Christopher Gilligan

Epidural Steroids, Etanercept, or Saline in Subacute Sciatica: A Multicenter, Randomized Trial

BACKGROUND Active surveillance (AS) and watchful waiting (WW) have been proposed as management strategies for low-risk, localized prostate cancer. PURPOSE To systematically review strategies for observational management of prostate cancer (AS or WW), factors affecting their utilization, and comparative effectiveness of observational management versus immediate treatment with curative intent. DATA SOURCES MEDLINE and Cochrane databases (from inception to August 2011). STUDY SELECTION Screened abstracts and reviewed full-text publications to identify eligible studies. DATA EXTRACTION One reviewer extracted data, and another verified quantitative data. Two independent reviewers rated study quality and strength of evidence for comparative effectiveness. DATA SYNTHESIS Sixteen independent cohorts defined AS, 42 studies evaluated factors that affect the use of observational strategies, and 2 evidence reports and 22 recent studies reported comparisons of WW versus treatment with curative intent. The most common eligibility criteria for AS were tumor stage (all cohorts), Gleason score (12 cohorts), prostate-specific antigen (PSA) concentration (10 cohorts), and number of biopsy cores positive for cancer (8 cohorts). For monitoring, studies used combinations of periodic PSA testing (all cohorts), digital rectal examination (14 cohorts), and rebiopsy (14 cohorts). Predictors of receiving no active treatment included older age, comorbid conditions, lower Gleason score, tumor stage, PSA concentration, and favorable risk group. No published studies compared AS with immediate treatment with curative intent. Watchful waiting was generally less effective than treatment with curative intent; however, applicability to contemporary patients may be limited. LIMITATIONS Active surveillance and WW often could not be differentiated in the reviewed studies. Published randomized trials have assessed only WW and did not enroll patients diagnosed by PSA screening. CONCLUSION Evidence is insufficient to assess whether AS is an appropriate option for men with localized prostate cancer. A standard definition of AS that clearly distinguishes it from WW is needed to clarify scientific discourse. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: A systematic review of randomized controlled trials

Background: The efficacy of epidural and facet joint injections has been assessed utilizing multiple solutions including saline, local anesthetic, steroids, and others. The responses to these various solutions have been variable and have not been systematically assessed with long-term follow-ups. Methods: Randomized trials utilizing a true active control design were included. The primary outcome measure was pain relief and the secondary outcome measure was functional improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the criteria developed by the American Society of Interventional Pain Physicians (ASIPP) for assessing interventional techniques. An evidence analysis was conducted based on the qualitative level of evidence (Level I to IV). Results: A total of 31 trials met the inclusion criteria. There was Level I evidence that local anesthetic with steroids was effective in managing chronic spinal pain based on multiple high-quality randomized controlled trials. The evidence also showed that local anesthetic with steroids and local anesthetic alone were equally effective except in disc herniation, where the superiority of local anesthetic with steroids was demonstrated over local anesthetic alone. Conclusion: This systematic review showed equal efficacy for local anesthetic with steroids and local anesthetic alone in multiple spinal conditions except for disc herniation where the superiority of local anesthetic with steroids was seen over local anesthetic alone.

Chronic Low Back Pain: Restoration of Dynamic Stability

Electrical stimulation for multifidus muscle contraction is a novel approach for treating chronic low back pain (CLBP). A multicenter, open‐label feasibility study investigated this modality in patients with continuing CLBP despite medical management and no prior back surgery and no known pathological cause of CLBP.

Development and Patient Satisfaction of a New Telemedicine Service for Pain Management at Massachusetts General Hospital to the Island of Martha’s Vineyard

OBJECTIVE Patients in remote areas lack access to specialist care and pain management services. In order to provide pain management care to patients remote from our center, we created a telemedicine pain clinic (telepain) at Massachusetts General Hospital (MGH) in Boston, MA to extend services to the Island of Marthas Vineyard. DESIGN Over 13 months, 238 telepain video clinic evaluations were conducted. A pain physician visited the island 1-2 days per month and performed 121 interventions. Given the novelty of telemedicine clinics, we surveyed patients to gauge satisfaction and identify perceived weaknesses in our approach that could be addressed. Forty-nine consecutive patients answered a 14-question, 5-point balanced Likert-scale survey with 1 (no, definitely not) being most negative and 5 (yes, definitely) being most positive. SETTING Patients on Marthas Vineyard referred for pain management consultation services via telemedicine. PATIENTS Forty-nine consecutive patients evaluated via telemedicine. INTERVENTIONS Likert-scale survey administered. MEASURES Questions measured patient impressions of video-based visits with their doctor, convenience of the visit, concerns about privacy, and whether they would recommend such a visit, among other items. RESULTS Mean respondent scores for each question were >4.3 indicating a favorable impression of the telepain clinic experience. Lowest mean scores were found when respondents were asked to compare the care they received by telepain versus an in-person visit, or whether they were able to develop a friendly relationship with the doctor. CONCLUSIONS The results suggest an overall positive reception of telepain by patients, yet highlight the challenge of building a patient-physician relationship remotely.

Spinal Cord Stimulator Implant Infection Rates and Risk Factors: A Multicenter Retrospective Study.

Spinal cord stimulation is an evidence‐based treatment for a number of chronic pain conditions. While this therapy offers improvement in pain and function it is not without potential complications. These complications include device failure, migration, loss of therapeutic paresthesia, and infection. This article looked to establish a modern infection rate for spinal cord stimulators, assess the impact of known risk factors for surgical site infections and to determine the impact of certain preventative measures on the rate of infection.

Spinal Cord Stimulation in a Patient with Spinal Epidural Lipomatosis

BACKGROUND AND OBJECTIVE Spinal cord stimulation is the most commonly used implantable neurostimulation modality for management of pain syndromes. For treatment of lower extremity pain, the spinal cord stimulator lead is typically placed in the thoracic epidural space, at the T10-T12 levels. Typically, satisfactory stimulation can be obtained relatively easily. Anatomical variability in the epidural space, such as epidural scarring, has been reported to prevent successful implantation of spinal cord stimulators. Spinal epidural lipomatosis describes an abnormal overgrowth of adipose tissue in the extradural space. Cases have documented spinal epidural lipomatosis complicating intrathecal baclofen pump implantation or causing repeated failure of epidural analgesia. However, so far, there is no published literature describing how spinal epidural lipomatosis affects spinal cord stimulation. CASE REPORT We report a case of spinal cord stimulation in a patient with spinal epidural lipomatosis. Very high impedance was encountered during the trial spinal cord stimulator lead placement. Satisfactory stimulation was only obtained after repeated repositioning of the spinal cord stimulator trial lead. Post-procedure thoracic spine magnetic resonance imaging revealed marked thoracic epidural lipomatosis. At the level where satisfactory stimulation was obtained, the thickness of the epidural fat was within normal limits. The patient eventually underwent placement of a laminotomy lead with good coverage and pain relief. CONCLUSION Spinal epidural lipomatosis significantly increases the impedance in the epidural space, making effective neurostimulation very difficult to obtain. Physicians should consider the possibility of spinal epidural lipomatosis when very high impedances are encountered during lead placement.

New Therapy for Refractory Chronic Mechanical Low Back Pain-Restorative Neurostimulation to Activate the Lumbar Multifidus: One Year Results of a Prospective Multicenter Clinical Trial: RESTORATIVE NEUROSTIMULATION FOR CLBP

The purpose of the international multicenter prospective single arm clinical trial was to evaluate restorative neurostimulation eliciting episodic contraction of the lumbar multifidus for treatment of chronic mechanical low back pain (CMLBP) in patients who have failed conventional therapy and are not candidates for surgery or spinal cord stimulation (SCS).

Muscle Control and Non-specific Chronic Low Back Pain: MUSCLE CONTROL & CLBP

Chronic low back pain (CLBP) is the most prevalent of the painful musculoskeletal conditions. CLBP is a heterogeneous condition with many causes and diagnoses, but there are few established therapies with strong evidence of effectiveness (or cost effectiveness). CLBP for which it is not possible to identify any specific cause is often referred to as non‐specific chronic LBP (NSCLBP). One type of NSCLBP is continuing and recurrent primarily nociceptive CLBP due to vertebral joint overload subsequent to functional instability of the lumbar spine. This condition may occur due to disruption of the motor control system to the key stabilizing muscles in the lumbar spine, particularly the lumbar multifidus muscle (MF).

Spinal Cord Stimulator Related Infections: Findings From a Multicenter Retrospective Analysis of 2737 Implants.

Surgical site infection is a potential complication of spinal cord stimulator (SCS) implantation. Current understanding of the epidemiology, diagnosis, and treatment of these infections is based largely on small clinical studies, many of which are outdated. Evidence‐based guidelines for management of SCS‐related infections thus rely instead on expert opinion, case reports, and case series. In this study, we aim to provide a large scale retrospective study of infection management techniques specifically for SCS implantation.

The Promise of Effective Pain Treatment Outcomes: Rallying Academic Centers to Lead the Charge

### The Pain of the Mind is Worse Than the Pain of the Body #### Publilius Syrus The dramatic impact of chronic pain was captured in a recent European study that followed patients suffering with chronic pain for 1 year: 40% of those patients had more pain and 40% had less pain, but 100% reported major, negative impacts of chronic pain on their quality of life ⇓. Half of patients believed that everything possible had been done to manage their pain. This insight into how patients with chronic pain fare reveals a number of salient points, perhaps most importantly highlighting this condition that persists without cure. Furthermore, accumulating evidence suggests that emotional processing in brain networks is more involved in chronic pain ⇓ alluding to the nature of the associated suffering with the condition. Despite significant advances in pain neurobiology, there remains an urgent need to define outcome measures for treatment options and to understand both short-term (i.e., symptom control) and long-term (i.e., disease modification) approaches to treatments that really work. Unfortunately, pain remains one of the most difficult conditions to live with and to treat. One of the major problems is that because treatments are not highly effective across populations, a wide variety of approaches is frequently used combining various pharmacological, interventional, and behavioral treatments outside of the setting of a coordinated interdisciplinary program. In academic pain clinics, where a more rational approach to treatment may be possible because of hospital standards and relevant lack of financial conflict of interests, financial pressures remain a factor. Patients will continue to reach out in hope that some current or new treatment will be highly effective. Without question, some patients receive treatments that are highly effective such as spinal cord stimulation for chronic radicular leg pain in the setting of postlaminectomy syndrome, but this is generally not defined in a rigorous way as compared to treatment for an …