The current state of training in pain medicine fellowships: An Association of Pain Program Directors (APPD) survey of program directors.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) approved the first pain medicine fellowship programs over three decades ago, designed around a pharmacological philosophy. Following that, there has been a rise in the transition of pain medicine education toward a multidisciplinary interventional model based on a tremendous surge of contemporaneous literature in these areas. This trend has created variability in clinical experience and education amongst accredited pain medicine programs with minimal literature evaluating the differences and commonalities in education and experience of different pain medicine fellowships through Program Director (PD) experiences. This study aims to gather insight from pain medicine fellowship program directors across the country to assess clinical and interventional training, providing valuable perspectives on the future of pain medicine education. METHODS: This study involved 56 PDs of ACGME-accredited pain fellowship programs in the United States. The recruitment process included three phases: advanced notification, invitation, and follow-up to maximize response rate. Participants completed a standard online questionnaire, covering various topics such as subcategory fields, online platforms for supplemental education, clinical experience, postgraduate practice success, and training adequacy. RESULTS: Surveys were completed by 39/56 (69%) standing members of the Association of Pain Program Directors (APPD). All PDs allowed fellows to participate in industry-related and professional society-related procedural workshops, with 59% encouraging these workshops. PDs emphasized the importance of integrity, professionalism, and diligence for long-term success. Fifty-four percent of PDs expressed the need for extension of fellowship training to avoid supplemental education by industry or pain/spine societies. CONCLUSION: This study highlights the challenge of providing adequate training in all Pain Medicine subtopics within a 12-month pain medicine fellowship. PDs suggest the need for additional training for fellows and discuss the importance of curriculum standardization.

Opioid Induced Hyperalgesia with Intrathecal Infusion of High-Dose Fentanyl.

INTRODUCTION: Despite being reported since 1943 as well as being the subject of a large body of literature since that time, no consensus has been reached regarding the etiology of opioid induced hyperalgesia (OIH). It is often described as a paradoxical increased pain response to noxious stimuli due to increased sensitization or an acute tolerance to opioids. CASE: We report the case of a 60 year old patient on chronic Intrathecal combined fentanyl and Bupivacaine who had worsening pain with increasing doses and improved after weaning off intrathecal opioids. CONCLUSION: OIH has been described in various settings including patients on methadone maintenance therapy, perioperative opioid administration, cancer patients on opioids, and healthy volunteers who are acutely exposed to opioids, including high dose intrathecal opioids such as Morphine and Sufentanil. To our knowledge, no cases of opioid induced hyperalgesia was previously reported in the case of intrathecal Fentanyl.

A randomized trial of epidural glucocorticoid injections for spinal stenosis.

BACKGROUND: Epidural glucocorticoid injections are widely used to treat symptoms of lumbar spinal stenosis, a common cause of pain and disability in older adults. However, rigorous data are lacking regarding the effectiveness and safety of these injections. METHODS: In a double-blind, multisite trial, we randomly assigned 400 patients who had lumbar central spinal stenosis and moderate-to-severe leg pain and disability to receive epidural injections of glucocorticoids plus lidocaine or lidocaine alone. The patients received one or two injections before the primary outcome evaluation, performed 6 weeks after randomization and the first injection. The primary outcomes were the score on the Roland-Morris Disability Questionnaire (RMDQ, in which scores range from 0 to 24, with higher scores indicating greater physical disability) and the rating of the intensity of leg pain (on a scale from 0 to 10, with 0 indicating no pain and 10 indicating "pain as bad as you can imagine"). RESULTS: At 6 weeks, there were no significant between-group differences in the RMDQ score (adjusted difference in the average treatment effect between the glucocorticoid-lidocaine group and the lidocaine-alone group, -1.0 points; 95% confidence interval [CI], -2.1 to 0.1; P=0.07) or the intensity of leg pain (adjusted difference in the average treatment effect, -0.2 points; 95% CI, -0.8 to 0.4; P=0.48). A prespecified secondary subgroup analysis with stratification according to type of injection (interlaminar vs. transforaminal) likewise showed no significant differences at 6 weeks. CONCLUSIONS: In the treatment of lumbar spinal stenosis, epidural injection of glucocorticoids plus lidocaine offered minimal or no short-term benefit as compared with epidural injection of lidocaine alone. (Funded by the Agency for Healthcare Research and Quality; ClinicalTrials.gov number, NCT01238536.).

Persistent Coronavirus Disease 2019 Headache Relieved with Sphenopalatine Ganglion Block.

According to the World Health Organization, as of September 2021, there have been over 226.8 million people diagnosed with coronavirus disease 2019 and over 4.6 million deaths from this disease. Out of those who have survived the coronavirus disease 2019 infection, many individuals have symptoms that linger on. We would like to describe the first report of a patient with a 5-month history of a persistent coro- navirus disease 2019 headache, which was finally successfully aborted with a single transnasal sphenopalatine ganglion block. A female in her early 50s presented to our pain clinic after suffering from a new, debilitating headache that began with the coronavirus disease 2019 illness and persisted for 5 months. Every evening the patient would experience a severe headache located deep inside/behind the left eye that would be resistant to analgesic medications. After 1 transnasal sphenopalatine ganglion block, the patient's coronavirus disease 2019 headache was completely resolved.

Anesthesia for laparoscopy: a review.

Laparoscopy is the process of inspecting the abdominal cavity through an endoscope. Carbon dioxide is most universally used to insufflate the abdominal cavity to facilitate the view. However, several pathophysiological changes occur after carbon dioxide pneumoperitoneum and extremes of patient positioning. A thorough understanding of these pathophysiological changes is fundamental for optimal anesthetic care. Because expertise and equipment have improved, laparoscopy has become one of the most common surgical procedures performed on an outpatient basis and to sicker patients, rendering anesthesia for laparoscopy technically difficult and challenging. Careful choice of the anesthetic technique must be tailored to the type of surgery. General anesthesia using balanced anesthesia technique including several intravenous and inhalational agents with the use of muscle relaxants showed a rapid recovery and cardiovascular stability. Peripheral nerve blocks and neuraxial anesthesia were both considered as safe alternative to general anesthesia for outpatient pelvic laparoscopy without associated respiratory depression. Local anesthesia infiltration has shown to be effective and safe in microlaparoscopy for limited and precise gynecologic procedures. However, intravenous sedation is sometimes required. This article considers the pathophysiological changes during laparoscopy using carbon dioxide for intra-abdominal insufflation, outlines various anesthetic techniques of general and regional anesthesia, and discusses recovery and postoperative complications after laparoscopic abdominal surgery.

Anesthesia for cesarean section in a patient with placenta previa and methylenetetrahydrofolate reductase deficiency.

We describe the anesthetic management of a patient with placenta previa presenting for a cesarean section, who had methylenetetrahydrofolate reductase (MTHFR) deficiency. Methylenetetrahydrofolate reductase deficiency increases homocysteine levels in the body and, therefore, predisposes to thrombosis. After a cerebrovascular accident at 8 weeks of gestational age, the patient received anticoagulants throughout the course of her pregnancy. Bleeding from the placenta previa occurred at 30 weeks of gestational age. Although general anesthesia was indicated for this patient because of her hemodynamic instability and an anticoagulated state, nitrous oxide is contraindicated in such patients. Thus, we chose a subarachnoid block because the patient remained hemodynamically stable, and anticoagulation had been stopped 8 hours before surgery. To our knowledge, there is no reported case of a parturient with MTHFR deficiency complicated with a cerebrovascular accident and associated with placenta previa presenting for a cesarean section. Anesthetic considerations are discussed in patients presenting with placenta previa associated with MTHFR deficiency.

Intraperitoneal and intravenous routes for pain relief in laparoscopic cholecystectomy.

BACKGROUND: Postoperative abdominal and shoulder pain are the most common complaints after elective laparoscopic cholecystectomy. Postoperative pain is multifactorial in origin, and therefore multimodal therapy may be needed to optimize pain relief. METHODS: We conducted a double-blind study where patients were randomly allocated to 1 of 5 groups of 20 patients each. Statistical significance was considered P<0.05. Group 1 received 40 mL bupivacaine 0.25% intraperitoneal spray. Group 2 received 40 mL bupivacaine 0.25% intraperitoneal spray mixed with 200 mg ketoprofen. Group 3 received 40 mL bupivacaine 0.25% intraperitoneal spray and intravenous 200 mg ketoprofen. Group 4 received 200 mg ketoprofen intravenously. Group 5 was the control group. RESULTS: Demographic data were similar in the 5 groups. As compared with the control group, group 1 had significantly lower abdominal pain scores at 6 hours; group 2 at 0, 1, 2, and 6 hours; group 3 at 0, 1, 2, 6, 12, and 24 hours; and group 4 at 2 hours. Group 1 had significantly lower shoulder pain scores at 1 and 6 hours; group 2 at 0 and 6 hours; and groups 3 and 4 at 0, 1, and 6 hours. The number of patients requiring postoperative rescue analgesics and the incidence of postoperative vomiting were significantly lower in group 3 only. CONCLUSIONS: A multimodal approach to pain management following elective laparoscopic cholecystectomy is best achieved with a combination of 40 mL bupivacaine 0.25% intraperitoneal spray and 200 mg intravenous ketoprofen, achieving the least incidence of postoperative vomiting.

Does pancuronium or cisatracurium delay the rate of arousal following remifentanil-based anesthesia?

STUDY OBJECTIVE: The present report investigates the rate of arousal following remifentanil-based anesthesia associated with the coadministration of pancuronium, which inhibits butyrylcholinesterase, or cisatracurium, which is partially metabolized by nonspecific esterases, versus vecuronium that is eliminated independently of ester hydrolysis. DESIGN, SETTING AND PATIENTS: Sixty patients, ASA I-II, scheduled for elective abdominal surgeries were enrolled in a double-blinded prospective study. In fact, patients were equally divided into three Groups with each Group receiving remifentanil and either one of the following three muscle relaxants: pancuronium, vecuronium or cisatracurium. MEASUREMENTS: The rate of arousal following discontinuation of anesthesia was assessed by Modified Aldrete Score. Time to eye opening on verbal command, tracheal extubation, Modified Aldrete Score >9, and time to discharge from the recovery room were recorded. MAIN RESULTS: Time to eye opening on verbal command, tracheal extubation, Modified Aldrete Score >9, and time to discharge from the recovery room were not significantly different between the three groups. CONCLUSION: The results suggest that recovery following remifentanil-based anesthesia is not delayed by the coadministration of pancuronium, cisatracurium versus vecuronium; and by the use of neostigmine for reversal of neuromuscular blockade.

Muallem endo-tracheal tube introducer: (METTI)--an aid for the difficult airway.

This is a brief report evaluating a new single use endotracheal tube introducer (METTI) which has a soft curved atraumatic tip. The introducer was tried in 44 patients, whose direct laryngoscopic view was simulated to Cormack IIIb score, and in six patients with real Cormack III score. The overall success rate of railroading of the tracheal tube over the introducer was 94% from the first attempt.

Occult spinal dysraphism: a challenge in pain management.

Spina bifida is a common birth defect affecting the central nervous system and represents a group of neural tube defects caused by congenital dysraphic malformations of the vertebral column and/or spinal cord. The anatomy in these patients is challenging and includes structural and vascular abnormalities including arteriovenous malformation or fistulae, and fatty substitution of paravertebral tissues. A magnetic resonance image (MRI) is needed for management of patients with lumbar radiculopathy and clinical features suspicious of occult spinal dysraphism. Risks and benefits of lumbar epidural steroids should be discussed comprehensively with those patients and in the best case scenario be avoided. Occult spinal dysraphism poses a clinical dilemma for interventional pain specialists managing those patients with lumbar radiculopathy. We report a case of occult spinal dysraphism discovered following the development of post-traumatic radicular symptoms.

A systematic review on the effectiveness of the Nucleoplasty procedure for discogenic pain.

BACKGROUND: Nucleoplasty is a minimally invasive procedure for treating pain caused by symptomatic disc herniation that is refractory to conservative therapy. Observational studies have reported differing outcomes for this procedure and thus its effectiveness is yet to be determined. STUDY DESIGN: A systematic review of the efficacy of the nucleoplasty procedure. OBJECTIVES: To assess the clinical efficacy of the nucleoplasty procedure for treating back pain from symptomatic, contained disc herniation and to evaluate the methodological quality of the included studies. METHODS: The relevant literature for nucleoplasty was identified through a search of the following databases: Pubmed, Ovid Medline, and the Cochrane library, and by a review of the bibliographies of the included studies. A review of the literature of the effectiveness of the nucleoplasty procedure for managing discogenic pain was performed according to the criteria for observational studies using a "Quality Index" scale to determine the methodological quality of the literature. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF) for therapeutic interventions. Recommendations were based on the criteria developed by Guyatt et al. OUTCOME MEASURES: The main outcome measures evaluated were the percentage of pain relief based on visual analogue scale (VAS) or numeric rating scale (NRS), percentage of patients with more than 50% reduction in pain, percentage of patients meeting one or more success criteria after nucleoplasty, and improvement in patient function. Secondary measures noted were reports of complications and the Quality Index scores of each study that was evaluated. RESULTS: The quality of evidence for improvement in pain or function after a nucleoplasty procedure is Level II-3. The recommendation is 1C/strong for the nucleoplasty procedure based on the quality of evidence available. The median Quality Index score was 16 (range 12 - 19), indicating adequate methodological quality of the available literature. None of the studies reported major complications related to nucleoplasty. CONCLUSIONS: Observational studies suggest that nucleoplasty is a potentially effective minimally invasive treatment for patients with symptomatic disc herniations who are refractory to conservative therapy. The recommendation is a level 1C, strongly supporting the therapeutic efficacy of this procedure. However, prospective randomized controlled trials with higher quality of evidence are necessary to confirm efficacy and risks, and to determine ideal patient selection for this procedure.

Resistance to cisatracurium in a patient with MELAS syndrome.

There are conflicting reports on the response of mitochondrial myopathy patients to the neuromuscular blocking drugs, showing either normal response or marked sensitivity. We present a patient with MELAS syndrome who underwent Nissen fundoplication and gastrojejunostomy. Marked resistance to the nondepolarizing muscle relaxant, cisatracurium was observed. The anesthesia management, as well as the various causes of resistance to cisatracurium in this patient are discussed.

Prophylactic methylene blue in a patient with congenital methemoglobinemia.

PURPOSE: To report the beneficial effect of prophylactic methylene blue administration before induction of anesthesia in a patient with congenital methemoglobinemia. CLINICAL FEATURES: A 26-yr-old male patient known to have congenital methemoglobinemia was scheduled for turbinectomy under general anesthesia. The patient was clinically cyanotic with a pulse oximetry of 91%. Arterial blood gas analysis showed a partial pressure of oxygen (PaO(2)) of 81.3 mmHg associated with a fractional oxyhemoglobin of 80.7%, and a methemoglobin fraction of 0.159. Preoperative iv administration of 1 mg.kg(-1) of methylene blue resulted, within five minutes, in a decrease of methemoglobin fraction down to 0.05 associated with an increase of the fractional oxyhemoglobin saturation up to 94.7%. After two hours, the methemoglobin fraction decreased to 0.01 and the fractional oxyhemoglobin concentration increased to 97.7%. Induction of anesthesia as well as intraoperative and postoperative course were uneventful without any episode of hypoxemia. Postoperatively, the methemoglobin fractions remained low for 24 hr, to be followed by a gradual increase up to 0.02 on the second day to reach 0.094 on the fifth day. CONCLUSION: The prophylactic preoperative methylene blue administration in a patient with congenital methemoglobinemia significantly decreased the methemoglobin level and increased the fractional oxygen saturation with a consequent increase of the safety margin against perioperative hypoxemia.