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3.
Bioelectron Med ; 52019 Jun 28.
Artigo em Inglês | MEDLINE | ID: mdl-31435499

RESUMO

Well-established in the field of bioelectronic medicine, Spinal Cord Stimulation (SCS) offers an implantable, non-pharmacologic treatment for patients with intractable chronic pain conditions. Chronic pain is a widely heterogenous syndrome with regard to both pathophysiology and the resultant phenotype. Despite advances in our understanding of SCS-mediated antinociception, there still exists limited evidence clarifying the pathways recruited when patterned electric pulses are applied to the epidural space. The rapid clinical implementation of novel SCS methods including burst, high frequency and dorsal root ganglion SCS has provided the clinician with multiple options to treat refractory chronic pain. While compelling evidence for safety and efficacy exists in support of these novel paradigms, our understanding of their mechanisms of action (MOA) dramatically lags behind clinical data. In this review, we reconstruct the available basic science and clinical literature that offers support for mechanisms of both paresthesia spinal cord stimulation (P-SCS) and paresthesia-free spinal cord stimulation (PF-SCS). While P-SCS has been heavily examined since its inception, PF-SCS paradigms have recently been clinically approved with the support of limited preclinical research. Thus, wide knowledge gaps exist between their clinical efficacy and MOA. To close this gap, many rich investigative avenues for both P-SCS and PF-SCS are underway, which will further open the door for paradigm optimization, adjunctive therapies and new indications for SCS. As our understanding of these mechanisms evolves, clinicians will be empowered with the possibility of improving patient care using SCS to selectively target specific pathophysiological processes in chronic pain.

6.
Reg Anesth Pain Med ; 43(8): 869-874, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30346346

RESUMO

BACKGROUND AND OBJECTIVES: While existing studies about onabotulinumtoxinA for chronic migraines have focused on injection location and appropriate dosing, little consideration has been given to patient body habitus and its potential impact on efficacy. We hypothesized that with increasing patient body mass index (BMI) there would be more subcutaneous fat separating targeted muscle groups from the skin surface, such that standard 0.5-inch needles used in existing protocols may not allow intramuscular injection. This may have implications for treatment planning. METHODS: Anatomically normal computed tomography scans of the head, neck, and face were randomly selected. Subjects were stratified into 4 groups based on BMI, with 30 patients in each group. Four standardized locations were chosen to obtain measurements from the skin surface to the underlying muscle fascia, including (1) frontalis, (2) temporalis, (3) semispinalis capitis, and (4) trapezius. RESULTS: Median depth for the temporalis was 12.65 mm (Q1 = 9.32 mm, Q3 = 15.08 mm) for the BMI greater than 35 kg/m group. Median depth for the semispinalis capitis was 13.77 mm (Q1 = 10.3 mm, Q3 = 15.7 mm) for the BMI 30 to 35 kg/m group, and 14.75 mm (Q1 = 11.00, Q3 = 17.00 mm) for the BMI greater than 35 kg/m group. Median depth for the trapezius was 13.95 mm (Q1 = 10.18 mm, Q3 = 19.00 mm) for the BMI greater than 35 kg/m group. These medians exceeded the length of the standard 0.5-inch (12.-mm) needle used in existing protocols. CONCLUSIONS: Our study demonstrates that with increasing BMI there is a greater distance between the skin surface and the muscle fascia of muscles that are targeted for injection in standard chronic migraine botulinum toxin injection protocols. Because of this, patient body habitus may be an important factor in injection technique.


Assuntos
Pontos de Referência Anatômicos/diagnóstico por imagem , Toxinas Botulínicas Tipo A/administração & dosagem , Transtornos de Enxaqueca/diagnóstico por imagem , Transtornos de Enxaqueca/tratamento farmacológico , Músculos do Pescoço/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Pontos de Referência Anatômicos/anatomia & histologia , Doença Crônica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Músculos do Pescoço/anatomia & histologia , Músculos do Pescoço/efeitos dos fármacos , Projetos Piloto , Distribuição Aleatória , Tomografia Computadorizada por Raios X/métodos , Adulto Jovem
7.
Reg Anesth Pain Med ; 43(5): 456-466, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29870457

RESUMO

BACKGROUND: Ketamine infusions have been used for decades to treat acute pain, but a recent surge in usage has made the infusions a mainstay of treatment in emergency departments, in the perioperative period in individuals with refractory pain, and in opioid-tolerant patients. The widespread variability in patient selection, treatment parameters, and monitoring indicates a need for the creation of consensus guidelines. METHODS: The development of acute pain ketamine guidelines grew as a corollary from the genesis of chronic pain ketamine guidelines. The charge for the development of acute pain ketamine guidelines was provided by the Boards of Directors of both the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine, who approved the document along with the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters. The committee chair developed questions based on input from the committee during conference calls, which the committee then refined. Groups of 3 to 5 panel members and the committee chair were responsible for answering individual questions. After preliminary consensus was achieved, the entire committee made further revisions via e-mail and conference calls. RESULTS: Consensus guidelines were prepared in the following areas: indications, contraindications for acute pain and whether they differ from those for chronic pain, the evidence for the use of ketamine as an adjunct to opioid-based therapy, the evidence supporting patient-controlled ketamine analgesia, the use of nonparenteral forms of ketamine, and the subanesthetic dosage range and whether the evidence supports those dosages for acute pain. The group was able to reach consensus on the answers to all questions. CONCLUSIONS: Evidence supports the use of ketamine for acute pain in a variety of contexts, including as a stand-alone treatment, as an adjunct to opioids, and, to a lesser extent, as an intranasal formulation. Contraindications for acute pain are similar to those for chronic pain, partly based on the observation that the dosage ranges are similar. Larger studies evaluating different acute pain conditions are needed to enhance patient selection, determine the effectiveness of nonparenteral ketamine alternatives, define optimal treatment parameters, and develop protocols optimizing safety and access to care.


Assuntos
Dor Aguda/tratamento farmacológico , Analgésicos/administração & dosagem , Anestesiologistas/normas , Ketamina/administração & dosagem , Manejo da Dor/normas , Sociedades Médicas/normas , Dor Aguda/diagnóstico , Dor Aguda/epidemiologia , Anestesia por Condução/métodos , Anestesia por Condução/normas , Consenso , Humanos , Infusões Intravenosas , Manejo da Dor/métodos , Estados Unidos/epidemiologia
8.
Reg Anesth Pain Med ; 43(5): 521-546, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29870458

RESUMO

BACKGROUND: Over the past 2 decades, the use of intravenous ketamine infusions as a treatment for chronic pain has increased dramatically, with wide variation in patient selection, dosing, and monitoring. This has led to a chorus of calls from various sources for the development of consensus guidelines. METHODS: In November 2016, the charge for developing consensus guidelines was approved by the boards of directors of the American Society of Regional Anesthesia and Pain Medicine and, shortly thereafter, the American Academy of Pain Medicine. In late 2017, the completed document was sent to the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters, after which additional modifications were made. Panel members were selected by the committee chair and both boards of directors based on their expertise in evaluating clinical trials, past research experience, and clinical experience in developing protocols and treating patients with ketamine. Questions were developed and refined by the committee, and the groups responsible for addressing each question consisted of modules composed of 3 to 5 panel members in addition to the committee chair. Once a preliminary consensus was achieved, sections were sent to the entire panel, and further revisions were made. In addition to consensus guidelines, a comprehensive narrative review was performed, which formed part of the basis for guidelines. RESULTS: Guidelines were prepared for the following areas: indications; contraindications; whether there was evidence for a dose-response relationship, or a minimum or therapeutic dose range; whether oral ketamine or another N-methyl-D-aspartate receptor antagonist was a reasonable treatment option as a follow-up to infusions; preinfusion testing requirements; settings and personnel necessary to administer and monitor treatment; the use of preemptive and rescue medications to address adverse effects; and what constitutes a positive treatment response. The group was able to reach consensus on all questions. CONCLUSIONS: Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. Adverse effects were few and the rate of serious adverse effects was similar to placebo in most studies, with higher dosages and more frequent infusions associated with greater risks. Larger studies, evaluating a wider variety of conditions, are needed to better quantify efficacy, improve patient selection, refine the therapeutic dose range, determine the effectiveness of nonintravenous ketamine alternatives, and develop a greater understanding of the long-term risks of repeated treatments.


Assuntos
Anestesia por Condução/normas , Anestesiologistas/normas , Dor Crônica/tratamento farmacológico , Ketamina/administração & dosagem , Manejo da Dor/normas , Guias de Prática Clínica como Assunto/normas , Sociedades Médicas/normas , Analgésicos/administração & dosagem , Anestesia por Condução/métodos , Dor Crônica/epidemiologia , Consenso , Humanos , Infusões Intravenosas , Manejo da Dor/métodos , Estados Unidos/epidemiologia
10.
Reg Anesth Pain Med ; 43(3): 225-262, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29278603

RESUMO

The American Society of Regional Anesthesia and Pain Medicine (ASRA) 2012 survey of meeting attendees showed that existing ASRA anticoagulation guidelines for regional anesthesia were insufficient for their needs. Those surveyed agreed that procedure-specific and patient-specific factors required separate guidelines for pain and spine procedures. In response, a guidelines committee was formed. After preliminary review of published complications reports and studies, the committee stratified interventional spine and pain procedures according to potential bleeding risk: low-, intermediate-, and high-risk procedures. The ASRA regional anesthesia anticoagulation guidelines were largely deemed appropriate for the low- and intermediate-risk categories, but the high-risk category required further investigation. The first guidelines specific to interventional spine and pain procedures were published in 2015. Recent reviews evaluating bleeding complications in patients undergoing specific interventional pain procedures, the development of new regional anesthesia and acute pain guidelines, and the development of new anticoagulants and antiplatelet medications necessitate complementary updated guidelines. The authors desired coordination with the authors of the recently updated regional and acute pain anticoagulation guidelines. The latest evidence was sought through extensive database search strategies and the recommendations were evidence based when available and pharmacology driven otherwise. We could not provide strength and grading of these recommendations because there are not enough well-designed large studies concerning interventional pain procedures to support such grading. Although the guidelines could not always be based on randomized studies or on large numbers of patients from pooled databases, it is hoped that they will provide sound recommendations and the evidentiary basis for such recommendations. This publication is intended as a living document to be updated periodically with consideration of new evidence.


Assuntos
Anestesia por Condução/normas , Anticoagulantes/administração & dosagem , Dor Crônica/cirurgia , Procedimentos Ortopédicos/normas , Manejo da Dor/normas , Dor Pós-Operatória/prevenção & controle , Assistência Perioperatória/normas , Inibidores da Agregação de Plaquetas/administração & dosagem , Coluna Vertebral/cirurgia , Anestesia por Condução/efeitos adversos , Anticoagulantes/efeitos adversos , Perda Sanguínea Cirúrgica/prevenção & controle , Dor Crônica/diagnóstico , Dor Crônica/fisiopatologia , Consenso , Esquema de Medicação , Humanos , Procedimentos Ortopédicos/efeitos adversos , Manejo da Dor/efeitos adversos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/fisiopatologia , Inibidores da Agregação de Plaquetas/efeitos adversos , Hemorragia Pós-Operatória/induzido quimicamente , Hemorragia Pós-Operatória/prevenção & controle , Padrões de Prática Médica/normas , Fatores de Risco , Resultado do Tratamento , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle
13.
Ochsner J ; 17(2): 199-203, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28638296

RESUMO

BACKGROUND: Complex regional pain syndrome (CRPS) comprises a group of conditions characterized by severe, debilitating pain that is disproportionate to any inciting event and is not distributed in a specific nerve distribution or dermatome. CASE REPORT: A 42-year-old female with a 2-year history of right upper extremity CRPS type I refractory to conventional management underwent an ultrasound-guided and fluoroscopy confirmed percutaneous peripheral nerve stimulation trial with a lead extending from the C6 to the T3 level to cover the cervical and upper thoracic sympathetic chain. The patient subsequently received a permanent ultrasound-guided lead and implantable pulse generator. At 1-month follow-up, the patient's pain intensity had declined from a weekly average of 8/10 to 1/10 on the verbal pain scale with marked improvement in function. The patient continues to be pain-free or experiences only minimal discomfort 7 years after the implant. She experienced no complications and has discontinued all her pain medications since the implant. CONCLUSION: The placement of a peripheral nerve-stimulating electrode resulted in sustained suppression of intractable pain secondary to CRPS. Ultrasonography guidance enabled the nonsurgical minimally invasive percutaneous approach. Use of ultrasonography may improve the safety of the procedure by permitting direct visualization of the related anatomic structures, thereby reducing the risk of injury to the inferior thyroid artery, vertebral artery, esophagus, intervertebral disc, and pleura.

14.
Neuromodulation ; 20(1): 51-62, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28042905

RESUMO

INTRODUCTION: The Neurostimulation Appropriateness Consensus Committee (NACC) was formed by the International Neuromodulation Society (INS) in 2012 to evaluate the evidence to reduce the risk of complications and improve the efficacy of neurostimulation. The first series of papers, published in 2014, focused on the general principles of appropriate practice in the surgical implantation of neurostimulation devices. The NACC was reconvened in 2014 to address specific patient care issues, including bleeding and coagulation. METHODS: The INS strives to improve patient care in an evidence-based fashion. The NACC members were appointed or recruited by the INS leadership for diverse expertise, including international clinical expertise in many areas of neurostimulation, evidence evaluation, and publication. The group developed best practices based on peer-reviewed evidence and, in the absence of specific evidence, on expert opinion. Recommendations were based on international evidence in accordance with guideline creation. CONCLUSIONS: The NACC has recommended specific measures to reduce the risk of bleeding and neurological injury secondary to impairment of coagulation in the setting of implantable neurostimulation devices in the spine, brain, and periphery.


Assuntos
Transtornos da Coagulação Sanguínea/terapia , Consenso , Gerenciamento Clínico , Terapia por Estimulação Elétrica , Hemorragia/terapia , Comitê de Profissionais/normas , Transtornos da Coagulação Sanguínea/etiologia , Terapia por Estimulação Elétrica/efeitos adversos , Terapia por Estimulação Elétrica/instrumentação , Terapia por Estimulação Elétrica/métodos , Medicina Baseada em Evidências , Hemorragia/etiologia , Humanos
15.
Neuromodulation ; 20(1): 31-50, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28042909

RESUMO

INTRODUCTION: The use of neurostimulation for pain has been an established therapy for many decades and is a major tool in the arsenal to treat neuropathic pain syndromes. Level I evidence has recently been presented to substantiate the therapy, but this is balanced against the risk of complications of an interventional technique. METHODS: The Neurostimulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society convened an international panel of well published and diverse physicians to examine the best practices for infection mitigation and management in patients undergoing neurostimulation. The NACC recommendations are based on evidence scoring and peer-reviewed literature. Where evidence is lacking the panel added expert opinion to establish recommendations. RESULTS: The NACC has made recommendations to improve care by reducing infection and managing this complication when it occurs. These evidence-based recommendations should be considered best practices in the clinical implantation of neurostimulation devices. CONCLUSION: Adhering to established standards can improve patient care and reduce the morbidity and mortality of infectious complications in patients receiving neurostimulation.


Assuntos
Consenso , Terapia por Estimulação Elétrica/efeitos adversos , Controle de Infecções/normas , Guias de Prática Clínica como Assunto , Comitê de Profissionais/normas , Humanos , Controle de Infecções/métodos , Neuralgia/terapia
16.
Neuromodulation ; 20(1): 15-30, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28042918

RESUMO

INTRODUCTION: Neurostimulation involves the implantation of devices to stimulate the brain, spinal cord, or peripheral or cranial nerves for the purpose of modulating the neural activity of the targeted structures to achieve specific therapeutic effects. Surgical placement of neurostimulation devices is associated with risks of neurologic injury, as well as possible sequelae from the local or systemic effects of the intervention. The goal of the Neurostimulation Appropriateness Consensus Committee (NACC) is to improve the safety of neurostimulation. METHODS: The International Neuromodulation Society (INS) is dedicated to improving neurostimulation efficacy and patient safety. Over the past two decades the INS has established a process to use best evidence to improve care. This article updates work published by the NACC in 2014. NACC authors were chosen based on nomination to the INS executive board and were selected based on publications, academic acumen, international impact, and diversity. In areas in which evidence was lacking, the NACC used expert opinion to reach consensus. RESULTS: The INS has developed recommendations that when properly utilized should improve patient safety and reduce the risk of injury and associated complications with implantable devices. CONCLUSIONS: On behalf of INS, the NACC has published recommendations intended to reduce the risk of neurological injuries and complications while implanting stimulators.


Assuntos
Consenso , Terapia por Estimulação Elétrica/métodos , Terapia por Estimulação Elétrica/normas , Doenças do Sistema Nervoso/terapia , Guias de Prática Clínica como Assunto , Comitê de Profissionais/normas , Medicina Baseada em Evidências , Humanos
18.
Headache ; 56(4): 801-7, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26997206

RESUMO

BACKGROUND: Occipital neuralgia is a form of neuropathic type of pain in the distribution of the greater, lesser, or third occipital nerves. Patients with intractable occipital neuralgia do not respond well to conservative treatment modalities. This group of patients represents a significant therapeutic challenge and may require interventional or invasive therapeutic approaches. PURPOSE: Occipital neuralgia frequently occurs as a result of nerve entrapment or irritation by a tight muscle or vascular structure, or nerve trauma during whiplash injury. Although the entrapment theory is most commonly accepted, it lacks strong clinical evidence to support it. Accordingly, the available interventional approaches have been targeting the accessible part of the occipital nerve rather than the entrapped part. CONCLUSION: Bedside sonography is an excellent imaging modality for soft tissue structures. Ultrasound not only allows distinguishing normal from abnormal entrapped occipital nerves, it can identify the level and the cause of entrapment as well. Ultrasound guidance allows precise occipital nerve blocks and interventions at the level of the "specific" entrapment location rather than into the site of "presumed" entrapment.


Assuntos
Neuralgia/diagnóstico , Neuralgia/etiologia , Neuralgia/terapia , Humanos , Síndromes de Compressão Nervosa/complicações , Lobo Occipital , Nervos Periféricos
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