Khalid Malik

Radiofrequency Applications to Dorsal Root Ganglia : A Literature Review

Application of radiofrequency currents to the dorsal root ganglia, in the treatment of various pain syndromes, has been clinically practiced for more than 30 yr. The clinical efficacy and the safety of this technique, however, remain poorly understood. The authors reviewed the literature on this modality of pain relief to determine its clinical efficacy, safety, and mechanisms of action. The two modalities in common clinical use were pulsed and continuous mode radiofrequency. These techniques were generally found to be safe, and the majority of the observational studies reported their clinical efficacy. Five randomized controlled trials evaluated their clinical use; these trials were relatively short-termed and small in size, and their results were variable. The mechanism of action of these techniques was unclear. Larger controlled clinical trials evaluating the long-term effects of these techniques and basic science research to determine their precise mode of action are needed.

Diagnostic criteria and treatment of discogenic pain: a systematic review of recent clinical literature.

BACKGROUND CONTEXT Pain innate to intervertebral disc, often referred to as discogenic pain, is suspected by some authors to be the major source of chronic low back and neck pain. Current management of suspected discogenic pain lacks standardized diagnosis, treatment, and terminology. PURPOSE In an attempt to determine whether patterns existed that may facilitate standardization of care, we sought to analyze the terminologies used and the various modes of diagnosis and treatment of suspected discogenic pain. STUDY DESIGN A systematic review of the recent literature. METHODS A Medline search was performed using the terms degenerative disc disease, discogenic pain, internal disc disruption while using the limits of human studies, English language, and clinical trials, for the last 10 years. The search led to a total of 149 distinct citations, of which 53 articles, where the intervertebral disc itself was considered the principal source of patients pain and was the main target of the treatment, were retained for further analysis. RESULTS The results of this review confirm and help quantify the significant differences that existed in the terminology and all the areas of diagnosis and treatment of presumed discogenic pain. CONCLUSIONS Our findings show that suspected discogenic pain, despite its extensive affirmation in the literature and enormous resources regularly devoted to it, currently lacks clear diagnostic criteria and uniform treatment or terminology.

Evidence-based case report: the prevention and management of postherpetic neuralgia with emphasis on interventional procedures.

Objective: A patient with postherpetic neuralgia (PHN) did not respond to medications, either singly or in combination, or to intrathecal methylprednisolone but responded to intrathecal alcohol. This evidenced-based case management article evaluates and grades the evidence for the prevention and treatment of PHN. Methods: A search of published English-language studies on the prevention and treatment of PHN was made. Results: Randomized clinical studies showed the efficacy of antiviral agents in the prevention of PHN and the use of anticonvulsants, antidepressants, opioids, and Lidoderm patch in the treatment of PHN (level A evidence). The role of epidural local anesthetic and steroid injections in preventing PHN has not been completely established (level B evidence). Intrathecal steroid injections and topical capsaicin may be effective in PHN (level B evidence). No randomized controlled study supports the usefulness of spinal cord stimulation and intrathecal alcohol. Conclusions: Postherpetic neuralgia should be managed pharmacologically. If not effective, intrathecal steroid injections or nerve blocks may be tried. Spinal cord stimulation or intrathecal alcohol should be used only as a last resort.

Prescription Patterns of Pain Medicine Physicians

Our study surveyed physician members of 3 American pain societies to determine prescription patterns and whether these practices reflect current expert opinion.

Scalene Muscle Injections for Neurogenic Thoracic Outlet Syndrome: Case Series

Abstract:  Scalene muscle injections are used to confirm the diagnosis of neurogenic thoracic outlet syndrome and predict the response of patients to surgery. We performed a retrospective study to determine if relief of pain was related to brachial plexus blockade in these patients.

Relationship Between Ultrasound Imaging and Eliciting Motor Response During Femoral Nerve Stimulation

Objective. Nerve stimulator–assisted localization of the femoral nerve is well described; however, direct ultrasound imaging of the femoral nerve branches may be challenging. The purpose of this study was to correlate the evoked motor responses obtained by femoral nerve stimulation and the topographic orientation of the femoral nerve branches during ultrasound examinations of the infrainguinal region. Methods. Eighty‐two patients undergoing total knee replacement were enrolled in this study. A 25‐mm, 5‐ to 10‐MHz broadband linear array transducer was used to identify the femoral nerve at the inguinal crease. The medial and lateral aspects of the femoral nerve were stimulated under ultrasound imaging. Twenty cadavers were dissected to support our clinical findings. Results. A quadriceps contraction was elicited in 1.2% and 96% of the patients when stimulating the medial and lateral aspects of the femoral nerve, respectively. In contrast, a sartorius muscle contraction was elicited in 94% and 0% when stimulating the medial and lateral aspects of the femoral nerve. Our findings during anatomic dissection revealed that the femoral nerve branch to the quadriceps muscle, when compared with the branch to the sartorius muscle, originated laterally in 95% and medially in 5% of the specimens. Conclusions. When using out‐of‐plane ultrasound imaging at the inguinal crease, directing the stimulating needle to the lateral half of the femoral nerve may be associated with a higher probability of encountering the motor branch to the quadriceps muscle.

Water-Cooled Radiofrequency: A Neuroablative or a Neuromodulatory Modality with Broader Applications?

We report the successful use of water-cooled radiofrequency where more traditional forms of neuroablation—conventional and pulsed radiofrequency—had failed to achieve adequate pain relief. We also discuss the mechanism of neural damage with water cooled radiofrequency and discuss why this technique may have a broader role in the management of a wide array of pain syndromes.

Efficacy of Pregabalin in the Treatment of Radicular Pain: Results of a Controlled Trial

Background: Pregabalin is commonly used to treat patients with various neuropathic pain syndromes. Objectives: The purpose of the present study was to evaluate the efficacy of pregabalin in patients with lumbar or cervical radicular pain. Patients and Methods: A prospective, randomized, double-blind trial was conducted in 39 patients with lumbar and cervical radicular pain, who received 3 weeks of either pregabalin (n = 10) or placebo (n = 9) treatment. Baseline pain and disability were evaluated before the treatment and were re-evaluated, along with overall patient satisfaction, after the 3 weeks of treatment. Results: Data on 19 of the 39 patients recruited were available for analysis. No statistically significant differences in the pain, disability, and patient satisfaction scores were found between the groups. When the individual patient scores were assessed, the placebo treatment was found to be efficacious in 4 of the 9 patients and pregabalin was effective in 2 of the 10 patients, but the difference was not statistically significant (P = 0.350). Conclusions: The present data do not suggest that pregabalin is more efficacious than placebo in the treatment of lumbar and cervical radicular pain. However, the small sample size of this study may have affected the ability to detect such a difference.

Vascular uptake of PMMA after spinal procedures

Vascular uptake of polymethylmethacrylate (PMMA), commonly known as bone cement, after spinal procedures, such as vertebroplasty (VB) and kyphoplasty (KP), is a frequent occurrence. Among the ensuing embolic phenomenon, pulmonary cement embolism (PCE) is the most prevalent. A large number of these patients may be asymptomatic. However, when symptoms occur, they vary widely in severity and may be delayed for days to weeks. Treatment of PCE is mainly supportive, and symptomatic patients may require anticoagulation for protracted period. In rare cases of PCE with systemic collapse, invasive or surgical embolectomy, which carries a high risk, may be necessary. Vigilance during VP and KP procedures and a cautious technique may reduce the risk of vascular PMMA uptake.

Disease-modifying Antirheumatic Drugs for the Treatment of Low Back Pain: A Systematic Review of the Literature

Low back pain (LBP) is a common source of pain and disability, which has an enormous adverse impact on affected individuals and the community as a whole. The etiologies of LBP are protean and local inflammation contributes to the majority of these processes. Although an array of potent disease‐modifying anti‐rheumatic drugs (DMARDs), which are typically anti‐inflammatory in character, have become clinically available only corticosteroids are routinely used for the treatment of LBP. To further investigate this potentially underutilized therapy, we reviewed the available literature to determine the role of DMARDs in the treatment of LBP. Our results show that the current DMARD use for LBP is indeed limited in scope and is characterized by isolated use and empiric selection of drugs from a range of available DMARDs. Moreover, the dose, frequency, and route of drug administration are selected arbitrarily and deviated from treatment protocols proposed for the management of other inflammatory conditions. The literature published on this topic is of low quality, and the results of the reviewed trials were inconclusive or demonstrated only short‐term efficacy of these medications. Based on the findings of this review, we recommend that the future DMARD use for LBP is initially limited to patients with debilitating disease who are unresponsive to conventional treatments, and the criteria for drug selection and routes of drug administration are clearly defined and may be modeled after treatment protocols for other inflammatory conditions.