OBJECTIVE: To evaluate the longer-term efficacy of 10 kHz spinal cord stimulation (SCS) in managing painful diabetic neuropathy (PDN) in a routine clinical setting after the transition from the 24-month SENZA-PDN study....OBJECTIVE: To evaluate the longer-term efficacy of 10 kHz spinal cord stimulation (SCS) in managing painful diabetic neuropathy (PDN) in a routine clinical setting after the transition from the 24-month SENZA-PDN study. METHODS: We contacted 142 participants who completed 24 months of postimplantation follow-up in the former randomized controlled trial (SENZA-PDN). Of these, 57 consented and responded to this longer-term post-study survey. Outcomes assessed included pain relief, health-related quality of life (HRQoL) measured using the EuroQol 5-Dimensional 5-Level (EQ-5D-5L) instrument, Patient Global Impression of Change (PGIC), HbA1c, and weight. RESULTS: Our survey captured patient-reported outcomes at a median of 4.1 years after implantation of a permanent 10 kHz SCS system. Among the surveyed participants, 76.8% (43 of 56) reported clinically meaningful pain relief (≥2 points), and 84.6% (44 of 52) achieved a clinically meaningful improvement in their EQ-5D-5L index score, with a final mean EQ-5D-5L index score of 0.825. Additionally, 74.5% (38 of 51) reported being "Better" or "A great deal better" on the PGIC scale. The surveyed participants reported a mean HbA1c level decrease of 0.4% (p = 0.027), with a more substantial improvement of 1.6% (p < 0.001) among those with type 2 diabetes (T2D) and a higher preimplantation HbA1c (>8%). Significant weight loss was also observed, with a mean reduction of 7.0 kg (p < 0.001) in the overall cohort and 8.7 kg (p < 0.001) in the subgroup with T2D and a higher BMI at preimplantation (≥35 kg/m). CONCLUSIONS: High-frequency SCS at 10 kHz provided sustained and clinically meaningful improvements in pain and HRQoL for PDN patients at 4.1 years postimplantation, with no explants in the cohort due to inefficacy. Alongside these benefits, participants experienced metabolic changes that included reductions in body weight and HbA1c beyond that achieved at 24 months, although changes in lifestyle and medication were not accounted for in this analysis. Notably, the cohort's final mean EQ-5D-5L index score was comparable to the US norm. These findings support 10 kHz SCS as a durable and effective treatment option for PDN in routine clinical practice.
BACKGROUND: The relationship between chronic musculoskeletal pain and cognitive function in older adults remains unclear. This study aimed to investigate whether the cognitive function of older adults with chronic muscul...BACKGROUND: The relationship between chronic musculoskeletal pain and cognitive function in older adults remains unclear. This study aimed to investigate whether the cognitive function of older adults with chronic musculoskeletal pain differs from asymptomatic older adults. METHODS: Four databases (PubMed, Science Direct, Web of Science, and Scopus) were searched. Two researchers independently reviewed the references against the eligibility criteria and performed the quality assessment of included studies using The National Institutes of Health (NIH) - Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. RESULTS: A total of 8484 references were found and ten articles, published between 2006 and 2021, were included. Only one study was classified as being of good quality, the remaining were of fair quality. Independent meta-analysis were performed for global cognition and specific cognitive domains (language, attention/orientation, executive function, memory, processing speed, and visuospatial skills). Differences between older adults with and without chronic musculoskeletal pain were found for the domains of general cognition (k = 10; d = -0.20; 95% CI = -0.38, -0.03; z = -2.25, p = 0.03) and language (k = 8; d = -0.16; 95% CI = -0.28, -0.05; z = -2.72, p = 0.006), with very low certainty of evidence. CONCLUSION: Overall, and considering the very low certainty of evidence for both global cognition and specific cognitive domains, we are uncertain about whether cognitive function differs between older adults with and without chronic musculoskeletal pain. Further research is needed comparing cognitive performance between older adults with and without chronic musculoskeletal pain, on the long-term impact of pain on cognitive functioning, and on the mechanisms underlying this potential relationship.
INTRODUCTION: Chronic and end-of-life pain in children is underreported and undermanaged. Current guidelines for pediatric chronic pain include medical and interventional modalities; however, the inclusion of neurosurgic...INTRODUCTION: Chronic and end-of-life pain in children is underreported and undermanaged. Current guidelines for pediatric chronic pain include medical and interventional modalities; however, the inclusion of neurosurgical treatments is uncommon and inconsistent. This systematic review presents the literature, and we provide recommendations for the role of neurosurgical procedures in treating chronic and end-of-life pain in children. METHODS: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines using three databases: PubMed, Embase, and Scopus. We included 40 studies presenting neurosurgical procedures for the treatment of chronic and end-of-life pain in children. RESULTS: Thirty-one (77.5%) manuscripts focused on the treatment of neuropathic pain, five (12.5%) focused on nociceptive pain, and four (10%) treated mixed pain conditions. The most common neurosurgical procedure was intrathecal opioid therapy via pump placement (29.3%), followed by spinal cord stimulation (26.8%). Neuropathic pain syndromes were primarily treated with neurostimulation (58%), demonstrating good efficacy. Ablative procedures (40%) were most effective for nociceptive pain syndromes. Both chordotomy and intrathecal pumps provided subjective pain relief for mixed pain syndromes. The quantification of procedural efficacy, including pain outcomes and grading scales, varied significantly across studies. CONCLUSION: Neurosurgical treatments for chronic pediatric pain are safe, although broad efficacy cannot be determined due to sparse literature and inadequately quantified pain responses. Guidelines for escalating chronic and end-of-life pain management in pediatric patients should be updated to include neurosurgical treatments and appropriate outcome scales. Focused research on appropriate patients, available neurosurgical therapies, and pediatric outcomes is warranted.
INTRODUCTION: Chronic pancreatitis is defined as a disease of the pancreas in which recurrent inflammatory episodes result in replacement of the pancreatic parenchyma by fibrous connective tissue in individuals with gene...INTRODUCTION: Chronic pancreatitis is defined as a disease of the pancreas in which recurrent inflammatory episodes result in replacement of the pancreatic parenchyma by fibrous connective tissue in individuals with genetic, environmental, and other risk factors. Pain is one of the most important symptoms of chronic pancreatitis and, in many cases, has chronic visceral nociceptive, nociplastic, and even neuropathic components, with evidence of both central and peripheral sensitization, neuroplasticity, and neurogenic inflammation. METHODS: The literature on the diagnosis and treatment of pain in chronic pancreatitis was reviewed and summarized. RESULTS: Treatment of abdominal pain in chronic pancreatitis is guided by pancreatic morphology on imaging, although the correlation between pain symptoms and pathoanatomical changes is not always straightforward. Patients with pancreatic duct obstruction are initially offered endoscopic or surgical therapies, while non-obstructive disease is mostly managed medically. Lifestyle changes and psychological support are of particular importance for all chronic pancreatitis patients. Analgesic options range from non-opioid medications to opioids and adjuvant agents. Interventional pain management may consist of radiofrequency treatment of the splanchnic nerves and spinal cord stimulation. To date, there are no randomized trials supporting their efficacy in the treatment of chronic pancreatitis pain, and the recommendation to consider these treatment options is justified by evidence from observational studies. Possible opioid-sparing effects of interventional pain treatments are important to consider because opioid use and dependency are common in chronic pancreatitis patients and associated with worse outcomes. Celiac plexus block is not generally recommended for chronic pancreatitis due to the limited quality of evidence, overall short duration of effect, and invasiveness of the procedure. Central sensitization can impact the effectiveness of invasive treatments. CONCLUSIONS: Managing pain in chronic pancreatitis is a complex task that requires a multidimensional and individualized approach. Due to the lack of randomized trials, treatment decisions are often guided by expert opinion. Integrating pharmacological and non-pharmacological interventions and collaborating with a multidisciplinary team are key components of effective chronic pancreatitis pain management.
Fisher HM, Kelleher SA, Somers TJ
… +12 more, Keefe FJ, Hooker JE, McDermott KA, La Camera DE, Brewer JR, Burns J, Jeddi RW, Kulich R, Polykoff G, Parker RA, Greenberg J, Vranceanu AM
BACKGROUND: Pain from musculoskeletal pain conditions is often persistent, bothersome, and negatively impacts physical function. Individuals with musculoskeletal pain report difficulty with walking and regular activities...BACKGROUND: Pain from musculoskeletal pain conditions is often persistent, bothersome, and negatively impacts physical function. Individuals with musculoskeletal pain report difficulty with walking and regular activities. For some, this may be related to overly negative pain cognitions, such as pain catastrophizing and kinesiophobia. In a geographically and racially diverse sample, we examined relationships between pain catastrophizing, kinesiophobia, and multimodal physical function (i.e., self-report, performance-based, objective). METHODS: Participants were sedentary adults with ≥3 months of chronic musculoskeletal pain. Participants completed self-report measures of pain catastrophizing (Pain Catastrophizing Scale), kinesiophobia (Tampa Scale of Kinesiophobia), and physical function (World Health Organization Disability Assessment Scale 2.0). Performance-based physical function was assessed in-clinic with the Six-Minute Walk Test (6MWT). Physical function was objectively measured with ≥4 days of ActiGraph wear outside the clinic. We conducted descriptive, correlation, and linear regression statistics in SPSS. RESULTS: Higher levels of pain catastrophizing (β = 0.42) and kinesiophobia (β = 0.25) were significantly associated with worse self-reported physical function. Neither pain catastrophizing nor kinesiophobia were related to performance-based or objectively measured physical function. The direction and significance of relationships between pain catastrophizing, kinesiophobia, and physical function measures were consistent in unadjusted and adjusted regression models. CONCLUSIONS: Pain catastrophizing and kinesiophobia are associated with an individual's perceived physical functioning. Behavioral interventions designed to enhance physical function may benefit from including cognitive restructuring to challenge catastrophic thoughts about pain, as well as thoughts about injuring oneself or worsening pain with movement. More work is needed to understand why neither pain catastrophizing nor kinesiophobia were significantly associated with performance-based or objective assessment of physical function. It is possible that other pain-related cognitions, for example self-efficacy for pain control, or variables (e.g., in vivo pain catastrophizing, mood, stress, sleep) assessed closer in time to performance-based or objective measures of physical function are more relevant.
BACKGROUND: Patients with lower extremity wounds often experience neuropathic pain; however, there is no validated assessment tool to specifically measure wound-related neuropathic pain. The study aimed to assess the pre...BACKGROUND: Patients with lower extremity wounds often experience neuropathic pain; however, there is no validated assessment tool to specifically measure wound-related neuropathic pain. The study aimed to assess the prevalence of neuropathic pain in lower extremity wounds using different assessment tools and to identify factors associated with neuropathic pain. METHODS: A cross-sectional study of 130 patients with lower extremity wounds of different etiologies assessed neuropathic pain through clinical examinations, the Short Form McGill Pain Questionnaire-2 (SF-MPQ-2), and the Douleur Neuropathique 4 Questions (DN4). Pain intensity was measured using the Visual Analog Scale (VAS). RESULTS: In total, 38 (29%) experienced neuropathic pain (DN4 score ≥ 4), and 75% (n = 97) described pain using one or more neuropathic pain descriptors on the SF-MPQ-2. The frequently reported descriptors on the neuropathic sub-scale were "pain caused by light touch" (59%) and "tingling or pins and needles" (49%). There was a positive correlation between DN4 and the neuropathic sub-scale of SF-MPQ-2, and the major difference between the tools is the design and time consumption. Univariate analysis revealed that younger age, arterial wound type, infection, and morphine consumption were associated with neuropathic pain (DN4 score ≥ 4). In multivariate analysis, arterial wound type increased the risk of neuropathic pain five-fold. Younger age and morphine consumption were also significantly associated with neuropathic pain, whereas infection was not. CONCLUSION: Neuropathic wound pain is frequent, and the prevalence relies on the applied assessment tool. Arterial wound type, younger age, and morphine consumption are associated with neuropathic wound pain.
OBJECTIVE: The current approval for all available spinal cord stimulation (SCS) devices set several limitations for magnetic resonance imaging (MRI). As a result, most of the necessary examinations are not possible withi...OBJECTIVE: The current approval for all available spinal cord stimulation (SCS) devices set several limitations for magnetic resonance imaging (MRI). As a result, most of the necessary examinations are not possible within the scope of the restrictive approvals and, if legally permitted, must be carried out off-label. This retrospective subgroup analysis investigates if the currently extended MRI approval of one specific device allows more MRI scans to be conducted within the manufacturer's recommendations. MATERIALS AND METHODS: Technical MRI data (saved in the DICOM headers) and medical treatment data for all MRI examinations on patients with Proclaim® implantable pulse generators (IPG; Proclaim® spinal cord stimulation systems, Abbott Laboratories, Plano, TX, USA) were examined. Due to a major change in our standard operating procedures for MRI scans in 2019, the two time periods (before and after 2019) were separately analyzed. RESULTS: We identified 62 MRI scans with the IPG. The entire implanted system was approved for MRI examinations in just over 50% of the cases, regardless of old and new approval. Options for lead placement were expanded in the new approval; however, this did not significantly improve the number of MR conditional devices. By contrast, for a higher specific absorption rate, significantly more scans within the recommendations are possible in Period 2 (p = 0.011). However, the number of possible scans did not reach statistical significance in Period 1 (p = 0.078). No device-related adverse events were noted. CONCLUSION: The new MRI approval is suitable for performing more scans within the manufacturer's specifications. Cervical leads remain problematic because longer leads are required, and the lower impedances inhibit the MRI mode.
AIM: To assess the influence of contrast material distribution patterns on treatment success in patients with chronic coccygodynia undergoing ganglion impar block (GIB). METHODS: An evaluation was conducted on 58 patient...AIM: To assess the influence of contrast material distribution patterns on treatment success in patients with chronic coccygodynia undergoing ganglion impar block (GIB). METHODS: An evaluation was conducted on 58 patients who underwent GIB from August 2021 to August 2023 at a university hospital's interventional pain management center. Numeric rating scale (NRS) scores were recorded before the procedure and at 1-month post-procedure. The patients were categorized into two groups based on treatment success, defined as at least a 50% reduction in the NRS score at 1 month. RESULTS: There were no significant differences between the two groups regarding age, gender, BMI, symptom duration, comorbidities, coccyx curvature type, presence of anterior/posterior subluxation, presence of posterior spicule, type of approach, contrast distribution direction, and contrast dye level. Patients with coccygodynia experienced statistically significant benefits from GIB treatment at the 1-month follow-up (p < 0.001). CONCLUSION: Although the use of contrast material in fluoroscopic procedures is the gold standard to prevent possible complications, the distribution pattern of contrast does not significantly affect the success of GIB treatment in patients with coccygodynia. Further prospective and long-term follow-up studies are required to validate these findings.
BACKGROUND: Chronic pelvic pain syndrome (CPPS) is pain in the region of the lower pelvis for three months or longer. Which is often accompanied by complaints of organ systems in the lower abdomen. CPPS is often a subjec...BACKGROUND: Chronic pelvic pain syndrome (CPPS) is pain in the region of the lower pelvis for three months or longer. Which is often accompanied by complaints of organ systems in the lower abdomen. CPPS is often a subjective diagnosis where electrodiagnostic tests are recommended as a supplement in defining a diagnosis. OBJECTIVE: Synthesize the clinical studies that describe electrodiagnostic testing in humans with a clinical diagnosis of CPPS. EVIDENCE REVIEW: Registered in PROSPERO (CRD42024510404). A systematic search in Medline/PubMed, Embase, CINAHL, and Web of science, from inception till February 2024, complemented with reference examining. Two reviewers independently reviewed titles, abstracts, and full-text papers, and performed data extraction. Reviews were excluded, and papers were included if patients were clinically diagnosed with CPPS and underwent EMG and/or SSEP. The QUADAS-2 tool was used to assess the quality of studies. FINDINGS: Fourteen papers were included concerning EMG and/or SSEP, nine papers reported on EMG and five on SSEP. In total, 432 patients clinically diagnosed with CPPS underwent electrodiagnostic testing. 152/277 patients showed abnormalities on EMG and 102/155 patients had abnormal findings on SSEP. Due to the lack of quantitative data, no meta-analysis could be performed. CONCLUSIONS: Abnormalities on electrodiagnostic testing are seen in half of the patients with CPPS, and therefore not recommended as a substitute in the diagnostic process. The low number of patients enrolled in this review needs to be taken into consideration when interpreting the results. Further research on the sensitivity of EMG and/or SSEP in PN is recommended.
BACKGROUND: The SpineJack implant system is an FDA-approved treatment modality for vertebral compression fractures (VCFs) with reported clinical efficacy comparable to the gold-standard balloon kyphoplasty. Specifically,...BACKGROUND: The SpineJack implant system is an FDA-approved treatment modality for vertebral compression fractures (VCFs) with reported clinical efficacy comparable to the gold-standard balloon kyphoplasty. Specifically, there is insufficient literature regarding the treatment and safety outcomes of the SpineJack when analyzing a specific subset of patients such as the cancer population. METHODS: This is an institutional-level retrospective study at a cancer center on the SpineJack implant consisting of 67 cancer patients (mean age 64 ± 13 years) undergoing a total of 94 SpineJack implantations inserted at 15 thoracolumbar vertebral levels for the treatment of pathologic vertebral compression fractures. The primary outcome of the study was the change in pain score based on the Numeric Rating Scale (NRS) and the secondary outcome was the change in opioid requirement based on morphine milligram equivalents (MME). The average follow-up period was 2 weeks. RESULTS: Post-procedure, a statistically significant decrease in pain severity was observed, with the mean pain score improving from 7.72 ± 2.29 points to 3.45 ± 2.55 points (p-value < 0.0001). Additionally, a reduction in opioid requirement was noted, with a decrease in MME from 66.42 ± 92.66 mg preoperatively to 43.1 ± 60.78 mg (p-value < 0.0001) postoperatively. There was a 1.5% (N = 1) incidence of adjacent level fracture (ALF) reported over an average of 2-week follow-up. The most common intraoperative complication reported was cement extravasation. CONCLUSION: Overall, treatment of cancer patients with pathologic fractures using the SpineJack procedure resulted in remarkably decreased pain scores, overall decreased MME requirements, a significantly low incidence of ALF (s), and minor intraoperative complications without long-term consequences. The SpineJack procedure is a clinically effective, low-risk treatment option for cancer patients with symptomatic, pathologic VCFs.
BACKGROUND: Cancer pain is a prevalent and debilitating symptom that impacts quality of life. Pain management remains challenging; however, due to various barriers, including stigma associated with opioid use, ambiguous...BACKGROUND: Cancer pain is a prevalent and debilitating symptom that impacts quality of life. Pain management remains challenging; however, due to various barriers, including stigma associated with opioid use, ambiguous roles of clinicians, and diverse attitudes toward pain management among healthcare professionals, patients, and carers. OBJECTIVE: To explore the attitudes surrounding cancer pain among patients, carers, and health professionals at a tertiary cancer hospital. METHODS: A cross-sectional online survey was conducted at the Peter MacCallum Cancer Centre. The survey included demographic measures and statements assessing attitudes toward cancer pain management. Data was analyzed using descriptive statistics in IBM SPSS 29. Ethics approval was granted by the Peter MacCallum HREC. RESULTS: 308 participants (153 patients and carers, 155 health professionals) completed the survey. The results revealed significant variability in attitudes surrounding cancer pain and its management. Discrepancies in understanding between health professionals and patients/carers were observed. Differing views on the goals of pain management were revealed, with 51.6% of patients/carers expecting pain elimination compared to 20.6% of health professionals. The roles of clinicians in pain management were also perceived differently, highlighting a lack of clarity in responsibilities. Both groups emphasized the need for increased education on cancer pain and its management. CONCLUSIONS: The study revealed substantial variability in attitudes toward cancer pain management among patients, carers, and health professionals. Discrepancies emerged in understanding, with many patients and carers uncertain about the nature of cancer pain, contrasting with health professionals' recognition of its complexity. The terminology distinguishing "cancer pain" from "non-cancer pain" may contribute to this confusion, suggesting a need to reconsider these semantics. Divergent views on clinician roles and opioid use underscored uncertainties, especially regarding specialist access and prescribing practices. Both groups emphasized the need for education to bridge these gaps, with clearer communication and revised guidelines potentially improving patient outcomes.
INTRODUCTION: Pain, comprising sensory and emotional elements, is influenced by pain catastrophizing, which magnifies pain and promotes helplessness and rumination. This study explores the relationship between pain catas...INTRODUCTION: Pain, comprising sensory and emotional elements, is influenced by pain catastrophizing, which magnifies pain and promotes helplessness and rumination. This study explores the relationship between pain catastrophizing and outcomes following selective nerve root blockade (SNRB) in patients with lumbar radicular pain (LRP). METHODS: A prospective cohort study of 103 LRP patients, confirmed by MRI, was conducted. All participants underwent SNRB at Umeå University Hospital. Outcomes were measured using PROMIS-29 and the Pain Catastrophizing Scale (PCS) at baseline and several intervals up to 84 days post-intervention. Patients were categorized into responder (≥30% pain reduction) and non-responder groups and stratified into three groups based on baseline PCS scores. Changes in outcomes from baseline to 14 days post-SNRB were analyzed in relation to PCS groups. PCS changes over time were evaluated between responders and non-responders. Statistical analyses assessed PCS and outcome changes. RESULTS: Baseline pain catastrophizing was not a significant predictor of pain response to SNRB. However, responders demonstrated significant reductions in pain catastrophizing following the intervention, suggesting that SNRB may influence cognitive coping mechanisms related to pain. CONCLUSION: SNRB reduces pain catastrophizing in LRP patients, although baseline catastrophizing does not predict pain outcomes. Addressing catastrophizing remains important but may serve better as an outcome measure rather than a predictor of treatment response.
INTRODUCTION: Placement of a spinal cord stimulator (SCS) is a neuromodulatory technique with several indications, including persistent spinal pain syndrome type 2 (PSPS2), painful diabetic neuropathy, non-surgical chron...INTRODUCTION: Placement of a spinal cord stimulator (SCS) is a neuromodulatory technique with several indications, including persistent spinal pain syndrome type 2 (PSPS2), painful diabetic neuropathy, non-surgical chronic low back pain, and complex regional pain syndrome. SCS is conventionally placed in a caudal to cranial fashion (anterograde), yet there are cases such that spinal fusion hardware and adhesions prevent this insertion technique. CASE PRESENTATION: Our patient is a 57-year-old man with PSPS2 who had extensive spinal fusion and epidural scarring extending from the sacrum to T10. The patient trialed and failed conservative medical management for his PSPS2 pain, with limited options available for pain relief. The decision was made to place the SCS leads in a retrograde manner at C7-T1, which were then threaded to the T10 level, offering the patient complete relief of back pain and >80% of bilateral lower extremity radicular symptoms. CONCLUSION: Here, we present another case in the literature of a permanently placed SCS performed in the retrograde fashion by an interventional chronic pain physician. Though the technique was off label, the retrograde approach offered the patient significant relief when all other treatment modalities failed. Despite the effective use of the retrograde approach, more studies are needed, including guidelines as to when to offer the retrograde approach for patients with inaccessible anatomy for a typical anterograde technique.