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1.
Pain Med ; 21(Suppl 2): S53-S61, 2020 12 12.
Artigo em Inglês | MEDLINE | ID: mdl-33313729

RESUMO

BACKGROUND: Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducer needle followed by the delivery of electric current after needle withdrawal. This modality has been used extensively to treat chronic pain, but only small series have been published involving postoperative pain. The ultimate objective of this study is to determine the postoperative effects of percutaneous PNS following moderately to severely painful ambulatory surgery within a real-world clinical practice setting. The primary hypothesis is that surgical pain and opioid consumption during the initial 7 days after surgery will be reduced by percutaneous PNS compared with usual and customary analgesia (dual primary outcome measures). DESIGN: A multicenter pragmatic effectiveness trial. We are randomizing participants having painful orthopedic surgical procedures of the upper and lower extremity to receive 14 days of either 1) electrical stimulation or 2) sham in a double-masked fashion. End points are being assessed at various time points over 12 postoperative months. SUMMARY: The postoperative experience will be much improved if percutaneous PNS provides potent analgesia while concurrently decreasing opioid requirements following painful surgery. Because this modality can be administered for up to 60 days at home, it may provide postoperative analgesia that outlasts surgical pain yet has relatively few risks and, unlike opioids, has no systemic side effects or potential for abuse, addiction, and overdose. Percutaneous PNS has the potential to revolutionize postoperative analgesia as it has been practiced for the past century. This study will inform key stakeholders regarding an evidence-based nonpharmacologic approach to the management of postoperative pain.

2.
Pain ; 2020 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-33021563

RESUMO

Phantom limb pain is thought to be sustained by reentrant neural pathways which provoke dysfunctional reorganization in the somatosensory cortex. We hypothesized that disrupting reentrant pathways with a 6-day-long continuous peripheral nerve block reduces phantom pain 4 weeks after treatment. We enrolled patients who had an upper- or lower-limb amputation and established phantom pain. Each was randomized to receive a 6-day perineural infusion of either ropivacaine or normal saline. The primary outcome was the average phantom pain severity as measured with a Numeric Rating Scale (0-10) at 4 weeks, after which an optional crossover treatment was offered within the following 0-12 weeks. Pretreatment pain scores were similar in both groups, with a median [interquartile range] of 5.0 [4.0, 7.0] for each. After 4 weeks, average phantom limb pain intensity was a mean (SD) of 3.0 (2.9) in patients given local anesthetic versus 4.5 (2.6) in those given placebo (difference (95% CI) 1.3 (0.4, 2.2), P=0.003). Patients given local anesthetic had improved global impression of change and less pain-induced physical and emotional dysfunction, but did not differ on depression scores. For subjects who received only the first infusion (no self-selected crossover), the median decrease in phantom limb pain at 6 months for treated subjects was 3.0 [0, 5.0] vs. 1.5 [0, 5.0] for the placebo group; there appeared to be little residual benefit at 12 months. We conclude that a 6-day continuous peripheral nerve block reduces phantom limb pain as well as physical and emotional dysfunction for at least 1 month.

4.
Mil Med ; 184(Suppl 1): 557-564, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30901395

RESUMO

Orthopedic trauma is a significant military problem, causing several of the most disabling conditions with high rates of separation from duty and erosion of military readiness. The objective of this report is to summarize the findings of case series of a non-opioid therapy-percutaneous peripheral nerve stimulation (PNS) - and describe its potential for postoperative analgesia, early opioid cessation, and improved function following orthopedic trauma. Percutaneous PNS has been evaluated for the treatment of multiple types of pain, including two case series on postoperative pain following total knee replacement (n = 10 and 8, respectively) and a case series on postamputation pain (n = 9). The orthopedic trauma induced during TKR is highly representative of multiple types of orthopedic trauma sustained by Service members and frequently produces intense, prolonged postoperative pain and extended opioid use following surgery. Collectively, the results of these three clinical studies demonstrated that percutaneous PNS can provide substantial pain relief, reduce opioid use, and improve function. These outcomes suggest that there is substantial potential for the use of percutaneous PNS following orthopedic trauma.


Assuntos
Analgésicos Opioides/administração & dosagem , Terapia por Estimulação Elétrica/normas , Manejo da Dor/normas , Dor Pós-Operatória/tratamento farmacológico , Analgésicos/administração & dosagem , Analgésicos/uso terapêutico , Analgésicos Opioides/uso terapêutico , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/métodos , Terapia por Estimulação Elétrica/métodos , Humanos , Manejo da Dor/métodos , Medição da Dor/métodos , Dor Pós-Operatória/etiologia , Recuperação de Função Fisiológica/efeitos dos fármacos
5.
Mil Med ; 184(Suppl 1): 537-541, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30901473

RESUMO

Chronic low back pain represents one of the most common sources of disability and a significant healthcare burden for the U.S. military. Present treatments for chronic back pain are often ineffective, poorly tolerated, invasive, destructive, and/or associated with complications and lead to the progression to invasive surgical procedures. There have been multiple calls for the development of a minimally invasive system that is effective without the risks or complications of existing surgical therapies, which could prevent the need for surgery and the recurrence of pain. The goal of this study was to evaluate a novel, minimally invasive approach using a percutaneous peripheral nerve stimulation (PNS) system designed to provide pain relief without surgery, to reduce complications, and provide a less-invasive treatment option. In nine subjects, percutaneous PNS improved participants' function, as evidenced by clinically and statistically significant reductions in pain, disability, and pain interference. Subjects also experienced reductions in opioid and non-opioid analgesic medication usage and reported improvements in quality of life with treatment. There were no serious or unanticipated adverse events. These results demonstrate the potential of percutaneous PNS as a non-surgical therapy to treat chronic back pain without opioids.


Assuntos
Dor Lombar/terapia , Manejo da Dor/normas , Nervos Periféricos , Estimulação Elétrica Nervosa Transcutânea/normas , Adulto , Dor Crônica/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Estimulação Elétrica Nervosa Transcutânea/métodos , Resultado do Tratamento
6.
Pain Med ; 20(4): 724-735, 2019 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-30690556

RESUMO

BACKGROUND: A national crisis of opioid-related morbidity, mortality, and misuse has led to initiatives to address the appropriate role of opioids to treat pain. Deployment of a guideline from the Centers for Disease Control and Prevention to reduce the risks of opioid therapy has raised substantial clinical and public policy challenges. The agency anticipated implementation challenges and committed to reevaluating the guideline for intended and unintended effects on clinician and patient outcomes. OBSERVATIONS: A multidisciplinary expert panel met to review the influence of the core recommendations of the guideline on pain management practices, principally regarding the estimated 5 to 8 million Americans with chronic pain currently on opioids. The panel identified implementation challenges, including application of dosage ceilings and prescription duration guidance, failure to appreciate the importance of patient involvement in decisions to taper or discontinue opioids, barriers to diagnosis and treatment of opioid use disorder, and impeded access to recommended comprehensive, multimodal pain care. Furthermore, policy-making and regulatory bodies may misapply guideline recommendations without flexibility and, sometimes, without full awareness of what the guideline contains. CONCLUSIONS AND RELEVANCE: The panel largely supported the guideline, endorsing its focal points of safety and comprehensive assessment and monitoring. To mitigate clinical and policy challenges identified with implementing the guideline, the panel discussed areas where viewpoints diverged and arrived at consensus proposals. The target audience includes the leaders and institutions that create policy and influence guideline implementation to include regulatory agencies, legislators, public and private payers, and health care systems.


Assuntos
Analgésicos Opioides/uso terapêutico , Manejo da Dor/métodos , Dor/tratamento farmacológico , Guias de Prática Clínica como Assunto , Uso Indevido de Medicamentos sob Prescrição/prevenção & controle , Centers for Disease Control and Prevention, U.S. , Consenso , Humanos , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Estados Unidos
7.
Mil Med ; 182(7): e1851-e1861, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28810982

RESUMO

BACKGROUND: In 2009, the Army Pain Management Task Force was chartered. On the basis of their findings, the Department of Defense recommended a comprehensive pain management strategy that included development of a standardized pain assessment system that would collect patient-reported outcomes data to inform the patient-provider clinical encounter. The result was the Pain Assessment Screening Tool and Outcomes Registry (PASTOR). The purpose of this study was to assess the validity and response burden of the patient-reported outcome measures in PASTOR. METHODS: Data for analyses were collected from 681 individuals who completed PASTOR at baseline and follow-up as part of their routine clinical care. The survey tool included self-report measures of pain severity and pain interference (measured using the National Institutes of Health Patient-Reported Outcome Measurement Information System [PROMIS] and the Defense and Veterans Pain Rating scale). PROMIS measures of pain correlates also were administered. Validation analyses included estimation of score associations among measures, comparison of scores of known groups, responsiveness, ceiling and floor effects, and response burden. RESULTS: Results of psychometric testing provided substantial evidence for the validity of PASTOR self-report measures in this population. Expected associations among scores largely supported the concurrent validity of the measures. Scores effectively distinguished among respondents on the basis of their self-reported impressions of general health. PROMIS measures were administered using computer adaptive testing and each, on average, required less than 1 minute to administer. Statistical and graphical analyses demonstrated the responsiveness of PASTOR measures over time.


Assuntos
Medição da Dor/instrumentação , Medição da Dor/normas , Psicometria/normas , Autorrelato , Adulto , Ira , Ansiedade/complicações , Depressão/complicações , Feminino , Humanos , Masculino , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Medição da Dor/métodos , Psicometria/instrumentação , Psicometria/métodos , Reprodutibilidade dos Testes , Inquéritos e Questionários
8.
Vasc Endovascular Surg ; 51(3): 146-148, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28190377

RESUMO

Early creation of arteriovenous fistulas (AVFs) decreases morbidity and mortality in patients with end-stage renal disease and is the standard of care in the United States. However, this procedure is frequently not accessible in low- and middle-income countries (LMICs). We present the first reported case of successful AVF creation as part of a humanitarian assistance mission. The patient was a 51-year-old male with diabetes, hypertension, and end-stage renal disease on hemodialysis via a temporary dialysis catheter. Preoperative assessment and patient selection were coordinated with the host nation (HN) nephrologist and dialysis team. The visiting surgical team provided education on AVF anatomy, complications, and cannulation techniques to the HN dialysis team. A left brachiocephalic AVF was created under regional anesthesia performed by the visiting surgeon and anesthesiologists. There were no postoperative complications, and the AVF was matured and accessed successfully by the HN dialysis team 7 weeks after creation. Performing AVFs as part of humanitarian assistance missions has the potential to significantly reduce morbidity and mortality in LMICs.


Assuntos
Derivação Arteriovenosa Cirúrgica , Comportamento Cooperativo , Comunicação Interdisciplinar , Falência Renal Crônica/terapia , Medicina Naval , Equipe de Assistência ao Paciente , Socorro em Desastres , Diálise Renal , Navios , Educação Médica Continuada , Educação Continuada em Enfermagem , Fiji , Humanos , Falência Renal Crônica/diagnóstico , Masculino , Pessoa de Meia-Idade , Nefrologistas/educação , Enfermagem em Nefrologia/educação , Estados Unidos
9.
Reg Anesth Pain Med ; 41(4): 494-500, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27187898

RESUMO

OBJECTIVE: In this study, we aimed to determine if stellate ganglion block (SGB) could reduce symptoms of posttraumatic stress disorder (PTSD) in comparison with sham therapy in military service members. METHODS: In a randomized trial in which both participants and assessors were blind, participants with PTSD received either an SGB or a sham procedure. Posttraumatic stress disorder symptoms were measured using the CAPS (Clinician-Administered PTSD Scale) and self-report measures of PTSD, depression, anxiety, and pain. Subjects underwent assessment before the procedure and at 1 week, 1 month, and 3 months after the procedure. Patients receiving sham injections were allowed to cross over to the treatment group, and participants who maintained criteria for PTSD were allowed to receive a second SGB treatment. RESULTS: Posttraumatic stress disorder, anxiety, and depression scores all showed improvement across time, but there was no statistically or clinically relevant difference in outcomes between the active and control groups. Individuals who crossed over from sham treatment to SGB similarly showed no greater improvement with the SGB treatment. Improvement in CAPS was greater with a second SGB treatment than after the first treatment. CONCLUSIONS: Although previous case series have suggested that SGB offers an effective intervention for PTSD, this study did not demonstrate any appreciable difference between SGB and sham treatment on psychological or pain outcomes. Future studies should examine if differences in treatment methods or patient population could allow individuals with PTSD to benefit from SGB, but current evidence does not support widespread or indiscriminant clinical use of the procedure for PTSD.


Assuntos
Bloqueio Nervoso Autônomo/métodos , Gânglio Estrelado/efeitos dos fármacos , Transtornos de Estresse Pós-Traumáticos/terapia , Bloqueio Nervoso Autônomo/efeitos adversos , California , Lista de Checagem , Cognição , Avaliação da Deficiência , Método Duplo-Cego , Feminino , Hospitais Militares , Humanos , Masculino , Militares , Escalas de Graduação Psiquiátrica , Autorrelato , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/psicologia , Fatores de Tempo , Resultado do Tratamento
10.
Pain Med ; 17(7): 1337-1342, 2016 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-27015690

RESUMO

OBJECTIVE: This study evaluated the efficacy of IV cosyntropin as an alternative to epidural blood patch (EBP) for refractory or severe post-dural puncture headache (PDPH). METHODS: Twenty-eight patients were randomized to receive EBP or intravenous cosyntropin after diagnosis with post-dural puncture headache. Efficacy was evaluated immediately after treatment and at 1 day, 3 days, and 7 days following treatment using self-reported verbal reported scores for pain and function related to their headache on a 10-point scale using two-way repeated measures analysis of variance (ANOVA) with multiple comparisons. RESULTS: Baseline information for the control and study cohorts showed no difference based on intent to treat analysis. EBP showed significant improvement over cosyntropin at day 1 (P < 0.001) for VRS pain and function scores; however, cosyntropin demonstrated similar efficacy to EBP immediately after treatment and days 3 and 7 post treatment (respectively, P = 0.459, P = 0.391 and 0.925 for pain and P = 0.189 and 0.478 for function). Treatment effects remained at day 1 after multivariate analysis (P < 0.001 and P = 0.002 for pain and function, respectively). CONCLUSIONS: It is reasonable to consider IV cosyntropin as the treatment of choice for patients in whom EBP is contraindicated or in austere environments where there is limited or no access to anesthesia trained providers. Future research should compare efficacy and cost of prophylaxis to treatment of PDPH with intravenous cosyntropin and evaluate the most effective dosing regimen, including duration, number, and strength of doses.

11.
Pain ; 156(12): 2585-94, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26447705

RESUMO

Occipital neuralgia (ON) is characterized by lancinating pain and tenderness overlying the occipital nerves. Both steroid injections and pulsed radiofrequency (PRF) are used to treat ON, but few clinical trials have evaluated efficacy, and no study has compared treatments. We performed a multicenter, randomized, double-blind, comparative-effectiveness study in 81 participants with ON or migraine with occipital nerve tenderness whose aim was to determine which treatment is superior. Forty-two participants were randomized to receive local anesthetic and saline, and three 120 second cycles of PRF per targeted nerve, and 39 were randomized to receive local anesthetic mixed with deposteroid and 3 rounds of sham PRF. Patients, treating physicians, and evaluators were blinded to interventions. The PRF group experienced a greater reduction in the primary outcome measure, average occipital pain at 6 weeks (mean change from baseline -2.743 ± 2.487 vs -1.377 ± 1.970; P < 0.001), than the steroid group, which persisted through the 6-month follow-up. Comparable benefits favoring PRF were obtained for worst occipital pain through 3 months (mean change from baseline -1.925 ± 3.204 vs -0.541 ± 2.644; P = 0.043), and average overall headache pain through 6 weeks (mean change from baseline -2.738 ± 2.753 vs -1.120 ± 2.1; P = 0.037). Adverse events were similar between groups, and few significant differences were noted for nonpain outcomes. We conclude that although PRF can provide greater pain relief for ON and migraine with occipital nerve tenderness than steroid injections, the superior analgesia may not be accompanied by comparable improvement on other outcome measures.


Assuntos
Glucocorticoides/uso terapêutico , Metilprednisolona/uso terapêutico , Transtornos de Enxaqueca/terapia , Neuralgia/terapia , Lobo Occipital , Tratamento por Radiofrequência Pulsada/métodos , Couro Cabeludo , Nervos Espinhais , Adulto , Anestésicos Locais/uso terapêutico , Bupivacaína/uso terapêutico , Preparações de Ação Retardada , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Humanos , Lidocaína/uso terapêutico , Masculino , Pessoa de Meia-Idade , Medição da Dor , Resultado do Tratamento
12.
J Trauma Stress ; 28(4): 330-8, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26243674

RESUMO

Although the experience of vicarious sensations when observing another in pain have been described postamputation, the underlying mechanisms are unknown. We investigated whether vicarious sensations are related to posttraumatic stress disorder (PTSD) symptoms and chronic pain. In Study 1, 236 amputees completed questionnaires about phantom limb phenomena and vicarious sensations to both innocuous and painful sensory experiences of others. There was a 10.2% incidence of vicarious sensations, which was significantly more prevalent in amputees reporting PTSD-like experiences, particularly increased arousal and reexperiencing the event that led to amputation (φ = .16). In Study 2, 63 amputees completed the Empathy for Pain Scale and PTSD Checklist-Civilian Version. Cluster analyses revealed 3 groups: 1 group did not experience vicarious pain or PTSD symptoms, and 2 groups were vicarious pain responders, but only 1 had increased PTSD symptoms. Only the latter group showed increased chronic pain severity compared with the nonresponder group (p = .025) with a moderate effect size (r = .35). The findings from both studies implicated an overlap, but also divergence, between PTSD symptoms and vicarious pain reactivity postamputation. Maladaptive mechanisms implicated in severe chronic pain and physical reactivity posttrauma may increase the incidence of vicarious reactivity to the pain of others.


Assuntos
Amputação/psicologia , Fadiga por Compaixão/epidemiologia , Dor/epidemiologia , Sensação , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Amputação/efeitos adversos , Amputados/psicologia , Dor Crônica/psicologia , Fadiga por Compaixão/psicologia , Empatia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor/psicologia , Medição da Dor , Membro Fantasma/etiologia , Prevalência , Escalas de Graduação Psiquiátrica , Índice de Gravidade de Doença , Transtornos de Estresse Pós-Traumáticos/psicologia
13.
BMJ ; 350: h1748, 2015 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-25883095

RESUMO

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.


Assuntos
Aminas/uso terapêutico , Analgésicos/uso terapêutico , Anti-Inflamatórios/administração & dosagem , Ácidos Cicloexanocarboxílicos/uso terapêutico , Dor Lombar/tratamento farmacológico , Metilprednisolona/administração & dosagem , Radiculopatia/tratamento farmacológico , Ácido gama-Aminobutírico/uso terapêutico , Adulto , Análise de Variância , Método Duplo-Cego , Feminino , Gabapentina , Humanos , Injeções Epidurais , Masculino , Pessoa de Meia-Idade , Medição da Dor
15.
Pain Med ; 14(6): 935-42, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23489466

RESUMO

BACKGROUND: There is currently no reliable treatment for phantom limb pain (PLP). Chronic PLP and associated cortical abnormalities may be maintained from abnormal peripheral input, raising the possibility that a continuous peripheral nerve block (CPNB) of extended duration may permanently reorganize cortical pain mapping, thus providing lasting relief. METHODS: Three men with below-the-knee (2) or -elbow (1) amputations and intractable PLP received femoral/sciatic or infraclavicular perineural catheter(s), respectively. Subjects were randomized in a double-masked fashion to receive perineural ropivacaine (0.5%) or normal saline for over 6 days as outpatients using portable electronic infusion pumps. Four months later, subjects returned for repeated perineural catheter insertion and received an ambulatory infusion with the alternate solution ("crossover"). Subjects were followed for up to 1 year. RESULTS: By chance, all three subjects received saline during their initial infusion and reported little change in their PLP. One subject did not receive crossover treatment, but the remaining two subjects reported complete resolution of their PLP during and immediately following treatment with ropivacaine. One subject experienced no PLP recurrence through the 52-week follow-up period and the other reported mild PLP occurring once each week of just a small fraction of his original pain (pretreatment: continuous PLP rated 10/10; posttreatment: no PLP at baseline with average of one PLP episode each week rated 2/10) for 12 weeks (lost to follow-up thereafter). CONCLUSIONS: A prolonged ambulatory CPNB may be a reliable treatment for intractable PLP. The results of this pilot study suggest that a large, randomized clinical trial is warranted.


Assuntos
Amidas/administração & dosagem , Bloqueio Nervoso/métodos , Dor Intratável/tratamento farmacológico , Membro Fantasma/tratamento farmacológico , Adulto , Anestésicos Locais/administração & dosagem , Humanos , Bombas de Infusão Implantáveis , Masculino , Ropivacaina , Resultado do Tratamento
17.
Anesth Analg ; 113(5): 1233-41, 2011 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-21918166

RESUMO

BACKGROUND: Radiofrequency facet denervation is one of the most frequently performed procedures for chronic low back pain. Although sensory stimulation is generally used as a surrogate measure to denote sufficient proximity of the electrode to the nerve, no study has examined whether stimulation threshold influences outcome. METHODS: We prospectively recorded data in 61 consecutive patients undergoing lumbar facet radiofrequency denervation who experienced significant pain relief after medial branch blocks. For each nerve lesioned, multiple attempts were made to maximize sensory stimulation threshold (SST). Mean SST was calculated on the basis of the lowest stimulation perceived at 0.1-V increments for each medial branch. A positive outcome was defined as a ≥50% reduction in back pain coupled with a positive satisfaction score lasting ≥3 months. The relationship between mean SST and denervation outcomes was evaluated via a receiver's operating characteristic (ROC) curve, and stratifying outcomes on the basis of various cutoff values. RESULTS: No correlation was noted between mean SST and pain relief at rest (Pearson's r=-0.01, 95% confidence interval [CI]: -0.24 to 0.23, P=0.97), with activity (r=-0.17, 95% CI: -0.40 to 0.07, P=0.20), or a successful outcome. No optimal SST could be identified. CONCLUSIONS: There is no significant relationship between mean SST during lumbar facet radiofrequency denervation and treatment outcome, which may be due to differences in general sensory perception. Because stimulation threshold was optimized for each patient, these data cannot be interpreted to suggest that sensory testing should not be performed, or that high sensory stimulation thresholds obtained on the first attempt should be deemed acceptable.


Assuntos
Denervação/métodos , Dor Lombar/terapia , Região Lombossacral/fisiologia , Tratamento por Radiofrequência Pulsada/métodos , Limiar Sensorial/fisiologia , Articulação Zigapofisária/fisiologia , Adulto , Idoso , Procedimentos Cirúrgicos Ambulatórios , Avaliação da Deficiência , Terapia por Estimulação Elétrica , Feminino , Seguimentos , Humanos , Dor Lombar/psicologia , Masculino , Pessoa de Meia-Idade , Militares , Medição da Dor , Limiar da Dor/fisiologia , Estudos Prospectivos , Curva ROC , Resultado do Tratamento
18.
Anesth Analg ; 110(2): 611-4, 2010 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-19917622

RESUMO

We report the cases of 4 patients who performed daily mirror therapy for 2 wk before undergoing elective limb amputation. One patient experienced no phantom limb pain (PLP). Two patients experienced rare episodes of mild PLP without effect on their participation in physical therapy (PT) or their quality of life. One patient reported daily, brief episodes of moderate PLP without effect on his participation in PT or his stated quality of life. These results indicate that preoperative mirror therapy may improve postamputation PT compliance and decrease the incidence of PLP. Future prospective studies are needed to confirm the results of this case series.


Assuntos
Amputação/efeitos adversos , Perna (Membro)/cirurgia , Militares , Dor/prevenção & controle , Membro Fantasma/prevenção & controle , Modalidades de Fisioterapia , Cuidados Pré-Operatórios , Explosões , Humanos , Traumatismos da Perna/cirurgia , Masculino , Dor/etiologia , Guerra , Adulto Jovem
19.
Mil Med ; 174(11): 1228-30, 2009 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-19960834

RESUMO

We present a 20-year-old previously healthy male who suffered a gunshot wound to the abdomen and underwent multiple surgeries because of abdominal abscess and fistula formation. Pain control was difficult to achieve despite high-dose opioid therapy. Post-traumatic stress disorder was a confounding factor in treating this patient's pain. Ten months after the original injury, the patient returned to the operating room for an exploratory laparotomy with restoration of bowel continuity and abdominal wall closure. The patient presented to the intensive care unit after a 12-hour operation with an open abdomen and the requirement of mechanical ventilation, sedation, and analgesia. Sedation and analgesia were difficult to achieve and maintain with combinations of extremely high doses of midazolam, lorazepam, propofol, and fentanyl (motor assessment activity scale [MAAS] scores of 5), but profoundly achievable with dexmedetomidine. Dexmedetomidine also improved the patient's mental stability, which resulted in improved patient care through compliance with physicians, nurses, and physical therapists.


Assuntos
Traumatismos Abdominais/cirurgia , Analgésicos não Entorpecentes/administração & dosagem , Dexmedetomidina/administração & dosagem , Ferimentos por Arma de Fogo/cirurgia , Fentanila/administração & dosagem , Humanos , Infusões Intravenosas , Lorazepam/administração & dosagem , Masculino , Midazolam/administração & dosagem , Militares , Medição da Dor , Propofol/administração & dosagem , Transtornos de Estresse Pós-Traumáticos/complicações , Adulto Jovem
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