Clinical Patient-Relevant Outcome Domains for Persistent Spinal Pain Syndrome-A Scoping Review and Expert Panels.

Large variation exists in the monitoring of clinical outcome domains in patients with persistent spinal pain syndrome (PSPS). Furthermore, it is unclear which outcome domains are important from the PSPS patient's perspective. The study objectives were to identify patient-relevant outcome domains for PSPS and to establish a PSPS outcomes framework. PubMed, CINAHL, Cochrane, and EMBASE were searched to identify studies reporting views or preferences of PSPS patients on outcome domains. The Arksey and O'Malley framework was followed to identify outcome domains. An expert panel rated the domains based on the importance for PSPS patients they have treated. A framework of relevant outcome domains was established using the selected outcome domains by the expert panel. No studies were found for PSPS type 1. Five studies with 77 PSPS type 2 patients were included for further analysis. Fourteen outcome domains were identified. An expert panel, including 27 clinical experts, reached consensus on the domains pain, daily activities, perspective of life, social participation, mobility, mood, self-reliance, and sleep. Eleven domains were included in the PSPS type 2 outcomes framework. This framework is illustrative of a more holistic perspective and should be used to improve the evaluation of care for PSPS type 2 patients. Further research is needed on the prioritization of relevant outcome domains.

Factors Predicting Clinically Relevant Pain Relief After Spinal Cord Stimulation for Patients With Chronic Low Back and/or Leg Pain: A Systematic Review With Meta-Analysis and Meta-Regression.

RATIONALE: To optimize results with spinal cord stimulation (SCS) for chronic low back pain (CLBP) and/or leg pain, including persistent spinal pain syndrome (PSPS), careful patient selection based on proved predictive factors is essential. Unfortunately, the necessary selection process required to optimize outcomes of SCS remains challenging. OBJECTIVE: This review aimed to evaluate predictive factors of clinically relevant pain relief after SCS for patients with CLBP and/or radicular leg pain, including PSPS. MATERIALS AND METHODS: In August 2023, PubMed, Cinahl, Cochrane, and EMBASE were searched to identify studies published between January 2010 and August 2023. Studies reporting the percentage of patients with ≥50% pain relief after SCS in patients with CLBP and leg pain, including PSPS at 12 or 24 months, were included. Meta-analysis was conducted to pool results for back, leg, and general pain relief. Predictive factors for pain relief after 12 months were examined using univariable and multivariable meta-regression. RESULTS: A total of 27 studies (2220 patients) were included for further analysis. The mean percentages of patients with substantial pain relief were 68% for leg pain, 63% for back pain, and 73% for general pain at 12 months follow-up, and 63% for leg pain, 59% for back pain, and 71% for general pain at 24 months follow-up assessment. The implantation method and baseline Oswestry Disability Index made the multivariable meta-regression model for ≥50% back pain relief. Sex and pain duration made the final model for ≥50% leg pain relief. Variable stimulation and implantation method made the final model for general pain relief. CONCLUSIONS: This review supports SCS as an effective pain-relieving treatment for CLBP and/or leg pain, and models were developed to predict substantial back and leg pain relief. To provide high-grade evidence for predictive factors, SCS studies of high quality are needed in which standardized factors predictive of SCS success, based on in-patient improvements, are monitored and reported.

Spinal Cord Stimulation for Failed Back Surgery Syndrome: to Trial or Not to Trial?

Spinal cord stimulation (SCS) is a recommended therapy to treat failed back surgery syndrome (FBSS). A trial period is practiced to enhance patient selection. However, its fundamental evidence is limited, especially concerning long-term benefit and therapy safety. We compared the long-term (5.3 ± 4.0 years) clinical outcome and therapy safety of a trialed and nontrialed implantation strategy, including multidimensional variables and pain intensity fluctuations over time. A multicenter cohort analysis was performed in 2 comparable groups of FBSS patients. Regarding eligibility, patients had to be treated with SCS for at least 3 months. While the Trial group comprised patients who underwent an SCS implantation after a successful trial, the No-Trial group encompassed patients who underwent complete implantation within 1 session. The primary outcome measures were pain intensity scores and complications. The Trial and No-Trial groups consisted of 194 and 376 patients (N = 570), respectively. A statistically but not clinically significant difference in pain intensity (P = .003; effect = 0.506 (.172-.839)) was found in favor of the Trial group. No interaction between a time dependency effect and pain intensity was noted. Whereas trialed SCS patients were more likely to cease opioid usage (P = .003; OR = .509 (.326-.792)), patients in the No-Trial group endured fewer infections (P = .006; proportion difference = .43 (.007-.083)). Although the clinical relevance of our findings should be proven in future studies, this long-term real-world data study indicates that patient-centered assessments on whether an SCS trial should be performed have to be investigated. According to the current ambiguous evidence, SCS trials should be considered on a case-by-case basis. PERSPECTIVE: The currently available comparative evidence, together with our results, remains ambiguous on which SCS implantation strategy might be deemed superior. An SCS trial should be considered on a case-by-case basis, for which further investigation of its clinical utility in certain patient populations or character traits is warranted.

Subcutaneous Stimulation as Add-on Therapy to Spinal Cord Stimulation in Patients With Persistent Spinal Pain Syndrome Significantly Increases the Total Electrical Charge per Second: Aspects on Stimulation Parameters and Energy Requirements of the Implanted Neurostimulators.

OBJECTIVE: In our previous multicenter randomized controlled trial, we demonstrated the clinical effectiveness of peripheral nerve field stimulation (PNFS) as add-on therapy to spinal cord stimulation (SCS) for the treatment of chronic back pain in patients with persistent spinal pain syndrome (PSPS) or failed back surgery syndrome (FBSS). To our knowledge, no previous study has investigated the effect of PNFS as an add-on to SCS on the energy consumption of the implanted neurostimulators. Therefore, in this study, we compared the specific stimulation parameters and energy requirements of a previously unreported group of patients with only SCS with those of a group of patients with SCS and add-on PNFS. We also investigated differences that might explain the need for PNFS in the treatment of chronic low back pain. MATERIALS AND METHODS: We analyzed 75 patients with complete sets of stimulation parameters, with 21 patients in the SCS-only group and 54 patients in the SCS + PNFS group. Outcome measures were average visual analog scale score, SCS parameters (voltage, frequency, and pulse width), SCS charge per second, and total charge per second. We analyzed baseline characteristics and differences between and within groups over time. RESULTS: Both groups had comparable patient characteristics at baseline and showed a significant decrease in back and leg pain. SCS charge per second did not significantly differ between the groups at baseline or at 12 months. The total charge per second was significantly higher in the active SCS + PNFS group than in the SCS-only group at baseline; in the SCS + PNFS group, this persisted for up to 12 months, and the SCS charge per second and total charge per second increased significantly over time. CONCLUSIONS: Our results show that add-on PNFS increases the total charge per second compared with SCS alone, as expected. However, further research is needed because our results do not directly explain why some patients require add-on PNFS to treat low back pain.

Spinal Cord Stimulation With Additional Peripheral Nerve/Field Stimulation Versus Spinal Cord Stimulation Alone on Back Pain and Quality of Life in Patients With Persistent Spinal Pain Syndrome.

INTRODUCTION: Persistent spinal pain syndrome (PSPS) or failed back surgery syndrome (FBSS) refers to new or persistent pain following spinal surgery for back or leg pain in a subset of patients. Spinal cord stimulation (SCS) is a neuromodulation technique that can be considered in patients with predominant leg pain refractory to conservative treatment. Patients with predominant low back pain benefit less from SCS. Another neuromodulation technique for treatment of chronic low back pain is subcutaneous stimulation or peripheral nerve field stimulation (PNFS). We investigated the effect of SCS with additional PNFS on pain and quality of life of patients with PSPS compared with that of SCS alone after 12 months. MATERIALS AND METHODS: This is a comparative study of patients with PSPS who responded to treatment with either SCS + PNFS or SCS only following a multicenter randomized clinical trial protocol. In total, 75 patients completed the 12-month follow-up: 21 in the SCS-only group and 54 in the SCS + PNFS group. Outcome measures were pain (visual analog scale), quality of life (36-Item Short Form Survey [SF-36]), anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), overall health (EuroQol Five-Dimension [EQ-5D]), disability (Oswestry Disability Index [ODI]), and pain assessed by the McGill questionnaire. RESULTS: There were no significant differences in baseline characteristics between the two groups. Both groups showed a significant reduction in back and leg pain at 12 months compared with baseline measurements. No significant differences were found between the groups in effect on both primary (pain) and secondary parameters (SF-36, HADS, EQ-5D, ODI, and McGill pain). CONCLUSION: In a subgroup of patients with chronic back and leg pain, SCS alone provided similar long-term pain relief and quality-of-life improvement as PNFS in addition to SCS. In patients with refractory low back pain not responding to SCS alone, adding PNFS should be recommended. CLINICAL TRIAL REGISTRATION: The Clinicaltrials.gov registration number for the study is NCT01776749.

Anesthesia and Analgesia Practice Pathway Options for Total Knee Arthroplasty: An Evidence-Based Review by the American and European Societies of Regional Anesthesia and Pain Medicine.

In 2014, the American Society of Regional Anesthesia and Pain Medicine in collaboration with the European Society of Regional Anaesthesia and Pain Therapy convened a group of experts to compare pathways for anesthetic and analgesic management for patients undergoing total knee arthroplasty in North America and Europe and to develop a practice pathway. This review is intended to be an analysis of the current literature to assist individuals and institutions in designing a pathway for total knee arthroplasty that is based on existing evidence and expert recommendation and may be customized according to individual settings.

Teaching concepts in ultrasound-guided regional anesthesia.

PURPOSE OF REVIEW: Ultrasound-guided regional anesthesia is a challenging, complex skill and requires competence in teaching. The aim of this study was to review current literature on identification of education and learning of ultrasound-guided regional anesthesia and to summarize recent findings on teaching concepts. RECENT FINDINGS: Several teaching programs have been described and implemented into daily routine. Factors relevant to current practice are the knowledge of sonoanatomy, the acquisition of manual skills, the teaching ability, and the feedback given to the trainee. Simulation is a rapidly growing field and is supported by the development of phantoms. Needle visualization is one of the core competencies that is necessary for successful ultrasound-guided procedures and could be supported by technical developments in the future to improve teaching concepts. SUMMARY: Although a lot of key questions cannot be answered by the latest study results, some interesting findings were able to improve existing education programs. These results should be tailored to the individual need of a trainee, and the effects of improved training programs on patient safety and quality of care have to be investigated. The see one, do one, teach one approach is obsolete and should be abandoned.

Low-dose dexamethasone during arthroplasty: What do we know about the risks?

Dexamethasone is commonly applied during arthroplasty to control post-operative nausea and vomiting (PONV). However, conflicting views of orthopaedic surgeons and anaesthesiologists regarding the use of dexamethasone raise questions about risks of impaired wound healing and surgical site infections (SSI).The aim of this systematic review is to determine the level of evidence for the safety of a peri-operative single low dose of dexamethasone in hip and knee arthroplasty.We systematically reviewed literature in PubMed, EMBASE and Cochrane databases and cited references in articles found in the initial search from 1980 to 2013 based on predefined inclusion criteria. The review was completed with a 'pro' and 'con' discussion.After identifying 11 studies out of 104, only eight studies met the inclusion criteria. In total, 1335 patients were studied without any incidence of SSI. Causes of SSI are multifactorial. Therefore, 27 205 patients would be required (power = 90%, alpha = 0.05) to provide substantiated conclusions on safety of a single low dose of dexamethasone.Positively, many studies demonstrated showed convincing effects of low-dose dexamethasone on prevention of PONV and dose-dependent effects on post-operative pain and quality of recovery. Dexamethasone induces hyperglycaemia, but none of the studies demonstrated a concomitant SSI.Conversely, animal studies showed that high dose dexamethasone inhibits wound healing.A team approach of anaesthesiologists and orthopaedic surgeons is mandatory in order to balance the risk-benefit ratio of peri-operatively applied steroids for individual arthroplasty patients.We did not find evidence that a single low dose of dexamethasone contributes to SSI or wound healing impairment from the current studies. Cite this article: Wegener JT, Kraal T, Stevens MF, Hollman MW, Kerkhoffs GMMJ, Haverkamp D. Low-dose dexamethasone during arthroplasty: what do we know about the risks? EFORT Open Rev 2016;1:303-309. DOI: 10.1302/2058-5241.1.000039.

Influence of arm position on ultrasound visibility of the axillary brachial plexus.

BACKGROUND: Contemporary axillary brachial plexus block is performed by separate injections targeting radial, median, ulnar and musculocutaneous nerve. These nerves are arranged around the axillary artery, making ultrasound visualisation sometimes challenging. In particular, the radial nerve can be difficult to localise deep to the artery. OBJECTIVES: The primary aim of this study was to investigate which arm position optimises the visibility of the radial nerve. Secondary aims were the visibility and position of the other nerves during varying arm positions. DESIGN: A prospective observational study. SETTING: University teaching hospital, November 2012. PARTICIPANTS: Twenty volunteers, recruited by an advertisement on the Department's bulletin board. Inclusion criterion age more than 18 years. EXCLUSION CRITERIA: refusal of ultrasound examination, restricted shoulder movement, local infection, BMI greater than 30 kg m⁻². INTERVENTION: One anaesthesiologist performed bilateral ultrasound examinations of the axillary brachial plexus on 20 volunteers. Each arm was placed in different positions [shoulder (S) 90° or 180° abduction, elbow (E) 0° or 90° extension] and scans were performed proximally in the axilla, and additionally 5 cm distally to this point [proximal (P) vs. distal (D)], resulting in eight different scans stored for off-line analysis performed by two blinded anaesthesiologists. MAIN OUTCOME MEASURES: For radial, median, ulnar and musculocutaneous nerve, visibility was assessed on a six-point visibility scale. Distances and angles of the nerves relative to the axillary artery and distances relative to the skin were measured. RESULTS: No significant differences between arm positions were found in the visibility score of radial (P = 0.359) and musculocutaneous nerves (P = 0.073). Visibility of the median nerve was improved in positions S90°/E0°/D and S180°/E0°/P (P = 0.02). The ulnar nerve was more visible in position S180°/E 0°/P and D (P = 0.007). The greatest distance between artery and radial nerve was 7.4 ±â€Š4.7 mm at an angle of 120 ±â€Š14° in position S180°/E 0°/D. CONCLUSION: The visibility of the radial nerve was not improved by varying positions of the arm. S180°/E0° provided the best overall visibility and accessibility of nerves. TRIAL REGISTRATION: https://www.toetsingonline.nl/to/ccmo_search.nsf/Searchform?OpenForm Identifier: NL42116.018.12.

Value of an electronic tutorial for image interpretation in ultrasound-guided regional anesthesia.

BACKGROUND AND OBJECTIVES: Use of ultrasound-guided regional anesthesia (UGRA) requires considerable training. An embedded electronic tutorial as an element of an ultrasound machine may help to identify sonoanatomy for novices. Therefore, we investigated whether an electronic tutorial could improve accuracy or speed of performance in identifying anatomical structures. METHODS: Thirty-five novices in UGRA participated in a workshop on brachial plexus sonoanatomy. Following a lecture and training in handling of ultrasound machines and hand-eye coordination, participants were randomized in either group S, using a standard ultrasound machine, or group T, using the same type of machine with an onboard electronic tutorial. Each participant had to identify 27 anatomical structures from the brachial plexus of a volunteer. A correctly identified structure scored 1 point. An experienced observer noted scores and time required. Scores ± SD (in %) and times ± SD (in seconds) were compared between groups by analyses of independent-samples t test and analysis of variance. Influence of anesthesia experience was determined by multivariate analyses. RESULTS: Group T scored significantly higher (16.8 ± 3.6 [62%] vs. 13.4 ± 4.4 [50%], P = 0.018), whereas time required was longer (1053 ± 244 vs. 740 ± 244 seconds, P = 0.001). Multivariate analysis revealed that experience had no influence on scores or time required. Examination of structures took more time in the beginning than at the end in group T. CONCLUSIONS: An electronic tutorial can help novices in UGRA identify anatomical structures. A significant increase in correct identifications was gained at the expense of significantly longer time required for this process. Increased time required may partly be related to unfamiliarity with the tutorial.

Long-term pain and functional disability after total knee arthroplasty with and without single-injection or continuous sciatic nerve block in addition to continuous femoral nerve block: a prospective, 1-year follow-up of a randomized controlled trial.

BACKGROUND AND OBJECTIVES: This is a follow-up to determine long-term outcomes after total knee arthroplasty (TKA) in patients enrolled in a previous randomized trial that found reduced postoperative pain after addition of sciatic nerve block to continuous femoral nerve block for TKA. METHODS: Physical function after TKA was evaluated at 3 and 12 months in patients (n = 89) receiving continuous femoral nerve block alone (group F), combined with a single-injection (group Fs) or continuous sciatic nerve block (group FCS) after TKA, until the second postoperative day. Physical function, stiffness, and pain were measured by using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score 12-item knee questionnaires, and visual analog scale at rest and during mobilization before TKA and 3 and 12 months afterward. Post hoc, a median split on poor functioning (WOMAC) was analyzed. RESULTS: Western Ontario and McMaster Universities Osteoarthritis Index, Oxford Knee Score 12-item knee, and visual analog scale scores improved significantly in all patients, without any differences among groups. Median (range) WOMAC at 3 months were in group F, 83 (20-97); group Fs, 72 (25-99); and group, FCS 76 (28-100) and at 12 months 87 (35-98), 77 (43-100), and 89 (35-100), respectively. CONCLUSIONS: No differences were detected in the secondary outcomes we examined. Thus, improved postoperative outcome did not translate into improved functional outcome or long-term pain.

Effect of local anesthetic volume (15 vs 40 mL) on the duration of ultrasound-guided single shot axillary brachial plexus block: a prospective randomized, observer-blinded trial.

BACKGROUND AND OBJECTIVES: One of the advantages of ultrasound-guided peripheral nerve block is that visualization of local anesthetic spread allows for a reduction in dose. However, little is known about the effect of dose reduction on sensory and motor block duration. The purpose of the present study was to compare the duration of sensory and motor axillary brachial plexus block (ABPB) with 15 or 40 mL mepivacaine 1.5%. METHODS: Thirty patients were randomly allocated to receive ultrasound-guided ABPB with either 15 (group 15 mL, n = 15) or 40 mL (group 40 mL, n = 15) mepivacaine 1.5%. Onset, efficacy, and duration of sensory and motor block were compared. RESULTS: Two patients in group 15 mL needed an additional rescue block before surgery and were excluded from subsequent analysis. The overall median duration of sensory and motor block was significantly shorter in group 15 mL (225 [148-265] mins vs 271 [210-401] mins and 217 [144-250] mins vs 269 [210-401] mins, respectively; P < 0.01). Duration of sensory and motor block of individual nerves was significantly shorter in group 15 mL (20%-40% reduction for sensory and 18%-37% for motor block). Time to first request of postoperative analgesia was also significantly reduced in group 15 mL (163 [SD, 39] vs 235 [SD, 59] mins, respectively, P < 0.05). There were no differences in the other block characteristics. CONCLUSIONS: In ABPB with mepivacaine 1.5%, reducing the dose from 40 mL to 15 mL (62.5%) shortens the overall duration of sensory and motor block by approximately 17% to 19%, reduces sensory and motor block duration of individual nerves by 18% to 40%, and decreases the time to first request of postoperative analgesia by approximately 30%.

Value of single-injection or continuous sciatic nerve block in addition to a continuous femoral nerve block in patients undergoing total knee arthroplasty: a prospective, randomized, controlled trial.

BACKGROUND AND OBJECTIVES: Continuous femoral nerve block in patients undergoing total knee arthroplasty (TKA) improves and shortens postoperative rehabilitation. The primary aim of this study was to investigate whether the addition of sciatic nerve block to continuous femoral nerve block will shorten the time-to-discharge readiness. METHODS: Ninety patients undergoing TKA were prospectively randomized to 1 of 3 groups: patient-controlled analgesia via femoral nerve catheter alone (F group) or combined with a single-injection (Fs group) or continuous sciatic nerve block (FCS group) until the second postoperative day. Discharge readiness was defined as the ability to walk and climb stairs independently, average pain on a numerical rating scale at rest lower than 4, and no complications. In addition, knee function, pain, supplemental morphine requirement, local anesthetic consumption, and postoperative nausea and vomiting (PONV) were evaluated. RESULTS: Median time-to-discharge readiness was similar: F group, 4 days (range, 2-16 days); Fs group, 4 days (range, 2-7 days); and FCS group, 4 days (range, 2-9 days; P = 0.631). No significant differences were found regarding knee function, local anesthetic consumption, or postoperative nausea and vomiting. During the day of surgery, pain was moderate to severe in the F group, whereas Fs and FCS groups experienced minimal pain (P < 0.01). Patients in the F group required significantly more supplemental morphine on the day of surgery and the first postoperative day. Until the second postoperative day, pain was significantly less in the FCS group (P < 0.01). CONCLUSIONS: A single-injection or continuous sciatic nerve block in addition to a femoral nerve block did not influence time-to-discharge readiness. A single-injection sciatic nerve block can reduce severe pain on the day of the surgery, whereas a continuous sciatic nerve block reduces moderate pain during mobilization on the first 2 postoperative days.