Dmitri Souzdalnitski

Obesity and chronic pain: systematic review of prevalence and implications for pain practice.

Abstract The combination of obesity and pain may worsen a patient’s functional status and quality of life more than each condition in isolation. We systematically searched PubMed/MEDLINE and the Cochrane databases for all reports published on obesity and pain. The prevalence of combined obesity and pain was substantial. Good evidence shows that weight reduction can alleviate pain and diminish pain-related functional impairment. However, inadequate pain control can be a barrier to effective lifestyle modification and rehabilitation. This article examines specific pain management approaches for obese patients and reviews novel interventional techniques for treatment of obesity. The infrastructure for simultaneous treatment of obesity and pain already exists in pain medicine (eg, patient education, behavioral medicine approaches, physical rehabilitation, medications, and interventional treatment). Screening for obesity, pain-related disability, and behavioral disorders as well as monitoring of functional performance should become routine in pain medicine practices. Such an approach requires additional physician and staff training. Further research should focus on better understanding the interplay between these 2 very common conditions and the development of effective treatment strategies.

How to Improve Needle Visibility

There are many advantages to the use of ultrasound in interventional pain medicine procedures. Ultrasound technology is currently growing exponentially due to its many advantages of improved and real-time high-resolution ultrasound imaging that results in successful pain management interventions. In addition, use of ultrasound for interventional pain management procedures avoids the many risks associated with radiation exposure to both the patient and practitioner.

Regional anesthesia and co-existing chronic pain.

Purpose of review Investigate the rational for incorporation of regional anesthesia techniques into a multimodal approach toward patients with co-existing chronic pain as increasing numbers of chronic pain patients are presenting for surgery. Recent findings There is a growing body of evidence suggesting that regional anesthesia may be superior to opioids for improved pain control along with increased patient satisfaction and decreased perioperative morbidity and mortality comparing to general anesthesia in patients with significant medical disease(s) and may also carry several economic benefits. Despite the prevalence of chronic pain and data suggesting that patients with chronic pain are prone to exacerbation of their condition(s) following surgery, regional anesthesia techniques for these patients is only beginning to be developed. Summary The systemic condition of chronic pain has important practical and clinical implications for regional anesthesia implementation by anesthesiologists and pain management physicians. Comprehensive preadmission assessment together with a complete medication history and close follow-up management should always be employed in patients with pre-existing chronic pain throughout the perioperative setting. Despite successful implementation of neural blockade, and to avoid opioid withdrawal, at least half the chronic pain patients daily pre-admission opioid dose should be continued daily throughout the perioperative period. Regional anesthesia is a preferable anesthetic option for perioperative management technique of patients with co-existing chronic pain, even if it requires supplementtion with sedation or general anesthesia. The specifics of regional anesthesia performance and practical strategies for regional anesthesia application in chronic pain patients, including implanted pain management devices, are reviewed in this study.

A low-cost, durable, combined ultrasound and fluoroscopic phantom for cervical transforaminal injections.

Background This technical report describes a durable, low-cost, anatomically accurate, and easy-to-prepare combined ultrasound (US) and fluoroscopic phantom of the cervical spine. This phantom is meant to augment training in US- and fluoroscopic-guided pain medicine procedures. Methods The combined US and fluoroscopic phantom (CUF-P) is prepared from commercially available liquid plastic that is ordinarily used to prepare synthetic fishing lures. The liquid plastic is heated and then poured into a metal canister that houses an anatomical cervical spine model. Drops of dark purple dye are added to make the phantom opaque. After cooling, tubing is attached to the CUF-P to simulate blood vessels. Results The CUF-P accurately simulates human tissue by imitating both the tactile texture of skin and the haptic resistance of human tissue as the needle is advanced. This phantom contains simulated fluid-filled vertebral arteries that exhibit pulsed flow under color Doppler US. Under fluoroscopic examination, the CUF-P–simulated vertebral arteries also exhibit uptake of contrast dye if mistakenly injected. Conclusions The creation of a training phantom allows the pain physician to practice needle positioning technique while simultaneously visualizing both targeted and avoidable vascular structures under US and fluoroscopic guidance. This low-cost CUF-P is easy to prepare and is reusable, making it an attractive alternative to current homemade and commercially available phantom simulators.

Occipital nerve entrapment within the semispinalis capitis muscle diagnosed with ultrasound

A 33-year-old man presented with a nine-month history of severe, refractory unilateral occipital neuralgia. The diagnosis was made based on the International Classification for Headache Disorders (ICHD-II) criteria for occipital neuralgia, including paroxysmal stabbing pain with persistent aching between paroxysms in the distributions of the greater occipital nerve (GON), tenderness over the affected nerve, and temporary relief from local anesthetic nerve block (1). There was no history of known trauma, prior skull base surgery, or rheumatoid arthritis, and there was no evidence of craniocervical junction abnormalities by magnetic resonance imaging (MRI). The patient failed to improve with physical therapy and multiple medication regimens, including nonsteroidal anti-inflammatory drugs, anticonvulsants, and antidepressants. Therefore, he was referred to our clinic for interventional pain management. Ultrasound scan revealed entrapment of the right GON as the nerve pierces the belly of the semispinalis capitis (Figure 1(a), (b)). The cross-sectional area of the GON was significantly larger than previously reported (2). The nerve continued to be enlarged as it became superficial after piercing the trapezius apponeurosis (Figure 1(c)). Increased cross-sectional nerve area in cases of entrapment neuropathy is well described (2). GON entrapment or irritation where the nerve pierces the belly of the semispinalis capitis is associated with GON axonal swelling, which is one of the proposed etiologies to the underlying occipital neuralgia. While this causal relationship has been proposed in the clinical literature, this entrapment zone has not been characterized with clinical imaging. The normative sonographic data indicate that the GON cross-sectional area is 2.0 0.1mm at this level (range, 1 to 4mm). The mean GON cross-sectional area in symptomatic patients following entrapment was 4.1 2.6mm (range, 2 to 13mm). The size of the GON typically remains the same until it branches in the occipital area (3). The GON in our patient was significantly larger than previously described, 16.5mm (3.5mm 2mm p) (2,3). In our patient, injection of 10 units of reconstituted botulinum toxin type-A to the belly of the semispinalis capitis on both sides of the entrapped GON produced sustained pain relief associated with occipital neuralgia. Figure 1(d) represents the normal sonographic appearance of the GON at the six-month follow-up visit. The patient continues to be pain free without supplemental medication use for more than a year now. Recent studies have shown that injection of Botulinum toxin A into the ‘‘presumable’’ sites of GON entrapment provided some relief in symptomatic patients (4). It reduced headache and led to some quality of life improvement for three months without significant reduction in pain medication usage (5). Our observations indicate that Botulinum toxin may provide sustained relief in patients with GON neuralgia when injected into a ‘‘specific’’ entrapment location (rather than into the site of a potential or ‘‘presumed’’ entrapment). The appropriate site for injection may be identified with bedside ultrasound imaging. The patient’s own deregulatory and compensatory mechanisms have a tremendous role in development and cessation of chronic pain. The normalization of biomechanics after the release of the occipital nerve is likely the source of the long-term recovery, rather than prolonged action of the Botulinum toxin itself.

Novel High-Frequency Peripheral Nerve Stimulator Treatment of Refractory Postherpetic Neuralgia: A Brief Technical Note

The study aims to describe an ultrasound (US)‐guided peripheral nerve stimulation implant technique and describe the effect of high‐frequency peripheral nerve stimulation on refractory postherpetic neuralgia.

Evidence-based approaches toward reducing cancellations on the day of surgery.

The need to plan and implement a profitable business model, which improves the quality of care, safety and patient satisfaction, while not adversely impacting the

LOW-DOSE KETAMINE AS AN ADJUNCT TO ROUTINE PAIN PRACTICE: ARE WE READY YET?

value- is overwhelming to physicians. Anesthesiologists are struggling to reduce unnecessary surgical cancellations. Cancellations on the day of surgery are widely recognized as a healthcare dilemma with potential negative impact on the provision of healthcare, including hospitals, patients and healthcare providers. Cancellation rates (CRs) vary significantly, from as low as 1% to as high as a quarter of elective outpatient cases and two-thirds of inpatient cases.[1] These rates depend on organizational factors, the types of surgery involved, patients’ medical conditions, and staff availability, among others. Redesigning workflow, improving perioperative patient care, and providing satisfactory human resource management have proven to be somewhat helpful, though the issue has yet to be resolved.[2] Thus far, the most reliable solution to this dilemma has been to analyze the details of cancellations for each organization, apply general rules derived from studies conducted on cancellations, and set reasonable expectations with regard to CRs with the clear understanding that the ideal rate simply does not exist.[3,4] The roles of patient assessment, preoperative education, and management have been debated for years. The evidence for the impact of preoperative clinics on the CRs is scant.[5] McKendrick et al., in this issue of Saudi J Anesthesia, demonstrated that the rolling out of a preoperative preparation clinic in one of the district hospitals located in the United Kingdom helped to decrease the number of cancellations on the day of surgery by about 50%, assuming no other interventions were involved. The authors of this study also discovered a dramatic 3-fold decrease in the number of no-shows with the introduction of the preoperative preparation clinic! These are noteworthy outcomes. Also, they found that CRs secondary to medical reasons dropped almost twice since the introduction of the preoperative preparation clinic. The length of the rollout (i.e., 5 years), which commenced in the year 2006, was, however, significant.[6] It may be considered as a limitation of the present study for the following reason. There has been increasing attention on telemedicine in recent years.[7] The remote preoperative assessments conducted through the preoperative preparation clinic appeared to have excellent potential because the outcomes projected seemed to be similar to those obtained with in-house clinics. While hospital, patient, and caregiver costs were dramatically decreased with the introduction of the clinic, McKendrick et al. did not examine the cost-effectiveness of their clinic in the study. It would be interesting to see how the rolling out of telephone/video examinations in the perioperative period would change CRs as well as costs. McKendrick et al. were surprised that the number of patients who called and cancelled their surgeries increased since the introduction of their preoperative preparation clinic. This, however, seems to be a positive sign, possibly indicating increased responsibility among patients with regard to their appointments. It could also potentially be attributed to patients’ exposure to improved perioperative patient education and personification in communication through preoperative preparation clinic services. As a result of this education, the number of patients who called and cancelled increased in comparison to the number of those who just did not show up for their appointments. This article brings up several other points to consider that may catch the attention of readers of this issue of the journal. The number of cancellations that were related to a variety of organizational and other problems during the last year of the study, but not related to patient compliance or medical condition, was found to be 2.5 times higher: 427 cancelled cases versus 177 in 2010, the last year of the study. Problems contributing to this increase included the following: The hospital or ward was full and was unable to accommodate the patient; lists overrunning (resulting in insufficient time to complete scheduled surgeries or requiring prioritization of emergency cases in access to operating rooms); missing notes; equipment failure; and non-availability of nursing staff or physicians. It is fair to say that organizational calamity became evident only after the rolling out of the preoperative preparation clinic. Five years prior, these numbers were comparable: 604-462 cancelled cases. The study opened Pandoras box, revealing significant room for improvement in terms of healthcare organization, with almost 250% more opportunities for improvement in this area than in the management of patients’ medical conditions or patient compliance. Studies have suggested that there are significant economical and psychological benefits to integrating an expected range of cancellations into operating room management processes, perioperative capacities in intensive care areas, and staff schedules, and not just “overbooking!”[8,9] In summary, preoperative clinics seem to be effective in helping to reduce the number of no-shows and cancellations on the day of surgery that are related to medical management. Further exploration of organization-related factors of cancellations and incorporation of telemedicine technology into routine perioperative care may help decrease CRs even further.