Efficacy and safety of the implantable, magnetic resonance imaging-compatible StimRouter neuromodulation system in the treatment of refractory lower urinary tract symptoms in multiple sclerosis patients.

BACKGROUND AND PURPOSE: Lower urinary tract symptoms (LUTS) significantly affect quality of life (QoL) of multiple sclerosis (MS) patients, and pharmacotherapy has limited efficacy. We investigated efficacy and safety of the implantable StimRouter neuromodulation system for treating refractory LUTS in MS. METHODS: This prospective, single-center, clinical trial was conducted at the Multiple Sclerosis Center of Lugano, Switzerland, involving MS patients treated with self-administered percutaneous tibial nerve stimulation delivered by StimRouter over 24 weeks. Changes in video-urodynamic parameters as well as LUTS severity were measured by Overactive Bladder Questionnaire (OAB-q), QoL using the Multiple Sclerosis Quality of Life (MSQoL-54), and treatment satisfaction using a 1-10 visual analogue scale. Adverse events were also recorded. RESULTS: Of 23 MS patients recruited, six had neurogenic detrusor overactivity (NDO), five had detrusor sphincter dyssynergia (DSD), and 12 had both NDO and DSD. Of patients with NDO, median bladder volume at first uninhibited contraction significantly increased from baseline to week 24 (median = 136 mL, interquartile range [IQR] = 101-244 mL vs. 343 mL, IQR = 237-391 mL; ß = 138.2, p = 0.001). No significant changes of urodynamic parameters were found in patients with DSD. OAB-q symptom scores progressively decreased, and OAB-q quality of life scores increased (ß = -0.50, p < 0.001 and ß = 0.47, p < 0.001, respectively), whereas MSQoL-54 scores did not significantly change (ß = 0.24, p = 0.084) in the overall population. Treatment satisfaction was overall high (median = 8, IQR = 6-9). No serious adverse events were recorded. CONCLUSIONS: StimRouter represents a minimally invasive, magnetic resonance imaging-compatible, self-administered neuromodulation device leading to objective and subjective improvements of OAB symptoms and related QoL in MS patients with refractory LUTS.

The effect of perioperative psychological interventions on persistent pain, disability, and quality of life in patients undergoing spinal fusion: a systematic review.

PURPOSE: Patients undergoing spinal fusion are prone to develop persisting spinal pain that may be related to pre-existent psychological factors. The aim of this review was to summarize the existing evidence about perioperative psychological interventions and to analyze their effect on postoperative pain, disability, and quality of life in adult patients undergoing complex surgery for spinal disorders. Studies investigating any kind of psychological intervention explicitly targeting patients undergoing a surgical fusion on the spine were included. METHODS: We included articles that analyzed the effects of perioperative psychological interventions on either pain, disability, and/or quality of life in adult patients with a primary diagnosis of degenerative or neoplastic spinal disease, undergoing surgical fusion of the spine. We focused on interventions that had a clearly defined psychological component. Two independent reviewers used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) to perform a systematic review on different databases. Risk of bias was evaluated using the Downs and Black checklist. Given study differences in outcome measures and interventions administered, a meta-analysis was not performed. Instead, a qualitative synthesis of main results of included papers was obtained. RESULTS: Thirteen studies, conducted between 2004 and 2017, were included. The majority were randomized-controlled trials (85%) and most patients underwent lumbar fusion (92%). Cognitive behavioral therapy (CBT) was used in nine studies (69%). CBT in the perioperative period may lead to a postoperative reduction in pain and disability in the short-term follow-up compared to care as usual. There was less evidence for an additional effect of CBT at intermediate and long-term follow-up. CONCLUSION: The existing evidence suggests that a reduction in pain and disability in the short-term, starting from immediately after surgery to 3 months, is likely to be obtained when a CBT approach is used. However, there is inconclusive evidence regarding the long-term effect of a perioperative psychological intervention after spinal fusion surgery. Further research is necessary to better define the frequency, intensity, and timing of such an approach in relation to the surgical intervention, to be able to maximize its effect and be beneficial to patients.

Dorsal Root Ganglion Stimulation in Chronic Painful Polyneuropathy: A Potential Modulator for Small Nerve Fiber Regeneration.

OBJECTIVES: Neuromodulatory treatments like spinal cord stimulation and dorsal root ganglion stimulation (DRGS) have emerged as effective treatments to relieve pain in painful polyneuropathy. Animal studies have demonstrated that neurostimulation can enhance nerve regeneration. This study aimed to investigate if DRGS may impact intraepidermal nerve fiber regeneration and sensory nerve function. MATERIALS AND METHODS: Nine patients with chronic, intractable painful polyneuropathy were recruited. Intraepidermal nerve fiber density (IENFD) quantification in 3 mm punch skin biopsy was performed 1 month before DRGS (placed at the level of the L5 and S1 dorsal root ganglion) and after 12- and 24-month follow-up. Quantitative sensory testing, nerve conduction studies, and a clinical scale score were also performed at the same time points. RESULTS: In 7 of 9 patients, DRGS was successful (defined as a reduction of ≥ 50% in daytime and/or night-time pain intensity), allowing a definitive implantable pulse generator implantation. The median baseline IENFD among these 7 patients was 1.6 fibers/mm (first and third quartile: 1.2; 4.3) and increased to 2.6 fibers/mm (2.5; 2.9) and 1.9 fibers/mm (1.6; 2.4) at 1- and 2-years follow-up, respectively. These changes were not statistically significant (p = 1.000 and 0.375). Sensory nerve tests did not show substantial changes. CONCLUSIONS: Although not significant, the results of this study showed that in most of the patients with implants, there was a slight increase of the IENFD at the 1- and 2-year follow-up. Larger-scale clinical trials are warranted to explore the possible role of DRGS in reversing the progressive neurodegeneration over time. CLINICAL TRIAL REGISTRATION: The Clinicaltrials.gov registration number for the study is NCT02435004; Swiss National Clinical Trials Portal: SNCTP000001376.

Effectiveness of percutaneous posterior tibial nerve stimulation for the management of bowel dysfunction in multiple sclerosis patients.

BACKGROUND: Neurogenic bowel dysfunctions (NBDs) in the form of both fecal incontinence (FI) and functional constipation (FC) are frequent in multiple sclerosis (MS) patients and significantly affect their quality of life. Therapeutic options are limited. OBJECTIVE: To investigate effectiveness of percutaneous posterior tibial nerve stimulation (PTNS) in MS patients suffering from FI and FC. METHODS: Prevalence and severity of FI and FC were prospectively collected among MS patients undergoing 12 weeks of PTNS for neurogenic bladder. The Cleveland Clinic Fecal Incontinence Score (CCFIS) and the Rome III criteria were used to define FI and FC, respectively. Subjective treatment satisfaction was estimated using the Benefit Satisfaction and Willingness to Continue (BSWC) questionnaire. RESULTS: A total of 60 patients undergoing PTNS suffered from NBDs (25 FI+/FC+, 5 FI+/FC-, 30 FI-/FC+). Median CCFIS decreased after PTNS from 12.0 (11.0-13.0) to 8.5 (7.0-11.0, p < 0.001), with particular improvements in liquid and flatal incontinence, pads' need, and lifestyle restrictions. Seven patients became FC free after PTNS and no patients developed FC during the study (p = 0.023). More than 50% of the patients were satisfied and willing to continue PTNS at study end. CONCLUSION: PTNS represents a valid minimally invasive alternative treatment for MS patients suffering from NBDs.

Dorsal Root Ganglion Stimulation for the Management of Intractable Painful Polyneuropathy: A Prospective Pilot Study.

OBJECTIVES: Dorsal root ganglion stimulation (DRGS) is a promising neurostimulation modality in the treatment of painful polyneuropathy. The aim of this prospective pilot study was to investigate the effect of DRGS on pain intensity in patients with intractable painful polyneuropathy. MATERIALS AND METHODS: Nine patients with chronic, intractable painful polyneuropathy in the lower limbs were recruited. In each subject, between two and four DRGS leads were placed at the level of the L5 and S1 dorsal root ganglion. If trial stimulation was successful, a definitive implantable pulse generator (IPG) was implanted. Pain intensity was scored using an 11-point numeric rating scale (NRS) and reported as median and interquartile range (IQR), and compared to baseline values using the Wilcoxon signed-rank test. Additionally, patients' global impression of change (PGIC), pain extent, presence of neuropathic pain, physical functioning, quality of life, and mood were assessed. RESULTS: Eight out of nine patients had a successful trial phase, of which seven received an IPG. Daytime pain decreased from a median (IQR) NRS score of 7.0 (5.9-8.3) to 2.0 (1.0-3.5) and 3.0 (1.6-4.9) in the first week and at six months after implantation, respectively. Similar effects were observed for night time and peak pain scores. CONCLUSIONS: The results of this study suggest that DRGS significantly reduces both pain intensity and PGIC in patients with intractable painful polyneuropathy in the lower extremities. Large-scale clinical trials are needed to prove the efficacy of DRGS in intractable painful polyneuropathy.

Dorsal Root Ganglion Stimulation in Experimental Painful Diabetic Polyneuropathy: Delayed Wash-Out of Pain Relief After Low-Frequency (1Hz) Stimulation.

OBJECTIVE: Up until now there is little data about the pain relieving effect of different frequency settings in DRGS. The aim of this study was to compare the pain relieving effect of DRGS at low-, mid-, and high-frequencies and Sham-DRGS in an animal model of painful diabetic neuropathy (PDPN). MATERIAL AND METHODS: Diabetes mellitus was induced by an intraperitoneal injection of streptozotocin in 8-week-old female Sprague-Dawley rats (n = 24; glucose ≥15 mmol/L: n = 20; mechanical hypersensitivity: n = 15). Five weeks later, a DRGS device was implanted at the L5 DRG. Ten animals were included for stimulation, alternating 30 minutes of low (1 Hz)-, mid (20 Hz)-, and high (1000 Hz)-frequencies and Sham-DRGS during four days, with a pulse width of 0.2 msec (average amplitude: 0.19 ± 0.01 mA), using a randomized cross-over design. The effect on mechanical hypersensitivity of the hind paw to von Frey filaments was evaluated. RESULTS: All DRGS frequencies resulted in a complete reversal of mechanical hypersensitivity and "a clinically relevant reduction" was achieved in 70-80% of animals. No significant differences in maximal pain relieving effect were found between the different frequency treatments (p = 0.24). Animals stimulated at 1000 and 20 Hz returned to baseline mechanical hypersensitivity values 15 and 30 min after stimulation cessation, respectively, while animals stimulated at 1 Hz did not. CONCLUSIONS: These results show that DRGS is equally effective when applied at low-, mid-, and high-frequency in an animal model of PDPN. However, low-frequency-(1 Hz)-DRGS resulted in a delayed wash-out effect, which suggests that this is the most optimal frequency for pain therapy in PDPN as compared to mid- and high-frequency.

Cervical Radiculopathy Caused by a Vertebral Artery Loop: Is a Focused Fluoroscopic-Guided Cervical Epidural Steroid Injection a Possible Treatment Modality?

We describe a case of a patient suffering with cervical radiculopathy due to vertebral artery loop with nerve root compression, treated with an epidural steroid injection. A 37-year-old man presented with a 2-year history of right-sided radicular pain along the C7 dermatome. Imaging showed a right-sided loop of the vertebral artery at the V1-V2 transition with contact on the C7 nerve root. The pain was resistant to conservative treatment, and the decision was made to perform a focused fluoroscopy-guided translaminar epidural steroid injection near the C7 nerve root. The procedure was uneventful, and the symptoms resolved completely after the procedure. Targeted epidural steroid injection might be a useful and safe diagnostic and therapeutic approach in patients affected by cervical radiculopathy due to a VA loop. To our knowledge, this is the first case of a VA loop associated with cervical radiculopathy treated with this technique.

Refill Procedures of Intrathecal Drug Delivery Systems With a Recessed Fill Port on the Pump Surface: A Prospective Comparison Study of Ultrasound-Guided vs. Blind Refill Technique.

OBJECTIVES: Structural differences of implantable drug delivery systems (IDDSs) might have an impact on the efficiency of needle access to the reservoir fill port (RFP). The aim of this study was to assess the efficiency of RFP needle access with an ultrasound (US)-guided vs. a blind refill technique in IDDSs with a Recessed RFP (Recessed-RFP-IDDS). MATERIALS AND METHODS: The primary outcome was the number of attempts needed to enter the RFP with a needle comparing the US-guided technique vs. the blind refill technique. The time to enter the RFP with the needle was a secondary outcome. We compared the amount of attempts between both techniques with the non-parametric Wilcoxon rank sum test. RESULTS: Fourteen adult patients underwent a total of 75 refills of their Recessed-RFP-IDDS during a period of 24 months. The median number of attempts to enter the RFP did not differ significantly between the US-guided technique and the blind refill technique (2.0 (IQR: 1-5) vs. 1.5 (IQR: 1-5.0), p = 0.572). The median time to enter the RFP with the needle did not differ significantly between both techniques (35.0 sec (IQR: 26.0-58.0) vs. 41.0 sec (IQR: 25.5-46.8), p = 0.878). CONCLUSION: The results of this study suggest that there is no difference in the RFP needle access efficiency between the US-guided and the blind refill technique in superficially located Recessed-RFP-IDDSs, if performed by experienced practitioners. However, the study did not address efficiency of the RFP needle access in IDDSs with aberrancy in pump location or refills performed by inexperienced staff.

Refill Port Identification of Intrathecal Drug Delivery System Devices With a Raised Fill Port.

OBJECTIVES: The aim of this study was to assess the accuracy of the manual identification of the reservoir fill port (RFP) for refill of intrathecal drug delivery systems (IDDSs) with a raised RFP on the pump surface (raised-RFP-IDDSs), and compare this to previously reported data of patients with IDDSs with a recessed RFP (recessed-RFP-IDDSs). METHODS: Nineteen patients underwent 2 IDDS refills for the treatment of noncancer pain or spasticity. The primary endpoint of this prospective observational study was the deviation between the needle insertion point and the RFP center, quantified by fluoroscopic visualization. A distance surpassing that between the center and the margin of the RFP of 4 mm was considered a clinically relevant deviation. The results were compared with previously reported data of a patient cohort with recessed-RFP-IDDSs, and the differences were tested using Student's t-test. RESULTS: The mean deviation from the RFP center was 4.9 mm (standard deviation = 3.7). The RFP identification accuracy deviated more than the clinically relevant difference in 17 out of 35 instances (48.6%). The number of attempts and median procedural time was significantly correlated to the needle deviation. The mean deviations in the raised-RFP-IDDS cohort were consistently lower compared to the recessed-RFP-IDDS cohort (first refill procedure 4.0 vs. 8.5, P < 0.001; second procedure 5.9 vs. 8.1, P = 0.074). CONCLUSION: The results of this study suggest that the manual localization of the RFP for raised-RFP-IDDSs is moderately accurate, and more accurate if compared to previously published accuracy of the template-guided technique for recessed-RFP-IDDSs.

Ease of Fill Port Access During the Ultrasound-Guided vs. the Blind Refill Technique of Intrathecal Drug Delivery Systems With a Raised Septum, a Prospective Comparison Study.

OBJECTIVES: The localization of the reservoir fill port of Intrathecal Drug Delivery Devices (IDDS) can be difficult. The purpose of this study was to assess the ease of fill port access during the ultrasound-guided refill technique compared to the blind refill technique in IDDSs with a raised septum on the pump surface. MATERIALS AND METHODS: Written informed consent was obtained from 19 adult patients undergoing regular refills of their Raised Septum IDDSs (RS-IDDSs). The primary outcome of this single center prospective comparison study was the number of attempts to enter the reservoir fill port with the needle comparing the ultrasound-guided technique vs. the blind technique. The number of skin punctures per refill procedure and time to enter the reservoir fill port was secondary outcomes. For between group comparisons the Friedman test for repeated measures on ranks was used. RESULTS: One hundred and eleven refill procedures were assessed in 19 patients over a period of 24 months. The median number of attempts to enter the reservoir fill port with the needle differed significantly between the ultrasound-guided technique and the blind technique (4 [IQR: 1-6] vs. 1 [IQR: 1-3], p = 0.018), in favor of the blind technique. The median time to enter the reservoir fill port differed significantly between the ultrasound-guided technique and the blind technique (58 sec [IQR: 38-94] vs. 22 sec [IQR: 16-40], p < 0.001). CONCLUSIONS: The results of this study suggest that for a RS-IDDS the blind refill technique needs significantly less attempts to enter the reservoir fill port than the US-guided refill technique.

Radiation Dose Exposure for Lumbar Transforaminal Epidural Steroid Injections and Facet Joint Blocks Under CT vs. Fluoroscopic Guidance.

BACKGROUND: Transforaminal epidural steroid injections (TFESIs) and facet joint blocks can be performed under fluoroscopy or computed tomography (CT) guidance. The purpose of this retrospective cohort study was to compare patient radiation dose for lumbar TFESIs and facet joint blocks under CT guidance vs. fluoroscopic guidance. METHODS: The primary outcome of this retrospective cohort study was the difference between the estimated effective dose (ED) of CT guidance and fluoroscopic guidance for TFESIs and facet joint blocks. Patients who had undergone these procedures with both CT and fluoroscopic guidance were eligible for this study. Dose-length product for CT-guided procedures and dose-area product for fluoroscopic-guided procedures were retrospectively collected and converted to ED. Within- or between-group comparisons were performed with appropriate nonparametric tests, using a P value of < 0.05 to indicate statistical significance. RESULTS: The 42 patients included in this study underwent a total of 100 procedures. The median estimated ED differed significantly between CT-guided injections and fluoroscopic-guided injections (1.59 mSv (interquartile range [IQR] 0.78 to 3.09) vs. 0.19 mSv (IQR 0.11 to 0.30) (Wilcoxon signed rank test, P < 0.001). CONCLUSIONS: The study results suggest that TFESIs and facet joint blocks performed with CT guidance are associated with more than 8 times higher patient radiation dose exposure compared to fluoroscopic guidance. There needs to be more vigilance with regards to CT guidance in interventional pain procedures.

Intrathecal Pump Refills, Pocket Fills, and Symptoms of Drug Overdose: A Prospective, Observational Study Comparing the Injected Drug Volume vs. the Drug Volume Effectively Measured Inside the Pump.

OBJECTIVES: One complication associated with the refill procedure of intrathecal drug delivery systems (IDDSs) include a "pocket fill," which is the inadvertent injection of the drug into the subcutaneous space surrounding the pump. The purpose of our study was to assess the mean volume discrepancy between the injected and the effective drug volume inside the IDDS reservoir after refills that did not lead to signs of overdose and to record at which volume discrepancy symptoms of overdose were noticed. MATERIALS AND METHODS: After 221 refill procedures performed in 19 adult patients, drug volume inside the reservoir was assessed with a fill level sensor, and the volume discrepancy between injected and measured volume was recorded. Symptoms of overdose were monitored. For between group comparisons the Mann-Whitney U test was used, using a p-value of <0.05 to indicate statistical significance. RESULTS: The median volume discrepancy in the 20 mL IDDSs was 0.40 mL (IQR: 0.18-0.61; 10th p: 0.0; 90th p: 0.74) whereas in the 40 mL IDDSs the median volume discrepancy was 1.3 mL (IQR: 1.06-1.74; 10th p: 0.81; 90th p: 2.2). Symptoms of overdose were observed after 6 out of the 221 refill procedures. Volumes at which the symptoms of overdose arose were between 1.15 and 4.5 mL in 20 mL IDDSs and between 2.08 and 4.88 mL in 40 mL IDDSs. CONCLUSIONS: A volume discrepancy of >1 mL in 20 mL IDDSs and of >2 mL in 40 mL IDDSs after refill should be regarded as potentially consequential with regard to risk of overdose possibly caused by a pocket fill. In case of potentially consequential volume discrepancies, hospitalization and monitoring is recommended to preclude late overdose symptoms outside the hospital.

The Accuracy of Template-Guided Refill Technique of Intrathecal Pumps Controlled by Fluoroscopy: An Observational Study.

OBJECTIVES: Intrathecal drug therapy is being utilized increasingly for the treatment of chronic refractory pain. However, performing the regular pump refill procedures caries the potential risk of medication injection into the subcutaneous tissue. The aim of this study was to assess the accuracy of this template-guided refill technique by means of fluoroscopic evaluation. MATERIALS AND METHODS: In 23 patients, the difference between the identification of the reservoir fill port center using the manufacturer's template and fluoroscopic guidance was assessed on four consecutive refill procedures by a two physicians. A distance surpassing that between the center and the margin of the port (3.5 mm) was considered a clinically relevant deviation. Analyses were performed with a one-sample t-test, with p < 0.05 indicating statistical significance. RESULTS: The mean difference distance between identification markings of the target with fluoroscopic guidance and with the template was 8.2 mm, with limited variance (2.7 mm). For all individual refill procedures, the port center identification accuracy differed significantly from zero (all p < 0.001) and from the clinically relevant cut-off point of 3.5 mm (all p < 0.001). Only seven attempts (6.4%) were within the margins of the fill port. CONCLUSIONS: Our results suggest poor accuracy of insertion point identification using the template. This highlights the potential risk of errors related to identification of the puncture site using the template-guided technique.

Reliability of the Pen-on-Paper Pain Drawing Analysis Using Different Scanning Procedures.

INTRODUCTION: Pen-on-paper pain drawing are an easily administered self-reported measure that enables patients to report the spatial distribution of their pain. The digitalization of pain drawings has facilitated the extraction of quantitative metrics, such as pain extent and location. This study aimed to assess the reliability of pen-on-paper pain drawing analysis conducted by an automated pain-spot recognition algorithm using various scanning procedures. METHODS: One hundred pain drawings, completed by patients experiencing somatic pain, were repeatedly scanned using diverse technologies and devices. Seven datasets were created, enabling reliability assessments including inter-device, inter-scanner, inter-mobile, inter-software, intra- and inter-operator. Subsequently, the automated pain-spot recognition algorithm estimated pain extent and location values for each digitized pain drawing. The relative reliability of pain extent analysis was determined using the intraclass correlation coefficient, while absolute reliability was evaluated through the standard error of measurement and minimum detectable change. The reliability of pain location analysis was computed using the Jaccard similarity index. RESULTS: The reliability analysis of pain extent consistently yielded intraclass correlation coefficient values above 0.90 for all scanning procedures, with standard error of measurement ranging from 0.03% to 0.13% and minimum detectable change from 0.08% to 0.38%. The mean Jaccard index scores across all dataset comparisons exceeded 0.90. CONCLUSIONS: The analysis of pen-on-paper pain drawings demonstrated excellent reliability, suggesting that the automated pain-spot recognition algorithm is unaffected by scanning procedures. These findings support the algorithm's applicability in both research and clinical practice.

Efficacy of Cervical Facet Joint Radiofrequency Ablation Using a Multitined Cannula, a Technical Note, and Observational Study.

BACKGROUND: Chronic cervical facet joint pain is a leading cause of pain and disability. In patients nonresponsive to conservative treatment, cervical facet radiofrequency ablation (RFA) has shown to be efficacious. However, the conventional RFA technique can be cumbersome. A novel RFA technique with a multitined cannula allows for a lateral approach and represents an attractive alternative option for cervical facet RFA. It offers a potentially shorter, less cumbersome procedure, with consequently less x-ray exposure and patient discomfort than the conventional cervical RFA. OBJECTIVES: To describe the novel RFA technique using the lateral approach with the multitined cannula at the cervical facet joints and to assess its efficacy in chronic cervical facet joint pain. STUDY DESIGN: This is a single-center observational study. SETTING: Interventional Pain Management Center, Switzerland. METHODS: The aim of this study is to describe the RFA technique using the lateral approach with the multitined cannula at the cervical facet joints and to assess its efficacy in chronic cervical facet joint pain. Eligible adult patients with chronic (> 3 months) cervical facet joint pain refractory to conservative treatment and confirmed by dual positive medial branch blocks, received a fluoroscopic-guided cervical facet RFA treatment using the multitined cannula. The primary outcome was pain relief. Secondary outcome measures included the proportion of patients reporting a >= 30% reduction of pain intensity 2 months after RFA, patient global impression of change (PGIC), need for pain medication, sleep quality, and patient satisfaction. RESULTS: We included 26 patients. The patients showed a clinically meaningful and significant pain relief at 2 months after cervical facet RFA (mean Numeric Rating Scale of 7.5 [1.9] at baseline to 4.2 [2.4]) and 58% of the patients reported >= 30% reduction of pain. An improvement on the PGIC was reported by 88.2% of the patients. No severe side effects or complications were observed. LIMITATIONS: Key limitations of our study were the relatively small sample size, the lack of a control group, and a relatively short-term follow-up duration. CONCLUSIONS: Our results suggest that cervical facet joint RFA using the novel technique with the multitined cannula results in significant pain reduction and improvement on the PGIC. While the conventional technique requires multiple ablations at each target level, the RFA with the multitined needle requires only a singular ablation, likely sparing time, radiation dose, discomfort, and costs. Our results merit consideration of replacement of the conventional technique with the novel technique using the multitined cannula. However, larger-scale clinical trials with an adequate long-term follow-up period are needed to prove the efficacy of RFA using the multitined cannula in cervical facet joint pain.

"Can't Intubate Can't Oxygenate" Situation in an Elective Patient in Suspected Sarcoidosis: A Case Report.

Anaesthetists and pulmonologists are well trained to follow the "can't intubate, can't oxygenate" (CICO) protocol but the procedure is rarely practised. This case report concerns an elective patient scheduled for endobronchial ultrasound bronchoscopy (EBUS) because of suspected sarcoidosis. Based on known medical history, anaesthesia for EBUS procedure was initiated with a laryngeal mask. The airway turned out to be difficult and the patient was not ventilable despite several efforts including curarization and orotracheal intubation. Rapid desaturation imposed to apply the CICO protocol with emergency cricothyroidotomy as extreme measure but also failed. 6-handed face mask ventilation was continued. Eventually, introduction of a microlaryngeal tube of the 3rd generation laryngeal mask, placed on the fibrescope, allowed endotracheal intubation. The patient fell into pulseless electrical activity, and the CICO protocol was started. Immediate cardiopulmonary resuscitation totally recovered vital functions. In the post-operative follow-up, no temporary or permanent cardiological and neurological sequels were found, but new medical history such as inconstant use of C-PAP (Continuous Positive Airway Pressure) and a significant weight gain since the last notable difficult intubation were uncovered, which explained the patient's compromised airways. Had this information been available prior to the scheduled operation, it would have indicated awake intubation with a local anaesthesia of the oropharynx and appropriate sedation of the patient. LEARNING POINTS: The CICO protocol was effective to manage an unanticipated difficult airway. The patient was resuscitated with the use of a microlaryngeal endotracheal tube of the 3rd generation laryngeal mask, placed on the fibrescope.The patient's previous and current medical condition is of vital importance for the pre-operative anaesthetic assessment.Specific questioning during the pre-operative anaesthetic interview could detect events that seem to be insignificant to the patient but are significant for a diagnostic intervention in a new situation.

Spinal cord stimulation in severe pharmacoresistant restless legs syndrome-two case reports.

Restless legs syndrome is a prevalent, sleep-related sensorimotor disorder with relevant impact on the patients' quality of life. For patients suffering from severe, pharmacoresistant restless legs syndrome, few therapeutic options remain to alleviate symptoms. In this case series, two patients with severe, pharmacoresistant restless legs syndrome were treated with epidural spinal cord stimulation and repeatedly assessed with polysomnography, including sleep structure and periodic limb movements as objective biomarkers not subject to placebo effects, during a 6-month follow-up period. One of the patients experienced excellent short- and long-term efficacy on subjective symptom severity (International RLS Study group rating scale 1 vs. 34 points at 3 months) and objective sleep parameters such as sleep architecture and periodic limb movements during sleep, while the second patient only reported short-term benefits from spinal cord stimulation. Ultimately, both patients opted for removal of the device for inefficacy. Based on the complex pathophysiology of restless legs syndrome and presumed mechanism of action of spinal cord stimulation in chronic pain disorders, we provide a detailed hypothesis on the possible modulating effect of spinal cord stimulation on the key symptoms of restless legs syndrome. Apart from describing a new therapeutic option for pharmacoresistant restless legs syndrome, our findings might also provide further insights into the pathophysiology of the syndrome.