Rahul Rastogi

Management of chronic pain in elderly, frail patients: finding a suitable, personalized method of control

The elderly population is projected to make up 20% of the total United States population by the year 2030. In addition, epidemiological data suggests increasing prevalence of chronic pain and frailty with advancing age. Pain, being a subjective symptom, is challenging to manage effectively. This is more so in elderly populations with age-specific physiological changes that affect drug action and metabolism. Elderly patients are also more likely to have multiple chronic health pathologies, declining function, and frailty. The barriers present for patients, providers, and health systems also negatively impact efficient and effective pain control. These factors result in disproportionate utilization of health resources by the older population group. The scientific literature is lagging behind in age-specific studies for the elderly population. As a result, there is a lack of age-specific standardized management guidelines for various health problems, including chronic pain. Increasing efforts are now being directed to studies on pain control in the elderly. However, pain management remains inconsistent and suboptimal. This article is an attempt to suggest an informed, comprehensive guide to achieve effective pain control in the presence of these limitations.

Supraclavicular decompression for neurogenic thoracic outlet syndrome in adolescent and adult populations

OBJECTIVE This study was conducted to better define clinical results and understand factors determining responsiveness to surgical treatment for neurogenic thoracic outlet syndrome (NTOS) in adolescent and adult populations. METHODS A retrospective review was conducted for 189 patients with disabling NTOS who underwent primary supraclavicular decompression (scalenectomy, brachial plexus neurolysis and first rib resection, with or without pectoralis minor tenotomy) from April 2008 to December 2010. Clinical characteristics were compared between 35 adolescent patients (aged<21 years) and 154 adults (aged>21 years). Functional outcome measures were assessed before surgery and at 3- and 6-month follow-up using a composite NTOS Index combining the Disabilities of the Arm, Shoulder and Hand (DASH) survey, the Cervical-Brachial Symptom Questionnaire (CBSQ), and a 10-point visual analog scale (VAS) for pain. RESULTS Adolescent and adult patients were not significantly different with respect to sex (overall 72.5% female), side affected (58.7% right, 60.3% dominant limb), bony anomalies (23.3%), previous injury (55.6%), coexisting pain disorders (11.1%), and positive responses to scalene muscle anesthetic blocks (95.6%). Compared with adults, adolescent patients had a significantly (P<.05) lower incidence of depression (11.4% vs 41.6%), motor vehicle injury (5.7% vs 20.1%), previous operations (11.4% vs 29.9%), preoperative use of opiate medications (17.1% vs 44.8%), and symptom duration>2 years (24.2% vs 50.0%). Mean preoperative NTOS Index (scale 0-100) was significantly lower in adolescent vs adult patients (46.5±3.6 vs 58.5±1.7; P=.009), and hospital length of stay was 4.4±0.2 vs 4.9±0.1 days (P=.03), but the rate of postoperative complications was no different (overall, 4.2%). Although both groups exhibited significant improvement in functional outcome measures at 3 and 6 months, adolescent patients had significantly lower NTOS Index (10.4±3.1 vs 39.3±3.3; P<.001) and use of opiate medications (11.4% vs 47.4%; P<.001) compared with adults. CONCLUSIONS Adolescents undergoing supraclavicular decompression for NTOS had more favorable preoperative characteristics and enhanced 3-month and 6-month functional outcomes than adults. Further study is needed to delineate the age-dependent and independent factors that promote optimal surgical outcomes for NTOS.

Early effectiveness of isolated pectoralis minor tenotomy in selected patients with neurogenic thoracic outlet syndrome

OBJECTIVE This study evaluated the early effectiveness of isolated pectoralis minor tenotomy (PMT) in the surgical treatment of selected patients with neurogenic thoracic outlet syndrome (NTOS) compared with supraclavicular decompression (SCD; as scalenectomy, neurolysis, and first rib resection) plus PMT (SCD+PMT). METHODS Data were obtained for 200 patients undergoing operative treatment for disabling NTOS between 2008 and 2011. Isolated PMT was offered to 57 patients with physical examination findings limited to the subcoracoid space, and SCD+PMT was offered to 143 with scalene triangle and subcoracoid findings. Functional outcomes were assessed before and 3 months after surgery using the Disabilities of the Arm, Shoulder and Hand (DASH) survey and related instruments. RESULTS There were no significant differences (P > .05) between PMT and SCD+PMT patients with respect to age (overall, 37 ± 1 years), sex (73% women), side affected (52% right, 14% bilateral), or the frequency of various NTOS symptoms, but fewer PMT patients had a bony anomaly (0% vs 18%; P < .01) or a history of injury (35% vs 61%; P < .01). Mean preoperative DASH scores were similar between PMT and SCD+PMT groups (49.9 ± 3.6 vs 50.8 ± 1.6), but previous use of opiate pain medications was higher in PMT patients (47% vs 20%; P = .0004). PMT was conducted as an outpatient procedure, whereas the mean hospital stay after SCD+PMT was 4.8 ± 0.1 days, with two patients (1%) requiring early reoperations for persistent lymph leaks. Mean DASH scores 3 months after surgery were significantly improved after isolated PMT (29.6 ± 4.2; P < .01) and SCD+PMT (41.5 ± 2.2; P < .01), but the mean extent of improvement in DASH scores was not significantly different in PMT (32% ± 9%) vs SCD+PMT (19% ± 5%). There were also no significant differences in the proportion of PMT vs SCD+PMT patients demonstrating improvement in functional outcome measures (75% vs 72%) or in overall use of opiate medications (35% vs 27%). CONCLUSIONS Isolated PMT is a low-risk outpatient procedure that is effective for the treatment of selected patients with disabling NTOS, with early outcomes similar to SCD+PMT. These findings emphasize the importance of recognizing subcoracoid brachial plexus compression as part of the spectrum of NTOS and support the role of PMT in surgical management.

Value of Targeted Epidural Blood Patch and Management of Subdural Hematoma in Spontaneous Intracranial Hypotension: Case Report and Review of the Literature

BACKGROUND Spontaneous intracranial hypotension (SIH) is a more common than previously noted condition (1-2.5 per 50,000 persons) typically caused by cerebrospinal fluid (CSF) leakage. Initial treatment involves conservative therapies, but the mainstay of treatment for patients who fail conservative management is the epidural blood patch (EBP). Subdural hematoma (SDH) is a common complication occurring with SIH, but its management remains controversial. METHODS In this report, we discuss a 62-year-old woman who presented with a 5-week history of orthostatic headaches associated with nausea, emesis, and neck pain. Despite initial imaging being negative, the patient later developed classic imaging evidence characteristic of SIH. Magnetic resonance imaging was unrevealing for the source of the CSF leak. Radionuclide cisternography showed possible CSF leak at the right-sided C7-T1 nerve root exit site. After failing a blind lumbar EBP, subsequent targeted EBP at C7-T1 improved the patients symptoms. Two days later she developed a new headache with imaging evidence of worsening SDH with midline shift requiring burr hole drainage. This yielded sustained symptomatic relief and resolution of previously abnormal imaging findings at 2-month follow-up. RESULTS A literature review revealed 174 cases of SIH complicated by SDH. This revealed conflicting opinions concerning the management of this condition. CONCLUSIONS Although blind lumbar EBP is often successful, targeted EBP has a lower rate of patients requiring a second EBP or other further treatment. On the other hand, targeted EBP has a larger risk profile. Depending on the clinic situation, treatment of the SDH via surgical evacuation may be necessary.

Chronic Pain Patients and Substance Abuse

The physical and mental states of human beings are governed by lifetime experiences and biopsychosocial makeup. They reinforce each other, and sometimes lead to maladaptive states, such as chronic pain, addiction, and so on. Pain and addiction are altered biopsychosocial experiences that are both subjective in nature and interact with one another. This interface of pain and addiction has brought about serious public health problems. It also poses ethical and healthcare dilemmas through the conflicting goals of managing pain states: pain relief, i.e. beneficence, and “do no harm”, i.e. nonmaleficence [Geppert C. To help and not to harm: ethical issues in the treatment of chronic pain in patients with substance use disorders. In: Clark MR, Treisman GJ, editors. Pain and depression. An interdisciplinary patient-centered approach. Adv Psychosom Med. Basel: Karger; 2004:25:151–71]. With the rise of medicinal management for chronic pain over the last two decades, addiction has become more prevalent, significantly increasing the risk of morbidity and mortality in this patient population. It is the responsibility of healthcare providers to utilize all the multimodal tools in their armamentarium to provide effective pain relief without unintentionally facilitating substance abuse.

Phantom limb pain

Phantom limb phenomenon (PLP) almost occurred on every patient who suffered ampu- tation surgery.The incidence of phantom limb pain was reported about 60%-70% of the PLP.The etio- pathogenesis of phantom limb pain remains unclear.However,both peripheral and central neural mecha- nisms have been described,along with superimposed psychological mechanisms.Recently,cortical reorgani- zation after amputation is recognized as another important central neural mechanism of phantom limb pain. While numerous treatments have been described,there is a little evidence supporting drug therapy,nerve block,surgery techniques,and psychological therapy.Until today,there is no unified recognition about the etiopathogenesis and treatments of phantom limb pain.

Postoperative Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS) is a complex, multifaceted, disabling and disproportionate spectrum of pain, vasomotor, sudomotor and trophic changes resulting from surgical or traumatic injury. There is some evidence that CRPS may play a primary role in thoracic outlet syndrome (TOS) patients, but because surgery is so often provided as a treatment for TOS there is an increased overall risk of development of CRPS in this patient group to start with. The pathophysiology of CRPS involves peripheral neurogenic inflammation and an intricate interaction of peripheral and central mechanisms involving the somatosensory, somatomotor and autonomic nervous systems. Due to lack of a specific diagnostic test, diagnosis remains clinical and laboratory tests supportive. Clinical diagnosis is made by the presence of sensory, vasomotor, sudomotor, and motor/trophic symptoms and signs as defined by the “Budapest criteria”. Treatment is challenging and a comprehensive approach including education, prevention, rehabilitation, psychotherapy, pharmacotherapy, and interventional modality seems logical. Early diagnosis, treatment and preemptive measures in high-risk patients are critical.