The interdisciplinary management of coccydynia: A narrative review.

Pain that develops in the coccyx or surrounding tissues is known as coccydynia, which occurs as a result of many etiologies both traumatic and nontraumatic. Although coccydynia most commonly affects middle-aged women, it may be found in both sexes and in all age groups. The aim of this article is to provide an overview of the presentation, diagnostic imaging, and pathophysiology of coccydynia, and to comprehensively review the current treatment options. A review of publications from 1990 to 2020 using search words related to the treatment of coccydynia in PubMed and Google Scholar was completed. Level II evidence was found supporting stretching, manipulation, and extracorporeal shock wave therapy. There are no data from high-quality studies to support injection-based therapy including corticosteroids, prolotherapy, nerve blocks, and radiofrequency ablation, although there are small retrospective and prospective observational studies suggesting benefit. Level III evidence was found supporting coccygectomy for chronic/refractory coccydynia. There are no data from randomized controlled trials to support the use of neuromodulation (sacral burst and dorsal root ganglion stimulation), although there are case reports suggesting benefit. High-level, comparative studies are lacking to guide the treatment of coccydynia and should be a focus for future research studies.

Treatment of chronic axial back pain with 60-day percutaneous medial branch PNS: Primary end point results from a prospective, multicenter study.

BACKGROUND: The objective of this prospective, multicenter study is to characterize responses to percutaneous medial branch peripheral nerve stimulation (PNS) to determine if results from earlier, smaller single-center studies and reports were generalizable when performed at a larger number and wider variety of centers in patients recalcitrant to nonsurgical treatments. MATERIALS & METHODS: Participants with chronic axial low back pain (LBP) were implanted with percutaneous PNS leads targeting the lumbar medial branch nerves for up to 60 days, after which the leads were removed. Participants were followed long-term for 12 months after the 2-month PNS treatment. Data collection is complete for visits through end of treatment with PNS (primary end point) and 6 months after lead removal (8 months after start of treatment), with some participant follow-up visits thereafter in progress. RESULTS: Clinically and statistically significant reductions in pain intensity, disability, and pain interference were reported by a majority of participants. Seventy-three percent of participants were successes for the primary end point, reporting clinically significant (≥30%) reductions in back pain intensity after the 2-month percutaneous PNS treatment (n = 54/74). Whereas prospective follow-up is ongoing, among those who had already completed the long-term follow-up visits (n = 51), reductions in pain intensity, disability, and pain interference were sustained in a majority of participants through 14 months after the start of treatment. CONCLUSION: Given the minimally invasive, nondestructive nature of percutaneous PNS and the significant benefits experienced by participants who were recalcitrant to nonsurgical treatments, percutaneous PNS may provide a promising first-line neurostimulation treatment option for patients with chronic axial back pain.

Percutaneous Peripheral Nerve Stimulation of the Medial Branch Nerves for the Treatment of Chronic Axial Back Pain in Patients After Radiofrequency Ablation.

OBJECTIVE: Lumbar radiofrequency ablation is a commonly used intervention for chronic back pain. However, the pain typically returns, and though retreatment may be successful, the procedure involves destruction of the medial branch nerves, which denervates the multifidus. Repeated procedures typically have diminishing returns, which can lead to opioid use, surgery, or implantation of permanent neuromodulation systems. The objective of this report is to demonstrate the potential use of percutaneous peripheral nerve stimulation (PNS) as a minimally invasive, nondestructive, motor-sparing alternative to repeat radiofrequency ablation and more invasive surgical procedures. DESIGN: Prospective, multicenter trial. METHODS: Individuals with a return of chronic axial pain after radiofrequency ablation underwent implantation of percutaneous PNS leads targeting the medial branch nerves. Stimulation was delivered for up to 60 days, after which the leads were removed. Participants were followed up to 5 months after the start of PNS. Outcomes included pain intensity, disability, and pain interference. RESULTS: Highly clinically significant (≥50%) reductions in average pain intensity were reported by a majority of participants (67%, n = 10/15) after 2 months with PNS, and a majority experienced clinically significant improvements in functional outcomes, as measured by disability (87%, n = 13/15) and pain interference (80%, n = 12/15). Five months after PNS, 93% (n = 14/15) reported clinically meaningful improvement in one or more outcome measures, and a majority experienced clinically meaningful improvements in all three outcomes (i.e., pain intensity, disability, and pain interference). CONCLUSIONS: Percutaneous PNS has the potential to shift the pain management paradigm by providing an effective, nondestructive, motor-sparing neuromodulation treatment.

Axillary Peripheral Nerve Stimulation for Chronic Shoulder Pain: A Retrospective Case Series.

OBJECTIVE: The objective of this study was to determine the effect of axillary peripheral nerve stimulation (PNS) on pain reduction in patients with chronic shoulder pain. Chronic shoulder pain was defined as pain greater than six months originating from any of the following and not the result of a stroke: subacromial impingement syndrome/rotator cuff pathology, glenohumeral joint arthritis, acromioclavicular joint arthritis, adhesive capsulitis, or biceps tendinopathy. MATERIALS AND METHODS: Eight adult patients with chronic shoulder pain, as defined above, who either did not respond to surgical intervention or who were deemed not ideal surgical candidates underwent permanent axillary PNS therapy. Follow-up ranged from 44 to 733 days (avg 445 days). The primary outcome was percent pain reduction, determined by the change in average numerical pain rating scale (NPRS). Additionally, secondary outcome measures were the change in opioid requirements and satisfaction rate. RESULTS: Based on the ≥50% pain reduction for treatment success, 88% (7/8) were "responders." Overall average pain reduction was 67% and 70% among responders; 62.5% (5/8) of patients reported that they used opioids prior to axillary PNS therapy for pain relief. Among these patients, 100% reported decreased opioid use after axillary PNS implant, with an average reduction of 88% (based on self-reported reductions). Additionally, 100% (8/8) of patients reported that they would recommend this therapy to other patients suffering from chronic pain. CONCLUSIONS: This retrospective case series provides level IV evidence supporting the use of axillary PNS therapy for the management of chronic shoulder pain. Additional, higher-level studies are required to further support its use.

Regenerative Medicine for Axial and Radicular Spine-Related Pain: A Narrative Review.

INTRODUCTION: Regenerative injection-based therapy has established itself as a therapeutic option for the management of a variety of painful musculoskeletal conditions. The aim of this work was to review the current literature regarding regenerative injection therapy for axial/radicular spine pain. METHODS: A comprehensive literature review was conducted on the use of regenerative medicine for axial/radicular spine pain. Eligible articles analyzed the therapeutic injection effects of platelet-rich plasma (PRP), prolotherapy, or mesenchymal signaling cells (MSCs) via intradiscal, facet joint, epidural, or sacroiliac joint delivery. RESULTS: Regarding intradiscal PRP, there are level I/IV studies supporting its use. Regarding intradiscal prolotherapy, there are level III to IV studies supporting its use. Regarding intradiscal MSCs, there are level I/IV studies supporting its use with the exception of one level IV study that found no significant improvement at 12 months. Regarding facet joint injections with PRP, there are level I/IV studies supporting its use. Regarding facet joint injections with prolotherapy, there are level IV studies supporting its use, though the one level I study did not demonstrate any statistical significance supporting its use. Regarding epidural injections with PRP, there are level I/IV studies supporting its use. Regarding epidural injections with prolotherapy, there are level IV studies supporting its use, though the one level I study did not demonstrate statistical significance beyond 48 hours. Regarding sacroiliac joint injections with PRP, there are level I/IV studies supporting its use. Regarding sacroiliac joint injections with prolotherapy, there are level I/III studies supporting its use. CONCLUSIONS: Currently, there are level I studies to support the use of PRP and MSC injections for discogenic pain; facet joint injections with PRP; epidural injections of autologous conditioned serum and epidural prolotherapy; and PRP and prolotherapy for sacroiliac joint pain. One level I study showed that facet joint prolotherapy has no significant benefit. Notably, no intervention has multiple published level I studies.

Twelve-Month Follow-up of a Randomized Clinical Trial Comparing Intradiscal Biacuplasty to Conventional Medical Management for Discogenic Lumbar Back Pain.

Objective: This report conveys 12-month outcomes of subjects treated with intradiscal biacuplasty (IDB) and conservative medical management (CMM) for chronic low back pain of discogenic origin, and results for subjects who elected to receive IDB + CMM 6 months after CMM-alone. Methods: Sixty-three subjects were originally randomized to the IDB + CMM group (N = 29) or CMM-alone (N = 34). Six months following continuous CMM-alone treatment, participants in this study group were permitted to "cross-over" to IDB + CMM (N = 25), and followed for an additional 6 months. The original IDB + CMM study subjects were followed for a total of 12 months (N = 22). Results: Pain reduction at 12 months was statistically significant and clinically meaningful in the original IDB + CMM group compared to baseline. Functional and disability outcomes were also improved statistically and clinically. Fifty-five percent of the IDB + CMM patients responded to treatment with a mean VAS reduction of 2.2 points at 12 months. Furthermore, 50% and 64% of subjects reported clinically significant improvements in SF36-PF and in ODI, respectively. There was a 1.7-point reduction (improvement) on a 7-point PGIC scale, and a 0.13-point increase (improvement) in the EQ-5D Health Index. Fifty-percent of cross-over subjects responded to IDB + CMM intervention. Mean outcome scores for cross-over subjects were similar to those of the originally-treated subjects, and functional and disability endpoints were improved statistically and clinically compared to respective baseline values. Conclusions: The study demonstrated long-term clinical effectiveness of IDB + CMM for treating chronic lumbar discogenic pain. Furthermore, the cross-over study subjects experienced similar improvements in pain, function, disability, and satisfaction.

Chronic sacroiliac joint and pelvic girdle dysfunction in a 35-year-old nulliparous woman successfully managed with multimodal and multidisciplinary approach.

BACKGROUND AND PURPOSE: Sacroiliac joint pain and dysfunction affect 15-25% of patients reporting low back pain, including reports of spontaneous, idiopathic, traumatic, and non-traumatic onsets. The poor reliability and validity associated with diagnostic clinical and imaging techniques leads to challenges in diagnosing and managing sacroiliac joint dysfunction. CASE DESCRIPTION: A 35-year-old nulliparous female with a 14-year history of right sacroiliac joint dysfunction was managed using a multimodal and multidisciplinary approach when symptoms failed to resolve after 2 months of physical therapy. The plan of care included four prolotherapy injections, sacroiliac joint manipulation into nutation, pelvic girdle belting, and specific stabilization exercises. OUTCOMES: The patient completed 20 physical therapy sessions over a 12-month period. At 6 months, the patient's Oswestry Disability Questionnaire score was reduced from 34% to 14%. At 1-year follow-up, her score was 0%. The patient's rating of pain on a numeric rating scale decreased to an average of 4/10 at 6 months and 0/10 at 1-year follow-up. DISCUSSION: A multidisciplinary and multimodal approach for the management of chronic sacroiliac joint dysfunction appeared successful in a single-case design at 1-year follow-up.

Rehabilitation perspectives of neuromodulation.

Chronic pain is one of the most prevalent and costly health care problems in the United States today. Two conditions, failed back surgery syndrome (FBSS) and complex regional pain syndrome (CRPS), in particular have been difficult to manage, resulting in increased disability and poorer quality of life measures for patients as well as increased treatments cost for payers. Given the cost of chronic pain management and overall subjectivity of analog pain scores, many payers are emphasizing the importance of functional outcomes as a means of assessing efficacy of treatment. Neuromodulation devices such as spinal cord stimulators are shown to be cost effective and able to improve functional outcomes and quality of life. Specific rehabilitation therapies also demonstrate improved functional outcomes. This article aims to discuss the role of rehabilitation in the patient with a neuromodulatory device. From the available data and our clinical experience, we recommend incorporating rehabilitation after placement of a neuromodulation device in order to optimize functional outcomes.

A critical appraisal of the evidence for botulinum toxin type A in the treatment for cervico-thoracic myofascial pain syndrome.

Myofascial pain syndrome (MPS) is a musculoskeletal condition characterized by regional pain and muscle tenderness associated with the presence of myofascial trigger points (MTrPs). The last decade has seen an exponential increase in the use of botulinum toxin (BTX) to treat MPS. To understand the medical evidence substantiating the role of therapeutic BTX injections and to provide useful information for the medical practitioner, we applied the principles of evidence-based medicine to the treatment for cervico-thoracic MPS. A search was conducted through MEDLINE (PubMed, OVID, MDConsult), EMBASE, SCOPUS and the Cochrane database for the period 1966 to 2012 using the following keywords: myofascial pain, muscle pain, botulinum toxin, trigger points, and injections. A total of 7 trials satisfied our inclusion criteria and were evaluated in this review. Although the majority of studies found negative results, our analysis identified Gobel et al.'s as the highest quality study among these prospectively randomized investigations. This was due to appropriate identification of diagnostic criteria, excellent study design and objective endpoints. The 6 other identified studies had significant failings due to deficiencies in 1 or more major criteria. We conclude that higher quality, rigorously standardized studies are needed to more appropriately investigate this promising treatment modality.

Treatment of myofascial pain.

SUMMARY The objective of this article was to perform a narrative review regarding the treatment of myofascial pain syndrome and to provide clinicians with treatment recommendations. This paper reviews the efficacy of various myofascial pain syndrome treatment modalities, including pharmacological therapy, injection-based therapies and physical therapy interventions. Outcomes evaluated included pain (visual analog scale), pain pressure threshold and range of motion. The evidence found significant benefit with multiple treatments, including diclofenac patch, thiocolchicoside and lidocaine patches. Trigger point injections, ischemic compression therapy, transcutaneous electrical nerve stimulation, spray and stretch, and myofascial release were also efficacious. The authors recommend focusing on treating underlying pathologies, including spinal conditions, postural abnormalities and underlying behavioral issues. To achieve maximum pain reduction and improve function, we recommend physicians approach myofascial pain syndrome with a multimodal plan, which includes a combination of pharmacologic therapies, various physical therapeutic modalities and injection therapies.

Successful peripheral nerve field stimulation for thoracic radiculitis following Brown-Sequard syndrome.

OBJECTIVE: The objective of this study is to present a novel approach to the treatment of thoracic radiculitis following Brown-Sequard syndrome with peripheral nerve field stimulation (PNFS). Furthermore, we endeavor to discuss the role of PNFS in the management of refractory neuropathic pain conditions including post-traumatic and post-surgical neuropathy particularly with regards to the post-surgical spine. MATERIALS AND METHODS: Presented is a 57-year-old man with history of thoracic microdiscectomy resulting in Brown-Sequard syndrome presented with chronic post-operative thoracic radicular pain radiating to the abdomen, refractory to conservative management. The patient underwent three intercostal nerve blocks from T7 to T9 with transient symptomatic relief. The patient's options were limited to chemomodulation, neuromodulation, or selective intercostal nerve surgical neurectomy. He subsequently underwent a PNFS trial and reported >75% pain reduction. Permanent percutaneous PNFS electrodes were implanted subcutaneously over the right T7 and T9 intercostal nerves and replicated the trial results. RESULTS: Neuromodulation produced pain relief with >90% improvement in pain compared with baseline both during the trial and following permanent implantation of the PNFS system. CONCLUSION: Chronic radicular pain may be difficult to manage in the post-surgical patient and often requires the use of multiple therapeutic modalities. In this case, we successfully utilized PNFS as it demonstrated greater technical feasibility when compared with dorsal column stimulation and repeat surgery; therefore, it may be considered for the management of post-surgical neuropathy. Further controlled studies are needed to evaluate the efficacy of PNFS as a treatment option.

Optimizing quality of life through palliative care.

Many developments have occurred in prevention and treatment of cancer, but death from this disease is still common. Of the 58 million people who died worldwide in 2005, 7.6 million died of cancer (http://www.who.int/cancer/en/). For dying patients, it is most important to improve quality of life and relieve suffering. Palliative care is the active total care of patients whose medical condition is not responsive to curative treatment. It encompasses all therapeutic modalities designed to enhance quality of life rather than eliminating disease. Each patient's definition of quality of life is unique, and therefore, it is important to treat each as an individual and holistically. Controlling cancer-related symptoms can ameliorate the limited remaining time patients have with family and friends. Palliative chemotherapy, rehabilitation, radiation therapy, surgery, and interventional pain management can help to achieve this objective. In this online update of an article published in a 2005 series on pain management, a case presentation describes the typical course of a patient with cancer who receives palliative care to reduce pain.