Faculty Bibliography

Prescription opioid abuse is a growing problem that has become a critical public health issue. The development of abuse-resistant opioid formulations is an emerging strategy aimed at curbing the abuse of opioid analgesics. Over the next few months to years, new products within this category will enter the market. This article serves to provide an introduction to many of the upcoming formulations that may find their way into the therapeutic arsenal of pain management practitioners

Pudendal neuralgia (PN) involves severe, sharp pain along the course of the pudendal nerve, often aggravated with sitting. Current therapies include medication management, nerve blocks, decompression surgery, and neuromodulation. The ideal management for PN has not been determined. We present a case of a female with 1.5 years of sharp, burning pain of the left gluteal and perineal regions. She could not sit for longer than 10 to 15 minutes. Sacroiliac joint, epidural, and piriformis injections did not improve her pain. She had tried physical therapy, occupational therapy, massage, and acupuncture but the pain persisted. Medication treatment with oxycodone-acetaminophen, extended release morphine sulfate, amitriptyline, and gabapentin provided only minor relief and she had failed other multianalgesic therapy. She had been unable to work at her desk job for over a year. She had a positive response to 2 diagnostic pudendal nerve blocks with lidocaine that provided pain relief for several hours. This patient elected to undergo pulsed radiofrequency (PRF) of the left pudendal nerve in hopes of achieving a longer duration and improved pain relief. PRF was carried out at a frequency of 2 Hz and a pulse width of 20 milliseconds for a duration of 120 seconds at 42 degrees Celsius. After the procedure she reported tolerating sitting for 4 to 5 hours. Her multianalgesic therapy was successfully weaned. At 5 months follow-up she felt motivated to return to work. One and a half years after the procedure the patient is only taking oxycodone-acetaminophen for pain relief and still has good sitting tolerance. There were no procedure-related complications. To our knowledge PRF for the treatment of PN has not been reported elsewhere in the literature. PRF is a relatively new procedure and is felt to be safer than continuous radiofrequency. Current literature suggests that PRF delivers an electromagnetic field, which modifies neuro-cellular function with minimal cellular destruction. We conclude that PRF of the pudendal nerve offers promise as a potential treatment of PN that is refractory to conservative therapy

Epidural steroid injections (ESIs) are the most commonly performed intervention in the United States to manage chronic and subacute low back and neck pain with radiculopathy. ESIs have been used for decades for the treatment of discogenic and osteoarthritic radicular conditions originating from the cervical, thoracic, and lumbar spine, as well as spondylosis, nonspecific radiculitis, and spinal stenosis. With the ever-increasing use of epidural steroids, there has been a disproportionate increase in popularity of transforaminal ESIs in particular. Since 2002, there has been a growing body of largely transforaminal epidural steroid case report literature that describes paralysis, stroke, and death that immediately follows the performance of these procedures. These complications are thought to be related to a combination of factors, which may include the technique used, underlying pathophysiology that is being treated, anatomical variations in the blood supply, as well as the specific injectate used. This article discusses the pathogenesis of these complications and puts the role of steroids in their causation into perspective

Objective. Spinal cord stimulator (SCS) parameter settings have been well studied; however, the goal of this exploratory study was to examine the SCS parameters used during intra-operative stimulation (IOS) at trial lead placement. Methods. In this retrospective study, we report the IOS parameter settings for 22 patients who underwent thoracic SCS lead trial for treatment of refractory low back and/or leg pain. Results. Paresthesia coverage was shown to differ depending upon the pain syndrome and the region involved (back and/or leg, p = 0.03). Certain stimulation parameters were demonstrated to be linked, including pulse width with rate (p = 0.04) and bipolar activation distance with amplitude (p < 0.01). Important variations in field configuration practice patterns also emerged. Conclusions. Larger prospective studies are required to confirm and extend the current results. The ultimate goal for this report is to establish a foundation for future studies to create an evidence-based standardized algorithm for IOS to enhance the success rate of SCS trial screening

Phantom limb pain has been well described in the literature. However, new-onset lumbar radicular pain superimposed on baseline lower extremity phantom pain is a clinical scenario that can be challenging to recognize. Furthermore, literature on recognition and treatment of phantom radiculopathy is all but lacking. We present a patient who experienced new-onset lumbar radiculopathy superimposed on her phantom pain that was successfully treated with fluoroscopic interlaminar and transforaminal epidural steroid injections