Effectiveness of plasma rich in growth factors in the management of chronic spinal pain: a case series of 32 patients.

Background: This prospective, case-series study aimed to assess the clinical effectiveness of plasma rich in growth factors (PRGF) in patients with chronic low back pain (LBP) and to identify the features of the responsive patients. Materials & methods: PRGF was injected into the intervertebral disc, epidural space and/or facet and sacroiliac joints of 32 patients with chronic LBP. The efficacy of the treatment was assessed by algo-functional scores after 3 and 6 months. Results: Overall, the patients did not ameliorate after PRGF treatment, although eight patients showed an algo-functional improvement. They were mainly males treated at two sites who were younger, less sedentary and with fewer musculoskeletal co-morbidities than the nonresponders. Conclusion: PRGF is a potential treatment in a specific subpopulation of difficult-to-treat patients affected by chronic LBP.

Plain language summary In this study, 32 patients with chronic low back pain (LBP) were treated with plasma rich in growth factors (PRGF) to evaluate its clinical efficacy up to 6 months. The results showed that, analyzing the total cohort, the PRGF did not ameliorate the patients' conditions. However, eight patients responded to the treatment by showing an algo-functional improvement. They were mainly males, younger than 50 years/old, with active lifestyle habits, and with less musculoskeletal co-morbidities than the patients who did not respond. Best results were obtained when PRGF was injected at one intervertebral disc plus facet joints at the corresponding level. In conclusion, PRGF may be an effective treatment if used in patients with specific characteristics.

A comparison of non-endoscopic and endoscopic adhesiolysis of epidural fibrosis.

Low back and leg pain may be due to many causes, one of which is scarring in the epidural space. Epidural scarring may provoke this pain for many reasons: nerves may be trapped by scars, while veins in the epidural space press down upon the nerves and become enlarged, putting pressure on the nerves. Endoscopic and percutaneous epidural adhesiolysis allows one to eliminate the deleterious effects of scar formation, which can both physically prevent the direct application of drugs to nerve and provide relief in patients who have not responded to epidurals, physical therapy or medication. A search of the MEDLINE and Embase databases was conducted for the period between 1970 and 2014 using the search terms "adhesiolysis", "lysis of adhesions", "epiduroscopy", "epidural neuroplasty", "epidural adhesions", "radiofrequency lysis adhesion" and "epidural scar tissue" in order to identify articles relevant for this review. The purpose of this review is to describe the effectiveness and complications present in a comparison of non-endoscopic, endoscopic and pulsed radiofrequency endoscopic procedures in lysis of adhesions in epidural fibrosis.

Single strip lesions radiofrequency denervation for treatment of sacroiliac joint pain: two years' results.

BACKGROUND: Sacroiliac joint pain can be managed by intra-articular injections or radiofrequency of its innervation. Single strip lesions radiofrequency denervation is a new system. The objective of this study was to present one of the first utilizations of this innovative technique. METHODS: 60 patients who met the diagnostic criteria for sacroiliac joint syndrome were enrolled in the study. In total, 102 single strip lesions radiofrequency denervations were performed. Pain intensity was measured with the Oswestry low back pain disability questionnaire and the Oswestry Disability Index whose scores were assessed at 1, 3, 6 and 12 months after the procedure. RESULTS: 91.8 % of the 102 radiofrequency treatments resulted in a reduction of more than 50% pain intensity relief at 1 month, 81.6% at 3 months and 59.16% at 6 months. In 35.7% of cases, the relief was continuative up to 1 year. No relief was observed in 12.24% of cases. The ODI scores improved significantly 1 month after the procedure, compared with the baseline scores. The ODI scores after 6 months improved very clearly compared with the baseline scores and with the 3-month scores. CONCLUSIONS: Single strip lesions radiofrequency denervation using the Simplicity III probe is a potential modality for intermediate term relief for patients with sacroiliac pain.

Percutaneous cervical cordotomy in cancer pain.

The aim of this study was to review all published articles in the literature in English regarding percutaneous cervical cordotomy in cancer pain. Percutaneous cordotomy may be used to relieve unilateral pain below the level of the neck arising from a variety of causes. It is particularly indicated for unilateral chest pain associated with malignant disease. We searched for reports on MEDLINE and EMBASE using the terms 'percutaneous cordotomy', 'fluoroscopy', 'computed tomography,' and 'cancer pain' up to and including 2013. Reports were also located through references of articles. This review leads us to conclude that percutaneous cervical cordotomy can be recommended even before considering the use of strong opioids.

Percutaneous cryoanalgesia in pain management: a case-series.

BACKGROUND: Cryoanalgesia, also known as cryoneuroablation or cryoneurolysis, is a specialized technique for providing long-term pain relief. METHOD: We present here retrospective data on pain relief and changes in function after cryoanalgesia techniques: we describe the effect of this procedure on articular facet syndromes, sacroiliac pain and knee pain. RESULTS: We reviewed the records of 18 patients with articular lumbar facet pain, knee pain and sacroiliac pain. The Visual Analog Scale and Patient's Global Impression of Change scale show satisfaction at 1 month after cryoablation, with the best scores after three months. Only three patients showed a worse condition than the first month. CONCLUSION: The majority of patients experienced a clinically relevant degree of pain relief and improved function following percutaneous cryoanalgesia.

Percutaneous cryoanalgesia in pain management: a case-series.

BACKGROUND: Cryoanalgesia, also known as cryoneuroablation or cryoneurolysis, is a specialized technique for providing long-term pain relief. METHODS: There are presented retrospective data on pain relief and changes in function after cryoanalgesia techniques: we describe the effect of this procedure on articular facet syndromes, sacroiliac pain and knee pain. We reviewed records of 18 patients with articular lumbar facet pain, knee pain and sacroiliac pain. RESULTS: Both the visual analog scale and the Patient's global impression of change scale showed an increase in patients' satisfaction already at 1 month after cryoablation, with the best scores after three months. Only three individuals displayed a worse condition than at the first month. CONCLUSION: The majority of patients experienced a clinically relevant degree of pain relief and improved function following percutaneous cryoanalgesia.

Cooled radiofrequency system relieves chronic knee osteoarthritis pain: the first case-series.

BACKGROUND: Knee osteoarthritis is a frequent cause of chronic knee pain. Therapeutic solutions include intra-articular injections with short-term pain relief and surgical therapy. Radiofrequency (RF) of genicular nerves has been previously reported with varying success. Cooling tissue adjacent to the electrode (cooled RF) increases the radius of lesion. We present here the first retrospective data on pain relief and changes in function after such cooled RF denervation. METHODS: We reviewed the records of nine patients with chronic knee pain who underwent cooled RF of genicular nerves. Visual analogue scale (VAS) and Western Ontario McMaster Universities OA index (WOMAC) were analysed. RESULTS: We observed an improvement in VAS pain scores 2 ± 0.5 at one month, 2.3 ± 0.7 at three months, 2.1 ± 0.5 at six months, and 2.2 ± 0.2 at 12 months after the procedure, and WOMAC score 20 ± 2, at one month, 22 ± 0.5 at three months, 21 ± 1.7 at six months, and 20 ± 1.0 at 12 months. CONCLUSION: The majority of patients with chronic knee pain experienced a clinically relevant degree of pain relief and improved function following cooled RF of genicular nerves at one, three, six and 12 months follow-up.

Radiofrequency neurotomy for the treatment of chronic pain: interference with implantable medical devices.

BACKGROUND: Radiofrequency is widely used in the treatment of chronic pain for its efficacy and low incidence of side effects and complications. Despite this, it is commonly believed that this kind of treatment could interfere with medical implantable devices. Potential interference between implanted devices such as pacemakers, defibrillators and spinal cord stimulators and the radiofrequency of neurotomy is an important concern for physicians caring for patients with these devices. METHODS: A retrospective study was conducted on 30 radiofrequency-treated patients, collected in five years out of more than 1,000 patients treated. Our cohort was selected due to the presence of implanted medical devices. Treatments include the radiofrequency neurotomy of the lumbar facet joints, intervertebral discs, sacroiliac joint and peripheral nerves. RESULTS: Out of 30 patients and 68 treatments, global radiofrequency ablation was considered safe, due to the absence of any problem during or after the procedure. In particular, procedures were never interrupted because of electrical interference with the implanted devices or for problems attributable to an aberrant activation of them. Neurological and physical exam did not show any alteration after the procedure. CONCLUSION: There are several theoretical concerns about radiofrequency treatments in patients with implantable electrical medical devices. However, there is no experimental evidence of electrical interference with the implanted devices. Our long experience strongly suggests that by following simple precautions, patients can benefit from radiofrequency pain-relieving procedures without any adverse events.

Coagulation management in epidural steroid injection.

The objective of this study was to review all published articles in the English language literature about the coagulation management of epidural corticosteroid injections (ESI) in humans. ESI are among the most commonly used procedures to manage chronic spinal pain, yet there is no conclusive review on the coagulation management of this popular procedure. We searched for reports using MEDLINE and EMBASE with the terms 'epidural and steroids', 'corticosteroids' or 'glucocorticosteroids', 'coagulation', and 'haematoma' up to and including the year 2012. Reports were also located through references of articles. We conclude that even though epidural steroid injection is one of the most used techniques in treating radicular pain, correct management of coagulation is necessary.

Patient radiation exposure during different kyphoplasty techniques.

The scope of this study was to quantify patient radiation exposure during two different techniques of kyphoplasty (KP), which differ by a cement delivery method, in order to assess whether or not one of the two used methods can reduce the patient dose. Twenty patients were examined for this investigation. One X-ray fluoroscopy unit was used for localization, navigation and monitoring of cement delivery. The patient biometric data, the setting of the fluoroscope, the exposure time and the kerma-area product (KAP) were monitored in all the procedures for anteroposterior (AP) and lateral (LL) fluoroscopic projections in order to assess the range of radiation doses imparted to the patient. Theoretical entrance skin dose (ESD) and effective dose (E) were calculated from intraoperatively measured KAP. An average ET per procedure was 1.5±0.5 min for the manual injection technique (study A) and 1.4±0.4 min for the distance delivery technique (study B) in the AP plane, while 3.2±0.7 and 5.1±0.6 min in the lateral plane, respectively. ESD was estimated as an average of 0.10±0.06 Gy for study A and 0.13±0.13 Gy for study B in the AP or/and 0.59±0.46 and 1.05±0.36 Gy in the lateral view, respectively. The cumulative mean E was 1.9±1.0 mSv procedure(-1) for study A and 3.6±0.9 mSv procedure(-1) for study B. Patient radiation exposure and associated effective dose from KP may be considerable. The technique of distance cement delivery appears to be slower than the manual injection technique and it requires a more protracted fluoroscopic control in the lateral projection, so that this system entails a higher amount of dose to the patient.

Systemic effects of epidural steroid injections.

The aim of this study was to review all the published articles in the English language literature regarding the systemic effects of epidural corticosteroid injections (ESIs) in humans. ESIs are among the procedures that are most commonly used to manage chronic back pain. However, there has been no conclusive review on the systemic effects of this popular procedure. Reports were searched for in MEDLINE and EMBASE using the terms 'epidural' and 'steroids', 'corticosteroids' or 'glucocorticosteroids' up to and including the year 2012. Reports were also located by examining the references in the identified articles. We concluded that even if epidural steroid injection is one of the most widely- -used techniques to treat radicular pain, it must be administered cautiously, with careful monitoring for systemic side effects. At the very least, a standardised protocol is necessary.

Ferritin in dialysis-related arthropathy: could it be a possible biochemical indicator of articular chronic pain?

BACKGROUND: The aim of our study was to evaluate laboratory data behaviour in two dialysis populations, with and without dialysis-related arthropathy and pain. METHODS: We produced an elaboration of more than 160,000 items of biochemical data of 25 dialysis-related arthropathy patients with chronic articular pain, and 25 patients asymptomatic for joint pain and arthropathy. The pain visual analogue scale (VAS) was employed for pain intensity determination. RESULTS: The serum level of ß-2 microglobulin was similar in the two groups of patients, while ferritin values were significantly higher in symptomatic patients. We excluded the possibility that the ferritin difference between the two groups was due to different iron storage and to an inflammatory profile. Furthermore, the pain VAS mean value was higher in patients who had higher ferritin and pain than in asymptomatic patients. CONCLUSION: It is important to underline that the higher value of ferritin in patients with chronic pain due to dialysis- -related arthropathy could represent a new stimulus for a deeper investigation of this indicator, setting a periodic revelation of pain intensity.

Development of the Italian version of the Tampa Scale of Kinesiophobia (TSK-I): cross-cultural adaptation, factor analysis, reliability, and validity.

STUDY DESIGN: Evaluation of the psychometric properties of a translated and culturally adapted questionnaire. OBJECTIVE: Translating, culturally adapting, and validating the Italian version of the Tampa Scale of Kinesiophobia (TSK-I) to allow its use for Italian-speaking patients with low back pain. SUMMARY OF BACKGROUND DATA: Increasing attention is being given to standardized outcome measures as a means of improving interventions for low back pain. A translated form of the TSK in patients with low back pain has never been validated in the Italian population. METHODS: The development of the TSK-I questionnaire involved its translation and back-translation, a final review by an expert committee, and testing of the prefinal version to establish its correspondence to the original English version. Psychometric testing included factor analysis, reliability by internal consistency (Cronbach's alpha) and test-retest repeatability (Intraclass Coefficient Correlation), discriminant validity (Pearson correlation) by comparing TSK-I to a visual analogue scale, the Roland Morris Disability Questionnaire, Beck's Depression Inventory and Anxiety Inventory. RESULTS: It took the authors 5 months to achieve a shared version of the TSK-I, which proved to be satisfactorily acceptable when administered to 178 subjects. Factor analysis indicated a 2-factor 13-item solution (38% of explained variance). The questionnaire showed acceptable internal consistency (alpha = 0.772) and high test-retest reliability (ICC = 0.956). Discriminant validity showed moderate to low correlations with visual analogue scale (r = 0.345), the Roland Morris Disability (r = 0.337), and Beck's Depression Inventory and Anxiety Inventory (r = 0.258 and r = 283). The subscales were also psychometrically analyzed. CONCLUSION: The TSK was successfully translated into Italian, showing a good factorial structure and psychometric properties, and replicating the results of existing English versions of the questionnaire. Its use is recommended for research purposes.

Vertebral body innervation: Implications for pain.

Vertebral fractures often cause intractable pain. To define the involvement of vertebral body innervation in pain, we collected specimens from male and female patients during percutaneous kyphoplasty, a procedure used for reconstruction of the vertebral body. Specimens were taken from 31 patients (9 men and 22 women) suffering high-intensity pain before surgery. In total, 1,876 histological preparations were obtained and analysed. Immunohistochemical techniques were used to locate the nerves in the specimens. The nerve fibres were labelled by indirect immunofluorescence with the primary antibody directed against Protein Gene Product 9.5 (PGP 9.5), a pan-neuronal marker; another primary antibody directed against type IV collagen (Col IV) was used to identify vessels and to determine their relationship with vertebral nerve fibres. The mean percentage of samples in which it was possible to identify nerve fibres was 35% in men and 29% in women. The percentages varied depending on the spinal level considered and the sex of the subject, nerve fibres being mostly present around vessels (95%). In conclusion, there is scarce innervation of the vertebral bodies, with a clear prevalence of fibres located around vessels. It seems unlikely that this pattern of vertebral body innervation is involved in vertebral pain or in pain relief following kyphoplasty.

Physical and emotional symptom burden of patients with end-stage heart failure: what to measure, how and why.

OBJECTIVE: Much of our understanding about symptom burden near the end of life is based on studies of cancer patients. The aim of this study was to explore physical and emotional symptom experience among end-stage chronic heart failure patients, looking for those symptoms mostly related to their global health status. METHODS: Forty-six patients with end-stage heart failure compiled the following: Edmonton Symptom Assessment Scale (ESAS) and Kansas City Cardiomyopathy Questionnaire (KCCQ). RESULTS: End-stage heart failure patients have many complaints and poor global health status. The most distressing symptoms reported were general discomfort and tiredness followed by anorexia and dyspnea. The KCCQ summary scores were highly correlated with ESAS (r = -0.78; P = 0.0001). Among the domains explored by the KCCQ, social functioning and self-efficacy showed the lowest correlation coefficients with ESAS (r = -0.50; P = 0.001 and r = -0.31; P = 0.003, respectively); concerning the physical limitation domain, the symptom score and the quality-of-life domain, the correlation coefficients were as follows: r = -0.71 (P = 0.0001), r = -0.75 (P = 0.0001) and r = -0.74 (P = 0.0001), respectively. In the multiple regression analysis of ESAS and KCCQ scores, general discomfort, depression and anxiety were the symptoms that mostly related with the results in the domains explored by the KCCQ. No independent predictor was found among symptoms and quality of life. CONCLUSION: General discomfort together with depression and anxiety were the symptoms that were mostly related with the physical limitation domain of global health status, but did not influence the social functioning and the self-efficacy domains. When ESAS is used together with KCCQ, comprehensive and quantitative information on a patient's physical, emotional and social distress is provided.

Gabapentin for neuropathic cancer pain: a randomized controlled trial from the Gabapentin Cancer Pain Study Group.

PURPOSE: To determine the analgesic effect of the addition of gabapentin to opioids in the management of neuropathic cancer pain. PATIENTS AND METHODS: One hundred twenty-one consecutive patients with neuropathic pain due to cancer, partially controlled with systemic opioids, participated in a multicenter, randomized, double-blind, placebo-controlled, parallel-design, 10-day trial from August 1999 to May 2002. Gabapentin was titrated from 600 mg/d to 1,800 mg/d in addition to stable opioid dose. Extra opioid doses were available as needed. Zero to 10 numerical scale was used to rate average daily pain. The average pain score over the whole follow-up period was used as main outcome measure. Secondary outcome measures were: intensity of burning pain, shooting/lancinating pain, dysesthesias (also scored on 0 to 10 numerical scale), number of daily episodes of lancinating pain, presence of allodynia, and daily extra doses of opioid analgesics. RESULTS: Overall, 79 patients received gabapentin and 58 (73%) completed the study; 41 patients received placebo and 31 (76%) completed the study. Analysis of covariance (ANCOVA) on the intent-to-treat population showed a significant difference of average pain intensity between gabapentin (pain score, 4.6) and placebo group (pain score, 5.4; P =.0250). Among secondary outcome measures, dysesthesia score showed a statistically significant difference (P =.0077; ANCOVA on modified intent-to-treat population = 115 patients with at least 3 days of pain assessments). Reasons for withdrawing patients from the trial were adverse events in six patients (7.6%) receiving gabapentin and in three patients receiving placebo (7.3%). CONCLUSION: Gabapentin is effective in improving analgesia in patients with neuropathic cancer pain already treated with opioids.

The HcrVf2 gene from a wild apple confers scab resistance to a transgenic cultivated variety.

The Vf gene from the wild species Malus floribunda 821 is the most studied apple scab resistance gene. Several molecular markers mapping around this gene were the starting point for a positional cloning project. The analysis of the bacterial artificial chromosome clones spanning the Vf region led to the identification of a cluster of genes homologous to the Cladosporium fulvum resistance gene family of tomato. One of these genes, HcrVf2 (homologue of the C. fulvum resistance genes of the Vf region), was used to transform the susceptible apple cultivar Gala. Four independent transformed lines resistant to apple scab were produced, proving that HcrVf2 is sufficient to confer scab resistance to a susceptible cultivar. The results show that direct gene transfer between cross-compatible species can be viable when, as in apple, the use of backcrosses to introduce resistance genes from wild species cannot exactly reconstitute the heterozygous genotype of clonally propagated cultivars.

[Health care quality in terminal cardiac decompensation: a "multidisciplinary" reflexion]. / Qualità dell'assistenza nello scompenso cardiaco terminale: una riflessione "multidisciplinare".

Although improved, the prognosis of chronic heart failure is still malignant, the survival rate being similar to that of cancer. Due to the relevant epidemiology of this disease, the terminal care of heart failure has a significant impact, searching for the best quality of cure and care.

Percutaneous ultrasound-guided radiofrequency thermal ablation of malignant osteolyses.

Metastases are the most common neoplastic pathology involving the skeletal system. The hallmark of skeletal metastases is pain that often compromises the patient's quality of life. Radiotherapy, surgery and chemotherapy are the cornerstones of the treatment, but these techniques are not completely effective. Radiofrequency thermal ablation (RFA) may offer an alternative to conventional therapies for pain control. At present, the main field of application of RFA is the treatment of primary or secondary tumors of the liver but, recently, the technique has been effectively used to treat various other tumors in organs such as the prostate, kidney, lung, brain, pancreas and breast and to control pain caused by osteoid osteomas. Five patients with six painful bone metastases underwent RFA. The patients were three women and two men, aged 40-77 years (mean: 63.4). The radiofrequency system consists of an insulated 18-gauge needle electrode attached to a 500-kHz RF generator (Radionics, Burlington, Mass, USA). Four of our five patients rapidly obtained pain relief. One patient was completely pain free within 48 hours of the procedure and the control of pain persisted for 88 weeks. Another three patients obtained at least fifty percent pain reduction that lasted, on average, 12 weeks. Our preliminary results confirm that ultrasound-guided RFA is a simple and safe technique for treating painful superficial bone metastases.