RESUMO
BACKGROUND: Intradural disc herniation (IDH) is a very rare and challenging diagnosis, with an estimated incidence of less than 1.5%. The pathogenesis of IDH remains uncertain. Definitive management remains surgical; however, some cases may initially be managed non-surgically. CASE: A middle-aged male with presented with acute right-sided lumbar radiculopathy following heavy lifting. History was significant for prior lumbar disc herniation managed non-surgically. Lumbar MRI demonstrated a large disc herniation. The patient was initially treated non-surgically with epidural steroid injections. At 4-months, he re-injured and follow-up images demonstrated the herniated disc penetrating the dura and the diagnosis of intradural disc herniation. CONCLUSIONS: The present case is rare because the IDH occurred at the L3-4 level and resulted in unilateral radiculopathy without cauda-equina symptoms and occurred in the absence of prior surgery. This patient was initially treated non-surgically with satisfactory relief, however, reinjury led to progression of IDH with new neurological deficits necessitating surgery.
RESUMO
Since the inception of spinal cord stimulation (SCS) in 1967, the technology has evolved dramatically with important advancements in waveforms and frequencies. One such advancement is Nevro's Senza® SCS System for HF10, which received Food and Drug and Administration (FDA) approval in 2015. Low-frequency SCS works by activating large-diameter Aß fibers in the lateral discriminatory pathway (pain location, intensity, quality) at the dorsal column (DC), creating paresthesia-based stimulation at lower-frequencies (30-120 Hz), high-amplitude (3.5-8.5 mA), and longer-duration/pulse-width (100-500 µs). In contrast, high-frequency 10 kHz SCS works with a proposed different mechanism of action that is paresthesia-free with programming at a frequency of 10,000 Hz, low amplitude (1-5 mA), and short-duration/pulse-width (30 µS). This stimulation pattern selectively activates inhibitory interneurons in the dorsal horn (DH) at low stimulation intensities, which do not activate the dorsal column fibers. This ostensibly leads to suppression of hyperexcitable wide dynamic range neurons (WDR), which are sensitized and hyperactive in chronic pain states. It has also been reported to act on the medial pathway (drives attention and pain perception), in addition to the lateral pathways. Other theories include a reversible depolarization blockade, desynchronization of neural signals, membrane integration, glial-neuronal interaction, and induced temporal summation. The body of clinical evidence regarding 10 kHz SCS treatment for chronic back pain and neuropathic pain continues to grow. There is high-quality evidence supporting its use in patients with persistent back and radicular pain, particularly after spinal surgery. High-frequency 10 kHz SCS studies have demonstrated robust statistically and clinically significant superiority in pain control, compared to paresthesia-based SCS, supported by level I clinical evidence. Yet, as the field continues to grow with the technological advancements of multiple waveforms and programming stimulation algorithms, we encourage further research to focus on the ability to modulate pain with precision and efficacy, as the field of neuromodulation continues to adapt to the modern healthcare era.
RESUMO
BACKGROUND: Chronic pain, the leading cause of disability in the world, imposes limitations on activities of daily living and diminishes quality of life leading to unnecessary patient suffering. The personal and socioeconomic costs of chronic pain cannot be overstated. Physicians are at the crux of the pandemic and must attempt to limit the spread of the virus while maintaining their professional responsibility to their patients and staff members. OBJECTIVE: The aim of this review is to analyze the existing literature to develop consensus recommendations for treating pain during the current COVID-19 pandemic. METHODS: Relevant literature was located via computer-generated citations between the months of March and May of 2020. Online computer searches of multiple databases including Google Scholar, CINAHL, PubMed, and Cochrane Review were conducted in conjunction with a thorough review of local, state, national, and international governmental and organizational websites to locate research on the area of interest. RESULTS: The guidelines in this review are meant to offer a framework to pain practitioners and organizations for providing highly effective, ethical, and safe care to patients while maintaining their commitment to mitigating the spread of the COVID-19 pandemic. Specific areas addressed include general and interventional-specific treatment and mitigation recommendations. CONCLUSIONS: We believe that the recommendations in this review, if used in conjunction with evolving recommendations of Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and federal, state, and local governing bodies, provides a path to not only mitigate the spread of the pandemic but also limit the adverse impact of pain and suffering in chronic pain patients.
