Risk of Suicide in Patients With Major Depressive Disorder and Comorbid Chronic Pain Disorder: An Insight From National Inpatient Sample Data.

BACKGROUND: Approximately 17.3 million adults in the United States have had a minimum of one major depressive episode. Comorbidity of depression and pain can affect individuals of any age, but is more prevalent in the elderly affecting up to 13% of people in the elderly population. Given that depression and suicidal ideation (SI) pose a considerable burden resulting in enormous suffering, there is a need to understand the factors of the relationship between chronic pain (CP), depression, and SI. OBJECTIVES: Our primary objective in this study was to compare suicidality (SI/attempt [SA]) between patients with major depressive disorder (MDD) and CP and a matched control group. The secondary objective was to compare length of stay, total hospital costs, and discharge disposition in these populations. STUDY DESIGN: The National Inpatient Sample (NIS) dataset developed by the Healthcare Cost and Utilization Project was used for this study. The NIS is a database of hospital inpatient stays derived from billing data submitted by hospitals to statewide data organizations across the United States. We obtained patient records from the NIS dataset for the years 2006 to 2017. All data were de-identified so Institutional Review Board approval was waived. METHODS: We used mean and standard error to describe continuous data and counts (percentage) to describe categorical data. Categorical data were compared using Rao-Scott adjusted chi-square tests and continuous data were compared using Student's t tests. Matching was performed using propensity scores in random order with a caliper size of 0.001. To assess predictors associated with suicidality, logistic regression analysis was performed. RESULTS: A total of 393,481 patients having MDD with CP (MDD+CP) were included in the analysis. The mean age was 49.4 years, and 54.9% of patients were women. Overall, rate of composite outcome of SI/SA was more prevalent in MDD+CP group (51% vs 41%, P < 0.001). Rate of SI was 48% vs 39% (P < 0.001) in the MDD+CP and MDD without CP (MDD-CP) groups, respectively. MDD+CP was one of the strongest predictors of suicidality, responsible for 48% more risk of SI/SA compared to MDD-CP group. In comparison to non-Whites, the rate of suicidality was 7.5% less in White population. Alcohol abuse and substance abuse were associated with 17% and 8% greater risk of SI/SA, respectively. For women, the odds of having SI/SA was 1.20 greater compared to men. LIMITATIONS: No information was available on the causal relationship between MDD+CP disorder and SI/SA. Retrospective studies are susceptible to recognition, reporting, and coding bias. There is no information available on medications use or the duration and severity of CP and bipolar disorder, which can all be confounding factors. CONCLUSIONS: Psychiatrists and other physicians must be cognizant of the presence of CP and the risk of suicide, especially when patients present with depressive symptoms. The treatment plan for this patient population should include routine screening for pain symptoms and risk assessment for SI.

Association of Spinal Cord Stimulator Implantation With Persistent Opioid Use in Patients With Postlaminectomy Syndrome.

Importance: The results of studies evaluating spinal cord stimulation (SCS) for postlaminectomy syndrome (PLS) have yielded mixed results. This has led to an increased emphasis on objective outcome measures such as opioid prescribing. Objective: To determine the association between SCS and long-term opioid therapy (LOT) for PLS. Design, Setting, and Participants: In this cohort study, adults with PLS were identified using the TriNetx Diamond Network and separated based on whether they underwent SCS. Patients were stratified according to baseline opioid use (opioid-naive or receiving LOT) and subsequent opioid therapy over the 12-month period ranging from 3 to 15 months post-SCS implantation or post-PLS index date. Statistical analysis was performed from June to December 2021. Exposure: SCS. Main Outcomes and Measures: The main outcome was cessation of opioid use among patients receiving LOT or abstinence from opioids among opioid-naive patients. Opioid-naive patients were defined as those receiving at most 2 opioid prescriptions per year, and patients on LOT were those receiving at least 6 opioid prescriptions per year. Results: Among 552 937 eligible patients treated between December 2015 and May 2021, 26 179 with PLS received an SCS implant. The median (IQR) patient age was 60 (51-69) years; 305 802 patients (55.3%) were female. Among those reporting racial identify (37.0% [204 758 patients]), 9.3% (18 971 patients) were African American, 0.3% (648 patients) were Asian, and 90.4% (185 139 patients) were White. Compared with those who did not receive an SCS, individuals who received an SCS were more likely to be using opioids preimplantation (mean [SD] prescriptions: 4.3 [8.5] vs 4.1 [9.3]; P < .001) but less likely to be using opioids after SCS implantation (mean [SD] prescriptions: 3.8 [8.2] vs 4.0 [9.4]; P = .006). In the 12-month study period, similar proportions in the SCS and no-SCS groups receiving baseline LOT remained on LOT (70.3% [n = 74 585] vs 69.2% [n = 3882], respectively; P = .10). In opioid-naive patients, SCS was associated with a small decreased likelihood of patients subsequently receiving LOT (7.6% vs 7.0%; difference, -0.6% [95% CI, -1.0% to -0.2%]; P = .003). In multivariable analysis, SCS was associated with an increased likelihood of not being on opioids in both opioid-naive (adjusted odds ratio [OR], 0.90 [95% CI, 0.85-0.96]; P < .001) and LOT patients (adjusted OR, 0.93 [95% CI, 0.88-0.99]; P = .02). White patients were significantly more likely to be diagnosed with PLS (ie, underwent surgery) (90.4% vs 85.2%; difference, 5.2% [95% CI, 5.1%-5.4%]; P < .001) and receive an SCS (93.7% vs 90.3%; difference, 3.4% [95% CI, 2.9% to 4.0%]; P < .001) than patients of other racial identities. Conclusions and Relevance: These findings suggest that under real-life conditions, SCS was associated with small, clinically questionable associations with opioid discontinuation and not starting opioids in the context of PLS.

Sensory Stimulation Threshold: A Viable Tool to Improve the Outcome of Lumbar Facet Radiofrequency Denervation?

BACKGROUND: Sensory stimulation threshold (SST) has been used as a surrogate marker to target a nerve branch for radiofrequency (RF) denervation; however, the validity of SST as a prognostic marker is still under debate. OBJECTIVE: To assess whether lower SST values correlate with better outcomes of radiofrequency denervation for facetogenic low back pain. DESIGN: Prospective cohort study. PATIENTS: Sixty-seven patients who underwent radiofrequency denervation for low back pain. METHODS: Correlations, between the average percentage of pain relief from diagnostic medial branch block (MBB) and RF denervation procedure outcome, and between SST and RF denervation procedure outcome, were analyzed using Spearman correlation coefficient (rs ). Wilcoxon rank sum test was performed to assess whether magnitude and duration of pain relief following RF denervation differed by the levels of SST (<0.5 and ≥0.5) or pain relief (<80% and ≥80%) from diagnostic MBB. RESULTS: There was a positive correlation between pain relief after diagnostic MBB and pain relief 2 weeks after denervation (rs 0.31, 95% CI 0.08 to 0.51, p < 0.01), but not between pain relief after MBB and pain relief 6 months after denervation, nor pain relief duration after denervation. There was a negative correlation between SST and pain relief 6 months after denervation (rs -0.41, 95% CI -0.59 to -0.18, p < 0.001). There was also a negative correlation between SST and pain relief duration after denervation (rs -0.33, 95% CI -0.53 to -0.09, p < 0.01). CONCLUSION: SST is a viable measurement with which to guide needle placement during RF denervation for lumbar facet pain, and enhances pain relief outcomes.

Are Psychotropic Medications Effective in Chronic Pain Management in Children and Adolescents? A Meta-Analysis of Randomized Control Trials.

OBJECTIVE: Data defining and subsequently guiding the use of psychotropic medications in children and adolescents is sparse. We conducted a meta-analysis of randomized control trials to examine the effectiveness of psychotropic medications in children and adolescents with chronic pain. METHODS: We conducted a comprehensive literature search from published studies, and annual scientific sessions of psychiatry conferences. We identified double-blind, randomized control trials (RCTs) in which psychotropic medications were compared to placebo. Data was collected for the total number of patients, baseline characteristics, and changes in pain score. Meta-analysis was performed using a random effect model evaluating average change in pain score and the number of patients with a reduction in pain score for both groups. Pooled data are expressed as standardized mean differences (SMD) and odds ratios (OR) with 95% confidence intervals (CI). RESULTS: We found 5 studies that included amitriptyline (n=2), citalopram (n=1), buspirone (n=1) and duloxetine (n=1). In the pooled analysis for the difference in the average change in pain score, 4 RCTs with 395 patients were included. After 12-13 weeks of therapy, reductions in pain score were significantly greater in the psychotropic drug group as compared to placebo (SMD: -0.77, 95% CI -1.54, 0.0001, p= 0.05). For the analysis on the number of patients with a reduction in pain, data were available for 445 patients (224-medication group, 221-placebo group). More patients in the psychotropic drug group experienced a meaningful reduction in pain score at 12-13 weeks of therapy compared to placebo (OR 1.66, 95% CI 1.08-2.54, p= 0.02). CONCLUSION: The results of this meta-analysis demonstrate significant analgesic efficacy of psychotropic medications in the management of children with chronic pain. This review is limited by the small number of studies included for analysis. There is a pressing need for more robust clinical trials to further investigate these promising findings.

Clinical and technical factors associated with knee radiofrequency ablation outcomes: a multicenter analysis.

BACKGROUND: There has been a surge in interest in radiofrequency ablation (RFA) of the genicular nerves over the past decade, with wide variability in selection, technique and outcomes. The aim of this study is to determine factors associated with treatment outcome. METHODS: We retrospectively evaluated the effect of 23 demographic, clinical and technical variables on outcomes in 265 patients who underwent genicular nerve RFA for knee pain at 2 civilian and 1 military hospital. A primary outcome was designated as a > 30% decrease in average knee pain score lasting at least 3 months without cointerventions. RESULTS: The overall rate of a positive response was 61.1% (95% CI 55.2% to 67.0%). In univariable analysis, larger electrode size (p=0.01), repeated lesions (p=0.02), having>80% pain relief during the prognostic block (p=0.02), not being on opioids (p=0.04), having no coexisting psychiatric condition (p=0.02), having a lower baseline pain score (p=0.01) and having >3 nerves targeted (p=0.02) were associated with a positive outcome. In multivariate logistic analysis, being obese (OR 3.68, 95% CI 1.66 to 8.19, p=0.001), not using opioids (OR 0.35, 95% CI 0.16 to 0.77, p=0.009), not being depressed (OR 0.29, 95% CI 0.10 to 0.82, p=0.02), use of cooled RFA (OR 3.88, 95% CI 1.63 to 9.23, p=0.002) and performing multiple lesions at each neural target (OR 15.88, 95% CI 4.24 to 59.50, p<0.001) were associated with positive outcome. CONCLUSIONS: We identified multiple clinical and technical factors associated with treatment outcome, which should be considered when selecting patients for RFA treatment and in the design of clinical trials.

Peri- and Postoperative Pain Management in Multiple Ligament Knee Surgery in the Hospital and Ambulatory Surgery Center Setting.

The multiligament knee injury presents as a complex injury pattern that has substantial potential to cause long-term disability. Patients who sustain this injury pattern experience significant pain not only immediately following injury but also throughout the perioperative and postoperative period. Treating pain with major orthopaedic procedures is challenging but technical success of a surgical repair becomes trivial when pain is not effectively managed. This article will (1) provide an outline of the types of pain most often sustained in the multiligament knee injury, (2) outline the phases of pain management for this injury, and (3) provide an overview of persistent postoperative pain. The principles of multimodal analgesia in combination with effective regional anesthesia and attentive intraoperative management can position patients for successful rehabilitation and recovery.

Permanent Paraplegia as a Complication of Injection of Contrast Media at L2-L3 Vertebral Level.

BACKGROUND: The lumbar intrathecal (subarachnoid) space is accessed for both therapeutic and diagnostic purposes. Occasionally, the needle may unintentionally enter the intrathecal space during lumbar interlaminar epidural steroid injections (LESIs)-one of the most commonly performed medical procedures in the United States. Ordinarily, this merely constitutes a minor complication or even a desired placement (in the case of some diagnostic procedures). However, some patients have a rare condition wherein the spinal cord terminates below the L2 vertebral level (tethered cord). In such cases, injections administered at the lumbar level may potentially result in spinal cord damage and irreversible paraplegia if the physician performing the intervention does not recognize the intramedullary position of the needle. OBJECTIVE: The aim of this study is to describe and analyze an unintentional L2-L3 injection of contrast medium into a tethered spinal cord. Many physicians may consider lumbar injections "safe" because the spinal cord usually terminates at or above the L2 vertebral level. However, complacency stemming from this false impression of safety contributes to nonadherence to practice guidelines, which may lead to catastrophic neurological complications. Presented here is the first published occurrence of paraplegia that resulted from contrast medium injection into the spinal cord during a myelography study performed below the L2 vertebral level. CONCLUSIONS: Disregard of the procedural guidelines by the physicians performing an elective diagnostic intervention may cause devastating neurological complications. The described casualty occurred because of failure to review previous imaging studies, injection of the contrast medium despite unsuccessful attempts to aspirate cerebrospinal fluid, and an unwillingness to terminate the procedure immediately when the patient reported an unusual sensation in both of his lower extremities. Consequently, we suggest that not only for cervical and thoracic but also for lumbar interlaminar ESIs, previous imaging studies should be reviewed before the injection.

Cervical Epidural Depth: Correlation Between Cervical MRI Measurements of the Skin-to-Cervical Epidural Space and the Actual Needle Depth During Interlaminar Cervical Epidural Injections.

Objective: The purpose of this study was to assess the correlation between skin-to-epidural space depth, as measured on cervical magnetic resonance imaging (MRI), and actual needle depth, as measured by Tuohy needle markings during cervical epidural steroid injections. Methods: We conducted a retrospective review of cervical MRI images to determine estimated depth from skin to epidural space. Of the 121 reviewed patients who underwent cervical epidural steroid injections, 81 met inclusion criteria and were retained for data analysis. Results: At the C6-C7 level, the estimated needle depth according to MRI images was 6.03 ± 1.15 cm (mean ± SD) and the actual needle depth was 5.62 ± 0.77 cm. At the C7-T1 level, the estimated needle depth based on MRI images was 5.90 ± 1.05 cm and the actual needle depth was 5.73 ± 0.98 cm. At both C6-C7 and C7-T1, MRI depth (P < 0.009, P < 0.001) and body mass index (P < 0.001, P < 0.002) were significantly associated with actual depth. Conclusions: Estimates of needle depth made with MRI were consistently slightly deeper than the actual loss-of-resistance needle depth, indicating that the provider should employ caution when using MRI predictive depths. Information garnered from preprocedure MRIs can be used to improve the safety of cervical epidural steroid injection procedures.

Does pain score in response to a standardized subcutaneous local anesthetic injection predict epidural steroid injection outcomes in patients with lumbosacral radiculopathy? A prospective correlational study.

OBJECTIVE: Epidural steroid injections (ESI) are the most commonly performed pain procedures. Despite numerous studies, controversy continues to surround their effectiveness. The purpose of this study is to determine whether a standard, clinical local anesthetic injection can predict outcomes for ESI. STUDY DESIGN: In this multicenter study, 103 patients received two ESI 2 weeks apart. Prior to their first injection, subjects rated the pain intensity of a standardized subcutaneous (SQ) injection of lidocaine prior to the full dose. Numerical rating scale pain scores were correlated with leg and back pain relief, and functional improvement, through 3-month follow-up. OUTCOME MEASURES: A composite successful outcome was predetermined to be a ≥2-point decrease in leg pain score, coupled with a positive global perceived effect. RESULTS: A small but significant relationship was found between SQ pain score and reduction in leg (r = -0.21, 95% CI -0.38 to -0.04; P = 0.03) and back pain (r = -0.22, 95% CI -0.36 to -0.07; P = 0.03). Subjects with a positive outcome at 1 month had a mean SQ pain score of 2.5 (SD 1.9) vs 4.1 (SD 2.7) in those with a negative outcome (P = 0.04). Subjects with SQ pain scores <4/10 had lower leg and back pain scores than those with pain scores ≥4 at 1-month (mean 3.2, SD 2.6 vs 5.1, SD 2.7 for leg, P < 0.01; mean 3.7, SD 2.6 vs 5.0, SD 3.0 for back, P = 0.02) and 3-month (mean 3.8, SD 2.7 vs 5.2, SD 3.1 for leg, P = 0.01; mean 4.0, SD 2.6 vs 4.9, SD 3.1 for back; P = 0.14) follow-up. CONCLUSIONS: The results of this study found a weak positive correlation between SQ pain scores and treatment results. Further research should consider whether pain perception in conjunction with other variables might prove to be a reliable predictor for ESI and other procedural outcomes.

Effect of MRI on treatment results or decision making in patients with lumbosacral radiculopathy referred for epidural steroid injections: a multicenter, randomized controlled trial.

BACKGROUND: Studies have shown that radiologic imaging does not improve outcomes in most patients with back pain, though guidelines endorse it before epidural steroid injections (ESIs). The objective of this study was to determine whether magnetic resonance imaging (MRI) improves outcomes or affects decision making in patients with lumbosacral radiculopathy referred for ESI. METHODS: In this multicenter randomized study, the treating physician in group 1 patients was blinded to the MRI results, while the physician for group 2 patients decided on treatment after reviewing the MRI findings. In group 1 subjects, an independent physician proposed a treatment plan after reviewing the MRI, which was compared with the treatment the patient received. RESULTS: Slightly lower leg pain scores were noted in the group 2 at 1 month compared with MRI-blinded patients in group 1 (mean scores, 3.6 vs 4.4) (P = .12). No differences were observed in pain scores or function at 3 months. Overall, the proportion of patients who experienced a positive outcome was similar at all time points (35.4% at 3 months in group 1 vs 40.7% in group 2). Among subjects in group 1 who received a different injection than that proposed by the independent physician, scores for both leg pain (4.8 vs 2.4) (P = .01) and function (38.7 vs 28.2) (P = .04) were inferior to patients whose injection correlated with imaging. Collectively, 6.8% of patients did not (group 2) or would not have (group 1) received an ESI after the MRI was reviewed. CONCLUSION: Magnetic resonance imaging does not improve outcomes in patients who are clinical candidates for ESI and has only a minor effect on decision making. Trial Registration clinicaltrials.gov Identifier: NCT00826124.

Current pharmacologic approaches to treating neuropathic pain.

Most neuropathic analgesic medications have been introduced initially for other medical conditions. Anticonvulsants, local anesthetics, and antidepressants later were found to be effective in the treatment of neuropathic pain. Carbamazepine and the newer anticonvulsants such as gabapentin, lamotrigine, topiramate, and oxcarbazepine are being used as first-line or adjunctive therapy. The newer agents have less potential for drug interactions and a more favorable side-effect profile. Lidocaine administered systemically or topically is useful for some peripheral and central neuropathic pain conditions. The tricyclic antidepressants amitriptyline, nortriptyline, and desipramine have been shown to be effective for the management of neuropathic pain, independent of their antidepressant property. All of the available analgesics have considerable side effects, which necessitate careful titration. Future drug research may focus on developing medications specifically for neuropathic pain. These designer agents may have more desirable action without the unwanted side effects.

The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns.

STUDY DESIGN: A multicenter, retrospective analysis of cervical epidurograms. OBJECTIVES: To determine the effectiveness of the loss of resistance (LOR) technique in identifying the cervical epidural space. To delineate the pattern of epidural contrast spread during cervical epidural steroid injections. BACKGROUND: Previous studies have shown that if performed without fluoroscopy, the LOR technique can result in inaccurate needle placement in up to 30% of lumbar epidural steroid injections. To date, no study has examined accuracy of LOR technique and pattern of radiographic contrast spread in cervical epidural levels. METHODS: Epidurograms of 38 cervical epidural steroid injections in 31 patients were reviewed. The number of LOR attempts and pattern of contrast spread was analyzed. The effects of age, gender, MRI results, previous cervical laminectomy, and the physician's level of training were correlated with results. RESULTS: The authors found a 53% rate of false LOR during the first attempt to enter the epidural space. Unilateral epidural contrast spread was found in 51% and ventral epidural spread was found in 28% of cases. The average number of cervical vertebral levels covered with 2 mL of contrast was 3.14, with significantly wider spread noted in those patients who had not undergone previous cervical laminectomy. Other variables did not influence the accuracy of needle placement and pattern of epidural contrast spread. CONCLUSIONS: The loss of resistance technique may not be an adequate method for ensuring accurate needle placement in blindly performed cervical epidural injections. The use of epidurography can improve the accuracy of needle placement and medication delivery to targeted areas of pathology.