Factors Associated With Recurrent Back Pain and Cyst Recurrence After Surgical Resection of 195 Spinal Synovial Cysts
Xu R, McGirt MJ, Parker SL, et al.
Spine (Phila Pa 1976). 2010 Feb 18. [Epub ahead of print]
STUDY DESIGN.: Retrospective study. OBJECTIVE.: Compare outcomes of different treatment methods for intraspinal synovial cysts. SUMMARY OF BACKGROUND DATA.: Intraspinal synovial cysts are cited as an increasing cause of back pain and radiculopathy. To date, few studies have compared outcomes of differing treatment methods in patients with synovial cysts. METHODS.: We retrospectively reviewed 167 consecutive patients undergoing surgical management of 195 symptomatic synovial cysts at a single institution over 19 years. The incidence of postoperative mechanical back pain, radiculopathy, and cyst recurrence was compared between patients undergoing unilateral hemilaminectomy (n = 51), bilateral laminectomy (n = 39), facetectomy with in situ fusion (n = 18), and facetectomy with instrumented fusion (n = 56). RESULTS.: A total of 155 (97.5%) patients presented with radiculopathy, 132(82.5%) with mechanical back pain, 31 (20%) with neurogenic claudication, and 5 (3.2%) with bladder dysfunction. Most cysts occurred in the lumbar spine. After surgery, back and radicular pain improved in 91.6% and 91.9% patients, respectively. By a mean follow-up of 16 +/- 9 months, 36 (21.6%) patients developed recurrent back pain, 20 (11.8%) recurrent leg pain, and 5 (3%) recurrent synovial cysts. Patients undergoing laminectomy had a significantly increased cyst recurrence incidence compared to fusion groups via log-rank test (P = 0.042), and this risk was decreased to baseline with instrumented fusion on reoperation. Laminectomy was also associated with the highest increased risk of recurrent back pain in both log-rank test (P = 0.018) and proportional hazards regression (HR): 1.64 (1.00-3.45), P = 0.05. Instrumented fusion had the lowest risk for back pain recurrence. CONCLUSION.: Hemilaminectomy or laminectomy remains one of the mainstay surgical treatments for symptomatic intraspinal synovial cysts. Our experience shows that the majority of patients undergoing decompression/excision of synovial cysts will have immediate improvement in back and leg pain. However, within 2 years,patients receiving hemilaminectomy or laminectomy alone have an increased incidence of back pain and cyst recurrence. Decompression with instrumented fusion appears to be associated with the lowest incidences of cyst recurrence or back pain.
Validation of Clinical Opiate Withdrawal Scale versus Clinical Institute Narcotic Assessment opioid withdrawal instrument
Tompkins DA, Bigelow GE, Harrison JA, et al.
Drug Alcohol Depend. 2009 Nov 1;105(1-2):154-9.
The Clinical Opiate Withdrawal Scale (COWS) is an 11-item clinician-administered scale assessing opioid withdrawal. Though commonly used in clinical practice, it has not been systematically validated. The present study validated the COWS in comparison to the validated Clinical Institute Narcotic Assessment (CINA) scale. METHOD: Opioid-dependent volunteers were enrolled in a residential trial and stabilized on morphine 30 mg given subcutaneously four times daily. Subjects then underwent double-blind, randomized challenges of intramuscularly administered placebo and naloxone (0.4 mg) on separate days, during which the COWS, CINA, and visual analog scale (VAS) assessments were concurrently obtained. Subjects completing both challenges were included (N=46). Correlations between mean peak COWS and CINA scores as well as self-report VAS questions were calculated. RESULTS: Mean peak COWS and CINA scores of 7.6 and 24.4, respectively, occurred on average 30 min post-injection of naloxone. Mean COWS and CINA scores 30 min after placebo injection were 1.3 and 18.9, respectively. The Pearson's correlation coefficient for peak COWS and CINA scores during the naloxone challenge session was 0.85 (p<0.001). Peak COWS scores also correlated well with peak VAS self-report scores of bad drug effect (r=0.57, p<0.001) and feeling sick (r=0.57, p<0.001), providing additional evidence of concurrent validity. Placebo was not associated with any significant elevation of COWS, CINA, or VAS scores, indicating discriminant validity. Cronbach's alpha for the COWS was 0.78, indicating good internal consistency (reliability). DISCUSSION: COWS, CINA, and certain VAS items are all valid measurement tools for acute opiate withdrawal.
Ethical issues in opioid prescribing for chronic pain.
Ballantyne JC, Fleisher LA.
Pain. 2010;148(3):365-7.
Medical ethics traditionally focused on ensuring that physicians used their powers benevolently. Since cure was unusual, palliation, symptom control and relief of suffering were central to the physician’s art. Not surprisingly, given their unique ability to control suffering, opioids were indispensable, and a constituent of many remedies. They were freely dispensed by pharmacists and physicians, their use being limited largely by the conscience of the individual, or by limited supplies. At the beginning of the 20th century, drug regulations were introduced into the United States and other industrialized nations. These regulations attempted to control the import, distribution and trade of narcotics, and placed the onus on physicians to control medical use of opioids. There was thus an immediate switch of the moral imperative from patient to physician, and in fact a chilling effect on the provision of opioids for pain. The stigmatization and criminalization of opioids produced by regulations continues to interfere with the rational use of opioids for pain to this day.
Integrative medicine approach to chronic pain.
Teets RY, Dahmer S, Scott E.
Prim Care. 2010;37(2):407-21.
Chronic pain can be a frustrating condition for patient and clinician. The integrative medicine approach to pain can offer hope, adding safe complementary and alternative medical (CAM) therapies to mitigate pain and suffering. Such CAM therapies include nutrition, supplements and herbs, manual medicine, acupuncture, yoga, and mind-body approaches. The evidence is heterogeneous regarding these approaches, but some evidence suggests efficacy and confirms safety. The integrative medicine approach can be beneficial in a patient with chronic pain. Copyright 2010 Elsevier Inc. All rights reserved.
Updated practice guidelines from the American Society of Anesthesiologists Task Force on Chronic Pain Management and the America
Benzon HT, Connis RT, De Leon-Casasola OA, et al.
Anesthesiology. 2010;112(4):810-33.
Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines.
Dagenais S, Tricco AC, Haldeman S.
Spine J. 2010;10(6):514-29.
BACKGROUND CONTEXT: Low back pain (LBP) is a prevalent, costly, and challenging condition to manage. Clinicians must choose among numerous assessment and management options. Several recent clinical practice guidelines (CPGs) on LBP have attempted to inform these decisions by evaluating and summarizing the best available supporting evidence. The quality and consistency of recommendations from these CPGs are currently unknown. PURPOSE: To conduct a systematic review of recent CPGs and synthesize their recommendations on assessing and managing LBP for clinicians. STUDY DESIGN/SETTING: Systematic review. METHODS: Literature search using MEDLINE, National Guidelines Clearinghouse, National Institute for Clinical Excellence, Internet search engines, and references of known articles. Only CPGs related to both assessment and management of LBP written in English were eligible; CPGs that summarized evidence from before the year 2000 were excluded. Data related to methods and recommendations for assessment and management of LBP were abstracted independently by two reviewers. Methodological quality was assessed using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument by two reviewers. RESULTS: The search uncovered 669 citations, of which 95 were potentially relevant and 10 were included in the review; 6 discussed acute LBP, 6 chronic LBP, and 6 LBP with neurologic involvement. Methods used to develop CPGs varied, but the overall methodological quality was high as defined by AGREE scores. Recommendations for assessment of LBP emphasized the importance of ruling out potentially serious spinal pathology, specific causes of LBP, and neurologic involvement, as well as identifying risk factors for chronicity and measuring the severity of symptoms and functional limitations, through the history, physical, and neurologic examination. Recommendations for management of acute LBP emphasized patient education, with short-term use of acetaminophen, nonsteroidal anti-inflammatory drugs, or spinal manipulation therapy. For chronic LBP, the addition of back exercises, behavioral therapy, and short-term opioid analgesics was suggested. Management of LBP with neurologic involvement was similar, with additional consideration given to magnetic resonance imaging or computed tomography to identify appropriate candidates willing to undergo epidural steroid injections or decompression surgery if more conservative approaches are not successful. CONCLUSIONS: Recommendations from several recent CPGs regarding the assessment and management of LBP were similar. Clinicians who care for patients with LBP should endeavor to adopt these recommendations to improve patient care. Future CPGs may wish to invite coauthors from targeted clinician user groups, increase patient participation, update their literature searches before publication, conduct their own quality assessment of studies, and consider cost-effectiveness and other aspects in their recommendations more explicitly. Copyright 2010 Elsevier Inc. All rights reserved.
Opioid medication and sleep-disordered breathing.
Yue HJ, Guilleminault C.
Med Clin North Am. 2010 May;94(3):435-46.
There has been a growing recognition of chronic pain that may be experienced by patients. There has been a movement toward treating these patients aggressively with pharmacologic and nonpharmacologic modalities. Opioids have been a significant component of the treatment of acute pain, with their increasing use in cases of chronic pain, albeit with some controversy. In addition to analgesia, opioids have many accompanying adverse effects, particularly with regard to stability of breathing during sleep. This article reviews the existing literature on the effects of opioids on sleep, particularly sleep-disordered breathing.
Management of headache in the elderly.
Robbins MS, Lipton RB.
Drugs Aging. 2010 May;27(5):377-98.
The diagnosis and management of headache disorders in the elderly are challenging. The evaluation of the elderly patient with new-onset or recurrent headache requires a grasp of the heterogeneous set of causes of secondary head pain disorders. Once such aetiologies are excluded, the correct primary headache disorder must be diagnosed. Although tension-type headache is the leading cause of new-onset headache in the elderly, other primary headache disorders such as migraine can manifest in later life, and one disorder, hypnic headache, occurs almost exclusively in the elderly. Primary chronic daily headache persists in elderly patients to a greater extent than the primary episodic headache disorders do. The treatment of elderly patients with primary headache disorders is multifaceted, including acute, prophylactic and at times transitional treatments. Knowledge of drug interactions is particularly important as polypharmacy is the rule. Concomitant illnesses may require adjustments in choice or dose of drugs. In addition, as many acute and preventive treatments are either contraindicated or poorly tolerated in the elderly, modifiable risk factors for headache progression and perpetuation must be addressed. In spite of these treatment complexities, there are numerous opportunities to bring relief to older patients with primary headache disorders from the currently available therapies. New treatment options for elderly patients with headache will soon be available, including acute, prophylactic and interventional techniques.
Gamma knife radiosurgery for multiple sclerosis–related trigeminal neuralgia.
Zorro O, Labato-Polo J, Kano H, et al.
Neurology 2009;73:1149-54.
Background: Surgical options for multiple sclerosis (MS) related to trigeminal neuralgia (TN), a severe and disabling pain disorder, include percutaneous rhizotomy, stereotactic radiosurgery, or microsurgical nerve section. Our goal was to evaluate clinical outcomes after gamma knife radio-surgery (GKRS) in patients with MS with TN.
Methods: We evaluated clinical outcomes in 37 patients with TN managed over a 12-year period. The maximum TN target dose varied between 70 and 90 Gy. Seventy-eight percent of patients had failed prior surgery. In 9, GKRS was the first procedure. Median follow-up was 56.7 months (range, 6–174). Pain relief was assessed in each patient by physicians who did not participate in the surgery.
Results: Eventual complete pain relief (BNI grade I) after GKRS and reasonable pain control (BNI grade I–IIIb) after GKRS were noted in 23 patients (62.1%) and 36 patients (97.3%) at some point in their course. Reasonable pain control (BNI grade I–IIIb) after GKRS was maintained in 82.6%, 73.9%, and 54.0% of patients after 1, 3, and 5 years. Fourteen patients (37.8%) underwent a second or a subsequent procedure for residual or recurrent pain. Eight patients underwent a second GKRS, 5 underwent percutaneous glycerol rhizotomy, and 1 underwent balloon micro-compression. The complication rate after GKRS was 5.4% (new onset of nondisabling paresthesias). No patient developed dysesthesias.
Conclusions:
Gamma knife radiosurgery is the most minimally invasive surgical technique for multiple sclerosis–related trigeminal neuralgia and has low morbidity. For this reason, gamma knife radiosurgery proved to be a satisfactory management strategy for multiple sclerosis–related trigeminal neuralgia.
Racial Differences in Osteoarthritis Pain and Function: Potential Explanatory Factors
Allen KD, Eugene OZ, Coffman CJ, et al.
Osteoarthritis Cartilage. 2009 Oct 1.
Objective: This study examined factors underlying racial differences in pain and function among patients with hip and / or knee osteoarthritis (OA). Methods: Participants were n=491 African Americans and Caucasians enrolled in a clinical trial of telephone-based OA self-management. Arthritis Impact Measurement Scales-2 (AIMS2) pain and function subscales were obtained at baseline. Potential explanatory variables included arthritis self-efficacy, AIMS2 affect subscale, problem- and emotion-focused pain coping, demographic characteristics, body mass index, self-reported health, joint(s) with OA, symptom duration, pain medication use, current exercise, and AIMS2 pain subscale (in models of function). Variables associated with both race and pain or function, and which reduced the association of race with pain or function by ≥10%, were included in final multivariable models. Results: In simple linear regression models, African Americans had worse scores than Caucasians on AIMS2 pain (B=0.65, p=0.001) and function (B=0.59, p<0.001) subscales. In multivariable models race was no longer associated with pain (B=0.03, p=0.874) or function (B=0.07, p=0.509), indicating these associations were accounted for by other covariates. Variables associated with worse AIMS2 pain and function were: worse AIMS2 affect scores, greater emotion-focused coping, lower arthritis self-efficacy, and fair or poor self-reported health. AIMS2 pain scores were also significantly associated with AIMS2 function. Conclusion: Factors explaining racial differences in pain and function were largely psychological, including arthritis self-efficacy, affect, and use of emotion-focused coping. Selfmanagement and psychological interventions can influence these factors, and greater dissemination among African Americans may be a key step toward reducing racial disparities in pain and function.
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