Outcomes of a Comprehensive Pain Rehabilitation Program for Patients With Fibromyalgia.

OBJECTIVE: To analyze opioid intake interference with psychological, well-being, and functional outcomes and medication tapering in patients with fibromyalgia admitted to the Mayo Clinic Pain Rehabilitation Program (MCPRP) in Florida. PATIENTS AND METHODS: A retrospective study on MCPRP outcomes was conducted. We reviewed the health records of 150 patients with fibromyalgia who participated in the program from May 1, 2014, to May 1, 2015. All patients were asked to fill out a survey at admission to and dismissal from the program. Surveys contained questions from the numeric pain score, Multidimensional Pain Inventory (perceived life control and interference of pain subscales), Center for Epidemiological Studies-Depression Scale, Pain Catastrophizing Scale, 36-Item Short-Form Health Status Survey (general health perceptions subscale), and Pain Self-Efficacy Questionnaire. A medical record review identified categories and number of medications at program admission and dismissal. Patients were divided in 2 groups: those whose concomitant medication did not include opioids at admission (no opioids group) and those whose concomitant medication included opioids at admission (opioids group). RESULTS: By dismissal from the MCPRP, patients with fibromyalgia in the no opioids group had a significant (P<.05) improvement in all the self-reported scores. Medication, including opioids, were effectively tapered at a substantially higher percentage in the opioids group. CONCLUSION: Benefit of the comprehensive pain rehabilitation program in patients with fibromyalgia was indicated by clinical improvements in pain severity, physical and emotional health, and functional capacity while successfully tapering medication. Opioid intake at admission may modify the program outcomes.

The Effectiveness of an Intensive Interdisciplinary Pain Rehabilitation Program in the Treatment of Post-Laminectomy Syndrome in Patients Who Have Failed Spinal Cord Stimulation.

Introduction: Post-laminectomy syndrome (PLS) patients who have previously undergone spinal cord stimulation and failed to have significant improvement create a unique challenge for ongoing pain management. We hypothesize that, following successful completion of intensive, interdisciplinary pain rehabilitation (IPR), this patient population can achieve a significant reduction in pain, improvement in mood, functional levels, and self-efficacy. Materials and methods: A retrospective chart review was conducted comparing the following for patients prior to enrollment in the IPR program and upon completion: numeric rating scale (NRS) pain scores; functional status via the six-minute walk test; mood via the Center for Epidemiologic Studies Depression Scale (CES-D), Multidimensional Pain Inventory (MPI) Life control scores and MPI Interference, and the Pain Catastrophizing Scale (PCS); and self-efficacy via the Pain Self-Efficacy Questionnaire (PSEQ). Results: Forty-three patients met inclusion criteria, with 17 males and 26 females and a mean age of 64 years. Patients demonstrated a statistically significant increase in six-minute walk test distance of 104 m, a decrease in average NRS pain score of 1.4 points, an increase in average MPI life control by 8.3 points, a decrease average MPI interference by 5.3 points, an increase in average Short Form-36 by 6.5 points, an increase in average PCS by 4.4 points, and an increase in average PSEQ score of 18.1. Their average mood via CES-D improved by 4.2 points. Conclusions: Intensive, interdisciplinary pain rehabilitation provides an effective therapeutic modality for patients with post-laminectomy syndrome who have failed spinal cord stimulation by decreasing pain levels and by increasing functional status and self-efficacy.

Needle placement for piriformis injection using 3-D imaging.

Piriformis syndrome is a pain syndrome originating in the buttock and is attributed to 6% - 8% of patients referred for the treatment of back and leg pain. The treatment for piriformis syndrome using fluoroscopy, computed tomography (CT), electromyography (EMG), and ultrasound (US) has become standard practice. The treatment of Piriformis Syndrome has evolved to include fluoroscopy and EMG with CT guidance. We present a case study of 5 successful piriformis injections using 3-D computer-assisted electromagnet needle tracking coupled with ultrasound. A 6-degree of freedom electromagnetic position tracker was attached to the ultrasound probe that allowed the system to detect the position and orientation of the probe in the magnetic field. The tracked ultrasound probe was used to find the posterior superior iliac spine. Subsequently, 3 points were captured to register the ultrasound image with the CT or magnetic resonance image scan. Moreover, after the registration was obtained, the navigation system visualized the tracked needle relative to the CT scan in real-time using 2 orthogonal multi-planar reconstructions centered at the tracked needle tip. Conversely, a recent study revealed that fluoroscopically guided injections had 30% accuracy compared to ultrasound guided injections, which tripled the accuracy percentage. This novel technique exhibited an accurate needle guidance injection precision of 98% while advancing to the piriformis muscle and avoiding the sciatic nerve. The mean (± SD) procedure time was 19.08 (± 4.9) minutes. This technique allows for electromagnetic instrument tip tracking with real-time 3-D guidance to the selected target. As with any new technique, a learning curve is expected; however, this technique could offer an alternative, minimizing radiation exposure.

Placement of an intrathecal catheter through a bony fusion mass using 3D image guidance: a case report.

OBJECTIVE: We describe the 3-dimensional (3D) image-guided placement technique for a lumbar intrathecal catheter through a dorsal fusion mass. This is the first time this technique has been reported. A patient with 6 prior spine surgeries and chronic pain syndrome presented with a challenging large dorsal fusion mass. The use of 3D cone beam computed tomography-based image guidance proved advantageous for the placement of an intrathecal drug delivery system (IDDS). METHOD: Under general anesthesia, image guidance was accomplished with the Medtronic Stealth S7 image guidance system, used in conjunction with the O-ARM (Medtronic Inc.). Using an image-guided probe over the skin surface, we navigated the dorsal fusion mass to identify a thin area at the L4-L5 level. A small incision was made and the image-guided probe was used to target the selected thin area and drill an adequate opening in the fusion mass. We inserted a Tuohy needle through the bony defect for passage of the intrathecal catheter. We confirmed adequate catheter placement using free flowing cerebrospinal fluid and fluoroscopy. The remainder of the IDDS implant proceeded per routine. RESULTS: The patient tolerated the procedure well and had no complications. The morphine IDDS improved his overall pain and function with minimal side effects. CONCLUSIONS: This is the first case report using 3D cone beam computed tomography-based image guidance for the placement of an intrathecal catheter through a bony fusion mass. This technique appears to be a viable option for IDDS implantation in patients with difficult anatomy.

Spinal cord stimulator--trial lead migration study.

OBJECTIVES: Investigate whether percutaneous spinal cord stimulator (SCS) leads migrate significantly during a 3-day trial, and determine whether the skin anchoring method influences lead migration. MATERIAL AND METHODS: Twenty patients were prospectively enrolled. Ten leads were anchored with suture and tape and 10 were anchored with tape only. A standardized X-ray protocol of lead position was obtained immediately following lead placement and upon completion of the trial. RESULTS: Using a standardized method, SCS leads were measured and movement was calculated. The average movement for leads anchored with tape only was 8.72 mm (SD=5.77), inferiorly; while movement for leads anchored with suture and tape was 24.49 mm (SD=11.3), inferiorly. A t-test revealed a significant difference between the groups (t=3.9, P=0.001). CONCLUSIONS: Percutaneous SCS trial electrodes migrate significantly, inferiorly, during a 3-day trial. Anchoring the trial electrodes to the skin with a suture and tape results in significantly greater inferior migration when compared with anchoring the lead with tape only.

Radiofrequency neurotomy for a patient with deep brain stimulators: proposed safety guidelines.

OBJECTIVE: To discuss the potential risks inherent to performing radiofrequency procedures in patients with deep brain neurostimulators, and to propose safety guidelines. DESIGN: Case report. SETTING: Tertiary care teaching hospital. SUBJECT: A 67-year-old male with intractable back pain due to advanced lumbar spondylosis, with a history of advanced Parkinson's Disease requiring two deep brain stimulators. INTERVENTION: Radiofrequency neurotomy lumbar facet joints. RESULTS: No atypical symptoms were reported during the procedure that would indicate iatrogenic injury from radiofrequency effect on the deep brain neurostimulators. The subject's back pain was relieved by 70% for greater than 6 months bilaterally. DISCUSSION: There are several theoretical concerns when using radiofrequency therapies on patients with neurostimulators. Our patient did not experience any known adverse events during or subsequent to the procedure. This article presents our proposed safety guidelines for using radiofrequency neurotomy on patients with deep brain stimulators. CONCLUSIONS: Radiofrequency medial branch neurotomy was performed on a patient with two deep brain stimulators with a satisfactory clinical outcome, and no adverse sequelae. Additional study is warranted regarding the safety and compatibility of brain neurostimulators and radiofrequency interventions.

Prevention and treatment of ankle sprain in athletes.

The frequent nature of ankle sprains and persistent disability that often ensues has lead to considerable medical costs. As prevention of disease and injury becomes an increasingly important part of the practice of medicine today, we strive to understand and identify interventions that optimally reduce the frequency of ankle sprain and re-injury. In doing so, considerable morbidity and unnecessary medical expenditures may potentially be averted. The prophylactic use of ankle braces is fairly common. Recent critical evaluation of their effectiveness supports their use for at least 6 months following injury in athletes who have sustained a moderate or severe sprain; however, their role in primary prevention of ankle sprain is less evident. Functional ankle rehabilitation is the mainstay of acute ankle sprain treatment and in recent reviews has been deemed preferable to immobilisation or early surgery for initial treatment of acutely injured ankles. Furthermore, certain components of ankle rehabilitation, such as proprioceptive exercises, have been found to protect the joint from re-injury. Multifaceted ankle sprain prevention programmes that incorporate a variety of strategies for injury reduction are also effective in sprain prevention, although the relative importance of each component of such programmes warrants further investigation. Surgery for ankle sprain is principally reserved for patients who fail a comprehensive non-operative treatment programme and can be highly successful in treating chronic functional instability. This paper examines the current literature regarding common ankle sprain prevention strategies and provides a review of appropriate treatment schemes.