Effectiveness of cervical spinal cord stimulation for the management of chronic pain.

INTRODUCTION: Scientific evidence supports spinal cord stimulation (SCS) as a cost-effective treatment option that, for many disease states, should be employed earlier in the treatment continuum. Reimbursement for SCS in the cervical spine has recently been challenged based on supposed lack of clinical literature. To refute this assumption, we analyzed data from an international registry to support the use of cervical SCS. MATERIALS AND METHODS: The following outcomes were collected as part of an institutional review board-approved, prospective, multicenter, international registry: pain relief, Pain Disability Index (PDI) score, quality of life (QoL), and satisfaction at 3, 6, and 12 months post-implantation. Descriptive statistics are provided for all measures. Changes from baseline in PDI scores were analyzed using Tukey's pairwise comparisons. RESULTS: Thirty-eight patients underwent implantation of SCS leads in the cervical spine at 16 study sites in the United States and 3 international study sites. Direct patient report of percentage of pain relief was 54.2%, 60.2%, and 66.8% at 3, 6, and 12 months post-implantation, respectively. Pain relief was categorized as excellent/good by 61.6% of patients at 3 months, with similar results observed at 6 and 12 months. PDI scores were significantly reduced at all time points. At 3 months post-implantation, 92.4% of patients indicated they were very satisfied/satisfied with the SCS device. No patients indicated that they were dissatisfied. Overall QoL was reported as improved/greatly improved by 73.1% of patients at 3 months. Similar results for QoL and satisfaction were reported at 6 and 12 months. CONCLUSION: The results suggest that the use of SCS in the cervical spine is a medically effective method of pain management that satisfies and improves the QoL of most patients. The use of SCS can reduce the high cost of direct medical treatment of pain, as well as increasing the productivity of patients, and therefore should be reimbursed in appropriately selected patients.

Oral versus topical Ibuprofen for chronic knee pain: a prospective randomized pilot study.

BACKGROUND: Topical ibuprofen provides an alternative treatment to oral ibuprofen for the treatment of chronic knee pain. OBJECTIVE: To compare the efficacy of topical versus oral ibuprofen in chronic knee pain treatment. STUDY DESIGN: Prospective, randomized, unblinded pilot study. SETTING: A private pain management practice. METHODS: Twenty patients received either ibuprofen tablets 3 times daily (2400 mg total) or 4% topical gel 4 times daily (320 mg total) for 2 weeks. Subjects completed the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index, the Medical Outcomes Study 12-Item Short Form (SF-12v2) Health Survey, and a satisfaction questionnaire. RESULTS: Comparison of WOMAC and SF-12v2 mean changes from baseline showed no differences between groups. Patient satisfaction and study treatment convenience were rated equivalently between groups. Within the topical group, significant improvements (P < 0.05) were experienced in the mean differences of WOMAC Pain scores from baseline to 2 weeks (-82.6, -158.3 to -6.8), WOMAC Stiffness scores from baseline to one week (-25.3, -50.0 to -0.6) and baseline to 2 weeks (-47.8, -95.7 to 0.1), WOMAC Physical Function scores from baseline to one week (-175.9, -348.6 to -3.2) and baseline to 2 weeks (-312.1, -580.5 to -43.7), and patient satisfaction scores from baseline to one week and baseline to 2 weeks. Within the oral group, significant improvements (P < 0.05) were experienced in mean differences of WOMAC Physical Function from baseline to one week (-342.6, -638.1 to -47.1) and baseline to 2 weeks (-323.2, -637.1 to -9.2). LIMITATIONS: As this was a preliminary investigation, the sample size of 20 subjects is a limitation in this study. CONCLUSION: Treatment of chronic knee pain with topical ibuprofen provided comparable clinical efficacy and patient satisfaction as oral ibuprofen in this pilot study.

Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids.

BACKGROUND CONTEXT: Selective transforaminal epidural injections are frequently employed in the treatment of pain emanating from the spine. Complication rates are typically low and include paresthesia, hematoma, epidural abscess, meningitis, arachnoiditis and inadvertent subdural or subarachnoid injection. Persistent paraplegia after lumbar transforaminal block has been recently reported. Undetected intra-arterial injection has been implicated as a possible cause. PURPOSE: We present a case of massive cerebellar infarction after uneventful selective cervical transforaminal block. Intra-arterial injection of corticosteroid is implicated with focus on particulate size of compound versus blood vessel dimension. Light microscopic data are presented to confirm the potential for embolic vascular occlusion. STUDY DESIGN/SETTING: Case report; light microscopic data. PATIENT SAMPLE: A patient underwent selective transforaminal block on the right at the C5-C6 level. There was C5-C6 disc herniation documented by magnetic resonance imaging and C6 radiculopathy by electromyographic studies. OUTCOME MEASURES: Patient follow-up from medical office records. METHODS: Needle placement at the C5-C6 foramen on the right was confirmed by biplanar fluoroscopy and injection of contrast medium. Frequent heme-negative aspirations were documented. RESULTS: In this patient, quadriparesis ensued shortly after injection of corticosteroid solution. The patient was admitted to the neurosurgical intensive care unit and ultimately underwent brainstem decompressive surgery when focal neurologic deficits became evident. Working diagnosis was massive cerebellar infarct. Light microscopic data are presented to illustrate particulate size in corticosteroid solutions and potential for embolic microvascular occlusion. Corticosteroid suspensions (and to a lesser extent solutions) contain large particles capable of occluding metarterioles and arterioles. CONCLUSIONS: We present a case of quadriparesis and brainstem herniation after selective cervical transforaminal block. We propose a potential role for corticosteroid particulate embolus during unintended intra-arterial injection as a potential mechanism.