Leonardo Kapural

Efficacy of Interlaminar vs Transforaminal Epidural Steroid Injection for the Treatment of Chronic Unilateral Radicular Pain: Prospective, Randomized Study

UNLABELLED OBJECTIVE, DESIGN AND SETTINGS: The purpose of this randomized, prospective study is to compare the efficacy of two different routes in administering epidural steroid injections interlaminar (IL) vs transforaminal (TF) in patients with unilateral radicular pain. PATIENTS We randomly enrolled and followed 64 patients with chronic radiculopathy. RESULTS Significant improvements were maintained throughout 6 months (24 weeks) of follow-up (P<0.001, respectively). The average visual analog scale (VAS) pain scores at 24 weeks improved to 4.0 ± 2.2 cm in the IL group and 3.8 ± 2.1 cm in the TF group (P=0.717). Baseline functional capacity was comparable for the IL and the TF group (52% vs 53%) when assessed using Oswestry (P=0.647). At 6 months, both groups improved, 39% for the IL group and 38% for the TF group, suggesting change from severe to moderate disability scoring range. There were 24 out of the 32 (75%) patients in the IL group at 24 weeks who improved more than 2 cm on the VAS scale and 17 patients (53%) had >50% of the pain relief. In the TF group, there were 27 out of the 32 (84%) patients with >2 cm improvement on VAS pain scale, and 20 of 32 (63%) with >50% improvement at 24 weeks. Functional capacity changes were similar, 16 out of the 32 patients (50%) improved 10 points or more on the Oswestry scale in the IL group and 21 out of the 32 in the TF group (66%). CONCLUSIONS Using either route of epidural injections to deliver steroids for unilateral chronic radiculopathy secondary to herniated intervertebral disc provided significant improvements in patients function and pain relief. However, we could not find a statistically significant difference between two indicated groups either in functional improvement or in reduction in pain, although half-dose of steroids delivered via TF route provided somewhat better long-term pain relief and functional capacity improvements.

Spinal Cord Stimulation for Intractable Chronic Pain

Spinal cord stimulation (SCS) is minimally invasive and reversible therapy for treatment of severe, otherwise nonresponsive chronic pain. Such approach is relatively safe, with very few side-effects, not addictive, and provides enduring therapeutic response. A number of clinical studies support the efficacy of spinal cord stimulation in treating failed back surgery syndrome and complex regional pain syndrome, as well as peripheral neuropathic pain, postamputation pain, postherpetic neuralgia, root and spinal cord injury pain. In addition, neurostimulation has been used to treat refractory angina, chronic abdominal pain, peripheral vascular disease, and vaso-occusive syndromes. Clinical use of spinal cord stimulation is expanding at very fast pace, and new technological modalities in SCS will provide a new clinical evidence with likely better pain control.

Prospective, Multicenter, Randomized, Double‐Blinded, Partial Crossover Study to Assess the Safety and Efficacy of the Novel Neuromodulation System in the Treatment of Patients With Chronic Pain of Peripheral Nerve Origin

Currently available central nervous system treatment strategies are often insufficient in management of peripheral neuropathic pain, prompting a resurgence of neuromodulation focused on peripheral pain. A new peripheral nerve stimulation device was investigated in a prospective, randomized, double blind, crossover study, looking specifically at efficacy and safety, with Food and Drug Administration oversight.

Clinical Applications of Neuromodulation: Spinal Cord Stimulation for Abdominal Pain

Chronic abdominal pain poses significant challenges to patients and physicians alike. For patients, pain can limit both professional and personal quality of life. It results in increased doctor visits, imaging and surgery interventions that frequently fail to find a cause or provide relief. For physicians, identification of etiology is fraught with difficulty, largely due to the fact that visceral pain is frequently diffuse and is poorly localized and referred to somatic structures. Abdominal pain is one of the most common complaints for primary care visits and is the leading reason for gastroenterological consultation. These challenges taken together with the high prevalence, frequent office visits and extensive work-up, as well as decreases in productivity, work hours, and socioeconomic status, make chronic abdominal pain a significant burden on the patient, physician, healthcare system, and society as a whole. In the United States alone, between 20 and 45 % of Americans will suffer from chronic visceral pain, of these only 50–70 % will have a definitive etiology of their pain identified. Recent research has provided data helping to better elucidate visceral pain pathways and the dorsal column’s role in not only transmission but also amplification of visceral pain. Exciting data in both animal models and human subjects has demonstrated that spinal cord stimulation of the dorsal horn can provide analgesia for chronic visceral pain and improve both quality of life and functional status.

Intradiscal Annuloplasty for the Treatment of Discogenic Pain

The term discogenic pain refers to pain arising from the disc itself. Discogenic pain is cited as the most common cause of chronic low back pain, accounting for approximately 26–39 % of patients with such pain etiology. Internal disc disruption (IDD) is the most common diagnosis leading to chronic low back pain and one of the major causes of chronic neck pain. Discogenic pain is a significant medical challenge, in terms of its clinical, social, economic, and public health implications. An extensive body of literature suggests that discogenic pain is likely to be multifactorial. The most significant risk factors are genetic inheritance, environmental influences, and lifestyle choices. Although available literature supports hypothesis that the intervertebral disc is an independent chronic pain generator, research related to the epidemiology of discogenic pain is still in its formative stage.