Pain physician
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Observational Study
The Long-term Outcome of Usual and Unusual Indications for Spinal Cord Stimulation: A Prospective Study.
Evidence of the efficacy of spinal cord stimulation (SCS) has been well demonstrated as a method of pain control for patients who exhibit failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS), and inoperable peripheral vascular diseases (PVD) ("usual indications"). However, a long-term study comparing the usual indications for which SCS is employed with those of other intractable painful conditions is still lacking. ⋯ Overall, SCS is an effective long-term treatment for chronic refractory pain. However, patients with usual indications for SCS have a higher success rate in SCS trials and a trend toward better outcomes after SCS implantation than do patients with unusual indications.
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Paresthesia-based spinal cord stimulation (SCS) depends upon dorsal column (DC) fiber activation to engage pain-relieving neural mechanisms. However, the mechanisms for 10-kHz paresthesia-free SCS have not been fully elucidated. Preclinical work has shown selective drive of inhibitory dorsal horn neurons, while other hypotheses suggest that DC fibers may be activated. To provide clinical data for guiding mechanism work, we analyzed paresthesia perception thresholds (PPT) over a range of low to high kHz frequency and compared those values to the stimulation parameters from the therapeutic 10-kHz SCS programs used by patients. ⋯ Therapeutic 10-kHz SCS uses stimulation amplitudes far lower than the PPT, providing evidence that therapeutic 10-kHz SCS does not activate dorsal column axons. Additionally, the PPT decreases with increasing kHz frequency, suggesting that a presumed asynchronous pattern of activation from kHz stimulation does not raise the threshold at which sensation occurs.
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Observational Study
Prophylactic Perioperative Fluid Infusion Strategy During Splanchnic Nerve Neurolysis to Prevent Systemic Hypotension: A Case Series of 70 Patients With Cancer.
When performing splanchnic nerve neurolysis (SNN), systemic hypotension may occur due to upper abdominal sympathetic blockade; therefore, appropriate periprocedural fluid resuscitation is crucial. ⋯ Our prophylactic perioperative fluid resuscitation for treating systemic hypotension post-SNN is sufficient and safe.
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Guidelines on the use of opioids in chronic pain management increasingly recommend consideration of buprenorphine for patients on long-term full agonist opioid therapy. Published strategies for patients' transitions to buprenorphine vary widely in terms of study design, dose, formulation, and timing of buprenorphine initiation. A further limitation in informing an ideal transition strategy is the paucity of data describing factors that influence the likelihood of a successful transition. ⋯ Our findings support the recommendation to trial buprenorphine in patients receiving chronic opioid therapy. This study's results also suggest that patient factors and shared decision-making are more important predictors of success than are the pharmacologic properties, potency, or dose of pre-rotation opioid exposure.