Incarceration and intrathecal pumps: A case report highlighting the challenges in abrupt discontinuation of intrathecal opioid and baclofen therapy [Meeting Abstract]
Introduction: Abrupt cessation of intrathecal baclofen and opioids can cause severe life-threatening withdrawal syndromes. Intrathecal pump (ITP) administration of baclofen and opioids allows for continuous, potent, and effective targeted drug delivery with consistent cerebrospinal fluid concentrations in a relatively tamper-resistant system for chronic intractable pain treatment. Routine management of the pumps is an important component of care. Incarceration of patients managed on ITP presents unique challenges to this mode of care. Case Report: We present a 54- year-old man with CRPS II of his right upper extremity who was stably managed for eight years on an ITP regimen consisting of baclofen 248mcg/d and hydromorphone 3mg/d (4,500 morphine oral equivalents) with additional oral oxycodone and diazepam. He was incarcerated for a period of nine months, during which his reservoir was allowed to run empty. Attempts by outpatient providers were made to have this refilled, but instead he was bridged with oral baclofen 60 mg daily and, at maximum, morphine 30 mg daily by prison providers. He did not suffer life-threatening withdrawal. At his first outpatient pain clinic visit after being released, the patient had effectively been weaned off all controlled substances without significant sequelae.
Conclusion(s): Prison systems face the challenge of encountering patients with pharmacological dependence, especially in the management of complex pain conditions. For this patient, the specialized care needed for ITP management was jettisoned in favor of a relatively miniscule oral weaning regimen that was surprisingly tolerated. This is contradictory to the conventional practice of gradual tapering of intrathecal medications
Reducing Post-Operative Pain Scores in Patients at Risk for Poor Pain Control through Perioperative Workflow Redesign [Meeting Abstract]
State of the field survey: spinal cord stimulator use by academic pain medicine practices
OBJECTIVE: The concept of neuromodulation via the use of spinal cord stimulators (SCS) was first established over forty years ago. Since then, its popularity has grown as numerous studies have demonstrated its utility to reduce chronic pain, improve patient function, and reduce long-term health care costs. The aim of this study was to update the pain medicine community on the evolution of SCS practice trends in academic centers. DESIGN: Ninety-three pain medicine fellowship programs in the United States were identified from the Accreditation Council for Graduate Medical Education Website and were contacted to participate in an internet survey. A 37-item questionnaire was inspired by a previous study performed by Fanciullo et al. Questions focused on three main themes regarding SCS clinical application, namely demographics, education, and technical matters. RESULTS: Completed surveys were received from 50 institutions, all of which reported performing SCS interventions. Annual implants ranged from 0 to 150. Fellowship training was cited as the most valuable modality for learning implantation. Nearly all programs reported manufacturer representative participation during SCS procedures, with a minority of program directors discouraging their involvement in fellow education. SCS trials were performed exclusively on an outpatient basis. The average length for trials was 4-7 days. The most common indication for SCS implantation was failed back surgery syndrome, which also had the highest 2-year success rate. Post procedure, patients generally were followed up every 2-4 weeks for device reprogramming, which was performed by company representatives 92% of the time. CONCLUSION: Standardized SCS training is imperative as the implementation of neuromodulation therapy continues to increase.
A new muscle pain detection device to diagnose muscles as a source of back and/or neck pain
BACKGROUND: Trigger point (TrPs) identification has become the mainstay of diagnosis for the treatment of Myofascial Pain Syndrome; however, manual pressure (MP) to identify TrPs by determining low-pressure pain threshold has low interrater reliability and may lack validity since it is done on inactive muscles. To elicit contractions and mimic an active muscle or movement that 'causes' pain, a Muscle Pain Detection Device (MPDD) has been developed. A selected muscle is stimulated and painful muscles are precisely detected, allowing distinctions between primary and referred muscle pain as well as distinguishing other functional muscle pain thought to cause MPS. METHODS: An IRB approved randomized controlled study is presented of MP (20 patients) control vs MPDD (20 patients) to identify which muscle(s) was the source of pain in subjects presenting to the NYU Pain Management Center with a minimum 3 months history of back pain. Patients were unaware of their diagnostic method. Subjects were injected in 1-3 sites identified via MP or MPDD by a separate, blinded physician. Prior to, and following treatment at one week and one month, the patients were administered Oswestry and visual analog scale pain questionnaires by a blinded evaluator, and their range of motion was measured by a blinded physical therapist. RESULTS: The MPDD group reported significantly larger improvements in pain, mood and Oswestry scores compared with the control (P < 0.05). Moreover, the MPDD group reported 82.5% pain relief at 1 month, compared with 53.2% in the control (P < 0.001). The range of motion measurements failed to reveal any significant difference between the groups. CONCLUSIONS: Using the MPDD appears to be more valid and potentially more reliable than palpation to identify muscles causing regional pain that could benefit from injections
A randomized controlled evaluation of a new muscle pain detection device (MPDD) to diagnose muscle pain as the source of back and/or neck pain in patients [Meeting Abstract]
Introduction: Manual pressure (MP) to identify Trigger Points (TrPs) by determining low pressure pain threshold has low inter-rater reliability and may lack validity since it is done on inactive muscles. Muscle pain is generally experienced with activity. To elicit a muscle contraction and mimic movement that causes pain, a Muscle Pain Detection Device (MPDD) has been developed. A selected muscle is stimulated and painful muscles are precisely detected, allowing distinctions between primary and referred muscle pain [in our nomenclature, Muscle Pain Amenable to Injection vs. TrPs] as well as distinguishing other functional muscle pain thought to cause myofascial pain syndrome. MPDD could provide a valid, reliable assessment of muscle pain which is frequently ignored/mistreated. Methods: An IRB approved doubleblind, randomized controlled study of the MPDD (20 patients) vs. MP (20 patients) control to identify which muscle(s) was the source of pain in 40 subjects presenting to the NYU Pain Management Center with a minimum 3 month history of back pain. Patients were unaware of their diagnostic group. Subjects were injected in 1-3 sites identified via MP or MPDD by a separate physician blinded from the method of detection. Prior to, and following treatment at one week and one month, the patients are given a physical exam and administered Oswestry and VAS pain questionnaires by a blinded evaluator. Results: The MPDD group reported statistically significant improvement in pain, mood and Oswestry scores at 1 week and one month (P < 0.004 - 0.001). The control reported no statistical improvements except for the Oswestry scores at 1 week. Moreover, the MPDD group reported 82.5% pain relief at 1 month, compared to 53.2% in the control (P < 0.001). Conclusion: Using the MPDD appears to be more valid and reliable than palpation to identify muscles causing regional pain that could benefit from muscle injections
Challenges to setting spinal cord stimulator parameters during intraoperative testing: factors affecting coverage of low back and leg pain
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
Successful treatment of phantom radiculopathy with fluoroscopic epidural steroid injections [Case Report]
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