Informed Consent for Spine Procedures: Best Practice Guideline from the American Society of Pain and Neuroscience (ASPN).

Introduction: The evolution of treatment options for painful spinal disorders in diverse settings has produced a variety of approaches to patient care among clinicians from multiple professional backgrounds. The American Society of Pain and Neuroscience (ASPN) Best Practice group identified a need for a multidisciplinary guideline regarding appropriate and effective informed consent processes for spine procedures. Objective: The ASPN Informed Consent Guideline was developed to provide clinicians with a comprehensive evaluation of patient consent practices during the treatment of spine pathology. Methods: After a needs assessment, ASPN determined that best practice regarding proper informed consent for spinal procedures was needed and a process of selecting faculty was developed based on expertise, diversity, and knowledge of the subject matter. A comprehensive literature search was conducted and when appropriate, evidence grading was performed. Recommendations were based on evidence when available, and when limited, based on consensus opinion. Results: Following a comprehensive review and analysis of the available evidence, the ASPN Informed Consent Guideline group rated the literature to assist with specification of best practice regarding patient consent during the management of spine disorders. Conclusion: Careful attention to informed consent is critical in achieving an optimal outcome and properly educating patients. This process involves a discussion of risks, advantages, and alternatives to treatment. As the field of interventional pain and spine continues to grow, it is imperative that clinicians effectively educate patients and obtain comprehensive informed consent for invasive procedures. This consent should be tailored to the patient's specific needs to ensure an essential recognition of patient autonomy and reasonable expectations of treatment.

Intervertebral Disc Degeneration: The Role and Evidence for Non-Stem-Cell-Based Regenerative Therapies.

The use of non-stem-cell-based regenerative medicine therapies for lumbar discogenic pain is an area of growing interest. Although the intervertebral disc is a largely avascular structure, cells located within the nucleus pulposus as well as annulus fibrosis could be targeted for regenerative and restorative treatments. Degenerative disc disease is caused by an imbalance of catabolic and anabolic events within the nucleus pulposus. As catabolic processes overwhelm the environment within the nucleus pulposus, proinflammatory cytokines increase in concentration and lead to further disc degeneration. Non-stem-cell-based therapies, which include growth factor therapy and other proteins, can lead to an increased production of collagen and proteoglycans within the disc.

Preliminary effects of low-intensity focused ultrasound treatment program for cancer-related neuropathic pain.

Aim: To evaluate the effectiveness of low-intensity focused ultrasound (LIFU) therapy in the management of cancer-related neuropathic pain (CNP). Methods: A retrospective review with 22 patients with CNP treated with LIFU therapy (frequency 3 Hz, 3 W/cm2, pulse mode duty cycle 50%) was conducted. Results: Out of the 22 patients, 15 had CNP secondary to chemotherapy-induced peripheral neuropathy. Compared with baseline, there was a significant reduction in numeric pain rating scale (p < 0.001). Additionally, 76.5% of patients (n = 13) were considered to be responders to LIFU therapy. Conclusion: LIFU therapy may be a viable treatment modality in the management of CNP, specifically chemotherapy-induced peripheral neuropathy, with a minimal side effect profile. Larger, prospective studies with a structured protocol are necessary.

Lay abstract With recent advancements in oncological treatments, there has been an increase in the number of cancer survivors. This has led to an increase in prevalence and burden of long-term side effects of oncological disease and associated treatments. Cancer-related neuropathic pain (CNP) is a debilitating pain condition that develops in the setting of direct tumor burden or as a result of cancer-related treatments, such as chemotherapy. Management can be challenging and clinicians are often limited to pharmacological agents and more invasive modalities. This study evaluated the effectiveness of low-intensity focused ultrasound (LIFU), a noninvasive, externally applied therapeutic ultrasound device, as a treatment for CNP. Twenty-two patients with CNP were treated with LIFU and found to have significant reduction in pain, suggesting LIFU may be an effective treatment modality in the management of CNP. This pilot study has laid the ground work for future prospective studies to further investigate the effects of LIFU on CNP.

Case report: bilateral tunneled epidural catheters to prevent unilateral analgesia for cancer-related pain.

OBJECTIVE: Unilateral analgesia often occurs with epidural analgesia. Traditional methods of troubleshooting this problem can be insufficient in obtaining adequate pain relief in a timely manner for terminal cancer patients. This case report demonstrates a safe and effective solution which can be utilized in these circumstances. CASE REPORT: A 55-year-old female with stage IV pancreatic cancer and life expectancy of a few weeks presented to the interventional pain clinic with intractable sacral pain. The decision to place an epidural catheter and external pump for analgesia was made. An epidural catheter placed at the L5-S1 level showed contrast spread only along the right nerve roots and a test dose produced only right-sided analgesia. Suspecting compartmentalization of the epidural space, a second left-sided epidural catheter was placed and bilateral analgesia was achieved by using both catheters. This dual catheter technique gave the patient effective bilateral analgesia until she passed away several weeks later. CONCLUSION: The bilateral epidural catheter technique is safe and effective in patients who present with persistent unilateral epidural analgesia despite exhausting traditional solutions.

Pedal Gangrenous Changes in the Digits of an Adolescent With Ulcerative Colitis: A Case Report.

Ulcerative colitis is an autoimmune inflammatory disease of the colon and is occasionally associated with thrombosis. We report the case of an adolescent with ulcerative colitis who presented with bilateral gangrenous toes without signs of ascending cellulitis. Radiographs indicated the presence of bilateral and erosive changes in the distal phalanges. The vascular team referred the patient for podiatric intervention for distal vasculitis and thrombosis of the digital vessels. Transphalangeal amputations were performed, and postoperative antibiotics were initiated. The surgical sites healed uneventfully, and the patient was able to resume daily activities. Thrombosis of the foot in the context of ulcerative colitis is a rare, but serious, complication that can lead to serious comorbidities, including amputation.

Multiple osteocartilaginous exostoses of the lower extremity: a case report.

An osteochrondoma is a benign osseous tumor capped by cartilage. Osteochondromas occurring at the distal tibia and fibula are uncommon and even more so when occurring at the first metatarsal head. Osteochondromas usually occur at the metaphysis of long bones; however, they can occur at other cortical bone metaphyses. This is a case report of a 54-year-old male with incidental radiographic findings of multiple osteochondromas around his ankles as well as a solitary osteochondromatous lesion growing proximally off the left first metatarsal head. The multiple osteochrondomas were evident on multiple views, and subsequent histological analysis of the solitary osteochondromatous lesion via total surgical excision confirmed a diagnosis of multiple hereditary osteochrondromatosis.

The effect of lung cancer on cytokine expression in peripheral blood mononuclear cells.

The purpose of this study is to evaluate cytokine expression by peripheral blood mononuclear cells (PBMC) from stage I lung cancer patients and to confirm these expression patterns by exposing PBMCs to lung cancer cells in vitro. Five altered cytokines in stage I lung cancer patients (CCL3, IL8, IL1ß, CXCL10, sIL2Rα) were identified in plasma from subjects (n = 15) before and after resection using a 30-plex panel protein assay. Gene expression studies using quantitative RT-qPCR were performed on PBMCs from stage I lung cancer patients (n = 62) before and after resection, and compared to non-cancer patients (n = 32) before and after surgery for benign disease. Co-culture experiments that exposed healthy donor PBMCs to lung cancer cells in vitro were performed to evaluate the effect on PBMC cytokine expression. PBMC gene expression of CCL3, IL8 and IL1ß was higher in lung cancer patients compared to the same patients at each of four sequential timepoints after removal of their tumors, while CXCL10 and IL2Rα were essentially unchanged. This pattern was also detected when lung cancer patients were compared to non-cancer patients. When non-cancer patients underwent surgery for benign diseases, these cytokine expression changes were not demonstrable. Lung cancer cell lines, but not benign bronchial epithelial cells, induced similar changes in cytokine gene and protein expression by healthy donor PBMCs in an in vitro co-culture system. We conclude that PBMCs from stage I lung cancer patients possess distinct cytokine expression patterns compared to both non-cancer patients, and lung cancer patients following tumor removal. These expression patterns are replicated by healthy donor PBMCs exposed to lung cancer cell lines, but not benign bronchial epithelial cells in vitro. These findings have implications for understanding the immune response to lung cancer.