Multidisciplinary Care of a Vertebral Fracture in a Patient with Hematopoietic Stem Cell Transplant: Safety Appropriateness in Interventional Pain Management and Rehabilitation Considerations.

Bone loss leading to fragility fracture is a highly prevalent late effect in hematopoietic stem-cell transplant patients, who are affected 8-9 times more than the general population, particularly for vertebral compression fractures. Spinal interventions such as lumbar epidural steroid injections and vertebral augmentation may be helpful for providing pain relief and improved function, quality of life and return to ambulation. However, interventional procedures should be approached with caution in these patients. Our study found that there is a paucity of scientific studies addressing the risks of spinal injections in these patients and there is no absolute recommendation specific to spinal injections in patients receiving immunosuppressive agents or who have a history of solid organ or hematopoietic stem cell transplant. It is imperative to consider proper timing of the intervention to minimize risks while optimizing the benefits of the intervention combined with a well-defined post-transplant rehabilitation plan. Moreover, the decision to proceed with spinal interventions should be done case by case and with caution. Therefore, this article reports the case of a multidisciplinary treatment for a vertebral compression fracture in a patient with a hematopoietic stem-cell transplant, in particular discussing safety appropriateness in interventional pain management and rehabilitation considerations for this condition in this patient population.

Third-degree full-thickness burns as a complication of cervical radiofrequency ablation.

A 46-year-old woman underwent a cervical radiofrequency ablation (RFA) for chronic neck pain. Following the procedure, two areas surrounding the grounding pad in the lumbar region developed full thickness third-degree burns. Burn injuries following cervical RFA are rarely reported and are most often associated with cardiac and solid tumour RFA. Only one other case has been reported in literature with a similar outcome following a thoracic facet RFA. In our case, the lesion was directly from the ground pad and not from the radiofrequency electrode, which is more often the culprit. This is the first case reported in the literature of a full-thickness skin burn from a cervical RFA. Physicians should be aware of the potential for severe burns around the RF probe and ground pad as sequelae of RFA, and we caution the use of sedation during the procedure, as patients will unlikely be able to report any unusual sensation.

Developments in Minimally Invasive Surgical Options for Vertebral Pain: Basivertebral Nerve Ablation - A Narrative Review.

Historically, intervertebral disc degeneration has been the etiological target of chronic low back pain; however, disc degeneration is not necessarily directly associated with pain, and many other anatomical structures are potential etiologies. The vertebral endplates have been postulated to be a source of vertebral pain, where these endplates become particularly susceptible to increased expression of nociceptors and inflammatory proliferation carried by the basivertebral nerve (BVN), expressed on diagnostic imaging as Modic changes. This is useful diagnostic information that can help physicians to phenotype a subset of low back pain, which is known as vertebral pain, in order to directly target interventions, such as BVN ablation, to this significant pain generator. Therefore, this review describes the safety, efficacy, and the rationale behind the use of BVN ablation, a minimally invasive spinal intervention, for the treatment of vertebral pain. Our current literature review of available up-to-date publications utilizing BVN ablation in the treatment of vertebral pain suggests that there is limited, but moderate-quality evidence that this is an effective intervention for reduction of disability and improvement in function, at short- and long-term follow-up, in addition to limited moderate-quality evidence that BVN RFA is superior to conservative care for pain reduction, at least at 3-month follow-up. Our review concluded that there is a highly clinical and statistically significant treatment effect of BVN ablation for vertebral pain with clinically meaningful benefits in pain reduction, functional improvements, opioid dose reduction, and improved quality of life. There were no reported device-related patient deaths or serious AEs based on the available literature. BVN ablation is a safe, well-tolerated and clinically beneficial intervention for vertebral pain, when proper patient selection and surgical/procedural techniques are applied.

Complex regional pain syndrome type II arising from a gunshot wound (GSW) associated with infective endocarditis and aortic valve replacement.

A 34-year-old man with a history of gunshot wound (GSW) to the right upper chest developed secondary aortic valve endocarditis (AVE) and was treated with an artificial valve placement (AVP). Three months after, he presented to an outpatient pain management clinic right arm pain and was diagnosed with complex regional pain syndrome type II (CRPS II). The patient underwent a diagnostic sympathetic ganglion block, before undergoing endoscopic thoracic sympathectomy surgery. Successful outcomes revealed decreased pain, opioid utilisation and improved tolerance to therapy and activities of daily living. To our knowledge, this is the first case reporting CRPS II arising from a GSW complicated by AVE followed by AVP, which emphasises how unforeseen syndromes can arise from the management of seemingly unrelated pathology. This case demonstrates the importance of timely and proper diagnosis of uncharacterised residual pain status post-trauma and differential diagnosis and management of chronic pain syndromes.

Rare extraspinal cause of acute lumbar radiculopathy.

A 60-year-old man presented to an outpatient pain management clinic with antalgic gait and left lower extremity (LLE) radiculopathy from an unknown aetiology. A lumbar MRI revealed minimal disc protrusion at L3 and a partially visualised left-sided kidney abnormality. Abdominal and pelvic CT demonstrated severe hydronephrosis of the left kidney compressing the left psoas major. The patient was immediately referred to an outside hospital for nephrology workup, and following nephrostomy tube, his radicular pain resolved. He remained asymptomatic at 4 weeks follow-up. We found two cases of postsurgical, retroperitoneal fluid collection that caused lumbar radiculopathy, but none associated with hydronephrosis. To our knowledge, this is the first case in the literature to report hydronephrosis as the potential aetiology of lumbar radiculopathy, which highlights an important clinical reminder: to consider extraspinal aetiologies in all patients who present with lumbar radiculopathy, when clinical symptoms, examination findings and diagnostic studies present with unusual characteristics.