Predicting spatio-temporal radiofrequency ablation temperature using deep neural networks.

Radiofrequency ablation (RFA) of the medial branch nerve is a widely used therapeutic intervention for facet joint pain. However, denervation of the multifidus muscle is an inevitable consequence of RFA. New ablation techniques with the potential to prevent muscle denervation can be designed using computational simulations. However, depending on the complexity of the model, they could be computationally expensive. As an alternative approach, deep neural networks (DNNs) can be used to predict tissue temperature during RFA procedure. The objective of this paper is to predict the tissue spatial and temporal temperature distributions during RFA using DNNs. First, finite element (FE) models with a range of distances between the probes were run to obtain the temperature readings. The measured temperatures were then used to train the DNNs that predict the spatio-temporal temperature distribution within the tissue. Finally, a separate data obtained from FE simulations were used to test the efficacy of the network. The results presented in this paper demonstrate that the network can achieve an error rate as low as 0.05%, accompanied by a 92% reduction in time compared to FE simulations. The approach proposed in this study will play a major role in the design of new RFA treatments for facet joint pain.

Abdominal Pain in Inflammatory Bowel Disease: An Evidence-Based, Multidisciplinary Review.

Abdominal pain is one of the most common and impactful symptoms associated with inflammatory bowel disease (IBD), including both Crohn's disease and ulcerative colitis. A great deal of research has been undertaken over the past several years to improve our understanding and to optimize management of this issue. Unfortunately, there is still significant confusion about the underlying pathophysiology of abdominal pain in these conditions and the evidence underlying treatment options in this context. There is also a relative paucity of comprehensive reviews on this topic, including those that simultaneously evaluate pharmacological and nonpharmacological therapeutic options. In this review, our multidisciplinary team examines evidence for various currently available medical, surgical, and other analgesic options to manage abdominal pain in IBD.

Treating Perioperative and Acute Pain in Patients on Buprenorphine: Narrative Literature Review and Practice Recommendations.

Opioid use disorder (OUD), a leading cause of morbidity and mortality in the USA, can be effectively treated with buprenorphine. However, the same pharmacologic properties (e.g., high affinity, partial agonism, long half-life) that make it ideal as a treatment for OUD often cause concern among clinicians that buprenorphine will prevent effective management of acute pain with full agonist opioid analgesics. Because of this concern, many patients are asked to stop buprenorphine preoperatively or at the onset of acute pain, placing them at high risk for both relapse and a difficult transition back to buprenorphine after acute pain has resolved. The purpose of this review is to summarize the existing literature for acute pain and perioperative management in patients treated with buprenorphine for OUD and to provide practical management recommendations for generalist practitioners based on evidence and clinical experience. In short, evidence suggests that sufficient analgesia can be achieved with maintenance of buprenorphine and use of both opioid and non-opioid analgesic options for breakthrough pain. We recommend that clinicians (1) continue buprenorphine in the perioperative or acute pain period for patients with OUD; (2) use a multi-modal analgesic approach; (3) pay attention to care coordination and discharge planning when making an analgesic plan for patients with OUD treated with buprenorphine; and (4) use an individualized approach founded upon shared decision-making. Clinical examples involving mild and severe pain are discussed to highlight important management principles.

Acupuncture in the Management of Medication Overuse and Drug-induced Aseptic Meningitis Headache: A Case Report.

Headache disorders are burdensome, both in terms of the number of people they affect, and in terms of associated healthcare spending. This report presents a 36-year-old female admitted to a tertiary university hospital with a primary complaint of intractable headache, caused by a combination of medication overuse headache, and headache secondary to aseptic meningitis. During her hospital stay, opioid analgesic doses were initially increased without success in an attempt to control her headache. Despite multiple medication trials the patient's headache failed to improve. On day ten of her hospitalization, she underwent a thirty-minute acupuncture session which resulted in immediate relief of her headache. She received one more acupuncture treatment the following day and was discharged to an acute inpatient rehabilitation facility on a vastly reduced dose of opioids. Instructions on how to taper the remaining opioids were provided, and the patient was scheduled for outpatient acupuncture therapy sessions for further headache management. This report demonstrates the importance of recognizing acupuncture as a viable treatment option for medication overuse headache and for headache secondary to systemic diseases such as aseptic meningitis. Furthermore, acupuncture should also be considered as a nonpharmacological modality to be used when tapering a patient off of high doses of opioids.

"Are We hurting ourselves?" What is the prevalence of back pain in anesthesia providers?

STUDY OBJECTIVE: Back injuries are a highly reported category of occupational injury in the health care setting. The daily clinical activities of an anesthesia provider, including lifting, pushing stretchers, transferring patients, and bending for procedures, are risk factors for developing low back pain. The purpose of this study is to investigate the prevalence of work related low back pain in anesthesia providers. DESIGN/SETTING: We conducted a cross-sectional survey study of anesthesia providers at an academic institution. PATIENTS: The target population included all 141 clinical anesthesia providers employed by the Penn State Milton S. Hershey Medical Center Department of Anesthesia. INTERVENTIONS: A survey study was conducted using the Oswestry Disability Index (ODI), a validated scoring system for low back pain. Additional questions related to the daily activities of clinical anesthesia practice were also asked. The survey instrument underwent pretesting and clinical sensibility testing to ensure validity and consistent interpretation. MEASUREMENTS: The primary self-reported measures were the prevalence of low back pain in anesthesia providers and an assessment of disability based on the ODI. Secondary functional measures included the impact of low back pain on work flow. MAIN RESULTS: Nearly half (46.6%) of respondents suffer from low back pain attributed to clinical practice. In this subset of respondents, 70.1% reported not having back pain prior to their anesthesia training. Of those with low back pain, 44% alter their work flow, and 9.8% reported missing at least one day of work. Six providers (5.3%) required surgical intervention. Using the ODI score interpretation guidelines, 46% of respondents had a "mild disability" and 2% had a "moderate disability." Respondents reporting feeling "burned out" from their job had a significantly higher average ODI score compared to those who did not (6.8 vs 3.3, respectively; P=.01). CONCLUSIONS: Nearly half of all anesthesia providers sampled suffer from low back pain subjectively attributed to their clinical practice. This leads to changes in work flow and missed days of work. The results of this study suggest a deficiency in the effectiveness of anesthesia training programs in teaching proper techniques to prevent musculoskeletal injuries.

Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study.

OBJECTIVE: To evaluate whether an epidural steroid injection or gabapentin is a better treatment for lumbosacral radiculopathy. DESIGN: A multicenter randomized study conducted between 2011 and 2014. Computer generated randomization was stratified by site. Patients and evaluating physicians were blinded to treatment outcomes. SETTINGS: Eight military, Veterans Administration, and civilian hospitals. PARTICIPANTS: 145 people with lumbosacral radicular pain secondary to herniated disc or spinal stenosis for less than four years in duration and in whom leg pain is as severe or more severe than back pain. INTERVENTIONS: Participants received either epidural steroid injection plus placebo pills or sham injection plus gabapentin. MAIN OUTCOME MEASURES: Average leg pain one and three months after the injection on a 0-10 numerical rating scale. A positive outcome was defined as a ≥ 2 point decrease in leg pain coupled with a positive global perceived effect. All patients had one month follow-up visits; patients whose condition improved remained blinded for their three month visit. RESULTS: There were no significant differences for the primary outcome measure at one month (mean pain score 3.3 (SD 2.6) and mean change from baseline -2.2 (SD 2.4) in epidural steroid injection group versus 3.7 (SD 2.6) and -1.7 (SD 2.6) in gabapentin group; adjusted difference 0.4, 95% confidence interval -0.3 to 1.2; P=0.25) and three months (mean pain score 3.4 (SD 2.7) and mean change from baseline -2.0 (SD 2.6) versus 3.7 (SD 2.8) and -1.6 (SD 2.7), respectively; adjusted difference 0.3, -0.5 to 1.2; P=0.43). Among secondary outcomes, one month after treatment those who received epidural steroid injection had greater reductions in worst leg pain (-3.0, SD 2.8) than those treated with gabapentin (-2.0, SD 2.9; P=0.04) and were more likely to experience a positive successful outcome (66% v 46%; number needed to treat=5.0, 95% confidence interval 2.8 to 27.0; P=0.02). At three months, there were no significant differences between treatments. CONCLUSIONS: Although epidural steroid injection might provide greater benefit than gabapentin for some outcome measures, the differences are modest and are transient for most people.Trial registration ClinicalTrials.gov Identifier: NCT01495923.

Incidence of neuropathic pain after cooled radiofrequency ablation of sacral lateral branch nerves.

OBJECTIVE: To determine the incidence of neuropathic pain after cooled radiofrequency ablation (RFA) of the sacral lateral branches for the treatment of chronic posterior sacroiliac joint complex pain. DESIGN: Retrospective chart review of all patients with chronic posterior sacroiliac joint complex pain who underwent cooled RFA of the sacral lateral branches in our practice between July 2011 and February 2014. SETTING: Single academic pain practice at a tertiary care medical center. SUBJECTS: Thirty-six patients with chronic posterior sacroiliac joint complex pain. METHODS: All charts were reviewed to determine the procedure date, unilateral or bilateral, number of levels treated, and number of individual lesions. Side effects were assessed for their presence or absence, character, intensity, duration, and whether treatment was initiated or symptoms resolved spontaneously. RESULTS: Forty-eight separate procedures were performed, with a total of 193 levels and 430 lesions. Three patients had transient postprocedure neuropathic pain yielding a 0.7% (95% confidence interval [CI]± 0.4%) rate of this complication per lesion. This proportion increases to 6.2% (95% CI ± 3.5%) per procedure and to 9.4% (95% CI ± 5.2%) per patient. CONCLUSION: The incidence of postprocedural neuropathic pain after cooled RFA for posterior sacroiliac joint complex denervation is low and in a similar range to that in the lumbar spine. We consider this procedure safe to be utilized by pain medicine practitioners.

Recommendations for a new curriculum in pain medicine for medical students: toward a career distinguished by competence and compassion.

OBJECTIVE: The education of physicians is a fundamental obligation within medicine that must remain closely aligned with clinical care. And although medical education in pain care is essential, the current state of medical education does not meet the needs of physicians, patients, or society. To address this, we convened a committee of pain specialist medical student educators. METHODS: Tasked with creating systematically developed and valid recommendations for clinical education, we conducted a survey of pain medicine leadership within the American Academy of Pain Medicine (AAPM). The survey was conducted in two waves. We asked AAPM board members to rate 194 previously published pain medicine learning objectives for medical students; 79% of those eligible for participation responded. RESULTS: The "Top 5" list included the awareness of acute and chronic pain, skillfulness in clinical appraisal, promotion of compassionate practices, displaying empathy toward the patient, and knowledge of terms and definitions for substance abuse. The "Top 10" list included the major pharmacological classes as well as skills in examination, communication, prescribing, and interviewing. The "Top 20" list included the pain care of cognitively impaired populations, those with comorbid illness, and older adults. With the survey results in consideration, the committee produced a new recommended topic list for curricula in pain medicine. We strongly recommend that adequate resources are devoted to fully integrated medical curricula in pain so that students will learn not only the necessary clinical knowledge but also be prepared to address the professional, personal, and ethical challenges that arise in caring for those with pain. CONCLUSIONS: We conclude that improved medical education in pain is essential to prepare providers who manifest both competence and compassion toward their patients.

Percutaneous mechanical disc decompression using Dekompressor device: an appraisal of the current literature.

OBJECTIVES: The objective of this study was to determine if the available literature answers the following questions: does percutaneous disc decompression using Dekompressor device relieve radicular pain caused by a small disc herniation? Is the duration of response stable and clinically worthwhile? Is relief of pain corroborated by improvements in physical and social function? Does relief of pain result in reduction in the use of other health care? Is there a risk of serious side effects or complications? DESIGN/SETTINGS: The study was designed as a narrative review and description of the available evidence, drawn from the databases of PubMed, EMBASE, and the Cochrane Library. Innovatively, the concept of the "context of the patient" was introduced in the assessment. It required the assessors to consider the alternatives the patients and their treating practitioners faced. RESULTS: The literature search identified three nonrandomized clinical trials, and a single case series. All studies were reasonably rigorous in reporting relief of pain and the use of analgesics. Evidence with respect to physical functioning was scarce. Although investigators reported on the relief of pain, they lacked rigor when reporting associated outcome measures such as use of other health care and physical functioning. CONCLUSIONS: Unfortunately, the context of a patient with persistent radicular pain caused by a small disc herniation is the lack of good alternatives to Dekompressor procedure. The moral question is whether Dekompressor is any less valid an option than perpetual opioids or discectomy. This question would be much easier to answer if the literature on Dekompressor was more rigorous and more compelling in its evidence.

Combination therapy for neuropathic pain: a review of current evidence.

Neuropathic pain is a debilitating chronic condition that remains very difficult to treat. Recently, a number of clinical studies have compared the effectiveness of combination drug therapy with monotherapy for neuropathic pain treatment. In this article, we summarize up-to-date clinical studies of combination therapy for the treatment of both cancer- and non-cancer-related neuropathic pain. Despite a relatively small number of clinical studies on this topic, several positive indications have emerged. First, clinical studies using gabapentin (five positive trials) and pregabalin (five positive trials and one negative trial) in combination with an opioid, cyclo-oxygenase-2 inhibitor or antidepressant have shown positive responses greater than the respective monotherapies for pain related to diabetic neuropathy and postherpetic neuropathy. Second, high-concentration (8%) topical capsaicin and a 5% lidocaine patch seem to be effective add-on therapies (a modality of combination therapy) for various neuropathic pain conditions. Third, combination therapy for cancer-related neuropathic pain has yielded only limited success based on a number of small-scale clinical studies. While there are benefits of using combination therapy for neuropathic pain treatment, including better pain relief and reduced adverse effects, more clinical studies are required in order to (i) make head-to-head comparisons between combination and single-drug therapies, (ii) identify symptom-specific combination therapies for distinctive clinical neuropathic pain conditions, (iii) explore combination therapies that include non-drug modalities such as physical therapy, psychological coping and biofeedback to facilitate functional restoration and (iv) develop new and objective evaluation tools for clinical outcome assessment.

Gadolinium encephalopathy after intrathecal gadolinium injection.

BACKGROUND: Gadolinium-induced encephalopathy is a well documented complication due to the inadvertent entrance of a high dose of gadolinium into the intrathecal compartment. In lab animals, injecting gadolinium into the intrathecal compartment resulted in neurotoxicity and seizures. It is also well recognized that the presence of autologous blood in the intrathecal compartment can cause a broad range of neurological changes that can include seizures and mental status changes. At the time of writing this report, there were no references in the literature of simultaneous injection of gadolinium and blood into the subarachnoid space. CASE: We present a case of a patient who received a high dose of gadolinium in the epidural space for needle placement confirmation during a fluoroscopically-guided epidural steroid injection for the treatment of lumbar radiculopathy. The injection was complicated by a wet tap necessitating an epidural blood patch for post-dural puncture headache. Shortly after the injection of the autologous blood, the patient developed grand-mal seizures and mental status changes requiring endotracheal intubation and admission to an intensive care unit. We describe the clinical course and management, as well as brain MRI findings and cerebrospinal fluid (CSF) changes. The patient made a complete recovery and was discharged. CONCLUSION: This case reinforces the need for using a low dose of gadolinium for the confirmation of needle placement in the epidural space, especially in procedures that carry the risk of inadvertent intrathecal injection.  We attribute these findings to inadvertent simultaneous intrathecal injection of high dose gadolinium and autologous blood. A literature review of the cases of gadolinium-induced encephalopathy is provided followed by discussion.

A genetic association study of the functional A118G polymorphism of the human mu-opioid receptor gene in patients with acute and chronic pain.

In this prospective, observational study we explored whether A118G single nucleotide polymorphism in the human mu-opioid receptor (MOR) gene could explain the inter-individual differences in opioid analgesic requirements in patients with acute postoperative pain and chronic pain. The frequency of the wild-type A118 MOR (major) and variant G118 MOR (minor) alleles in the subjects with chronic, noncancer pain (n = 121) and opioid-naïve subjects with acute postoperative pain (n = 101), serving as the control group, were examined. The relationships among the A118G MOR genotype, opioid requirements, and the numerical pain score were analyzed in both groups. The frequency of the minor allele was significantly lower in the subjects with chronic pain when compared with the group with acute postoperative pain (0.079 versus 0.158; P = 0.009 by chi2 test). No statistically significant association was observed between the presence of A118G MOR polymorphism and the average postoperative pain score or the doses of morphine used in the immediate postoperative period. In the high-quartile, opioid utilization, chronic pain patients, the homozygotic carriers of the major allele required significantly higher opioid dose than did the carriers of the minor allele. The results indicate that although the presence of the minor allele does not appear to affect opioid analgesic use in acute postoperative pain, the minor allele is less common in chronic pain patients, especially in those requiring higher doses of opioid analgesics.

Treatment of patients with arthritis-related pain.

Many causes of arthritic pain are encountered in clinical practice. Osteoarthritis is the most common form of arthritis in the United States, afflicting tens of millions of people. The authors review current literature on the treatment of patients with osteoarthritis. They discuss nonpharmacologic therapy such as physical therapy, weight reduction, and osteopathic manipulative treatment. Pharmacologic treatment of patients with osteoarthritis includes acetaminophen, nonsteroidal anti-inflammatory drugs, tramadol hydrochloride, and opiate analgesics in patients who failed all other treatment modalities. Patients who failed medical management should be referred for consideration for surgery.