIn this multi-center retrospective study, 71 patients who underwent sympathetic blocks followed by ketamine infusions at 4 hospitals were evaluated. Sympathetically maintained pain (SMP) was defined as ≥ 50% immediate pain relief after sympathetic block and a positive response to ketamine was defined as ≥ 30% pain relief lasting over 3 weeks.ResultsFactors associated with a positive response to ketamine in univariable analysis were the presence of SMP (61.0% success rate vs...
Occipital neuralgia is a primary headache disorder characterized by intermittent, sharp stabbing ... more Occipital neuralgia is a primary headache disorder characterized by intermittent, sharp stabbing occipital pain. Diagnosis is made by history, clinical examination, and positive response to anesthetic block of the greater occipital nerve. Occipital neuralgia should be differentiated from cervicogenic headache, migraines, and other causes of headaches as some of them may manifest with similar symptoms, including occipital pain and allodynia, and may also respond to occipital nerve block. Conservative treatment with physical therapy and low-dose antiepileptics or tricyclic antidepressants can be effective. Refractory cases may respond to occipital nerve block, Botox injection, pulse radiofrequency, or occipital nerve stimulation.
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