Case report: Dorsal root ganglion stimulator lead fracture.

BACKGROUND: One of the unique advances in neuromodulation for chronic pain has been spinal cord stimulators (SCS) and dorsal root ganglion stimulators (DRG-S). These devices have aided in conditions such as neuropathic pain, complex regional pain syndromes, failed back surgery, and peripheral neuropathies. With these benefits, however, complications from implantable stimulators have included lead fractures and migration. The authors reviewed a lead migration, kinking, and subsequent fracture event involving a patient with complex regional pain syndrome (CRPS) II, who was treated with a DRG-S. CASE PRESENTATION: The case report follows this patient, from their past medical history to assessment of appropriate qualifications for neuromodulation, to successful surgical placement, to follow-up care. The authors further monitored assessment of inefficacy of pain relief, and identification of lead migration and kinking through imaging. In the process of removal, due to lead stress, lead fracturing occurred. After lead removal, the leads were fully replaced, and the patient was followed up and experienced improved pain relief. CONCLUSION: The case report assesses probable mechanisms of lead fracture and considerations for physicians for future assessment and triage of neuromodulation efficacy.

Challenges in Utilizing Telehealth for Chronic Pain.

PURPOSE OF REVIEW: Chronic pain in the USA has presented with higher prevalence rates among women, older adults, those unemployed, living in poverty, living in rural environments, and adults with public health insurance. The COVID-19 pandemic has heavily played into the biopsychosocial model of pain. Consequently, greater impacts have affected patients with mood disorders, opioid abuse, and chronic pain. Concurrently, telemedicine has become a popular vehicle during the COVID-19 pandemic in continuing to provide quality patient care. The purpose of this article is to review the benefits and challenges related to the delivery of telemedicine for patients with chronic pain. RECENT FINDINGS: The benefits of telemedicine have been examined from patient psychosocial and convenience factors as well in relation to medical practice efficiency. Within chronic pain management, one of telemedicine's most effective utilization is seen via post-injection follow-up and assessment of further necessary interventions. Challenges also exist in this framework, from lack of physical examination and convenient close therapeutic monitoring and drug screening, to technological and resource cost capabilities of older and disadvantaged chronic pain patients, to barriers in establishing patient-provider rapport. During the COVID-19 pandemic, telehealth services were covered at rates comparable to in-person visits. Health insurance coverage and payment were major barriers for implementation of telemedicine prior to the pandemic. It is difficult to predict ongoing coverage and payment of telehealth services, although the benefits in terms of access and patient satisfaction have clearly been demonstrated. While telemedicine has proven to be a very useful tool with a wealth of advantages, the delivery of virtual healthcare for chronic pain poses a set of challenges that will need to be met to ensure the quality and standard of care continue to be upheld.

Development of a Model for Training and Assessing Open Image-Guided Liver Tumor Ablation.

BACKGROUND: Image-guided microwave ablation (MWA) is a technically demanding procedure, involving advanced visual-spatial perception skills. This study sought to create and evaluate a low-cost model and training curriculum for open ultrasound-guided liver tumor MWA. METHODS: Simulated tumors were created, implanted into bovine livers, and visualized by ultrasound. A high-fidelity abdominal model was constructed, with a total cost of $30. Experienced physicians in MWA performed simulated ablations and evaluated the model. Expert performance metrics were established and served as targets for our training curriculum. These included time, number of passes, number of repositionings, and percentage of tumor ablated. Next, 8 novice trainees completed our deliberate practice curriculum. Participants' performances were recorded throughout. RESULTS: Physicians completed a structured feedback questionnaire rating the model's realism and training utility at 8/10 and 10/10, respectively. Tumors appeared hyperechoic and were clearly visualized on ultrasound. Trainees performed a total of 32 ablations. Our trainees' performance improved significantly in all outcomes of interest in the postcurriculum ablations compared to precurriculum ablations. CONCLUSION: We have created a cost-effective, high-fidelity model of MWA, with a deliberate practice curriculum. Trainees can practice to proficiency with clear target metrics prior to participating in clinical cas.