Painful boney metastases.

Up to 90% of patients with metastatic or advanced stage cancer will experience significant cancer-related pain. Approximately half or more of patients diagnosed with cancer may experience bone pain. It has been estimated that tumor metastases to the skeleton affects roughly 400,000 US citizens annually. Carcinoma from breast, lung, and prostate cancers account for approximately 80% of secondary metastatic bone disease. Bone metastases may cause devastating clinical complications associated with dramatic reductions in quality of life, mobility, and independence, as well as excruciating refractory pain. Associated complications from osseous metastases also present a substantial economic burden. Currently, there are still a significantly high number of patients suffering with unrelieved pain from osseous metastases. Treatments for painful osseous metastases may not only diminish pain but also may improve quality of life and independence/mobility, and reduce skeletal morbidity, potential pathologic fractures, spinal cord compression, and other "skeletal-related events." Treatment strategies for painful osseous metastases include the following: systemic analgesics, intrathecal analgesics, glucocorticoids, radiation (external beam radiation, radiopharmaceuticals), ablative techniques (radiofrequency ablation and cryoablation), bisphosphonates, chemotherapeutic agents, inhibitors of RANKL-RANK interaction (eg, denosumab), hormonal therapies, interventional techniques (eg, kyphoplasty), and surgical approaches. Although the mechanisms underlying the development of bone metastases remain incompletely understood, there appears to be important bi-directional interactions between the tumor and the bone microenvironment. A greater understanding of the pathophysiology of painful osseous metastases may lead to better and more selective targeted analgesic therapy. Additionally, potential future therapeutic approaches to painful osseous metastases may revolutionize approaches to analgesia for this condition, leading to optimal outcomes with maximal pain relief and minimal adverse effects.

Cervical radicular pain: the role of interlaminar and transforaminal epidural injections.

Chronic neck pain and cervical radicular pain are relatively common in the adult population. Treatment for chronic radicular pain recalcitrant to conservative management includes surgical management as well as interventional techniques with epidural injections utilizing either an interlaminar approach or transforaminal approach. Although there have been multiple systematic reviews and randomized clinical trials of cervical interlaminar epidural injections, the literature is sparse in reference to cervical transforaminal epidural injections. Overall, there is good evidence for the effectiveness of cervical interlaminar epidural injections in managing cervical disc herniation and fair evidence in managing central spinal stenosis and postsurgery syndrome. The evidence is poor, however, for cervical transforaminal epidural injections. Complications with cervical interlaminar epidural injections are rare, but more commonly occur with transforaminal epidural injections and can be fatal. Emerging concepts in pain include further randomized trials; proper placebo design; focus on control design (either active control or placebo control); and appropriate methodologic quality assessment and evidence synthesis.

Buprenorphine in the treatment of non-suicidal self-injury: a case series and discussion of the literature.

A global public health problem, non-suicidal self-injury (NSSI) is highly prevalent in both males and females, and tends to first occur in adolescence. NSSI is correlated with a history of childhood trauma, and with a variety of developmental and psychiatric disorders. NSSI is associated with increased risk of morbidity and premature death from suicide, accidents, and natural causes. Current treatment approaches are inadequate for a substantial number of people. Converging evidence for opioid system dysregulation in individuals with NSSI make this a promising area of investigation for more effective treatments. The pharmacological profile of buprenorphine, a potent µ-opioid partial agonist and κ-opioid antagonist, suggests that it may be beneficial. In this paper, we describe the successful treatment of severe NSSI with buprenorphine in six individuals, followed by discussion and further recommendations.

Personalized pharmacotherapy for treatment approaches focused at primary insomnia.

The treatment of primary insomnia may be complex and clinically challenging. A comprehensive multidimensional evaluation with a thorough history and physical examination coupled with appropriate testing/imaging will facilitate development of a working diagnosis. Optimal treatment strategies of challenging cases typically involve interdisciplinary team approaches (including a sleep medicine specialist) providing multimodal approaches to treatment, including nonpharmacologic and pharmacologic strategies. A stepped care approach to treatment may serve as a useful guide for health care providers unfamiliar with sleep disturbance issues. Treatment plans based on sound medical judgment, clinical insight, and a thorough and global understanding of particular patient's comorbid conditions may lead to optimal patient-specific/patient-focused/patient centered personalized care.

Perioperative intravenous acetaminophen and NSAIDs.

BACKGROUND: Unrelieved postoperative pain may result in pain/suffering, as well as multiple physiological and psychological consequences (e.g., splinting, impaired gastrointestinal motility/ileus, and impaired wound healing) which may adversely affect perioperative outcomes and contribute to increased length of stay. Multimodal or balanced analgesia, utilizing regional analgesic techniques (where possible) and nonopioid analgesics appear to represent a viable strategy to decrease systemic opioid consumption and improve postoperative analgesia. The use of multimodal analgesic strategies may result in reduced frequency and severity of unwanted opioid-related adverse effects, better clinically meaningful pain relief, diminished opioid consumption, and an overall improvement of patient satisfaction as well as health outcomes (e.g., earlier ambulation and discharge). OBJECTIVES: Review key aspects of intravenous (i.v.) acetaminophen (APAP) use in the postoperative setting. DESIGN: Focused literature review. RESULTS: Intravenous APAP is safe, effective for mild-to-moderate postoperative pain, well-tolerated, and has a very favorable side effect profile with no clearly demonstrated clinically significant drug-drug interactions. It does not exhibit any significant effects on platelet aggregation and therefore may be the preferred nonopioid analgesic when surgical bleeding is an issue. CONCLUSION: The i.v. formulation of APAP represents a safe and effective first-line analgesic agent for the treatment of acute mild-to-moderate pain in the perioperative setting when oral agents may be impractical or when rapid onset with predictable therapeutic dosing is required.

Fibromyalgia syndrome: a discussion of the syndrome and pharmacotherapy.

Fibromyalgia is a complex condition that is characterized by chronic widespread pain and multiple other symptoms, including fatigue, sleep disturbances, cognitive dysfunction, stiffness, and depressive episodes. Fibromyalgia may coexist and/or overlap with other conditions that may involve central sensitivity, including chronic fatigue syndrome, irritable bowel syndrome, irritable bladder syndrome or interstitial cystitis, and temporomandibular disorder. The pathophysiology of fibromyalgia remains uncertain but is believed to be partly the result of central systems affecting afferent processing as well as impaired endogenous pain-inhibitory systems. Abnormal central nociceptive processing may contribute to fibromyalgia, producing heightened responses to various noxious stimuli with resulting mechanical hyperalgesia. Fibromyalgia remains a clinical diagnosis. There has been a recent paradigm shift away from requiring 11 or more out of 18 tender points and instead focusing on the presence of chronic widespread pain as well as symptoms of fatigue, unrefreshed sleep, and other somatic complaints. Although there is no known cure for fibromyalgia, multidisciplinary team efforts using combined treatment approaches, including patient education, aerobic exercise, cognitive behavioral therapy, and pharmacologic therapies (serotonin norepinephrine reuptake inhibitors [eg, duloxetine, milnacipran] and alpha 2-delta receptor ligands [eg, pregabalin]) may improve symptoms as well as function of patients with fibromyalgia.

Explosive growth of facet joint interventions in the Medicare population in the United States: a comparative evaluation of 1997, 2002, and 2006 data.

BACKGROUND: The Office of Inspector General of the Department of Health and Human Services (OIG-DHHS) issued a report which showed explosive growth and also raised questions of lack of medical necessity and/or indications for facet joint injection services in 2006.The purpose of the study was to determine trends of frequency and cost of facet joint interventions in managing spinal pain. METHODS: This analysis was performed to determine trends of frequency and cost of facet jointInterventions in managing spinal pain, utilizing the annual 5% national sample of the Centers forMedicare and Medicaid Services (CMS) for 1997, 2002, and 2006.Outcome measures included overall characteristics of Medicare beneficiaries receiving facet joint interventions, utilization of facet joint interventions by place of service, by specialty, reimbursement characteristics, and other variables. RESULTS: From 1997 to 2006, the number of patients receiving facet joint interventions per 100,000Medicare population increased 386%, facet joint visits increased 446%, and facet joint interventions increased 543%. The increases were higher in patients aged less than 65 years compared to those 65 or older with patients increasing 504% vs. 355%, visits increasing 587% vs. 404%, and services increasing 683% vs. 498%.Total expenditures for facet joint interventions in the Medicare population increased from over $229 million in 2002 to over $511 million in 2006, with an overall increase of 123%. In 2006, there was a 26.8-fold difference in utilization of facet joint intervention services in Florida compared to the state with the lowest utilization - Hawaii.There was an annual increase of 277.3% in the utilization of facet joint interventions by general physicians, whereas a 99.5% annual increase was seen for nurse practitioners (NPs) and certified registered nurse anesthetists (CRNAs) from 2002 to 2006. Further, in Florida, 47% of facet joint interventions were performed by general physicians. CONCLUSIONS: The reported explosive growth of facet joint interventions in managing spinal pain in certain regions and by certain specialties may result in increased regulations and scrutiny with reduced access.

Potential analgesic mechanisms of acetaminophen.

Despite nearing the end of the decade of pain research, the analgesic mechanisms of one of the most widely used and popular analgesics remains uncertain. Acetaminophen (APAP) (paracetamol [PARA]) has been used clinically for over a half of a century and although clinicians seem to be comfortable with its benefits, risks, and limitations, they still remain in the dark as to precisely what is providing its pain relief. What does seem clearer is that the predominant mechanisms of APAP's analgesic effects are in the central nervous system (CNS). Although, which central effects are largely responsible for APAP's effects on pain continue to be uncertain. Perhaps, the most accepted theory is that of APAP's positive effects on the serotonergic descending inhibitory pathways. However, interactions with opioidergic systems, eicosanoid systems, and/or nitric oxide containing pathways may be involved as well. Furthermore, endocannabinoid signaling may play a role in APAP's activation of the serotonergic descending inhibitory pathways. A greater understanding of APAP's analgesic mechanisms may promote optimal utilization of analgesic polypharmacy.

Evidence-based medicine, systematic reviews, and guidelines in interventional pain management: part 4: observational studies.

Evidence-based medicine (EBM) stresses the examination of evidence from clinical research and describes it as a shift in medical paradigms, in contrast to intuition, unsystematic clinical experience, and pathophysiologic rationale. While the importance of randomized trials has been created by the concept of the hierarchy of evidence in guiding therapy, much of the medical research is observational. There is competition, contrast, and a feeling of inferiority and uselessness for observational studies, created by a lack of understanding of medical research. However, observational studies and randomized clinical trials (RCTs) can be viewed as the steps of observation and experimentation that form the basis of the scientific methodology. Further, rational healthcare practices require knowledge about the etiology and pathogenesis, diagnosis, prognosis, and treatment of disorders. The reporting of observational research is often not detailed and clear enough with insufficient quality and poor reporting, which hampers the assessment of strengths and weaknesses of the study and the generalizability of the mixed results. Thus, design, implementation, and reporting of observational studies is crucial. The biased interpretation of results from observational studies, either in favor of or opposed to a treatment, and lack of proper understanding of observational studies, leads to a poor appraisal of the quality. Similar to the Consolidated Standards of Reporting Trials (CONSORT) statement for the reporting of randomized trials, the Strengthening of the Reporting of Observational Studies in Epidemiology (STROBE) statement was developed with recommendations to improve the quality of reporting observational studies. The STROBE statement consists of a checklist of 22 items, which relate to the title, abstract, introduction, methods, results, and discussion sections of articles. Multiple types of observational studies are conducted; however, 3 types have been highlighted in the STROBE document and also in the present review, which include cohort studies, case-controlled studies, and cross-sectional studies. This comprehensive review provides an introduction and rationale, types, design, and reporting of observational studies; outcomes assessment and data presentation and analysis; statistical analysis, results, and a discussion of observational studies.

Systematic review of therapeutic lumbar transforaminal epidural steroid injections.

BACKGROUND: Epidural injection of corticosteroids is one of the most commonly used interventions in managing chronic spinal pain. The transforaminal route to the lumbar epidural space for steroid injection has gained rapid and widespread acceptance for the treatment of lumbar and leg pain. However, there are few well-designed randomized, controlled studies to determine the effectiveness of epidural injections. The role and value of transforaminal lumbar epidural steroid injections is still questioned. STUDY DESIGN: A systematic review of transforaminal epidural injection therapy for low back and lower extremity pain. OBJECTIVE: To evaluate the effect of transforaminal lumbar epidural steroid injections in managing lumbar (low-back) and sciatica (leg) pain. METHODS: The available literature of lumbar transforaminal epidural injections in managing chronic low back and lower extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to November 2008, and manual searches of the bibliographies of known primary and review articles. OUTCOME MEASURES: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. RESULTS: The indicated evidence is Level II-1 for short-term relief and Level II-2 for long-term relief in managing chronic low back and lower extremity pain. LIMITATIONS: The limitations of this systematic review include the paucity of literature. CONCLUSION: The indicated evidence for transforaminal lumbar epidural steroid injections is Level II-1 for short-term relief and Level II-2 for long-term improvement in the management of lumbar nerve root and low back pain.

Analysis of growth of interventional techniques in managing chronic pain in the Medicare population: a 10-year evaluation from 1997 to 2006.

BACKGROUND: Recent reports of the United States Government Accountability Office (GAO), the Medicare Payment Advisory Commission (MedPAC), and the Office of Inspector General (OIG) expressed significant concern with overall fiscal sustainability of Medicare and exponential increase in costs for interventional pain management techniques. Interventional pain management (IPM) is an evolving specialty amenable to multiple influences. Evaluation and isolation of appropriate factors for increasing growth patterns have not been performed. STUDY DESIGN: Analysis of the growth of interventional techniques in managing chronic pain in Medicare beneficiaries from 1997 to 2006. OBJECTIVE: To evaluate the use of all interventional techniques. METHODS: The standard 5% national sample of the CMS carrier claim record data for 1997, 2002, and 2006 was utilized. This data set provides information on Medicare enrollees in the fee-for-service Medicare program. Current procedural technology (CPT) codes for 1997, 2002, and 2006 were used to identify the number of procedures performed each year, and trends in expenditures. RESULTS: Interventional techniques increased significantly in Medicare beneficiaries from 1997 to 2006. Overall, there was an increase of 137% in patients utilizing IPM services with an increase of 197% in IPM services, per 100,000 Medicare beneficiaries. The majority of the increases were attributed to exponential growth in the performance of facet joint interventions. There was a 13.9-fold difference in the increase between the state with the lowest rate and the state with the highest rate in utilization patterns of interventional techniques (California 37% vs. Connecticut 514%), with an 11.6-fold difference between Florida and California (431% vs. 37% increase). In 2006, Florida showed a 12.7-fold difference compared to Hawaii with the lowest utilization rate. Hospital outpatient department (HOPD) expenses constituted the highest increase with fewer patients treated either in an ambulatory surgery center (ASC) or in-office setting. Overall HOPD payments constituted 5% of total 2006 Medicare payments, in contrast to 57% of total IPM payments, an 11.4-fold difference. LIMITATIONS: The limitations of this study include a lack of inclusion of Medicare participants in Medicare Advantage plans and potential documentation, coding, and billing errors. CONCLUSION: This study shows an overall increase of IPM services of 197% compared to an increase of 137% in patients utilizing IPM services from 1997 to 2006.

Systematic review of the role of sedation in diagnostic spinal interventional techniques.

BACKGROUND: There is ongoing controversy regarding the validity of controlled diagnostic blocks due to variability in sensitivity, specificity, and accuracy. Consequently, identification of false-positive rates, false-negative rates, and placebo responses is crucial. The reasons described for false-positive responses to diagnostic anesthetic blocks are many; however, sedation and psychological factors have been implied as causes. Further, there is no consensus with regards to sedation prior to controlled diagnostic blocks and their influence on the accuracy and validity of a diagnosis. STUDY DESIGN: A systematic review of the literature evaluating the influence of sedation on diagnostic spinal interventional techniques. OBJECTIVES: To systematically assess the quality of clinical studies evaluating the diagnostic accuracy of controlled diagnostic blocks in the diagnosis of chronic spinal pain. METHODS: A comprehensive evaluation of the literature relating to sedation in diagnostic interventional techniques was performed. The methodologic quality assessment of the studies was carried out by utilizing Agency for Healthcare Research and Quality (AHRQ) methodologic quality criteria with scores of 50 or higher included in the assessment of the level of evidence. Level of evidence was based on the U.S. Preventive Services Task Force (USPSTF) criteria for the assessment of accuracy of diagnostic studies. LIMITATIONS: All 3 of the studies were produced by one group of authors. Thus paucity of the literature on the subject of facet joint pain and the lack of literature on the subjects of discogenic pain and sacroiliac joint pain are major limitations. RESULTS: Three studies were identified which met inclusion and methodologic assessment quality criteria. Sedation can be a confounding factor in a small population of patients specifically if fentanyl is employed and non-stringent criteria are followed. Based on the 3 randomized double-blind trials with stringent criteria utilizing 80% pain relief and the ability to perform prior painful movements without any significant pain following the diagnostic injection in evaluation of facet joint pain, the indicated evidence is Level II-1. CONCLUSION: This systematic review provides no significant evidence of the influence of sedation either with midazolam or fentanyl in the evaluation of cervical and lumbar facet joint pain with controlled cervical and lumbar facet joint nerve blocks with an indicated evidence of Level II-1, with application of stringent criteria of at least 80% pain relief and the ability to perform previously painful movements after the diagnostic blocks.

Systematic review of intrathecal infusion systems for long-term management of chronic non-cancer pain.

BACKGROUND: Disability, societal, and health impact of chronic intractable pain secondary to various failed therapies is a major issue. As advanced therapy, implantable therapies, which include intrathecal devices and spinal cord stimulation systems, are frequently used in managing chronic intractable pain. Thus, continuous infusion of intrathecal medication is one of the methods used for the control of chronic, refractory, cancer, and non-cancer pain. However, despite the high costs of chronic non-cancer pain, it has been claimed that there is a lack of evidence for intrathecal infusion systems and the cost effectiveness of these systems has been questioned in improving pain and function. STUDY DESIGN: A systematic review of intrathecal infusion devices for chronic non-cancer pain. OBJECTIVE: To determine the efficacy, utilization, safety, and complications associated with the use of intrathecal infusion devices for long-term management of chronic non-cancer pain. METHODS: Literature search was performed through EMBASE, Medline, Cochrane databases, and systematic reviews identified from 1966 to December 2008. Studies were then reviewed and assessed using the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies and the Cochrane Musculoskeletal Review Group criteria for randomized trials. The level of evidence was determined using 5 levels of evidence, ranging from Level I to III with 3 subcategories in Level II, based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). OUTCOME MEASURES: The primary outcome measure was pain relief (short-term relief < or = one-year and long-term > one-year). Secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake were also utilized. RESULTS: The level of evidence for intrathecal infusion systems indicated either Level II-3 or Level III (limited) based on U.S. Preventive Services Task Force (USPSTF) criteria. LIMITATIONS: The limitations of this study include the paucity of literature, lack of quality evidence, and lack of randomized trials. CONCLUSION: This systematic review illustrates Level II-3 or Level III (limited) evidence for intrathecal infusion systems for long-term relief in chronic non-cancer pain.

Systematic review of percutaneous adhesiolysis and management of chronic low back pain in post lumbar surgery syndrome.

BACKGROUND: Post lumbar surgery syndrome or failed back surgery syndrome with persistent pain continues to increase over the years. The speculated causes of post lumbar laminectomy syndrome include acquired stenosis, epidural fibrosis, arachnoiditis, radiculopathy, and recurrent disc herniation. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome. Percutaneous epidural adhesiolysis has been employed in interventional pain management in the treatment of chronic, refractory low back and lower extremity pain after back surgery. STUDY DESIGN: A systematic review of randomized trials and observational studies. OBJECTIVE: To evaluate the effectiveness of percutaneous adhesiolysis in managing chronic low back and lower extremity pain due to post lumbar surgery syndrome. METHODS: A comprehensive literature search was conducted utilizing electronic databases, as well as systematic reviews and cross references from 1966 through December 2008. The quality of individual articles used in this analysis was assessed by modified Cochrane review criteria for randomized trials and the Agency for Healthcare Research and Quality (AHRQ) criteria for assessment of observational studies. Clinical relevance was evaluated using 5 questions according to the criteria recommended by the Cochrane Review Back Group. Analysis was conducted using 5 levels of evidence, ranging from Level I to III, with 3 subcategories in Level II. OUTCOME PARAMETERS: The primary outcome measure was pain relief (short-term relief of at least 6 months and long-term relief of more than 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and change in opioid intake. RESULTS: Of the 13 studies considered for inclusion, 3 randomized trials and 4 observational studies met the inclusion criteria for methodologic quality assessment and evidence synthesis based on methodologic quality scores of 50 or more. Evidence of percutaneous adhesiolysis in the management of chronic low back pain in post-lumbar surgery syndrome is Level I to Level II-1, with evidence derived from 3 randomized trials. LIMITATIONS: There is a paucity of efficacy and pragmatic trials. No trials have been published after 2006. CONCLUSION: The indicated level of evidence for percutaneous adhesiolysis is Level I or II-1 based on the US Preventative Services Task Force (USPSTF) criteria.

Effectiveness of spinal endoscopic adhesiolysis in post lumbar surgery syndrome: a systematic review.

BACKGROUND: Post lumbar surgery syndrome with persistent chronic low back and lower extremity pain is common in the United States. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome (FBSS). Percutaneous adhesiolysis with a catheter or direct visualization of the spinal canal and the contents with an endoscope are techniques employed in resistant cases when patients fail to respond to conservative modalities of treatment, including fluoroscopically directed epidural injections. Some patients failing to respond to percutaneous adhesiolysis are candidates for spinal endoscopic adhesiolysis. However, literature evaluating the effectiveness of spinal endoscopic adhesiolysis is sparse and discussions continue about its effectiveness, utility, and complications. STUDY DESIGN: A systematic review of the available literature. OBJECTIVE: To evaluate the effectiveness and safety of spinal endoscopic adhesiolysis in the management of chronic low back and lower extremity pain in post surgical patients with chronic recalcitrant pain, non-responsive to conservative modalities of management and fluoroscopically directed epidural injections. METHODS: A search of relevant resources (PubMed, EMBASE, and the Cochrane database) was accomplished and the resulting publications were examined based on the inclusion/exclusion criteria set forth. Randomized controlled trials and observational studies were included in the search. Two reviewers assessed the studies' methodologies and outcomes. Randomized clinical trials were assessed and scored based on the criteria established by the Cochrane methodological assessment criteria of randomized clinical trials and the observational studies were assessed and scored based on the Agency for Healthcare Research and Quality (AHRQ) criteria. Clinical relevance was evaluated utilizing Cochrane review criteria. Analysis was conducted using 5 levels of evidence, ranging from Level I to III, with 3 subcategories in Level II. OUTCOME MEASURES: The primary outcome measure was pain relief (> or = 50%) in follow-up for at least 6 months. Pain relief for longer than 6 months was considered long-term and 6 months or less was considered short-term. The secondary outcome measures were functional and psychological status, return to work, patient satisfaction, and opioid intake. RESULTS: Of the 13 studies considered for inclusion, one randomized trial and 5 observational studies met inclusion criteria for evidence synthesis based on the inclusion criteria and methodologic quality scores of 50 or more. The indicated level of evidence for endoscopic adhesiolysis is Level II-1 or II-2 evidence for short- and long-term relief based on the U.S. Preventive Services Task Force (USPSTF) criteria. LIMITATIONS: There was a paucity of literature for randomized trials. CONCLUSION: Spinal endoscopic adhesiolysis may be used as an effective treatment modality for chronic refractory low back pain and radiculopathy that is related to epidural adhesions.

Spinal cord stimulation for patients with failed back surgery syndrome: a systematic review.

BACKGROUND: Failed back surgery syndrome is common in the United States. Management of post lumbar surgery syndrome with multiple modalities includes interventional techniques, resulting in moderate improvement, leaving a proportion of patients in intractable pain. The systematic reviews of long-term benefits and risks of spinal cord stimulation (SCS) for patients with failed back surgery syndrome showed limited to moderate evidence and cost effectiveness. However, with the exponential increase in surgery in the United States, spinal cord implants are also increasing. Thus, the discussion continues with claims of lack of evidence on one hand and escalating increases in utilization on the other hand. STUDY DESIGN: A systematic review of SCS in patients with failed back surgery syndrome. OBJECTIVES: This systematic review is undertaken to examine the evidence from randomized controlled trials (RCTs) and observational studies to evaluate the effectiveness of SCS in post lumbar surgery syndrome and to demonstrate clinical and cost effectiveness. METHODS: Review of the literature was performed according to the Cochrane Musculoskeletal Review Group Criteria as utilized for interventional techniques for randomized trials and the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies. The 5 levels of evidence were classified as Level I, II, or III with 3 subcategories in Level II based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to December 2008, and manual searches of bibliographies of known primary and review articles. OUTCOME MEASURES: The primary outcome measure was pain relief (short-term relief < or = one-year and long-term > one-year). Secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake were utilized. RESULTS: The indicated evidence is Level II-1 or II-2 for long-term relief in managing patients with failed back surgery syndrome. LIMITATIONS: The limitations of this review included the paucity and heterogeneity of the literature. CONCLUSION: This systematic review evaluating the effectiveness of SCS in relieving chronic intractable pain of failed back surgery syndrome indicated the evidence to be Level II-1 or II-2 for clinical use on a long-term basis.

Overview of pain management in older persons.

The purpose of this article is to situate the social and demographic context of pain management in older adults. It summarizes representative literature on the age and sex composition of pain among older adults and considers sources of assessment bias that likely lead to the conflicting descriptions of prevalence. It also describes treatment options that are both available and acceptable to older adults.

Special issues and concerns in the evaluation of older adults who have pain.

Older patients who have pain present unique challenges for clinicians. On the one hand, care must be taken to treat the pain aggressively while avoiding hampering the patient with excessive side effects, such as drowsiness, nausea and vomiting, and constipation. On the other hand, the clinician must be aware of the growing problem of prescription drug abuse and assess whether or not the patient or his or her family is at risk. Indeed, the concern for assessment is not solely centered on the patient but also extends to the family and extended support network, which may or may not have the patient's best interests at heart when it comes to pain medications. Supposing that addiction and abuse are solely the purview of the young is no longer acceptable, and we have the burden of assessing for problematic behavior while also trying to convince some patients that they would benefit from pain medicine.

Interventional techniques for back pain.

Most Americans will be afflicted by some form of spine-related pain in their lifetime. In older patients, the most frequent source of back pain is lumbar spinal stenosis or vertebral compression fracture. Although most back pain is self-limited, some patients will require interventional techniques. This article reviews minimally invasive techniques for treating back pain, lumbosacral radicular pain, lumbar spinal stenosis, and compression fractures.

Variations in opioid responsiveness.

It has been appreciated for some time now that humans react differently to opioids. A specific opioid such as morphine sulfate may have specific analgesic effects for certain patients with postherpetic neuralgia whereas in other patients with postherpetic neuralgia, it may provide quite different analgesic qualities. Also, in any one individual patient a particular opioid may provide better analgesia than other opioids. Furthermore, these differences are not unique to analgesia; they can also be seen with other opioid effects/toxicities. Though many of the differences can be classified neatly into pharmacokinetic and pharmacodynamic differences, there are certain differences which still remain incompletely understood. Also, clinicians are not yet able to easily predict which patients will respond well or poorly to various opioids. As research unravel the various genetics, biochemical, and receptor interaction differences of opioids in humans, it is hoped that easily obtainable, cost-effective testing will become available to aid clinicians in choosing an optimal opioid analgesic for an individual patient, a process which is currently accomplished via health care provider judgment along with trial and error. In the future, knowledge gained from databases on knockout rodents, pharmacogenetics, and gene polymorphisms may impact on the ability of clinicians to predict patient responses to doses of specific opioids in efforts to individualize optimal opioid analgesic therapy. It is conceivable that eventually information of this type may translate into improved patient care. In the future, armed with data of this type, clinicians may become quite adept at tailoring appropriate opioid therapy as well as optimal opioid rotation strategies.