James P. Rathmell

Polyanalgesic consensus conference 2007: recommendations for the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel.

Background.  Expert panels of physicians and nonphysicians in the field of intrathecal therapies convened in 2000 and 2003 to make recommendations for the rational use of intrathecal analgesics based on the preclinical and clinical literature known up to those times. An expert panel of physicians convened in 2007 to update previous recommendations and to form guidelines for the rational use of intrathecal opioid and nonopioid agents.

ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine

Neurologic complications associated with regional anesthesia and pain medicine practice are extremely rare. The ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine addresses the etiology, differential diagnosis, prevention, and treatment of these complications. This Advisory does not focus on hemorrhagic and infectious complications, because they have been addressed by other recent ASRA Practice Advisories. The current Practice Advisory offers recommendations to aid in the understanding and potential limitation of neurologic complications that may arise during the practice of regional anesthesia and pain medicine.

Acute Post-Surgical Pain Management: A Critical Appraisal of Current Practice

The Acute Pain Summit 2005 was convened to critically examine the perceptions of physicians about current methods used to control postoperative pain and to compare those perceptions with the available scientific evidence. Clinicians with expertise in treatment of postsurgical pain were asked to evaluate 10 practice-based statements. The statements were written to reflect areas within the field of acute-pain management, where significant questions remain regarding everyday practice. Each statement made a specific claim about the usefulness of a specific therapy (eg, PCA or epidural analgesia) or the use of pain-control modalities in specific patient populations (eg, epidural analgesia after colon resection). Members of the American Society of Regional Anesthesia and Pain Medicine (ASRA) were asked, via a Web-based survey, to rate their degree of agreement with each of the 10 statements; 22.8% (n = 632) of members responded. In preparation for the pain summit, a panel member independently conducted a literature search and summarized the available evidence relevant to each statement. Summit participants convened in December 2005. The assigned panel member presented the available evidence, and workshop participants then assigned a category for the level of evidence and recommendation for each statement. All participants then voted about each statement by use of the same accept/reject scale used earlier by ASRA members. This manuscript details those opinions and presents a critical analysis of the existing evidence supporting new and emerging techniques used to control postsurgical pain.

The role of intrathecal drugs in the treatment of acute pain.

Intrathecal opioids are widely used as useful adjuncts in the treatment of acute and chronic pain, and a number of non-opioid drugs show promise as analgesic drugs with spinal selectivity. In this review we examine the historical development and current use of intrathecal opioids and other drugs that show promise for treating pain in the perioperative period. The pharmacology and clinical use of intrathecal morphine and other opioids is reviewed in detail, including dosing guidelines for specific surgical procedures and the incidence and treatment of side effects associated with these drugs. Available data on the use of non-opioid drugs that have been tested intrathecally for use as analgesics are also reviewed. Evidence-based guidelines for dosing of intrathecal drugs for specific surgical procedures and for the treatment of the most common side effects associated with these drugs are presented.

Clinicopathologic Review of 142 Cases of Lacrimal Gland Lesions

A review of 142 lacrimal gland biopsies performed during a 25-year period at a major eye hospital showed that 78% of lacrimal gland lesions were of nonepithelial origin and only 22% were primary epithelial neoplasms. The nonepithelial lesions included inflammation (64%) and lymphoid tumors (14%), whereas the epithelial lesions included dacryops (6%), pleomorphic adenoma (12%), and malignant epithelial tumors (4%). These results contradict the much quoted dictum that 50% of lacrimal gland lesions are primary epithelial tumors and 50% are nonepithelial lesions.

Polyanalgesic Consensus Conference 2012: Recommendations for the Management of Pain by Intrathecal (Intraspinal) Drug Delivery: Report of an Interdisciplinary Expert Panel: INTRATHECAL THERAPY CONSENSUS

Introduction:  The use of intrathecal (IT) infusion of analgesic medications to treat patients with chronic refractory pain has increased since its inception in the 1980s, and the need for clinical research in IT therapy is ongoing. The Polyanalgesic Consensus Conference (PACC) panel of experts convened in 2000, 2003, and 2007 to make recommendations on the rational use of IT analgesics based on preclinical and clinical literature and clinical experiences.

Epidural Steroids: A Comprehensive, Evidence-based Review

Abstract Epidural steroid injections (ESIs) are the most widely utilized pain management procedure in the world, their use supported by more than 45 placebo-controlled studies and dozens of systematic reviews. Despite the extensive literature on the subject, there continues to be considerable controversy surrounding their safety and efficacy. The results of clinical trials and review articles are heavily influenced by specialty, with those done by interventional pain physicians more likely to yield positive findings. Overall, more than half of controlled studies have demonstrated positive findings, suggesting a modest effect size lasting less than 3 months in well-selected individuals. Transforaminal injections are more likely to yield positive results than interlaminar or caudal injections, and subgroup analyses indicate a slightly greater likelihood for a positive response for lumbar herniated disk, compared with spinal stenosis or axial spinal pain. Other factors that may increase the likelihood of a positive outcome in clinical trials include the use of a nonepidural (eg, intramuscular) control group, higher volumes in the treatment group, and the use of depo-steroid. Serious complications are rare following ESIs, provided proper precautions are taken. Although there are no clinical trials comparing different numbers of injections, guidelines suggest that the number of injections should be tailored to individual response, rather than a set series. Most subgroup analyses of controlled studies show no difference in surgical rates between ESI and control patients; however, randomized studies conducted by spine surgeons, in surgically amenable patients with standardized operative criteria, indicate that in some patients the strategic use of ESI may prevent surgery.

Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration.

PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints, and are not intended to replace local institutional policies. In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data. This document updates the “Practice Guidelines for the Prevention, Detection and Management of Respiratory Depression Associated with Neuraxial Opioid Administration” adopted by ASA in 2007, and includes new survey data and recommendations pertaining to monitoring for respiratory depression. Methodology

Persistent postsurgical pain: the path forward through better design of clinical studies.

CHRONIC pain continues to be a major humanitarian and socioeconomic burden with slow progress in the development of new preventive and therapeutic options. Persistent postsurgical pain (PPP) is a well-known and common clinical entity with a reported incidence between 5 and 50% of patients after various common operations. PPP has received increased interest during the past 10–15 yr. These patients can be studied before injury is inflicted, and thus, PPP provides a special opportunity to understand pathogenic mechanisms for developing a chronic pain state or the transition from an acute to a chronic pain state. What have we learned from clinical trials regarding pathogenic mechanisms of PPP and the effects of preventive or therapeutic interventions? Despite the increased attention to PPP, most studies have done little more than codify the striking frequency with which this problem occurs after many disparate types of surgery: from inguinal herniorrhaphy to thoracotomy to breast surgery. It is likely that the pathogenic mechanisms leading to PPP are multiple, and thus, more rigorous study design will be required to better understand how the problem evolves and who is at greatest risk. Such careful study design has been the exception rather than the rule. What we do know is that those that seem to be most relevant are gender, psychosocial factors, preoperative pain at the site of surgery or in other body regions, the type of surgical trauma, nerve damage, acute postoperative pain and inflammatory responses, perioperative analgesia, type of disease, recurrence of malignancy, and adjuvant therapy. Several years ago, the International Association for the Study of Pain defined PPP as a persistent pain state that is apparent more than 2 months postoperatively that cannot be explained by other causes (recurrence of disease, inflammation, and others). Most of the available literature has followed the lead of this overly simplistic definition and is composed of reports with insufficient pain assessment and little information regarding its consequences. Too often, studies on PPP have been conducted using a single assessment, asking patients simply to report whether they have persistent pain at one point in time using only a simple yes or no answer. Future studies should include not only a detailed assessment of the location, characteristics, and evolution of painful symptoms and associated changes in neurologic function but also assessments of the consequences of persistent pain on physical and social function. These studies must be performed on a procedure-specific basis because the type of surgery has different consequences on specific organ functions, and new assessment scales must be developed and validated for individual procedures. We have only limited information from validated procedure-specific scoring systems, the most comprehensive example being the post groin hernia surgery pain scale. Finally, previous classifications of PPP as neuropathic and nociceptive pain have lacked specific objective criteria for such subgroupings, leading to the artificial concept that these two types of pain can be easily teased apart—even more damaging is the concept that the treatment for these two interwoven pain syndromes somehow differs. Indeed, many patients with PPP report both sensory abnormalities and localized stimulus-evoked pain, suggesting that both abnormal nerve function and ongoing nociception play a role in PPP. Less than a handful of studies have included detailed neurophysiologic assessment of PPP. There is a dramatic need for similar procedure-specific studies that are conducted prospectively to detail the evolution and characteristics of PPP and include pain-related functional impairment scales to assess the real impact of this problem. The pathogenic factors involved in PPP may be divided into patientand surgery-related factors, of which preoperative factors to be assessed in detail include psychosocial factors, pain and its consequences, nociceptive function, and gender. Of the intraoperative factors, type of anesthesia, surgical approach (magnitude of tissue damage), nerve identification, and nerve injury are obviously important, and postoperative factors should include a detailed description of the type of analgesia, duration, early follow-up with neurophysiologic assessments, disease data, and detailed assessment of pain and its functional consequences. Although 2 months postoperatively has been proposed as a criterion for PPP, the definition was not based on procedure-specific data, and after some operations, a continuous inflammatory response may be apparent calling for assessments for at least 3–6 months postoperatively to provide useful information. Although these requirements for study design may seem obvious and easy to include in clinical trials, an example from a Accepted for publication November 17, 2009. The authors are not supported by, nor maintain any financial interest in, any commercial activity that may be associated with the topic of this article.

Intrathecal morphine for postoperative analgesia: A randomized, controlled, dose-ranging study after hip and knee arthroplasty

In this series, we examined analgesia and side effects of intrathecal morphine sulfate (ITMS) after hip and knee arthroplasty over a dose range of 0.0–0.3 mg. Eighty patients undergoing hip (n = 40) or knee (n = 40) arthroplasty were randomized to receive ITMS (0.0, 0.1, 0.2, or 0.3 mg). A patient-controlled analgesia (PCA) device provided free access to additional analgesics. Morphine use, pain relief, and side effects were recorded for 24 h. Data were analyzed with analysis of variance and linear regression. After hip arthroplasty, morphine use was less in patients receiving 0.1, 0.2, or 0.3 mg of ITMS than in control patients (P < 0.05). After knee arthroplasty, ITMS did not reduce postoperative morphine requirements. Nausea and vomiting and the incidence of oxygen saturation <93% were similar in all groups. Pruritus was more common after ITMS. Patients receiving 0.2 or 0.3 mg of ITMS were more satisfied with their pain control than those receiving 0.0 or 0.1 mg after both hip and knee arthroplasty. Analgesic needs are greater after knee arthroplasty than after hip arthroplasty. We conclude that combining small-dose (0.2 mg) ITMS with PCA morphine provides good to excellent pain control in most patients after total hip or knee arthroplasty. However, PCA morphine use was reduced by the addition of ITMS only after hip arthroplasty.