Lumbar Transgrade Dorsal Root Ganglion Stimulation Lead Placement in Patients with Post-Surgical Anatomical Changes: A Technical Note.

BACKGROUND: Stimulation of the dorsal root ganglion (DRG-S) has been shown to be an efficacious treatment option for refractory neuropathic pain syndromes. However, placement of the percutaneous leads for trial implantation can be challenging in patients with prior spinal surgical interventions resulting in anatomical changes and adhesions. METHODS: This technical report describes the transgrade placement of DRG-S leads in 4 patients with back pain surgery histories in whom secondary to specific anatomical pathologies the traditional anterograde placement of DRG-S leads was not feasible. RESULTS: We used a transgrade placement approach, entering superior and contralateral to the target level of placement, resulting in uncomplicated and effective placement of DRG-S leads. CONCLUSIONS: Transgrade lead placement for DRG-S may be an efficacious alternative to traditional anterograde DRG lead placement in cases where interlaminar access below the level of the DRG is not available, or desirable. Further studies are needed to clarify the safety and applicability of this approach.

Filum Terminale Needle Placement During Caudal Epidural Steroid Injection.

OBJECTIVE: Caudal epidural steroid injections (ESIs) are commonly used to treat lumbar radicular pain. Touhy needles are placed under live fluoroscopic guidance to ensure epidural administration of medication. This is a case report of direct needle and catheter placements into and through the filum terminale during a caudal approach to the epidural space. DESIGN: Single case report. SETTING: Beth Israel Deaconess Medical Center. PATIENT: A 69-year-old woman who suffered from chronic low back and leg pain from lumbosacral radiculopathy, failed back surgery syndrome, and lumbar facet arthropathy. INTERVENTIONS: Caudal epidural steroid injection. OUTCOME MEASURES: Patient safety. RESULTS: The needle and catheter placement were confirmed via intrathecal contrast spread to be in the filum terminale, which prompted abortion of the procedure. CONCLUSIONS: Although caudal ESI is a relatively safe and routine intervention, care must be taken to ensure proper placement of needle, catheter, and injectate. While contrast is injected to ensure appropriate epidural spread, it serves also to reveal unexpected and unwanted spread. We present the first report of a needle being inserted directly into the filum terminale during a caudal ESI.

Ultrasound-Guided Cryoablation of a Traumatic Hip Disarticulation Neuroma.

OBJECTIVE: Traumatic amputation at the pelvic level is a rare procedure with few studies addressing long-term complications. Painful neuroma formation may form at the site of nerve transection and cause significant impairments in daily living. Ultrasound-guided cryoablation therapy has grown in popularity and should be considered in patients with painful neuromas. This is a case report of complete pain relief in a patient with rare traumatic hip disarticulation with neuroma formation, treated with ultrasound-guided cryoablation. The patient gave consent for publication. DESIGN: Single case report. SETTING: Mount Sinai Medical Center. PATIENT: A 57-year-old man with traumatic hip disarticulation over 30 years ago with a 10-year history of severe residual limb pain from neuroma formation. INTERVENTIONS: Ultrasound-guided cryoablative injection therapy. OUTCOME MEASURES: Pain reduction. RESULTS: Ultrasound-guided cryoablation of a traumatic hip disarticulation neuroma resulting in complete pain relief and improved functionality and independence. CONCLUSIONS: This case illustrates a rare incidence of painful neuroma formation in a patient with traumatic hip disarticulation. Cryoablation with ultrasound guidance resulted in resolution of all pain. We report, to the best of our knowledge, the first occasion of an ultrasound-guided cryoablation resulting in complete pain relief in a traumatic hip disarticulation neuroma.

Myofascial low back pain.

Low back pain is a common condition that is encountered by both primary care physicians as well as various specialists, which include: orthopedic surgeons, physical medicine and rehabilitation specialists, neurologists, rheumatologists, and pain management specialists. Associated muscular pain is very common and often a reactive response from nociception from other structures. Myofascial pain may arise, which is characterized by the presence of myofascial trigger points (MTrPs) that are located in fascia, tendons, and/or muscle. This article reviews the current evidence regarding the pathophysiology, assessment, and recommended treatment options for myofascial low back pain.

Two-Needle Technique for Lumbar Radiofrequency Medial Branch Denervation: A Technical Note.

BACKGROUND: Radiofrequency ablation (RFA) of the medial branches of the dorsal rami has been reported to relieve facet joint-related back pain for 6 months to 1 year in 60% of patients. Although providing benefit in a significant proportion of patients, there remains a group of patients who do not experience any pain relief from RFA or experience only benefit from the ablation for a short period. Failure of RFA has been attributed to technical failure of coagulating the nerve or coagulation of a minimal section of the nerve, allowing for early reinnervation. Increasing the success rate and duration of relief may require techniques that increase the likelihood of successful nerve ablation over a relevant distance by maximizing lesion size. OBJECTIVES: The aim of this technical note is to detail a modification to the current commonly used lumbar medial branch radiofrequency (RF) denervation approach to increase lesion size. STUDY DESIGN: This is a technical report describing a novel two-needle approach to lumbar RF medial branch denervation. SETTING: Large private interventional pain management institute. METHODS: A dual needle placement of two 10-mm active tip RF cannulas separated by 6 mm is used to optimally contact the superior articular process (SAP) from its ventral to dorsal borders, which encompasses the anticipated course of the medial branch nerves. RESULTS: The described technique creates a lesion that we estimate to be 11.0-mm wide and 11.6-mm long along the course of the medial branch adjacent to the SAP ensuring adequate coverage and treatment. LIMITATIONS: This report does not encompass a systematic evaluation of the clinical safety and efficacy of the two-needle RFA approach. Future studies will have to assess the long-term efficacy and safety of the approach. CONCLUSIONS: The detailed two-needle approach to lumbar RF medial branch denervation appears to be promising in terms of projected treatment success by coagulating a large volume of tissue, in a cost- and time-efficient manner.