Sanjog Pangarkar

The Risk of Radiation Exposure to the Eyes of the Interventional Pain Physician

It is widely accepted that the use of medical imaging continues to grow across the globe as does the concern for radiation safety. The danger of lens opacities and cataract formation related to radiation exposure is well documented in the medical literature. However, there continues to be controversy regarding actual dose thresholds of radiation exposure and whether these thresholds are still relevant to cataract formation. Eye safety and the risk involved for the interventional pain physician is not entirely clear. Given the available literature on measured radiation exposure to the interventionist, and the controversy regarding dose thresholds, it is our current recommendation that the interventional pain physician use shielded eyewear. As the breadth of interventional procedures continues to grow, so does the radiation risk to the interventional pain physician. In this paper, we attempt to outline the risk of cataract formation in the scope of practice of an interventional pain physician and describe techniques that may help reduce them.

Medical marijuana for failed back surgical syndrome: a viable option for pain control or an uncontrolled narcotic?

M.J. is a 54-year-old woman with diffuse low back and bilateral leg pain. She has had 4 spinal surgeries over the past 12 years for her pain, including 2 laminectomies at L4-L5 and L5-S1, a fusion from L4-L5 to the sacrum, and a subsequent revision from L3 to the sacrum. The first surgery provided her 4 years of relief, but all other surgeries resulted in no measurable relief. Various interventional treatments have failed to help, including a spinal cord stimulator trial. She has no focal weakness on lower limb examination but has some subjective numbness in her lower extremities bilaterally and is areflexic in the Achilles tendon bilaterally. She sees a pain psychologist weekly for sessions that include pain coping skills and biofeedback. She denies any depression and scores well on standardized depression inventories. The apparent lack of depression may be due to the psychoaffective effects of opioids; she currently takes scheduled sustained release oxycodone 40 mg every 12 hours, with occasional oxycodone for breakthrough pain control. However, she believes that thesemedications only partially control her pain. She has had routine urine drug screens that show compliance with the treatment regimen. She has heard of people taking medical marijuana for pain control and wonders if that will be a viable option for her instead of escalating the dose of opioids. Sunil K. Aggarwal, MD, PhD, and Gregory Carter, MD, MS, will argue that medical marijuana is an appropriate treatment for this patient, and Sanjog Pangarkar, MD, Mark Miedema, MD, and Bianca Tribuzio, DO, will argue that medical marijuana is not a viable option for this patient.

The Use of Ketamine in Neuropathic Pain

Hyperactivity of N-methyl-d-aspartate (NMDA) receptors may be one of the factors in the genesis of neuropathic pain (NP). Ketamine is a dissociative anesthetic and analgesic that is the most potent NMDA receptor antagonist currently available for human use. There is a growing body of literature for three decades suggesting efficacy of subanaesthetic doses of ketamine in the treatment of NP, particularly the pain in complex regional pain syndromes. The primary limitations of ketamine use are secondary to psychotomimetic and, to a lesser extent, sympathetic activation. The purpose of this article is to review the history, pharmacology, pharmacodynamics, clinical benefits, and limitations of ketamine for treatment of NP. Methods of administration and management of adverse effects are highlighted based on the clinical experience of the authors.

Alleviating Thoracotomy Pain With Intercostal Liposomal Bupivacaine: A Case Report

Thoracotomy pain is common after chest surgery and may result from injury to the lung pleura, intercostal muscles, costovertebral joint, or intercostal nerves. Inappropriately controlled postoperative pain can hinder recovery and increase the risk of complications such as infection, atelectasis, blood clots, and development of post‐thoracotomy pain syndrome. A number of treatment options for acute pain are available, most of which require systemic medications or indwelling catheters that may be contraindicated in patients on anticoagulants. We present the case of a patient with post‐thoracotomy pain that effectively was treated with an ultrasound‐guided nerve block with liposomal bupivacaine. The patient experienced pain relief without adverse event. Liposomal bupivacaine may be considered a potential treatment option for patients with severe acute post‐thoracotomy pain in whom other modalities have not worked or are contraindicated.

Driving Under the Influence of Opioids

A 45-year-old man presents to your clinic as a new patient. His medical history is negative; however, his surgical history reveals a history of an L4-S1 posterior decompression and fusion that was performed 5 years earlier. The fusion was performed for a well-established chronic left-sided L5 and S1 lumbar radiculopathy. The patient’s low back pain and left lower extremity pain improved for 3 months and then returned to his presurgical level of 7/10. Postsurgical magnetic resonance imaging shows stable fusion structure without evidence of new disk herniations, with scar tissue surrounding the left-sided L5 and S1 nerve roots. The patient refuses further surgery or interventional options. In your clinic, he fills out a Screener and Opioid Assessment for Patients with PaineRevised (SOAPP-R), and his final score is 6, which indicates low risk for opioid misuse. His examination is consistent with failed back surgery syndrome (FBSS), and you believe it is appropriate to have him start taking a low-dose opioid medication. The patient signs a controlled substance agreement (CSA) in your clinic, submits a baseline urine drug screen, and after failing to find adequate relief with noneopioid-based therapies, the patient was given a prescription for morphine sulfate extended release, 15 mg twice a day. At his follow-up visit 1 month later, he reports that this medication provides good relief and limited adverse effects. His urine drug screen is appropriate for the medication prescribed, and his state prescription database monitoring program reveals no aberrancies. He would like to continue to commute to work and asks if it is safe for him to drive while taking long-acting morphine. Drs Ameet Nagpal and Rachel Xu will argue that operating a motor vehicle while taking opioid medication is not recommended because they can cause cognitive impairment. Drs Sanjog Pangarkar and Ian Dworkin will argue that the patient is taking a stable dose of long-acting opioids and therefore, with no history of cognitive-related adverse effects, driving would be considered safe.

Poster 376: AbobotulinumtoxinA Efficacy in Post-Traumatic Headache

Disclosures: Mickey Lui: I Have No Relevant Financial Relationships To Disclose Objective: To assess the efficacy of platelet-rich plasma shoulder injection compared to physical therapy or exercise therapy for rotator cuff shoulder pathology. Design: Systematic review randomized controlled trials. Setting: Outpatient clinics. Participants: Subjects selected in combined randomized control trials with shoulder pain due to rotator cuff pathology who have not undergone surgical intervention, n 1⁄4 152, PRP n 1⁄477, placebo/PT/exercise therapy n 1⁄4 75. Interventions: Platelet-rich plasma shoulder injection versus placebo control or targeted shoulder physical therapy or shoulder exercise therapy. Main Outcome Measures: Visual analog scale (VAS), Shoulder range of motion (ROM) in flexion, extension, external rotation, internal rotation, at baseline, immediate, 3-4 weeks, 3, 6, and 12 months postintervention. Results: A systematic search across multiple databases was performed for clinical trials that involved non-operative platelet-rich plasma (PRP) shoulder injections for treatment of shoulder rotator cuff pathology. The database requisition resulted in 71 articles in published under clinical trials. Two authors independently reviewed and selected 13 publications for additional review. Of the 13 publications 3 met criteria with non-operative PRP injection compared to placebo or physical exercise intervention. In review of the 3 selected publications PRP was not superior to placebo control and was not significantly better than physical therapy or exercise therapy for shoulder pain or function due to rotator cuff pathology. Conclusions: Platelet-rich plasma for non-operative rotator cuff shoulder pathology is not superior to placebo and does not offer significant benefits over conventional physical therapy or exercise therapy. Level of Evidence: Level I

Poster 409: Toxicology Immunoassay to Evaluate for the Presence of Tetrahydrocannabinol (THC) in a Commercially Sold Cannabidiol (CBD) Formulation: A Case Report

Disclosures: Natasha Mehta: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Sphenopalatine ganglia (SPG) is suspended in the pterygopalatine fossa with sympathetic, parasympathetic, and somatosensory contributions from the superior cervical ganglion, greater petrosal nerve, and maxillary nerve, respectively. This ganglion has been linked to trigeminal autonomic cephalgias and migraines. Few patients are refractory to conservative treatments. SPG blocks have been utilized for pain management in these cases. A 54-year-old woman presented with photo-oculodynia syndrome and cluster-type hemicephalgias that initially improved with vocational modifications. Over the years she failed monotherapies, including oxygen, but had partial relief with topirimate, oxcarbazepine, gabapentin, and naproxen. She still experienced functionally debilitating photophobia, atypical facial pain, and trigeminal neuralgia. Exam significant for photophobia producing severe right ocular headaches. Setting: Outpatient Rehabilitation Center. Results: Transnasal SPG blocks improved visual convergence and drilling facial pain. She was taught self-administration of SPG blocks with lidocaine applied with Q-Tips every other day and photo-oculodynia exacerbations gradual improved. Over the last 2 years she regained tolerance for sunlight and fluorescent lights without the need for shading. Discussion: The SPG is accessible via a transnasal approach posterior to the middle turbinate, lateral approach through the infratemporal fossa, or transoral approach through the greater palatine foramen. Adverse effects of intranasal approach with anesthetic include epistaxis, dysesthesia, and temporary diplopia. Due to the rare risk of anesthetic toxicity or infection, this patient started with 1% lidocaine solution. The transoral and lateral approaches are complex, sometimes done with imaging guidance. The transnasal approach is technically simpler and can be taught to the correctly selected patient. Conclusions: SPG blocks have been successfully performed for over a century, utilizing various agents or neuromodulation. Limitations to topical hydrophobic anesthetic are duration of effect and accuracy. There have been case reports of cumulative relief over time with repetitive SPG blocks. This person was able to learn the technique to perform independently as needed. Level of Evidence: Level V

Poster 417: Improving Amputation Outcomes with Ketamine Infusions in Treatment-Resistant Complex Regional Pain Syndrome: A Case Report

Conclusions: There have been less than one hundred cases documenting the complications of NMO during pregnancy. The use of immunosuppressant and muscle relaxants to treat the neurological and musculoskeletal clinical manifestation of NMO is limited in pregnancy. It is therefore prudent to investigate response to physical therapy modalities in this patient population. This case illustrates the necessity for a multidisplinary approach for successful rehabilitation of patients with NMO complicated by pregnancy. Level of Evidence: Level V

Poster 415 Epidemiology of Naloxone use for Opioid Overdose in a Tertiary Care Medical Center.

Disclosures: Sheena Aurora: Consulting fees or other remuneration (payment) Allergan, eNeura, Merck, Teva, Speakers bureau Allergan Objective: To evaluate the effect of onabotulinumtoxinA on headache-day severity in patients with chronic migraine (CM). Design: Two multicenter, phase 3, double-blind, parallel-group, placebo-controlled, 24-week studies. Setting: 122 global sites from the PREEMPT (Phase 3 Research Evaluating Migraine Prophylaxis Therapy) Study. Participants: Participants had a history of migraine and met International Classification of Headache Disorders (2nd edition) migraine diagnostic criteria, with headaches 15 days/month. Interventions: OnabotulinumtoxinA (155 U e 195 U) or placebo every 12 weeks for 2 treatment cycles. Main Outcome Measures: Headache-day severity was assessed at baseline and 24 weeks. Treatment responders were defined as those achieving 1-grade improvement in average daily headache severity (ADHS) score at week 24 compared with baseline. Results: 1384 patients received onabotulinumtoxinA (n1⁄4688) or placebo (n1⁄4696). At baseline, the percentage of severe + moderate headache days was 37.3% + 27.3% in the onabotulinumtoxinA group and 37.0% + 27.3% in the placebo group (P1⁄4.58 and P1⁄4.97 for severe and moderate days, respectively). At week 24, the proportion of patients with severe + moderate headache days was significantly lower for onabotulinumtoxinA (21.3% + 15.6%) compared with placebo (26.3% + 17.3%; P<.001 for both comparisons). OnabotulinumtoxinA produced a significant decrease in the number of severe headache days per 28-day period at week 24 (onabotulinumtoxinA, e4.5; placebo, e3.0; P<.001). Responder analyses indicated that significantly more patients receiving onabotulinumtoxinA than placebo demonstrated 1-grade improvement from baseline in ADHS score (35.8% vs 23.1%, P<.001) at week 24. Conclusions: Among patients with CM, use of onabotulinumtoxinA significantly reduced the number of severe and moderate headache days. In conjunction, significantly more patients treated with onabotulinumtoxinA had 1-grade improvements in ADHS scores compared with placebo. This is consistent with previously reported benefit of onabotulinumtoxinA in reducing daily headache severity in patients with CM. Level of Evidence: Level I

Poster 413 A Case Study Investigating Opioid Medication Utilization in Patients with Complex Regional Pain Syndrome Before and After Ketamine Infusion Therapy

Disclosures: Sheena Aurora: Consulting fees or other remuneration (payment) Allergan, eNeura, Merck, Teva, Speakers bureau Allergan Objective: To evaluate the effect of onabotulinumtoxinA on headache-day severity in patients with chronic migraine (CM). Design: Two multicenter, phase 3, double-blind, parallel-group, placebo-controlled, 24-week studies. Setting: 122 global sites from the PREEMPT (Phase 3 Research Evaluating Migraine Prophylaxis Therapy) Study. Participants: Participants had a history of migraine and met International Classification of Headache Disorders (2nd edition) migraine diagnostic criteria, with headaches 15 days/month. Interventions: OnabotulinumtoxinA (155 U e 195 U) or placebo every 12 weeks for 2 treatment cycles. Main Outcome Measures: Headache-day severity was assessed at baseline and 24 weeks. Treatment responders were defined as those achieving 1-grade improvement in average daily headache severity (ADHS) score at week 24 compared with baseline. Results: 1384 patients received onabotulinumtoxinA (n1⁄4688) or placebo (n1⁄4696). At baseline, the percentage of severe + moderate headache days was 37.3% + 27.3% in the onabotulinumtoxinA group and 37.0% + 27.3% in the placebo group (P1⁄4.58 and P1⁄4.97 for severe and moderate days, respectively). At week 24, the proportion of patients with severe + moderate headache days was significantly lower for onabotulinumtoxinA (21.3% + 15.6%) compared with placebo (26.3% + 17.3%; P<.001 for both comparisons). OnabotulinumtoxinA produced a significant decrease in the number of severe headache days per 28-day period at week 24 (onabotulinumtoxinA, e4.5; placebo, e3.0; P<.001). Responder analyses indicated that significantly more patients receiving onabotulinumtoxinA than placebo demonstrated 1-grade improvement from baseline in ADHS score (35.8% vs 23.1%, P<.001) at week 24. Conclusions: Among patients with CM, use of onabotulinumtoxinA significantly reduced the number of severe and moderate headache days. In conjunction, significantly more patients treated with onabotulinumtoxinA had 1-grade improvements in ADHS scores compared with placebo. This is consistent with previously reported benefit of onabotulinumtoxinA in reducing daily headache severity in patients with CM. Level of Evidence: Level I