Jason S. Eldrige

Efficacy of intervertebral disc regeneration with stem cells - A systematic review and meta-analysis of animal controlled trials

Management of intervertebral disc (IVD) degenerative disease is challenging, as it is accompanied by irreversible loss of IVD cells. Stem cell transplantation to the disc has shown promise in decelerating or arresting the degenerative process. Multiple pre-clinical animal trials have been conducted, but with conflicting outcomes. To assess the effect of stem cell transplantation, a systematic review and meta-analysis was performed. A comprehensive literature search was conducted through Week 3, 2015. Inclusion criteria consisted of controlled animal trials. Two reviewers screened abstracts and full texts. Disagreements were resolved by a third reviewer. Random effects models were constructed to pool standardized mean difference (SMD). Twenty two studies were included; nine of which were randomized. Statistically significant differences were found with the stem cell group exhibiting increased disc height index (SMD=3.64, 95% confidence interval (CI): 2.49, 4.78; p<0.001), increased MRI T2 signal intensity (SMD=2.28, 95% CI: 1.48, 3.08; p<0.001), increased Type II collagen mRNA expression (SMD=3.68, 95% CI: 1.66, 5.70; p<0.001), and decreased histologic disc degeneration grade (SMD=-2.97, 95% CI: -3.97, -1.97; p<0.001). There was statistical heterogeneity between studies that could not be explained with pre-planned subgroup analyses based on animal species, study designs, and transplanted cell types. Stem cells transplanted to the IVD in quadruped animals decelerate or arrest the IVD degenerative process. Further studies in human clinical trials will be needed to understand if such benefit can be translated to bipedal humans.

Management of Cerebral Spinal Fluid Leak Complicating Spinal Cord Stimulator Implantation

Abstract:  Accidental puncture of the dura mater with resultant leakage of cerebral spinal fluid (CSF) and development of postdural puncture headache (PDPH) is a known potential complication of percutaneous placement of spinal cord stimulator (SCS) leads. However, the implications and management strategies for this complication have not been thoroughly reported. We report two cases of SCS lead placement complicated by CSF leak and PDPH.

Incidence of Clinically Significant Percutaneous Spinal Cord Stimulator Lead Migration

To examine the incidence of percutaneous spinal cord stimulator lead migration, given current hardware and surgical technique.

Stem cell therapy for intervertebral disk regeneration

ABSTRACTIntervertebral disk degeneration has been considered an irreversible process characterized by a decrease in cell viability, attenuation of proteoglycan and type II collagen synthesis, and dehydration of nucleus pulposus. Stem cell therapy specifically addresses the degenerative process and offers a potentially effective treatment modality. Current preclinical studies show that mesenchymal stem cells have the capacity to repair degenerative disks by differentiation toward chondrocyte-like cells, which produce proteoglycans and type II collagen. There has been evidence that mesenchymal stem cell transplantation into the intervertebral disk increases the intradiskal magnetic resonance imaging T2 signal intensity, increases the disk height, and decreases the degenerative grade in animal models. Appropriate selection of cell carriers/matrix is important because it may prevent cell leakage into the spinal canal and provide an environment that facilitates cell proliferation and differentiation. Although human cell therapy trials for degenerative disk disease are on the horizon, potential issues might arise. The authors hereby review the current state of regenerative cell therapy in degenerative disk disease, with emphasis in cell source, techniques for cellular expansion, induction, transplantation, potential benefit, and risks of the use of this novel medical armamentarium in the treatment of degenerative disk disease.

Impact of celiac neurolysis on survival in patients with pancreatic cancer

BACKGROUND Pancreatic cancer (PC) often produces pain that is difficult to control. Celiac neurolysis (CN) is performed with the goal of improving pain control and quality of life while reducing opioid-related side effects. OBJECTIVE We aimed to evaluate whether CN provides a survival advantage for PC patients. DESIGN Retrospective case-control study. SETTING Single tertiary-care referral center. PATIENTS Review of a prospectively maintained database identified patients with unresectable PC who underwent CN over a 12-year period. Each patient was matched to 2 control patients with unresectable PC. INTERVENTION CN, which included both celiac plexus neurolysis (CPN) and celiac ganglia neurolysis (CGN). MAIN OUTCOME MEASUREMENTS Median survival in Kaplan-Meier curves and hazard ratios. RESULTS A total of 417 patients underwent CN and were compared with 840 controls with PC. Baseline characteristics were similar except the CN group had greater weight loss and pain requiring opioids. A mean of 16.6 ± 5.8 mL of alcohol was administered. For patients who underwent CN, the median survival from the time of presentation was shorter compared with controls (193 vs 246 days; hazard ratio 1.32; 95% confidence interval, 1.13-1.54). There was no difference in survival with unilateral or bilateral injection. However, EUS-guided CN was associated with longer survival compared with non-EUS approaches, and those who received CPN had longer survival compared with CGN. LIMITATIONS Single center, retrospective. CONCLUSION Our study suggests that CN is an independent predictor of shortened survival in PC patients. A prospective study is needed to verify the findings and determine whether shortened survival results from CN or from other features such as performance status and tumor-related characteristics. It is also imperative to verify our finding that EUS-guided CN provides a survival advantage over other approaches and whether CPN prolongs survival compared with CGN.

Knee Extensor Strength Is Associated with Pressure Pain Thresholds in Adults with Fibromyalgia

Objective Individuals with fibromyalgia (FM) have lower muscle strength and lower pressure pain thresholds (PPT). The primary aim of this study was to determine the associations between muscle strength and PPT in adults with FM to test the hypothesis that greater measures of muscle strength would be associated with greater values of PPT. Secondary aims included determining the effects of pain severity and the peak uptake of oxygen (Vo2) on the associations between muscle strength and PPT. Methods Knee extensor and flexor strength (N = 69) was measured in the dominant leg using a dynamometer, and PPT was assessed using an electronic algometer. Pain severity was determined using the Multidimensional Pain Inventory, and peak Vo2 uptake was quantified using an electronically braked cycle ergometer. Results Univariable linear regression analysis demonstrated a significant association between PPT (dependent variable) and isometric knee extensor (P<.001), isokinetic (60°/s) knee extensor (P = .002), and isokinetic (60°/s) knee flexor strength (P = .043). In a multiple variable linear regression analysis adjusted for age, sex, pain severity, body mass index and peak Vo2 uptake, a significant association was found between PPT and isometric knee extensor strength (P = .008). In a similar multiple variable analysis, a significant association was found between PPT and isokinetic knee extensor strength (P = .044). Conclusion Greater measures of isometric and isokinetic knee extensor strength were significantly associated with greater values of PPT in both univariable and multiple variable linear regression models. Trial Registration ClinicalTrials.gov NCT01253395

Occipital Neuromodulation: Ultrasound Guidance for Peripheral Nerve Stimulator Implantation

We report a case of chronic left‐sided occipital neuralgia in a 21‐year old female patient. The patient in question suffered from chronic greater occipital neuralgia for a duration of many years, which had been refractory to other conservative medical management strategies. Blockade of the greater occipital nerve with local anesthetic was consistently useful in attenuating the patients pain, though the effects were always short lived. Consequently, a successful trial of greater occipital nerve stimulation was undertaken.

Fibrin glue to treat spinal fluid leaks associated with intrathecal drug systems.

Intrathecal drug delivery systems (IDDSs) are used to treat resistant pain states as well as intractable spasticity via medication delivery into the spinal fluid. Risks associated with implantation of these devices include infection, bleeding, intrathecal granuloma formation, and neurologic sequelae similar to other neuraxial procedures. Intrathecal catheter placement creates the additional risk of persistent spinal fluid leak, which can lead to postdural puncture headaches as well as seroma formation and may require subsequent surgical exploration or explantation. This retrospective case series examines 3 patients at a single institution with persistent spinal fluid leak after IDDS placement (and explantation in one case) resulting in headache and/or seroma formation that were treated with epidural fibrin glue.

Atypical facial pain treated with upper thoracic dorsal column stimulation.

INTRODUCTION Spinal cord stimulation (SCS) is the most commonly used implantable neurostimulation modality for management of pain syndromes. We present a patient with history of right facial pain successfully treated for refractory angina with SCS and had coincident near resolution of facial pain. CASE DESCRIPTION A 45 year old male with documented coronary vasospasm presented for consideration of SCS for refractory angina. He underwent successful implantation with significant improvement in his intractable chest pain. Additionally, during trial and post-implantation, the patient described almost complete resolution of his chronic facial pain. Prior to implantation, the facial pain had been thoroughly evaluated without a discernible cause. He had been symptomatically treated for atypical facial pain (AFP) with gabapentin. Post-implantation, the patient was able to discontinue gabapentin and described near complete resolution of his AFP. DISCUSSION SCS is one of the most promising treatment options for refractory angina. Numerous randomized, controlled trials have demonstrated efficacy in increasing exercise duration and time to angina, decreasing number of angina attacks, sublingual nitrate consumption, and number of ischemic episodes. Reductions in pain, sympathetic tone, and myocardial oxygen demand as well as improvement in coronary microcirculatory blood flow have all been proposed as beneficial outcomes of stimulation. AFP is a poorly understood condition, often without etiology, and most commonly treated symptomatically. The resolution of our patients AFP is secondary to unclear mechanism(s). We propose SCS may have altered central processing or spinal trigeminal nucleus fibers; additionally, the pain may have been sympathetically mediated and altered by SCS.

Clinical Efficacy of an Ultrasound-Guided Greater Occipital Nerve Block at the Level of C2

Background and Objectives The purpose of this prospective open-label study was to investigate the analgesic effects of an ultrasound-guided greater occipital nerve (GON) block at the level of C2, as the nerve courses superficially to the obliquus capitis inferior muscle. Methods Patients with a diagnosis of occipital neuralgia or cervicogenic headache were recruited for the study. Ultrasound-guided GON blocks at the level of C2 were performed by experienced clinicians according to a standardized protocol. Numeric rating scale pain scores were recorded preinjection and at 30 minutes, 2 weeks, and 4 weeks after injection. Results A total of 14 injections were performed with a mean procedure time of 3.75 minutes. Anesthesia in the GON distribution was achieved for 86% of patients at 30 minutes postinjection. Compared with baseline, numeric rating scale scores decreased by a mean of 3.78 at 30 minutes (P < 0.001), 2.64 at 2 weeks (P = 0.006), and 2.21 at 4 weeks (P = 0.01). There were no significant adverse events reported during the study period. Conclusions This prospective open-label study demonstrated successful blockade of the GON at the level of C2 using a novel ultrasound-guided technique. Significant reductions in pain scores were observed over the 4-week study period, and no adverse events were reported. The observations from this study provide important preliminary data for future randomized trials involving patients with occipital neuralgia and cervicogenic headache.