Epidural spread of surgical site infection from spinal cord stimulation trial.

We present a case of deep surgical site infection (SSI) at a spinal cord stimulator (SCS) trial implantation site, resulting from an allergic reaction to an unknown agent. A 38-year-old female with complex regional pain syndrome began an SCS trial, noting 100% pain relief for 5 days. Fluid drainage from the surgical site was reported on POD6 and trial leads were removed the following day. The patient was hospitalized with sepsis. Blood cultures revealed Staphylococcus aureus. MRIs showed skin breakdown and cellulitis of the paraspinal musculature extending into the epidural space. The patient was maintained with antibiotics and rigorous wound care for 9 days and the surgical site infection resolved. The patient proceeded to SCS implantation, and reported good pain relief with the implanted device.

This case report describes the treatment of an infection developed during a spinal cord stimulator (SCS) trial period. SCS are medical devices used to treat pain, they work by applying electrical current to the areas of the spinal cord that cause patients' pain. Before patients get an SCS device implanted, they often undergo a trial period first. During a trial, the stimulator device stays outside the body, and only the wires carrying electricity to the spinal cord are implanted. Typically, SCS trial and implantation procedures are safe and result in effective pain relief. However, infections are a dangerous potential complication that can result from these procedures. In our case, the patient developed an infection during an SCS trial period, likely resulting from an allergic reaction to their surgical dressings. The infection traveled down the wires and nearly reached the spinal cord. Since the infection was quickly identified and managed, devastating complications were avoided. The patient was able to get a permanent SCS after the infection was resolved, and had effective pain relief. Our report emphasizes the importance of using strict infection prevention techniques, and monitoring patients for signs of infection throughout SCS trials.

Outcomes After Injection-Based Therapy: A Pain Outcomes Questionnaire for Veterans Univariate Analysis.

Background: The Pain Outcomes Questionnaire-For Veterans (POQ-VA) was developed within the Veterans Health Administration (VHA) as a brief but psychometrically sound pain outcomes instrument that assesses key domains. In routine clinical practice, it is valid and reliable for evaluating effectiveness of treatment of chronic noncancer pain in veterans. We hypothesized that POQ-VA scores would improve across multiple domains in the veteran population following injection-based interventional treatment for chronic pain. Methods: We aggregated all available POQ-VA reports from veterans who underwent ≥ 1 interventional pain procedures between April 1, 2009 and April 1, 2019. Patients were included who had pre- and posttreatment POQ-VA results separated by ≤ 6 months (N = 112). A paired-samples t test was used to compare means, standard deviations, and ranges for each POQ-VA domain. Individual question responses were analyzed using a nonparametric Wilcoxon matched-pairs signed-rank test. Results: All POQ-VA domains showed a statistically significant decrease posttreatment (P ≤ .03). Directionally, the responses to 17 of 20 individual POQ-VA questions reflect a small but statistically significant positive treatment response (P < .04). Conclusions: Most veterans undergoing injection therapy for chronic pain had statistically significant improvements in POQ-VA measures within a 6-month period. To conduct more rigorous, multivariate studies, continued and widespread use of the POQ-VA instrument is warranted.

Receipt of Physical Therapy and Chiropractic Care by Adults Diagnosed with Chronic Pain: Analysis of the 2016-2018 Rhode Island All Payer Claims Database.

OBJECTIVE: To examine trends and factors associated with physical therapy (PT) and chiropractic care use among Rhode Islanders with private or publicly-funded health insurance who were diagnosed with chronic pain from 2016-2018. METHODS: We measured monthly PT and chiropractic care use from the RI All Payer Claims Database, and conducted logistic regression to identify factors associated with utilization. RESULTS: There were 284,942 unique adults with chronic pain representing over one-quarter of insured persons in the state. Chiropractic care use remained unchanged but was more prevalent (7.2%) than PT whose use increased minimally from 4.0% (2016) to 4.5% (2018). Traditional Medicare or Medicaid enrollment was associated with lower odds of receiving PT and chiropractic care than in private plans. CONCLUSIONS: PT and chiropractic care use varied across payers; however, there were little to no changes in their use over time despite clinical guidelines that encourage non-pharmacologic options to manage chronic pain.

Using Radiology images to characterize an angle of insertion for S1/S2 and SI joint injections: A retrospective observational study.

Objective: Sacroiliac (SI) joint, S1 and S2 nerve root pathology are well documented in literature as common etiologies for low back pain. Evidence demonstrating starting angle of needle insertion during S1/S2 transforaminal and SI joint injections are lacking. Using computerized tomography (CT) radiography of the lumbosacral spine, this retrospective observational study seeks to characterize a starting angle of needle insertion at the sacral spine. Methods: This was a single-centered, retrospective observational study performed on adult cancer patients who had CT radiography of their lumbosacral spine, without significant sacral pathology, at our hospital from January 2016 and May 2021. For each patient, we determined the anatomical location of where the S1/S2 neural foramen and SI joint widens up. Using the annotation tools available in EIM image viewer, a maximum level and minimum level of insertion was recorded in order to calculate the average angle of insertion needed for procedural performance. Results: Through the analysis of 64 patients, average angle of insertion was 25° â€‹± â€‹1.36 for S1, 34° â€‹± â€‹1.93 for S2, and 33° â€‹± â€‹1.95 for SI injections. There were no statistically significant differences in angles when stratified based on laterality, gender, age, and BMI. Conclusion: Average angle of insertion to target the S1, S2 neural foramen and SI joint are 25° ipsilateral oblique, 34° ipsilateral oblique, and 33° contralateral oblique respectively starting with a squared sacral endplate. To our knowledge, there are no studies in the current literature that have attempted to identify an entry angle to target these anatomical structures. Six key words: Chronic Pain, SI Joint Pain, Steroid Injection, S1 Transforaminal, S2 Transforaminal, Needle Placement.

An Evaluation of the Online Quality of Content of United States Accredited Pain Medicine Fellowship Training Programs.

BACKGROUND: Pain medicine fellowship applicants often seek information about programs from the Internet, which is becoming even more relevant with the transition to virtual interviews as a consequence of the global pandemic. Previous literature has revealed the significance of training program websites as part of the application process in other specialties. OBJECTIVES: The objective of this cross-sectional study was to evaluate the content, design, organization, and user friendliness by using a composite score to determine the quality of the pain medicine fellowship websites (PMFW). METHODS: Accredited pain medicine fellowship programs was queried from three databases for pain medicine education: (1) Electronic Residency Application Service (ERAS); (2) the Fellowship and Residency Electronic Interactive Database (FREIDA); and (3) the National Resident Matching Program (NRMP). Programs that appeared within one and/or more databases were eligible for study inclusion. PMFW were evaluated for the accessibility of recruitment and education content items. The quality of PMFW was determined as multifactorial composed of four dimensions: content, design, organization, and user friendliness. RESULTS: For program recruitment, PMFW contained an average of 12 ± 4.0 of 32 content items (38%) for fellowship programs: (1) 83% of fellowship programs specified the number of positions available for the 2021 Match; (2) 17% indicated alumni career placement; (3) 6.8% supplied interview dates; and (4) merely 4.9% detailed the selection process. For program education, PMFW contained an average of 7 ± 3.4 of 16 content items (44%): (1) 70% of programs provided a rotation schedule; (2) 49% detailed operative experiences; and (3) just 16% included simulation training. Regarding the quality based on content, design, organization, and user friendliness, the average PMFW was not "good" with only 1% of PMFW meeting "great" standards. A kappa value of 0.92 was calculated for inter-rater reliability. CONCLUSIONS: The web presence of pain medicine fellowship programs falls short of providing essential accessibility, content, design, organization, and user friendliness to allow applicants to adequately access information about program characteristics. There are ample opportunities to increase the effectiveness of PMFW to benefit training programs and to inform prospective applicants, especially given the rise of virtual applications and interviews.

An evaluation of impact factor bias of clinical trials published in pain journals.

BACKGROUND AND OBJECTIVE: Studies with nonsignificant results are less likely to be published or published in lower impact factor journals. To determine whether a similar phenomenon occurs in pain literature, we explored impact factor bias in peer-reviewed pain journals. METHODS: A PubMed search involving randomized controlled trials in pain journals during 2012 through 2018 was performed. The primary outcome was the publication impact factor. Exclusion criteria included commentaries, editorials, meta-analyses, reviews, and animal studies. The average impact factor for each journal was determined. The primary independent variable was a study with a positive outcome. RESULTS: Of the 9 journals evaluated, 1108 articles met our inclusion criteria and were included in our analysis. The quartiles for the impact factor for the journals included were 2.5, 2.9, and 3.6. A multivariate analysis identified sample size greater than 100, description of a sample size calculation, presence of a stated hypothesis, and presence of sponsorship funding as independent predictors of publication in a journal with greater impact factor. In contrast, positive results were not associated with publication in a greater impact factor journal, even when forced into the model, P = 0.49. CONCLUSIONS: After adjusting for study factors associated with publication, there is no evidence of impact factor bias within the pain literature. The lack of impact factor bias in the pain literature is a positive finding for the field and should benefit scientific development and the clinical care of patients.

Flip Your Perspective: Dextrocardia and its Effect on Monitoring and Management.

Dextrocardia is a rare congenital disorder characterized by an anatomically flipped heart that is positioned in the right instead of the left side of the thorax. Anatomical variants, such as this, are vital to be aware of as they can alter patient monitoring and management. In this case report, we describe a patient with dextrocardia whose anatomy affected intraoperative monitoring while undergoing a successful aortic valve replacement surgery.