Faculty Bibliography

Background:Spinal cord stimulation is an established treatment option for certain chronic pain conditions which have been previously unresponsive to conservative therapies or potentially for a subset of patients who have not improved following spine surgery. Prior to permanent lead implantation, stimulator lead trials are performed to ensure adequate patient benefit. During these trials, one of the most common complications and reasons for failure is the displacement and migration of the trial leads, resulting in lost therapeutic coverage. Other complications include infection and dislodged bulky dressings. There is a paucity of literature describing an adequate procedural method to prevent these common complications. Objective:This study utilizes a series of 19 patients to evaluate a new technique for securing percutaneous spinal cord simulator trial leads, which may minimize dislodgement and migration complications and improve the rate of trial success. Study Design:Retrospective case series. Setting:New Jersey Medical School, Department of Anesthesiology, Pain Management Division. Methods:A retrospective chart review was conducted on 19 consecutive patients undergoing placement of the percutaneous thoracic spinal cord stimulator trial leads for pain associated with lumbar spine pathology over a two-year period (2010-2012). Results:Of the 19 patients in our cohort, there was one trial lead displacement, no lead migrations, and no site infections. Thirteen patients went on to permanent lead implantation. This improved trial lead placement technique had a high success rate with a low number of complications. Limitations:Small sample size, retrospective case series, and no control group for comparison. Conclusion:This case series was able to demonstrate that our described novel spinal cord stimulator trial lead placement and dressing technique can decrease the incidence of lead displacement and migration, thus improving trial success.

INTRODUCTION: With increasing trends to decrease overall opiate use for analgesia¹, recent contamination issues in steroid manufacturing for spinal injections and subsequent outbreaks of fungal meningitis², and more recent emphasis on cost-effective therapies^3,4, yoga has become an attractive therapeutic option for CLBP. The goal of this study was to provide an updated systematic review examining the therapeutic effect of yoga on CLBP. METHOD: Literature was sought from a query of 4 major databases (Medline, Embase, Cochrane Library, PsycINFO) from their inception to June 2015 (See Figure 1). Studies were deemed appropriate for inclusion if the following criteria were met: (1) a randomized control trial design, (2) focused on patients with low back pain, (3) sought to study any physically active form of Yoga, and (4) reported the measurement of patient specific outcome measures (i.e. pain, functional status, disability score, quality of life measure). RCTs that met criteria were analyzed for methodological quality using the JADAD scoring scale. RCTs that met a score of 3 or more were included for quantitative analysis. RESULTS: Seventeen full text articles (15 study cohorts) were included in the systematic review. The methodological strength of these studies ranged between a 1 and 4 on the Jadad scoring scale. Of the 17 grouped trials, 15 individually reported author's conclusions supporting improvement in patient reported outcome measures in patients receiving Yoga therapy as compared with other usual treatments, education, and other non-invasive comparators. 8 studies with a JADAD score > 3 of which 7 were utilized for group analysis. An analysis of grouped VAS scores yielded a finding consistent with the majority of the studies included in the review. Mean baseline VAS score before yoga therapy is 5.45 with range between 4.06 and 6.73 (n>30 across the 7 RCTs). Mean pain score improvements compared to baseline following yoga-therapy showed 38.3% reduction at 1-2 weeks; a 35.1% reduction at 4-6 weeks; 52.8% reduction at 10-12 weeks; a 56.2% reduction at 24 to 26 weeks; and a 49.2% reduction at 48 weeks. Plot of yoga's effect on VAS scores over timeshows the best fit line follows an exponential decay model with the parameter of 0.396 (the inverse rate constant of 2.5 weeks) with a 95% confidence interval of [-0.75, 0.867] and a p-value close to significance (p<0.1). CONCLUSION: Current body of evidence is of mixed quality and requires filtering for high quality RCTs. Despite adequate numbers of high quality RCTs and the heterogeneity in yoga forms across different populations, the effect of yoga seems consistent in reducing VAS scores according to an exponential decay model. Due to lack of adequate studies examining the immediate and long term effects of yoga on CLBP, future RCTs examining VAS scores to fill in existing data gaps are needed to provide a clearer picture of the time-dependence of yoga's effect. Functional aspect of pain was not assessed in this review

BACKGROUND: Acute blood pressure (BP) elevations in neurosurgical patients are associated with serious neurologic, cardiovascular, or surgical site complications. Clevidipine, an ultra-short-acting dihydropyridine calcium antagonist, has been shown to be efficacious and safe for acute hypertension in cardiac surgery. This study assessed the efficacy and safety of clevidipine in controlling perioperative hypertension in the neurosurgical setting. METHODS: Patients scheduled for intracranial surgery were prospectively enrolled after giving consent. Clevidipine (0.5 mg/mL in 20% lipid solution, which was to be initiated at 10 mg/h and titrated to effect) was administered as the primary antihypertensive agent for perioperative hypertension, with target BPs of less than 130 mm Hg. Other vasoactive drugs were administered as needed for treating systolic BP (SBP) less than 90 mm Hg or greater than 130 mm Hg. The primary study endpoint was the proportion of patients not requiring rescue antihypertensives to maintain target SBP (<130 mm Hg). RESULTS: Twenty-two patients were enrolled. One patient did not require antihypertensive therapy. Seventeen patients (17 of 21, 81%) were treated with clevidipine alone; one received clevidipine in the postanesthesia care unit only. Twenty-eight hypertensive episodes (defined as any new acute BP elevation requiring clevidipine initiation) were documented. SBP was reduced to target level within 15 minutes in 22 of 28 episodes (78.6%). Two mild hypotensive episodes occurred after the initiation of clevidipine infusion; these transient decreases in BP were treated with vasoactive drugs and resolved within 5 minutes. CONCLUSIONS: Clevidipine is effective and safe for perioperative hypertension in patients undergoing intracranial procedures. Rapid control of BP is possible with higher starting doses. Drug effects resolved rapidly after drug discontinuation