Effectiveness of combined dorsal root ganglion and spinal cord stimulation: a retrospective, single-centre case series for chronic focal neuropathic pain.

OBJECTIVE: This case series retrospectively reviewed the outcomes in patients implanted with combined, synchronous dorsal root ganglion stimulation (DRGS) and spinal cord stimulation (SCS) connected to a single implantable pulse generator (IPG) in a tertiary referral neuromodulation centre in the United Kingdom. METHODS: Twenty-six patients underwent a trial of DRGS+SCS for treating focal neuropathic pain between January 2016 and December 2019, with a follow-up in February 2022. A Transgrade approach was employed for DRGS. Patients were provided with 3 possible stimulation programs: DRGS-only, SCS-only, or DRGS+SCS. Patients were assessed for pain intensity, patients' global impression of change (PGIC), preferred lead(s) and complications. RESULTS: Twenty patients were successful and went on for full implantation. The most common diagnosis was Complex Regional Pain Syndrome. After an average of 3.1 years follow-up, 1 patient was lost to follow-up, and 2 were non-responders. Of the remaining 17 patients, 16 (94%) continued to report a PGIC of 7. The average pain intensity at Baseline was 8.5 on an NRS scale of 0-10. At the last follow-up, the average NRS reduction overall was 78.9% with no statistical difference between those preferring DRGS+SCS (n = 9), SCS-only (n = 3) and DRGS-only (n = 5). The combination of DRGS+SCS was preferred by 53% at the last follow-up. There were no serious neurological complications. CONCLUSIONS: This retrospective case series demonstrates the potential effectiveness of combined DRGS+SCS with sustained analgesia observed at an average follow-up of over 3 years. Implanting combined DRGS+SCS may provide programming flexibility and therapeutic alternatives.

A preliminary prospective observational study of the effectiveness of high-concentration capsaicin cutaneous patch in the management of chronic post-surgical neuropathic pain.

INTRODUCTION: Chronic post-surgical neuropathic pain is difficult to treat. Topically applied analgesics provide an alternative to systemic therapy in localised neuropathic pain syndromes. The aim of this study was to prospectively assess whether 8% capsaicin is effective in surgically induced neuropathic pain. METHODOLOGY: Patients were screened for neuropathic pain using DN4 questionnaire. Validated questionnaires were completed at baseline and at 6 and 12 weeks (BPI, HADS, PGIC), and the affected area was mapped. The study received ethical approval from the local research ethics committee. RESULTS: There were 12 participants. The most common operation was open thoracotomy (n = 8). There was a significant improvement in pain-interference from baseline to 12 weeks (p = .018). There were no significant changes in pain intensity or in the HADS. Repeat patches were performed for 4 participants on a second occasion (33%) and for 3 participants a third time (25%). There was a significant reduction in the surface area of the painful region on second (p = .04) and third applications (p = .023). At 12 weeks, 17% rated their symptoms very much better, 8% were much better, and 33% were minimally better, while 42% rated their symptoms no better. CONCLUSIONS: This prospective study provides preliminary evidence for an improvement in patient outcomes with 8% capsaicin in surgically induced neuropathic pain. Improvements were noted in pain interference, and significant reductions in the painful surface area were noted for those who underwent subsequent treatments. Findings should be replicated in a randomised control trial to establish causation.

A desktop systems analysis of critical incidents within a university hospital department of anaesthesia.

INTRODUCTION: Medical error is frequently the result of latent systems factors. Incident reporting systems face many challenges including inability of the system to process reports adequately, inadequate feedback mechanisms and lack of staff engagement especially from doctors. This paper describes a pragmatic physician-led desktop approach to a systems analysis of anaesthesia-related critical incidents which could be used to enhance incident reporting processing within the existing national incident reporting system. METHODS: Anaesthesiologists within a university teaching hospital were encouraged to report incidents anonymously during the 6-month study period from July 2019 to January 2020. Information was collected on incident details, outcome and preventability. A desktop systems analysis was performed to categorise incidents and to determine contributory factors. Latent errors were considered according to the level of the organisational hierarchy at which they occurred and solutions directed accordingly. RESULTS: Seventy cases were included giving a reporting rate of 1.76%. Airway/breathing circuit problems (34%) were most frequently cited incidents, followed by other equipment (27%), medication errors (20%) and airway events (19%). The vast majority of events were considered preventable. Most incidents were near misses or of negligible adverse effect with only 6% requiring more than minor treatment. Organisational and strategic contributory factors were identified in 83% of cases, 93% of which were addressable within the department. CONCLUSION: Implementing local incident reporting systems can be used to complement existing systems at the macro and mesolevel and can be used to improve system processing, create a phased response to latent errors and enhance engagement.

Novel use of combination of electromyography and ultrasound to guide quadratus lumborum block after open appendicectomy.

The quadratus lumborum (QL) block facilitates the administration of anaesthesia to the anterior abdominal wall. The use of ultrasound (US) improves the accuracy of the QL block and reduces the risk of adverse events. Electromyography (EMG) in combination with US for muscle plane blocks has not been described previously. We postulated that the addition of EMG-guided needle positioning might assist the execution of this block. This case report describes the first use of combined needle EMG and US to carry out a QL block performed for postoperative analgesia following an open appendicectomy.