Atypical refractory occipital neuralgia treated with a unilateral dual-lead occipital nerve stimulator: a case report.

Aim: To describe the successful treatment of atypical occipital neuralgia (ON) using a unilateral dual-lead occipital nerve stimulator.Setting: Outpatient clinic/operating room.Patient: A 53-year-old male with atypical ON.Case description: Patient was previously diagnosed with treatment-refractory left-sided trigeminal neuralgia with atypical occipital distribution. On presentation, his symptoms were consistent with ON with distribution to the left fronto-orbital area. He received a left-sided nerve stimulator implant targeting both the greater and lesser occipital nerves.Results: Patient reported pain relief from a numerical rating scale 10/10 to 3-4/10.Conclusion: ON with referred ipsilateral trigeminal distribution should be considered when patients present with simultaneous facial and occipital pain. Further, a dual-lead unilateral stimulator approach may be a viable treatment.

Atypical, persistent inflammation to the left occipital nerve treated with a neuromodulator: a case reportAim: To describe the successful treatment of atypical headache using a one-sided nerve stimulator.Setting: Outpatient clinic/operating room.Patient: A 53-year-old male with atypical headache.Case description: Patient was previously diagnosed with left-sided chronic facial pain with pain to the back of the head. He previously failed to improve with medication and underwent Botox injections and several surgical operations targeting the nerves responsible for his pain symptoms with no improvement. He recently underwent a nerve-stimulating device trial, designed to alter the activity levels of the targeted nerve, that targeted a nerve in the back of his head. This significantly improved his pain and he ultimately presented for an official stimulator implant. Upon presentation, his symptoms were consistent with left-sided headache to the back of the head with distribution to the left eye area.Results: Patient reported significant pain relief from 10/10 to a 3-4/10, with a 10 representing the worst pain the patient has ever felt.Conclusion: Left-sided headache on the back of the head that can distribute to the left eye area should be a consistent thought for pain/headache practitioners. Further, this stimulator placement approach may be a viable treatment.

Effect of Stellate Ganglion Block Treatment on Posttraumatic Stress Disorder Symptoms: A Randomized Clinical Trial.

Importance: This is the first multisite, randomized clinical trial of stellate ganglion block (SGB) outcomes on posttraumatic stress disorder (PTSD) symptoms. Objective: To determine whether paired SGB treatments at 0 and 2 weeks would result in improvement in mean Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) total symptom severity scores from baseline to 8 weeks. Design, Setting, and Participants: This multisite, blinded, sham-procedure, randomized clinical trial used a 2:1 SGB:sham ratio and was conducted from May 2016 through March 2018 in 3 US Army Interdisciplinary Pain Management Centers. Only physicians performing the procedures and the procedure nurses were aware of the intervention (but not the participants or assessors); their interactions with the participants were scripted and limited to the 2 interventions. Active-duty service members on stable psychotropic medication dosages who had a PTSD Checklist-Civilian Version (PCL-C) score of 32 or more at screening were included. Key exclusion criteria included a prior SGB treatment, selected psychiatric disorders or substance use disorders, moderate or severe traumatic brain injury, or suicidal ideation in the prior 2 months. Interventions: Paired right-sided SGB or sham procedures at weeks 0 and 2. Main Outcomes and Measures: Improvement of 10 or more points on mean CAPS-5 total symptom severity scores from baseline to 8 weeks, adjusted for site and baseline total symptom severity scores (planned a priori). Results: Of 190 screened individuals, 113 (59.5%; 100 male and 13 female participants; mean [SD] age, 37.3 [6.7] years) were eligible and randomized (74 to SGB and 39 to sham treatment), and 108 (95.6% of 113) completed the study. Baseline characteristics were similar in the SGB and sham treatment groups, with mean (SD) CAPS-5 scores of 37.6 (11.2) and 39.8 (14.4), respectively (on a scale of 0-80); 91 (80.0%) met CAPS-5 PTSD criteria. In an intent-to-treat analysis, adjusted mean total symptom severity score change was -12.6 points (95% CI, -15.5 to -9.7 points) for the group receiving SGB treatments, compared with -6.1 points (95% CI, -9.8 to -2.3 points) for those receiving sham treatment (P = .01). Conclusions and Relevance: In this trial of active-duty service members with PTSD symptoms (at a clinical threshold and subthreshold), 2 SGB treatments 2 weeks apart were effective in reducing CAPS-5 total symptom severity scores over 8 weeks. The mild-moderate baseline level of PTSD symptom severity and short follow-up time limit the generalizability of these findings, but the study suggests that SGB merits further trials as a PTSD treatment adjunct. Trial Registration: ClinicalTrials.gov identifier: NCT03077919.

Mechanical and shape memory properties of porous Ni50.1Ti49.9 alloys manufactured by selective laser melting.

Near equiatomic NiTi shape memory alloys were fabricated in dense and designed porous forms by Selective Laser Melting (SLM) and their mechanical and shape memory properties were systematically characterized. Particularly, the effects of pore morphology on their mechanical responses were investigated. Dense and porous NiTi alloys exhibited good shape memory effect with a recoverable strain of about 5% and functional stability after eight cycles of compression. The stiffness and residual plastic strain of porous NiTi were found to depend highly on the pore shape and the level of porosity. Since porous NiTi structures have lower elastic modulus and density than dense NiTi with still good shape memory properties, they are promising materials for lightweight structures, energy absorbers, and biomedical implants.

Development of a tele-anesthesia preoperative clinic to support distant military treatment facilities for the European regional medical command.

Landstuhl Regional Medical Center (LRMC) provides primary care services for more than 65,000 beneficiaries and specialty care and hospitalization for 245,000 U.S. Service Members and their Families serving in Europe. These personnel are located in Germany, Italy and Belgium (See Fig 1). Anesthesia preoperative diagnosis/work was done by telemedicine at the distant, end user site, and significant cost savings and enhanced patient service was accomplished. A novel use of existing technologies was implemented to enhance provider and patient satisfaction and create a sustainable, user friendly system.

Esophageal perforation and pneumothorax after routine intraoperative orogastric tube placement.

Orogastric and nasogastric tubes are routinely inserted in anesthetized patients to both reduce the volume of stomach contents and decrease the incidence of postoperative nausea. We present a case of esophageal perforation and subsequent pneumothorax after insertion of an orogastric tube in a patient undergoing routine shoulder arthroscopy.

A multicenter, randomized, controlled study evaluating preventive etanercept on postoperative pain after inguinal hernia repair.

BACKGROUND: Chronic postsurgical pain (CPSP) affects between 5% and 70% of surgical patients, depending on the surgery. There is no reliable treatment for CPSP, which has led to an increased emphasis on prevention. In this study, we sought to determine whether preventive etanercept can decrease the magnitude of postoperative pain and reduce the incidence of CPSP. METHODS: We performed a multicenter, randomized study in 77 patients comparing subcutaneous etanercept 50 mg administered 90 minutes before inguinal hernia surgery with saline. Patients, surgeons, anesthesiologists, the injecting physician, nursing staff, and evaluators were blinded. The primary outcome measure was a 24-hour numerical rating scale pain score. Secondary outcome measures were postanesthesia care unit pain scores, 24-hour opioid requirements, time to first analgesic, and pain scores recorded at 1 month, 3 months, 6 months, and 12 months. RESULTS: Mean 24-hour pain scores were 3.3 (95% confidence interval [CI], 3.2-4.6) in the etanercept and 3.9 (95% CI, 2.6-4.0) in the control group (P=0.22). The mean number of analgesic pills used in the first 24 hours was 4.0 (SD, 2.8) in the treatment versus 5.8 (SD, 4.2) in the control group (P=0.03). At 1 month, 10 patients (29%) in the treatment group reported pain versus 21 (49%) control patients (P=0.08). The presence of pain at 1 month was significantly associated with pain at 3 months (hazard ratio, 0.74; 99% CI, 0.52-0.97; P=0.03). CONCLUSION: Although preventive etanercept was superior to saline in reducing postoperative pain on some measures, the effect sizes were small, transient, and not statistically significant. Different dosing regimens in a larger population should be explored in future studies.

The application of genomic and molecular data in the treatment of chronic cancer pain.

Many cancer patients will develop complex pain syndromes requiring aggressive, innovative, and comprehensive multimodal pain management strategies. Recently, data from both animal studies and clinical trials have allowed clinical research to focus on creating applicable clinical treatment strategies. This article is a review of genomic and molecular data, which has contributed to creating novel modalities for use in clinical pain management of patients with cancer-induced pain.

Battlefield analgesia: a brief review of current trends and concepts in the treatment of pain in US military casualties from the conflicts in Iraq and Afghanistan.

SUMMARY Battlefield analgesia and post-injury pain management is a high priority within the military medical community. The combined military services of the USA have developed a Pain Task Force and clinical practice guidelines to ensure that adequate analgesia is provided to our wounded soldiers as far forward as the point of injury on the battlefield. As a result of this emphasis, novel analgesic techniques and equipment have led to improved pain management. Continuous peripheral nerve blocks, intranasal ketamine, battlefield acupuncture and other adjuncts have all been utilized safely and successfully. The ability to provide rapid analgesia as early in the course of injury as possible not only helps with the immediate pain of the soldier, but potentially minimizes the risk of developing chronic postinjury pain. During the long medical evacuation system the risks of both undertreatment and overtreatment of pain are very real. Future studies and observation will help to delineate best treatment regimens and pave the way for the next generation of medical providers to positively impact a soldier's recovery. This article is written from the perspective of the USA with a focus on the conflicts in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom).

Neck pain during combat operations: an epidemiological study analyzing clinical and prognostic factors.

UNLABELLED: STUDY DESIGN. Prospective observational study among soldiers medically evacuated out of theaters of combat operations for neck pain, with retrospective analysis of variables associated with return-to-duty. OBJECTIVES: To provide an epidemiological overview of the burden of neck pain in deployed soldiers involved in combat operations and to identify factors associated with return-to-duty. SUMMARY OF BACKGROUND DATA: Neck pain represents one of the leading causes of medical evacuation out of theaters of combat operations. Yet when compared to other diagnostic categories, treatment outcomes, militarily defined as returning a soldier to duty, remain appallingly low. METHODS: Demographic, military-specific, and outcome data were prospectively collected over a 2-week period at the Deployed Warrior Medical Management Center in Germany on 374 consecutive soldiers medically evacuated out of theaters of combat operations for a primary diagnosis pertaining to neck pain between 2004 and 2007. The 2-week period represents the maximal allowable time an evacuated soldier can spend in treatment before disposition (i.e., return to theater or evacuate to United States) is rendered. Electronic medical records were reviewed to examine the effect the following variables had on the categorical outcome measure, return-to-unit: age, gender, service-affiliation, rank and seniority, smoking history, coexisting psychiatric diagnosis, prior neck pain, mechanism of injury, whether or not the injury was combat-related, presence of headache, quality of symptoms, correlation with radiologic imaging, and referral to pain specialist. RESULTS: Only 14% of service members returned to their units. Significant correlations were found between female gender and non-army service affiliation, and a service member returning to their unit. Weak trends toward returning to duty were noted for nonsmokers, absence of prior neck pain, concomitant psychiatric diagnosis, corresponding complaints of headache, and referral to a pain specialist. CONCLUSION: The treatment of service members medically evacuated for neck pain at the main receiving center, the level IV military treatment facility in Landstuhl, Germany, is associated with a low return-to-unit rate. Future studies should consider whether treating personnel predisposed towards a positive outcome with the limited resources available can improve return-to-duty rates.