Outpatient percutaneous and endoscopic surgery in interventional pain management.

The evolution of interventional pain management from inception through the present is examined. Increasing demand from patients, referring physicians and third party payors for proven interventions which provide long-term functional relief of symptoms or primary correction of common spinal pain syndromes is discussed. The role of current palliative therapy as compared to the proven clinical validity of outpatient percutaneous and endoscopic spinal surgical techniques is reviewed. Practitioners are encouraged to transition from the use of spinal injections and narcotics of unproven benefit to percutaneous and endoscopic spinal intervention as primary therapy of herniated lumbar disc, discogenic spinal pain, and lumbar spinal stenosis in appropriately selected patients. SD, Expenditures and health status among adults with back and neck problems.

Percutaneous laser disc decompression for the treatment of discogenic lumbar pain and sciatica: a preliminary report with 3-month follow-up in a general pain clinic population.

OBJECTIVE: Our aim was to evaluate the short-term efficacy of percutaneous laser disc decompression (PLDD) for the treatment of lumbar discogenic pain and sciatica. BACKGROUND DATA: PLDD has been reported to be a safe, effective, minimally invasive treatment option for patients with lumbar spinal pain associated with herniated disc, as an alternative to open spinal surgery. The present study was designed to evaluate the effectiveness of the procedure in patients attending a comprehensive interventional pain management clinic. MATERIALS AND METHODS: Thirty-two consecutive patients with discogenic lumbar spinal pain with or without sciatica were identified by MRI scanning and discography. Patients with symptoms attributable to a herniated or degenerated lumbar disc were treated with PLDD utilizing the neodymium-YAG laser. The primary endpoint of the study was the standardized symptom score on the American Academy of Orthopedic Surgery (AAOS) Outcomes Assessment Questionnaire for neurogenic and back pain symptoms at pre-treatment baseline, and at 3 months after laser treatment. RESULTS: Of the 30 patients with sciatica at baseline, 24 (80%) reported improvement in sciatica symptoms at three months, with a mean improvement of 68% (p = 0.001 from baseline values). Of the 32 patients with discogenic pain at baseline, 24 (75%) reported improvement at 3 months, with a mean improvement of 44% (p = 0.0005 from baseline values). No instances of infection, nerve injury, or clinically significant bleeding were identified during the 3-month follow-up period. Similar results were also seen in seven patients undergoing PLDD for residual back pain and sciatica following open spinal surgery. Sixty-three percent of patients complained of new-onset or worsening of mechanical low back pain following PLDD, thought to be related to the procedure. Back pain was considered mild to moderate and was self-limited, or responsive to analgesics and lumbar facet block with or without lumbar rhizotemy. CONCLUSION: PLDD with the neodymium-YAG laser is a safe and effective treatment for discogenic lumbar pain and sciatica during a preliminary 3-month follow-up period in a general pain management practice setting. Post-procedural mechanical low back pain is common and easily treated without sequellae. No instances of infection, neural injury, or other serious complications were observed.

Catheter-associated masses in patients receiving intrathecal analgesic therapy.

UNLABELLED: A cohort of seven patients receiving intrathecal analgesic drug therapy for chronic intractable pain underwent radiocontrast myelography and computed tomography (CT) scanning to screen for catheter-associated intrathecal masses. Three of seven patients examined had intraspinal masses associated with the tip of the drug infusion catheter after a total of 118 mo of therapy. The index case presented with exacerbation of neuropathic pain and paralysis of the left lower extremity. The two additional cases detected by CT myelography were asymptomatic at the time the catheter-associated mass was assessed. The mean duration of therapy before diagnosis of the catheter-associated mass was 19.6 mo, with a range of 16-25 mo. An intergroup comparison of demographic and treatment variables between patients, with and without catheter-associated masses, demonstrated that patients with masses were younger and were receiving a larger morphine dose than patients without masses. The differences were statistically significant (P = 0.05). In one patient with an asymptomatic catheter-associated intrathecal mass, regression of the mass was observed after cessation of therapy. In a second asymptomatic patient, the mass remained stable over 1 yr of continued treatment after substitution of hydromorphone for morphine without interruption of therapy. Neither asymptomatic patient has subsequently developed additional neurologic findings or injury after detection of occult catheter-associated intrathecal masses and clinical intervention. We suggest that all patients receiving long-term intrathecal analgesia should undergo periodic radiographic surveillance to further define their risk of developing occult catheter-associated masses and to allow intervention before neurologic injury can develop. IMPLICATIONS: Catheter-associated intrathecal masses were detected in three of seven patients receiving long-term intrathecal analgesia. In the two asymptomatic patients, timely clinical intervention was associated with the avoidance of subsequent neurologic injury and spontaneous resolution of one of the occult masses.