The efficacy of high-intensity laser therapy in wound healing: a narrative review.

High-intensity laser therapy (HILT) has recently been incorporated into wound management therapeutic protocols (Mosca RC et al. (2019) Photobiomodulation Therapy for Wound Care: A Potent, Noninvasive, Photoceutical Approach. Adv Skin Wound Care 32(4):157-167. https://doi.org/10.1097/01.ASW.0000553600.97572.d2 ). Laser therapy is increasingly used as an adjunct to therapeutic interventions in clinical practice (Dundar U et al. (2015) Effect of high-intensity laser therapy in the management of myofascial pain syndrome of the trapezius: a double-blind, placebo-controlled study. Lasers Med Sci 30(1):325-332. https://doi.org/10.1007/s10103-014-1671-8 ). This study aimed to evaluate the efficacy of HILT and the potential benefits of incorporating co- interventions alongside HILT in wound management. The following databases were searched up to April 2023: Embase, MEDLINE, PubMed, and Cinahl, as well as manual searches. The search keywords included high- intensity laser therapy, high-power laser therapy, laser therapy, wound, ulcer, and wound healing. The primary measures were decreased wound surface area (WSA) and improved wound appearance (WA) or other objective wound assessment tools containing these two values. Six human studies investigating HILT in wound healing treatment and one animal study assessing the wound-healing effects of HILT in acute wounds of mice were selected (Thabet AAE, Mahran HG, Ebid AA, Alshehri MA. Effect of pulsed high intensity laser therapy on delayed caesarean section healing in diabetic women. J Phys Ther Sci.;30(4):570-575. doi:, Ebid AA, Thabet A, Helal O (2018) (2011) Efficacy of pulsed high intensity Nd: Yag Laser in Treatment of Chronic Diabetic Foot Ulcer. Energy for Health pp. 25-30); (Ebid AA, El-Kafy EM, Alayat MS (2013) Effect of pulsed Nd: YAG laser in the treatment of neuropathic foot ulcers in children with spina bifida: a randomized controlled study. Photomed Laser Surg 31(12):565-570. https://doi.org/10.1089/pho.2013.3533 ); (Hong SE et al. (2016) Effects of neodymium-yttrium-aluminum garnet (Nd: YAG) pulsed high-intensity laser therapy on full thickness wound healing in an experimental animal model. J Cosmet Laser Ther 18(8):432-437. https://doi.org/10.1080/14764172.2016.1202421 ); (Lu Q et al. (2021) Clinical effects of high-intensity laser therapy on patients with chronic refractory wounds: a randomised controlled trial. BMJ Open 11(7):e045866. https://doi.org/10.1136/bmjopen-2020-045866 ); (Pereira FLC et al. (2020) Use of a High-Power Laser for Wound Healing: A Case Report. J Lasers Med Sci 11(1):112-114. https://doi.org/10.15171/jlms.2020.19 ); (Thabet AAE et al. (2018) Effect of pulsed high intensity laser therapy on delayed caesarean section healing in diabetic women. J Phys Ther Sci 30(4):570-575. https://doi.org/10.1589/jpts.30.570 ); (Nussbaum EL, Baxter GD, Lilge L (2003) A Review of Laser Technology and Light-Tissue Interactions as a Background to Therapeutic Applications of Low Intensity Lasers and Other Light Sources. Phys Therapy Reviews 8(1):31-44. https://doi.org/10.1002/lsm.20769 ). This limited number of studies exhibited varying treatment parameters, blinding procedures, wound etiologies, irradiation protocols, and testing areas (Thabet AAE, Mahran HG, Ebid AA, Alshehri MA. Effect of pulsed high intensity laser therapy on delayed caesarean section healing in diabetic women. J Phys Ther Sci. ;30(4):570-575. doi:, Ebid AA, Thabet A, Helal O (2018) (2011) Efficacy of pulsed high intensity Nd: Yag Laser in Treatment of Chronic Diabetic Foot Ulcer. Energy for Health pp. 25-30); (Ebid AA, El-Kafy EM, Alayat MS (2013) Effect of pulsed Nd: YAG laser in the treatment of neuropathic foot ulcers in children with spina bifida: a randomized controlled study. Photomed Laser Surg 31(12):565-570. https://doi.org/10.1089/pho.2013.3533 ); (Hong SE et al. (2016) Effects of neodymium-yttrium-aluminum garnet (Nd: YAG) pulsed high-intensity laser therapy on full thickness wound healing in an experimental animal model. J Cosmet Laser Ther 18(8):432-437. https://doi.org/10.1080/14764172.2016.1202421 ); (Lu Q et al. (2021) Clinical effects of high-intensity laser therapy on patients with chronic refractory wounds: a randomised controlled trial. BMJ Open 11(7):e045866. https://doi.org/10.1136/bmjopen-2020-045866 ); (Pereira FLC et al. (2020) Use of a High-Power Laser for Wound Healing: A Case Report. J Lasers Med Sci 11(1):112-114. https://doi.org/10.15171/jlms.2020.19 ); (Thabet AAE et al. (2018) Effect of pulsed high intensity laser therapy on delayed caesarean section healing in diabetic women. J Phys Ther Sci 30(4):570-575. https://doi.org/10.1589/jpts.30.570 ); (Nussbaum EL, Baxter GD, Lilge L (2003) A Review of Laser Technology and Light-Tissue Interactions as a Background to Therapeutic Applications of Low Intensity Lasers and Other Light Sources. Phys Therapy Reviews 8(1):31-44. https://doi.org/10.1002/lsm.20769 ). All selected studies demonstrated favorable results in improving wound conditions (Thabet AAE, Mahran HG, Ebid AA, Alshehri MA. Effect of pulsed high intensity laser therapy on delayed caesarean section healing in diabetic women. J Phys Ther Sci. ;30(4):570-575. doi:, Ebid AA, Thabet A, Helal O (2018) (2011) Efficacy of pulsed high intensity Nd: Yag Laser in Treatment of Chronic Diabetic Foot Ulcer. Energy for Health pp. 25-30); (Ebid AA, El-Kafy EM, Alayat MS (2013) Effect of pulsed Nd: YAG laser in the treatment of neuropathic foot ulcers in children with spina bifida: a randomized controlled study. Photomed Laser Surg 31(12):565-570. https://doi.org/10.1089/pho.2013.3533 ); (Hong SE et al. (2016) Effects of neodymium-yttrium-aluminum garnet (Nd: YAG) pulsed high-intensity laser therapy on full thickness wound healing in an experimental animal model. J Cosmet Laser Ther 18(8):432-437. https://doi.org/10.1080/14764172.2016.1202421 ); (Lu Q et al. (2021) Clinical effects of high-intensity laser therapy on patients with chronic refractory wounds: a randomised controlled trial. BMJ Open 11(7):e045866. https://doi.org/10.1136/bmjopen-2020-045866 ); (Pereira FLC et al. (2020) Use of a High-Power Laser for Wound Healing: A Case Report. J Lasers Med Sci 11(1):112-114. https://doi.org/10.15171/jlms.2020.19 ); (Thabet AAE et al. (2018) Effect of pulsed high intensity laser therapy on delayed caesarean section healing in diabetic women. J Phys Ther Sci 30(4):570-575. https://doi.org/10.1589/jpts.30.570 ); (Nussbaum EL, Baxter GD, Lilge L (2003) A Review of Laser Technology and Light-Tissue Interactions as a Background to Therapeutic Applications of Low Intensity Lasers and Other Light Sources. Phys Therapy Reviews 8(1):31-44. https://doi.org/10.1002/lsm.20769 ). Although insufficient data support using HILT in wound management, the promising results encourage further research. HILT appears effective in wound healing, but more high-quality studies are needed to identify optimal laser protocols.

Use of Temporary Percutaneous Peripheral Nerve Stimulation in an Oncologic Population: A Retrospective Review.

OBJECTIVES: Patients with an underlying cancer diagnosis may experience pain from many sources. Temporary, percutaneous peripheral nerve stimulation (PNS) is a minimally invasive procedure that can control pain in those who have failed conservative management. The purpose of this retrospective review is to show the use of PNS in managing pain in the oncologic setting. MATERIALS AND METHODS: Temporary, percutaneous PNS was placed under fluoroscopic or ultrasound guidance for 15 patients at a cancer pain facility. Cases were grouped by subtypes of cancer pain (ie, tumor-related, treatment-related, cancer-associated conditions, and cancer-independent). Before PNS, patients were refractory to medical management or previous interventional treatments. Patients were observed with routine clinic visits to monitor pain levels via visual analog scale (VAS) and quality-of-life measures. PNS was removed after the indicated 60-day treatment period. RESULTS: This retrospective review presents ten successful cases of oncologic-related pain treated with PNS. Patients with subtypes of pain that were tumor related, from cancer-associated conditions, and cancer independent all experienced a similar degree of pain relief. However, patients with cancer-treatment-related pain experienced the least analgesia from PNS. We also present six cases in which PNS did not provide adequate pain relief. CONCLUSION: PNS is an emerging technology in neuromodulation that may be useful in managing pain, especially in the oncologic population. Patients with cancer-related and non-cancer-related pain localized to a specific nerve distribution should be considered appropriate candidates for PNS. Further research is needed to optimize patient selection and indications for PNS in the population with cancer.

A comprehensive review of the typical and atypical side effects of gabapentin.

BACKGROUND: Gabapentin, a widely prescribed medication for various neuropathic pain conditions, has demonstrated efficacy in managing diverse neurological disorders. While conventional side effects are well-documented, a growing body of evidence suggests the existence of atypical side effects, necessitating comprehensive exploration. This paper aims to systematically review and summarize the literature on the atypical side effects of gabapentin, shedding light on manifestations beyond the conventional spectrum. METHODS: A systematic review was conducted, encompassing peer-reviewed articles published up to the knowledge cutoff date in November 2023. Databases, specifically PubMed, were searched for relevant studies, focusing on atypical side effects such as myoclonus, ataxia, pediatric aggression, respiratory depression, pneumonia, pregnancy complications, sleep interference, encephalopathy, peripheral edema, suicidal ideation, dyskinesia, anorgasmia, and myopathy. Inclusion criteria comprised studies with a focus on gabapentin-related atypical side effects, published in recognized journals and involving human subjects. RESULTS: The review identified a spectrum of atypical side effects associated with gabapentin use, ranging from neurological manifestations like myoclonus and ataxia to behavioral changes such as pediatric aggression and suicidal ideation. Additionally, respiratory complications, pregnancy-related issues, sleep disturbances, and rare complications like encephalopathy and myopathy were observed. Literature synthesis provided insights into the incidence, clinical presentation, and potential mechanisms underlying these atypical side effects. CONCLUSION: This comprehensive review highlights the diverse range of atypical side effects associated with gabapentin use, expanding beyond conventional knowledge. Healthcare practitioners must be cognizant of these manifestations, recognizing their potential impact on patient well-being. As clinical decision-making relies on a thorough understanding of a medication's side effect profile, this review contributes to enhancing awareness and fostering informed practices in the prescription and management of gabapentin. Further research is warranted to elucidate the mechanisms and risk factors associated with these atypical side effects, refining our understanding of gabapentin's safety profile.

Peripheral Nerve Stimulation for Back Pain in Patients With Multiple Myeloma as Bridge Therapy to Radiation Treatment: A Case Series.

OBJECTIVES: Patients with spinal lesions or vertebral compression fractures from multiple myeloma often present with back pain that restricts their ability to lie flat and prevents them from undergoing cancer treatment. Temporary, percutaneous peripheral nerve stimulation (PNS) has been described for cancer pain secondary to oncologic surgery or neuropathy/radiculopathy from tumor invasion. The purpose of this case series is to show the use of PNS as an analgesic bridge therapy to treat myeloma-related back pain and allow patients to complete their course of radiation. MATERIALS AND METHODS: Temporary, percutaneous PNS was placed under fluoroscopic guidance for four patients with unremitting low back pain secondary to myelomatous spinal lesions. Before PNS, the patients had pain refractory to medical management and were unable to tolerate radiation mapping and treatment owing to low back pain while supine. Patients were followed with routine clinic visits to monitor pain and progression through cancer therapy. PNS was removed after approximately 60 days or after completion of radiation. RESULTS: This case series presents four successful cases of PNS to treat low back pain from myelomatous spinal lesions and associated vertebral compression fractures. PNS targeted the medial branch nerves to treat both nociceptive and neuropathic low back pain. All four patients successfully completed radiation therapy with PNS in place. CONCLUSIONS: PNS can effectively treat low back pain secondary to myeloma-related spinal lesions as a bridge therapy to radiation. The use of PNS is a promising option for back pain from other primary or metastatic tumors. Further research is needed into the use of PNS for cancer-related back pain.

Dorsal root ganglion stimulation for chemotherapy-induced peripheral neuropathy.

BACKGROUND: Chemotherapy-induced peripheral neuropathy (CIPN) is a common consequence of cancer treatment that can be persistent and difficult to manage. Dorsal root ganglion stimulation (DRG-S) is a recently introduced but understudied treatment modality. This study explored the effect of DRG-S on pain and symptom burden associated with CIPN. METHODS: Patients with CIPN who underwent a DRG-S trial between January 2017 and August 2022 were identified through chart review after IRB approval was obtained. Demographic data, procedure details, pre-and postoperative scores, including the Numerical Rating Scale (NRS) and Edmonton Symptom Assessment System (ESAS), and duration of follow-up were recorded. Statistical analysis included descriptive statistics and paired t-tests to compare pre-and postoperative scores. RESULTS: Nine patients with an even mix of solid and hematologic malignancies underwent DRG-S trial and had a statistically significant decrease in NRS scores, with a mean reduction of 2.3 in their average pain (p = 0.014), 2.6 in worst pain (p = 0.023), and 2.1 in least pain (p = 0.018). Eight patients (88.9%) underwent permanent DRG-S implantation. Mean NRS scores remained lower than preoperative baselines through the first year of follow-up. Statistically significant reductions were noted at 3 months in average (2.1, p = 0.006) and least pain scores (1.9, p = 0.045), which further decreased after 6-12 months (average: 3.6, p = 0.049; least: 3.4, p = 0.023). Only the pain component of ESAS scores showed a significant reduction with DRG-S (2.0, p = 0.021). All patients endorsed improved sensation, 75% decreased their pain medication usage, and 37.5% reported complete pain relief by 2 years. CONCLUSION: Dorsal root ganglion stimulation can be an effective treatment for pain related to CIPN and deserves further investigation.

Methylene blue for intractable pain from oral mucositis related to cancer treatment: a randomized phase 2 clinical trial.

BACKGROUND: Oral mucositis (OM) in patients receiving cancer therapy is thus far not well managed with standard approaches. We aimed to assess the safety and effectiveness of methylene blue (MB) oral rinse for OM pain in patients receiving cancer therapy. METHODS: In this randomized, single-blind phase 2 clinical trial, patients were randomized to one of four arms: MB 0.025%+conventional therapy (CTx) (n = 15), MB 0.05%+CTx (n = 14), MB 0.1%+CTx (n = 15), or CTx alone (n = 16). Intervention groups received MB oral rinse every 6 h for 2 days with outcomes measured at days 1-2; safety was evaluated up to 30 days. The primary outcome measured change in the pain numeric rating scale (0-10) from baseline to day 2. Secondary outcome measured change in oral function burden scores from baseline to day 2, World Health Organization OM grades, morphine equivalent daily doses, and adverse events. The trial was registered with ClinicalTrials.gov ID: NCT03469284. RESULTS: Sixty patients (mean age 43, range 22-62 years) completed the study. Compared with those who received CTx alone, those who received MB had a significant reduction of pain scores at day 2 of treatment (mean ± SD); 0.025%: 5.2 ± 2.9, 0.05%: 4.5 ± 2.9, 0.1%: 5.15 ± 2.6) and reduction of oral function burden scores (0.025%: 2.5 ± 1.55, 0.05%: 2.8 ± 1.7, 0.1%: 2.9 ± 1.60). No serious adverse events were noted, but eight patients reported burning sensation of the oral cavity with the first dose, and this caused one patient to discontinue therapy. CONCLUSIONS: MB oral rinse showed significant pain reduction and improved oral functioning with minimal adverse effects. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT03469284.

Normal Saline Trigger Point Injections vs Conventional Active Drug Mix for Myofascial Pain Syndromes.

BACKGROUND: Myofascial pain syndrome (MPS) originates in the muscle and fascia. MPS presents with referred pain specific for each muscle and a trigger point that reproduces the symptoms. Trigger-point-injection (TPI) is an effective approach to treating MPS. Some TPI agents, however, are associated with systemic and local side effects. OBJECTIVE: The aim of this study was to evaluate the effectiveness of TPI with a conventional active drug mixture (CADM) vs. that with normal saline solution (NS) alone in patients with MPS presenting to the emergency department (ED). METHODS: Adults with MPS diagnosed in the ED, participants were randomly assigned to receive TPI with NS or with CADM. Pain intensity was scored using a 0-10 numeric rating scale prior to and after TPI, before discharge and 2 weeks after TPI. RESULTS: Among 48 patients analyzed, 23 received TPI with NS. The mean pain scores were as follows: immediately before TPI, 7.59 (NS) and 7.44 (CADM); immediately after TPI, 2.22 (NS) and 1.76 (CADM); prior to discharge, 1.52 (NS) and 1.76 (CADM). At 2-week follow up, the mean pain scores were 4.29 (NS) and 4.14 (CADM). Pain was significantly reduced after TPI in both groups. At 2 weeks, the mean pain scores were similar between the groups. No adverse events were reported. CONCLUSION: In cases of MPS in the ED, pain can be controlled with TPI independent of the injectate. TPI with NS may be preferred over CADM because of its lower cost and more favorable side effect profile.

Methylene Blue for the Treatment of Intractable Pain Associated with Oral Mucositis.

Oral mucositis is a common and often debilitating complication among cancer patients receiving radiation therapy to the head and neck or chemotherapy agents, or undergoing hematopoietic stem cell transplantation. Pain and decreased oral function associated with oral mucositis may persist long after the conclusion of therapy. Although most patients respond to conservative management, a subset of patients develops intractable pain with severe consequences. For some, the use of total parenteral nutrition with insertion of percutaneous endoscopic gastrostomy feeding tubes is the only alternative. Current recommendations to treat mucositis and its related pain include basic oral care, bland oral rinses, topical anesthetics, and systemic analgesics. We believe that chemical neurolysis of the affected areas with methylene blue used as an oral rinse is a noninvasive, efficient, safe, and cost-effective alternative that can provide prolonged analgesia in patients with intractable pain of oral mucositis. The benefits of this therapy are reflected in its improvement of patients' quality of life by enabling oral feeding and controlling pain. We report a series of 5 consecutive patients with intractable oral mucositis-related pain despite conventional treatment with systemic opiates. All 5 patients responded well to the use of 0.05% methylene blue as mouth rinse, demonstrating sustained analgesia over 3 weeks. The treatment was tolerated well, and overall patient satisfaction was very high. We also observed that methylene blue rinse significantly reduced the total opioid requirement, as demonstrated by reductions in the patients' morphine equivalent daily dose scores after its use. Our case series suggests that 0.5% methylene blue oral rinse therapy is an effective and inexpensive modality that can be used safely to palliate intractable oral pain in patients with mucositis associated with cancer treatment. To our knowledge, this is the first report using this therapy to treat pain from oral mucositis.

Magnetic fields and intrathecal pump malfunction.

Medical technology has impacted the overall life expectancy. Many conditions traditionally considered fatal are now curable. Surviving chronic diseases and aging of the population have increased the number of people with chronic pain. Many devices are also available to manage severe refractory pain. As such, implantable drug-delivery system (IDDS) is a small battery-powered, programmable pump implanted under the subcutaneous tissue of the abdomen and connected to a small catheter tunneled into the spine. Implantable drug-delivery system is used for the administration of morphine, ziconotide, baclofen, or their mixtures into the cerebrospinal fluid. Like many medical devices, IDDS has technical glitch which limits its performance under certain conditions. Implantable drug-delivery system is susceptible to magnetic field such as a magnetic resonance imaging (MRI) which can temporarily stall the rotor of the pump motor and suspend drug delivery. We encountered a patient from out of town seen at emergency department with increased pain and symptoms of opiates withdrawal after intermittent IDDS malfunction. He denied any exposure to magnetic fields or MRI. However, the pump interrogation showed multiple motor stall events in the event log. After a detailed inquiry, the most likely cause of pump malfunction appears to be frequent placement of a laptop computer on his abdomen close to the pump. The magnets in the laptop speakers may have caused the rotor of the pump motor to stall during the computer use, and frequent stall has caused symptoms of withdrawal. No other mechanical failures were found. The patient was discharged home after the symptoms resolved, and the pump was reprogrammed.

Safety and efficacy of peripheral nerve stimulation of the occipital nerves for the management of chronic migraine: long-term results from a randomized, multicenter, double-blinded, controlled study.

BACKGROUND: Recent studies evaluated short-term efficacy and safety of peripheral nerve stimulation (PNS) of the occipital nerves for managing chronic migraine. We present 52-week safety and efficacy results from an open-label extension of a randomized, sham-controlled trial. METHODS: In this institutional review board-approved, randomized, multicenter, double-blinded study, patients were implanted with a neurostimulation system, randomized to an active or control group for 12 weeks, and received open-label treatment for an additional 40 weeks. Outcomes collected included number of headache days, pain intensity, migraine disability assessment (MIDAS), Zung Pain and Distress (PAD), direct patient reports of headache pain relief, quality of life, satisfaction and adverse events. Statistical tests assessed change from baseline to 52 weeks using paired t-tests. Intent-to-treat (ITT) analyses of all patients (N = 157) and analyses of only patients who met criteria for intractable chronic migraine (ICM; N = 125) were performed. RESULTS: Headache days were significantly reduced by 6.7 (±8.4) days in the ITT population (p < 0.001) and by 7.7 (±8.7) days in the ICM population (p < 0.001). The percentages of patients who achieved a 30% and 50% reduction in headache days and/or pain intensity were 59.5% and 47.8%, respectively. MIDAS and Zung PAD scores were significantly reduced for both populations. Excellent or good headache relief was reported by 65.4% of the ITT population and 67.9% of the ICM population. More than half the patients in both cohorts were satisfied with the headache relief provided by the device. A total of 183 device/procedure-related adverse events occurred during the study, of which 18 (8.6%) required hospitalization and 85 (40.7%) required surgical intervention; 70% of patients experienced an adverse event. CONCLUSION: Our results support the 12-month efficacy of PNS of the occipital nerves for headache pain and disability associated with chronic migraine. More emphasis on adverse event mitigation is needed in future research. TRIAL REGISTRATION: Clinical trials.gov (NCT00615342).

The effect of clonidine pretreatment on epidural resiniferatoxin in a neuropathic pain rat model.

Resiniferatoxin (RTX) is an ultrapotent synthetic TRPV1 (transient receptor potential vanilloid subtype 1) agonist with significant initial transient hyperalgesia followed by a prolonged analgesic effect in response to thermal stimulus. Using a rat model of neuropathic pain, we evaluated the effect of pretreatment with clonidine-which has been shown to relieve intradermal capsaicin-induced hyperalgesia-on the initial hyperalgesic response and the thermal analgesic property of RTX. Thirty-six male rats were divided into 6 treatment groups (n=6 each):RTX 500 ng, RTX 1 µg, clonidine 20 µg (Cl), Cl＋RTX 500 ng, Cl＋RTX 1 µg, or normal saline 20 µL (control). We evaluated the short-term (180 min) and long-term (20 days) analgesic effects of RTX after thermal stimulation and mechanical stimulation. RTX had significant initial transient hyperalgesia followed by a prolonged analgesic effect in response to the thermal stimulus, but the RTX 500 ng and RTX 1 µg groups showed no initial short-term thermal hyperalgesic responses when pretreated with clonidine. The Cl＋RTX 1 µg rats' behavior scores indicated that they were more calm and comfortable compared to the RTX 1 µg rats. Even though we cannot precisely confirm that pretreatment with clonidine potentiates or adds to the analgesic effect of RTX, clonidine pretreatment with epidural RTX eliminated the initial RTX-associated hyperalgesic response and systemic toxicity in this neuropathic pain rat model.

Analysis of adverse events in the management of chronic migraine by peripheral nerve stimulation.

OBJECTIVE: In this study, we analyze device- and procedure-related adverse events (AEs) from a recent prospective, multicenter, double-blinded controlled study that utilized peripheral nerve stimulation (PNS) of occipital nerves for management of chronic migraine. METHODS: PNS device characteristics (lead length and spacing), surgical techniques including lead orientation (parallel or perpendicular to the nerve), and implantable pulse generator (IPG) placement (upper buttock, abdomen, infraclavicular, or lower axilla) in 157 patients were analyzed to identify any relationship with the AE incidence rate. Number of prior PNS implants performed (NPPIP) by the implanter and its relationship with different AE categories (hardware-related, biological, and stimulation-related events) and frequently observed device/procedure-related AEs (lead migration/fracture/breakage, persistent pain at the lead/IPG location, unintended/undesirable changes in stimulation, infection) were also evaluated. Three-way ANOVA tests were utilized to evaluate the dependence of AE occurrence on the variables described above. RESULTS: IPG pocket locations closer to the lead (e.g. infraclavicular region) were associated with a lower AE incidence rate (p < 0.05). Higher NPPIP was related to lower stimulation- and hardware-related AEs (p < 0.05), frequently observed AEs like lead migration, pain, and infection (p < 0.05), and procedure-related additional surgeries (p < 0.05). CONCLUSION: Implantation of the IPG closer to the lead location was associated with reduced AEs. PNS is a relatively new procedure, and the skill and precision in performing these procedures improves with experience. Our results demonstrate that as the implanter gains more experience with these procedures, a significant reduction in device- and procedure-related AEs may be expected.

Long-Term Anti-Allodynic Effect of Immediate Pulsed Radiofrequency Modulation through Down-Regulation of Insulin-Like Growth Factor 2 in a Neuropathic Pain Model.

Pulsed radiofrequency (PRF) is effective in the treatment of neuropathic pain in clinical practice. Its application to sites proximal to nerve injury can inhibit the activity of extra-cellular signal-regulated kinase (ERK) for up to 28 days. The spared nerve injury (SNI)+ immPRF group (immediate exposure to PRF for 6 min after SNI) exhibited a greater anti-allodynic effect compared with the control group (SNI alone) or the SNI + postPRF group (application of PRF for 6 min on the 14th day after SNI). Insulin-like growth factor 2 (IGF2) was selected using microarray assays and according to web-based gene ontology annotations in the SNI + immPRF group. An increase in IGF2 and activation of ERK1/2 were attenuated by the immPRF treatment compared with an SNI control group. Using immunofluorescent staining, we detected co-localized phosphorylated ERK1/2 and IGF2 in the dorsal horn regions of rats from the SNI group, where the IGF2 protein predominantly arose in CD11b- or NeuN-positive cells, whereas IGF2 immunoreactivity was not detected in the SNI + immPRF group. Taken together, these results suggest that PRF treatment immediately after nerve injury significantly inhibited the development of neuropathic pain with a lasting effect, most likely through IGF2 down-regulation and the inhibition of ERK1/2 activity primarily in microglial cells.

Acute rhabdomyolysis in a patient with long-term exposure to intrathecal ziconotide: a case report.

INTRODUCTION: Ziconotide is an intrathecally administered nonopioid analgesic for the treatment of severe chronic pain. Previous reports have noted rhabdomyolysis in patients receiving ziconotide during the initial single-shot trial or due to concurrent medical problems. We present a case of an acute rhabdomyolysis following an intrathecal bolus injection of ziconotide on a patient who had long-term exposure to the drug. CASE REPORT: The patient suffered from chronic neuropathic pain with diagnosis of failed back surgery syndrome and received intrathecal ziconotide for 2 years. Moderate side effects resulting from dose escalation led to a discontinuation of the drug. The pump medication was changed to morphine, which failed to provide adequate analgesia even with dose titration. A single intrathecal bolus of ziconotide, as an adjunctive therapy, resulted in good pain control. Two months later, the patient received a second ziconotide injection. Sixteen hours after the injection, she presented to local emergency center with nausea, vomiting, diarrhea, and myalgia. She had significantly increased CK levels and was admitted for intravenous hydration and close observation. Her serum CK level peaked at 4940 IU/L. The patient was discharged on hospital day 3 with a CK level of 808 IU/L. Her symptoms resolved without renal impairment. DISCUSSION: The clinical scenario described is a case of acute rhabdomyolysis from an intrathecal bolus injection of ziconotide in a patient with prior long-term exposure to the drug. The decrease in CK levels coincided well with the average half-life of ziconotide; however, the rhabdomyolysis may have been potentiated by hypokalemia.

Peripheral nerve stimulation for the treatment of primary headache.

A headache is a common neurological disorder, and large numbers of patients suffer from intractable headaches including migraine, tension headache and cluster headache, etc., with no clear therapeutic options. Despite the advances made in the treatment of headaches over the last few decades, subsets of patients either do not achieve adequate pain relief or cannot tolerate the side effects of typical migraine medications. An electrical stimulation of the peripheral nerves via an implantable pulse generator appears to be good alternative option for patients with treatment-refractory headaches. A number of clinical trials show considerable evidence supporting the use of peripheral nerve stimulator (PNS) for headaches not responding to conservative therapies. However, the mechanism by which PNS improves headaches or predicts who will benefit from PNS remains uncertain. The decision to use PNS should be individualized based on patient suffering and disability. Hence, further work is imperative. Here, we discuss the mechanism, indication, efficacy, implant technique, and complications of PNS.

Insurance disparities in the outcomes of spinal cord stimulation surgery.

OBJECTIVES: The Affordable Care Act aims to expand health insurance and to help narrow existing health care disparities. Medicaid patients have previously been noted to be at an increased risk for impaired access to health care, delayed medical treatment, and the receipt of substandard care. Conversely, those with commercial insurance may be subject to overtreatment. The goal of this study was to evaluate how Medicaid versus commercial insurance status affects outcomes following spinal cord stimulation (SCS) surgery. MATERIALS AND METHODS: A retrospective cohort study of 13,774 patients underwent either percutaneous or paddle permanent SCS implantation, selected from the Thomson Reuter's MarketScan database between 2000 and 2009. Patients were characterized by age at initial procedure, gender, baseline comorbidity burden, procedure-associated diagnosis code, follow-up, and type of insurance (Medicaid vs. commercial insurance). Outcome measures included probability of reoperation, timing and type of reoperation, presence of postoperative complications (immediate, 30 days, and 90 days), and overall utilization of health resources postoperatively. Multivariate analysis was performed comparing the relative effect of insurance status on outcomes following initial surgery. RESULTS: Medicaid patients had greater healthcare resource utilization as measured by medications prescribed, emergency department visits, and length of stay; however, commercially insured patients had significantly higher overall costs ($110,908 vs. $64,644, p < 0.0001). Commercial and Medicaid patients did not significantly differ in their complication rates during the index hospitalization or at 30 days or 90 days postoperatively. The group were also not significantly different in their two-year reoperation rates (7.32% vs. 5.06%, p = 0.0513). CONCLUSIONS: There are substantial insurance disparities that affect healthcare utilization and overall cost following SCS. Efforts for national healthcare reform should examine system factors that will reduce socioeconomic disparities in outcomes following SCS.

Trends of opioid prescription in cancer patients utilizing telemedicine: a retrospective study.

Aim: Prescribing patterns among healthcare practitioners remain a recurring theme of interest in the opioid crisis. This study aims to provide insight on opioid prescribing patterns for cancer pain in telemedicine and in-person encounters during COVID-19. Materials & methods: A retrospective chart review of 1000 encounters (500 telemedicine and 500 in-person) at an academic tertiary care comprehensive cancer center. Results: On average, overall, significantly higher narcotics (in morphine milligram equivalents [MME]) prescribed for patients receiving telemedicine services. In-person encounters had a significantly higher proportion of narcotic (in MME) increases in subsequent visits. Conclusion: Our institution continues to adapt telehealth services as an additional care venue and deeper insight helps mitigate development of maladaptive opioid prescribing patterns.

Case report: use of high-intensity laser therapy for treatment of trigeminal neuralgia.

Trigeminal neuralgia represents a form of chronic facial pain that is characterized by its incapacitating nature. The current therapeutic approaches encompass pharmacological agents with carbamazepine or non-pharmacologic options including utilization of percutaneous rhizotomy, Gamma knife radiosurgery or microvascular decompression may be indicated in certain cases. While the interventions may be effective, medications have negative side effects and procedures are invasive which can pose challenges for patients with various comorbidities. High-intensity laser therapy (HILT) has demonstrated safety and efficacy for many types of chronic pain such as musculoskeletal, autoimmune and neuropathic. Herein, we demonstrate the benefits of HILT therapy in the management of trigeminal neuralgia in a 72 year-old patient with a complex history of facial surgery and radiation who had failed pharmacological treatments and denied any invasive procedures.

Trigeminal neuralgia causes severe facial pain, often requiring medications or invasive procedures. High-intensity laser therapy (HILT), known for treating many chronic pains, was explored for a 72 year-old patient with a complex medical history. Previous treatments had failed, and alternatives carried risks. HILT, a safe approach improving blood flow, was given for 3 days, targeting the painful area in the face. The patient experienced improved tissue oxygen supply and pain relief. The follow-up visit at 4 weeks showed sustained relief, enhanced jaw movement and no side effects. Although promising, further research is needed to confirm HILT's effectiveness for trigeminal neuralgia on a larger scale.

Risk factors for surgical site infection in advanced neuromodulation pain procedures: a retrospective study.

Aim: To assess the effects of diabetes mellitus (DM) and related variables on surgical site infection (SSI) risk in neuromodulation. Methods: This retrospective study followed patients who underwent neuromodulation procedures for at least 9 months to identify postoperative infections. Demographics, clinical characteristics and surgical outcomes were compared. Results: Of 195 cases included, 5 (2.6%) resulted in SSIs. Median HbA1c was significantly higher for the cases with SSIs (8.2 vs 5.6%; p = 0.0044). The rate of SSI was significantly higher among patients with DM (17.9 vs 0%; p = 0.0005), HbA1c≥7% (37.5 vs 0%; p = 0.0009), and perioperative glucose ≥200 mg/dl (40 vs 2.3%; p = 0.0101). Conclusion: DM, elevated HbA1c and perioperative hyperglycemia may all contribute to increased risk of SSIs with neuromodulation procedures.

Infections are feared complications of surgery. It is important to identify factors that increase the risk of infection to prevent these complications. This study looked at the effects of diabetes and high blood sugar on the risk of infection associated with pain procedures. The researchers followed patients who had these procedures and looked for any infections that occurred afterward. They found that patients with diabetes and high blood sugar levels before surgery were more likely to develop infections after these procedures. More research can help establish blood sugar targets so that physicians can better manage this risk for their patients.

Genicular nerve neurolysis with phenol for chronic knee pain: A case series.

Chronic knee pain continues to be a common complaint amongst patients and continues to grow as the elderly population lives longer. New ways to treat chronic pain conditions, including chronic knee pain, are necessary as increased co-morbidities prevent patients from being surgical candidates. Recently, the genicular nerves have received more attention due to their role in innervating the anterior knee joint capsule as well as the intraarticular and extraarticular knee ligaments. Initial interest in the genicular nerve included radiofrequency ablation. RFA while effective, also brings with it increased procedure and equipment costs with a non-response rate of around 25%. Alcohol neurolysis of the genicular nerve is being seen as a potential alternative, low-cost, effective option for relieving chronic knee pain in patients. Previous case reports have focused on the use of alcohol, we report the use of phenol for genicular neurolysis. Of the four genicular nerve branches, only three are targeted due to the proximity of the inferolateral genicular nerve to the common peroneal nerve. The purpose of this case report is to show the effectiveness of phenol for neurolysis of the genicular nerves in relieving chronic knee pain in patients in which surgery is not an option.