Cooled Radiofrequency Ablation vs. Thermal Radiofrequency Ablation for Pain Management Procedures

Radiofrequency ablation (RFA) is a technique used to treat a variety of conditions including cancers and cardiac arrhythmias, and has become increasingly used in decreasing chronic pain in people with musculoskeletal disorders. When an area of the body becomes irritated and inflamed due to a condition such as osteoarthritis, a pain signal is transmitted to the brain through the nerve which supplies the affected area. If this signal can become disrupted by destroying the transmitting nerve, some of the pain perceived from the affected area can be decreased.  Commonly targeted nerves include the medial branches of the dorsal rami which innervated the facet joints in the spine, the S1-3 lateral nerves which innervate the SI joint and the geniculate nerves, which provide innervation to the knee. These nerves can be targeted under ultrasound or x-ray guidance, and destroyed by a process called radiofrequency ablation.

 

Radiofrequency ablation uses an alternating electrical current to deliver energy in the form of heat to a probe tip. Damage to the tissue first occurs to an area just beyond the tip through resistance heating. A difference in impedance between this small area of tissue and probe tip causes the small area of tissue to produce conductive heat. This transfers heat to adjacent tissue and expands the area of damaged tissue.  The temperature from the conductive heat is sensed by a device within the probe and allows the temperature at the tip to be monitored. Maximum tissue destruction occurs at temperatures between 60C and 70C.  However, when the temperature exceeds 100C (212F) steam and coagulation occur at the probe tip. To prevent this, most thermal radiofrequency devices automatically shut off when the probe reaches this temperature. If the device shuts off prematurely, however, this can result in an ineffective lesion. To keep the probe at an ideal temperature, a probe with a cooled tip may be used. In these cooled radiofrequency ablation systems saline is pumped through the probe tip, turns around within the tip and then returns to the pump. This mechanism allows for the ability to lengthen ablation times and to allow for larger lesions to be formed. As the nerves are not usually visualized directly when nerve ablation procedures are performed, a larger lesion theoretically would have a better chance at contacting and destroying more of the pain-transmitting nervous tissue.

 

Commonly targeted nerves for radiofrequency ablation are the medial branches of the dorsal rami which innervate the facet joints in the spine and contribute to some types of back pain. There have been several trials, including a recent randomized controlled trial, which have directly compared cooled and thermal RFA. In these trials there was no statistically significant difference in pain reduction between the two types of RFA.


Another commonly ablated nerve system is the geniculate nerves which provide sensation to the knee and transmit the pain signals from the knee joint.  Thermal RFA has been demonstrated lead to greater improvement in pain relief and function compared to sham RFA and also to decrease pain when compared to non-interventional therapy. The first study to employ cooled RFA was by Davis et al in 2018, and demonstrated improved pain relief and function when compared to intra-articular steroid injection. Based on the current literature, both thermal and cooled RFA are effective in patients who respond to lidocaine blocks of the geniculate nerves. However, more data are needed to determine if cooled RFA is more effective than thermal RFA in controlling pain and improving function. 

 

Both cooled and thermal radiofrequency ablation of the nerves which innervate the sacroiliac (SI) joint have been shown to be effective in reducing pain in patients with SI joint pain for up to a year. Cooled RFA has been compared directly to thermal RFA, in 2003 Cheng et al compared 30 patients who received thermal RFA and 58 who received cooled RFA. Both cooled and traditional RFA provided more than 50% pain reduction for 3-6 months in the majority of patients. However, there was no difference between cooled and thermal RFA in the duration of pain even after adjusting for potentially confounding variables.

 

Cooled and thermal radiofrequency ablation procedures are used to help control pain. They work by destroying nerve tissue which transmits pain signals from painful areas within the body. They are commonly used to help control certain types of back pain, SI joint pain and knee pain. Cooled radiofrequency ablation uses a fluid-cooled probe and allows for the formation of larger lesions at the probe tip. This increases the chance that the procedure destroys the target nerve tissue, and theoretically should allow for more successful procedures and decreased pain.  Currently, both cooled and thermal radiofrequency ablation techniques have been shown to decrease pain and increase function in most people who respond to initial nerve blocks. Data so far suggests that there are not significant differences in pain reduction between cooled and thermal RFA. However, there is not yet good high-quality data comparing the two types directly with respect to differences in patient pain or function.

 

References:

 

Ball R. The Science of Conventional and Water-Cooled Monopolar Lumbar Radiofrequency Rhizotomy: An Electrical Engineering Point of View. Pain Physician 2014; 17:E175-E211

 

Zachary L. McCormick, Marc Korn, Rajiv Reddy, Austin Marcolina, David Dayanim, Ryan Mattie, Daniel Cushman, Meghan Bhave, Robert J. McCarthy, Dost Khan, Geeta Nagpal, David R. Walega, Cooled Radiofrequency Ablation of the Genicular Nerves for Chronic Pain due to Knee Osteoarthritis: Six-Month Outcomes, Pain Medicine, Volume 18, Issue 9, September 2017, Pages 1631–1641

 

Lorentzen T. A cooled needle electrode for radiofrequency tissue ablation: thermodynamic aspects of improved performance compared with conventional needle design. Acad Radiol. 1996 Jul;3(7):556-63.

 

Dukewich, M et al. Comparative Effectiveness Review of Cooled Versus Pulsed Radiofrequency Ablation for the Treatment of Knee Osteoarthritis: A Systematic Review
 Pain Physician. 2017 Mar;20(3):155-171.

 

Mccormick, M et al. Randomized prospective trial of cooled versus traditional radiofrequency ablation of the medial branch nerves for the treatment of lumbar facet joint pain. Regional anesthesia and pain medicine. 2019 Mar;Vol.44(3), pp.389-397.

Pilcher T et al. Convective cooling effect on cooled-tip catheter compared to large-tip catheter radiofrequency ablation. Pacing Clin Electrophysiol. 2006 Dec;29(12):1368-74.

Jamison, D et al. Radiofrequency techniques to treat chronic knee pain: a comprehensive review of anatomy, effectiveness, treatment parameters, and patient selection. Journal of pain research, 2018;11, 1879–1888.

Choi W et al. Radiofrequency treatment relieves chronic knee osteoarthritis pain: a double-blind randomized controlled trial. Pain. 2011;152(3):481–487.

Sarı S et al.  Which one is more effective for the clinical treatment of chronic pain in knee osteoarthritis: radiofrequency neurotomy of the genicular nerves or intra-articular injection? Int J Rheum Dis. 2016 Aug 12.

Biswas B et al. Water-cooled radiofrequency neuroablation for sacroiliac joint dysfunctional pain. Journal of anaesthesiology, clinical pharmacology. 2016;32(4), 525–527.

 

Cheng J et al. Comparative outcomes of cooled versus traditional radiofrequency ablation of the lateral branches for sacroiliac joint pain. Clin J Pain. 2013;29:132–7

Laminectomy: Description, Indications and Post-Operative Care

Laminectomy is a surgery that creates space within the spinal canal by removing the lamina—the back part of your vertebra that covers your spinal canal. Laminectomy surgery is sometimes referred to “decompression surgery” as it also relieves pressure on the spinal cord and/or nerve roots. Usually the pressure is caused by bony overgrowths referred to as “bone spurs” secondary to arthritis within the spinal canal. Bone spurs will develop overtime with aging.

 

 

Once conservative treatment including but not limited to anti-inflammatory medications, neuropathic medications, physical therapy and/or corticosteroid injections have failed, a laminectomy may be recommended if severe symptoms persist or progress rapidly. Indications for the procedure include excessive back pain, numbness that may radiate down your arms or legs, muscle weakness making it difficult to stand or ambulate for a prolonged period of time or if you lose control of your bowel or bladder. In rare cases, a laminectomy may be more urgent to treat a herniated disc within the spinal canal.

 

For the most part, a laminectomy is a safe procedure that will require general anesthesia. The surgeon will typically make a small incision (depending on your body size) in your back and move certain muscles away to gain access to your spine. Depending on the condition, the surgeon may use a smaller incision (minimally-invasive) and a surgical microscope to perform the operation.

 

After the laminectomy, you are moved to a recovery room so that medical professionals can monitor you for complications after surgery and anesthesia. Potential complications include bleeding at the site of surgery (hematoma), infection, blood clots, additional nerve injury or cerebrospinal fluid leak. They will do a full neuromuscular physical exam and you may be able to go home the same day or have a short stay within the hospital. If the surgery includes a spinal fusion, your hospital length of stay is usually longer and you may be discharged to an acute rehabilitation unit prior to going home.

 

Post-operative care includes sitting upright to support your back for no more than 30 minutes at a time. You should lie on a firm mattress, and avoid soft couches or recliners. You may lie on your side, but not on your stomach. You should avoid bending, lifting anything greater than 10 pounds, pushing, twisting, stooping or straining for approximately 6 to 8 weeks until you are cleared for normal activity by your surgeon. These are typically referred to as spine precautions. You will also have to keep your surgical incision clean and dry, being careful when you bathe or shower as to not get the area wet, which can exacerbate infection risk. Lastly, you may require stronger prescription pain medication up to two weeks after the surgery, which is quite normal.  The staples or sutures that were placed to keep the incision closed are typically removed after 2 weeks. After a simple laminectomy, most people should expect a full recovery within 2-4 months.

References:

Pengel LH, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: systematic review of its prognosis. BMJ 2003; 327:323.

Willems PC, Staal JB, Walenkamp GH, de Bie RA. Spinal fusion for chronic low back pain: systematic review on the accuracy of tests for patient selection. Spine J 2013; 13:99.

Trief PM, Grant W, Fredrickson B. A prospective study of psychological predictors of lumbar surgery outcome. Spine (Phila Pa 1976) 2000; 25:2616.

Brox JI, Reikerås O, Nygaard Ø, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain 2006; 122:145.

Brox JI, Nygaard ØP, Holm I, et al. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis 2010; 69:1643.

Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 1991; 73:802.

Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am 2009; 91:1295.

Stem Cell Therapy for Osteoarthritis

Osteoarthritis is a highly prevalent pain disorder involving erosion of articular cartilage and damage to subchondral bone and surrounding cell tissue. The avascularity of articular cartilage and limited regeneration of chondrocytes create limitations in self-healing. Current therapies include pharmacologic agents such as NSAIDs and opioids as well as surgical procedures such as joint replacements, none of which serve to reverse the damage to articular cartilage despite the complications they carry. Emerging evidence for the use of stem cell therapy for chondrogenesis has led to great interest and the opening of stem cell centers nationwide for the treatment of osteoarthritis. It is prudent to review the evidence thus far of the efficacy of these treatments to better inform our patients of their options.

The first generation of stem cell therapy involved bone marrow-derived mesenchymal stem cells (MSC), which were associated with donor site morbidity and pain and low cell number on harvest. These issues led to the investigation into alternative sources for MSCs, including periosteum, muscle, synovial membrane and adipose tissue. Since MSCs have the ability to differentiate into chondrocytes, osteoblasts, myoblasts, adipocytes and fibroblasts depending on the conditions under which they are stimulated, they offer great potential for tissue regeneration of various kinds.

Stromal vascular fraction (SVF) of adipose tissue has become the most popular substrate for the study of stem cell therapy for osteoarthritis, given that the stem cells contained within are abundant in number and easy to harvest. Despite concern that adipose derived mesenchymal stem cells (ADSCs) have limited chondrogenic potential, recent evidence demonstrate their ability to be induced along chondrocyte pathways under specific conditions, and animal models confirmed their chondrogenesis effect in vivo.

A metanalysis of human clinical studies on the effects of ADSCs on osteoarthritis was published earlier this year. All studies prepared ADSCs in the form of stromal vascular fraction (SVF), the component of lipoaspirate that contains ADSCs, pericytes, vascular adventitia cells, fibroblasts, preadipocytes, monocytes, macrophages and red blood cells. The 16 studies varied regarding site and time of SVF collection via liposuction, site of treatment (e.g. knees vs ankles), and whether the SVF was used with biologics such as platelet rich plasma (PRP) and fibrin.

All 16 studies reported favorable clinical outcomes, i.e. pain and function scores. 5 studies reported patient satisfaction rate, all of which were above 90%. 8 studies also reported radiological outcomes via MRI or X-ray, with mixed outcome measures showing an overall promising trend. MRI findings included improved cartilage thickness in most of the studies. Complication rates were reported in 7 studies, which were minor and included swelling at the procedural site.

The favorable clinical and radiographical outcomes shown in the metanalysis should be taken with a grain of salt, as there was high variability in all studies regarding data collected and use of biological adjuvants. This makes cross-study comparison difficult and leads to possible confounding of the actual weight of ADSCs’ effect. Biologics such as platelet rich plasma (PRP) have been shown to contain growth factors which potentially increase chondrocyte viability and differentiation, and may improve the synthetic capacity of MSCs. There was also significant variability in the methods used to prepare the ADSCs, as well as the methods for assessing chondrogenic potential of the harvested SVF. In the studies which reported it, the average percentage of ADSC in the SVF was only 9.2%, with the majority of the injectate being comprised of the other aforementioned SVF components. There was also great intra-study variability in the percentage of ADSC in SVF, with little analysis of possible factors contributing to this such as patient age or methods of preparation.

In summary, stem cell therapy in the treatment of osteoarthritis pain has shown promising results in early clinical trials, however these trials are limited by their lack of procedural standardization and potential biases. It will be worth following further investigations of this treatment modality as procedures are refined to introduce less variability.

References

Dubey NK, Mishra VK, Dubey R, Syed-Abdul S, Wang JR, Wang PD, Deng WP. Combating Osteoarthritis through Stem Cell Therapies by Rejuvenating Cartilage: A Review. Stem Cells Int. 2018 Mar 22;2018:5421019.

Hurley ET, Yasui Y, Gianakos AL, Seow D, Shimozono Y1, Kerkhoffs GMMJ, Kennedy JG. Limited evidence for adipose-derived stem cell therapy on the treatment of osteoarthritis. Knee Surg Sports Traumatol Arthrosc. 2018 Apr 30.

The chronic pain puzzle – Is DBS the missing piece?

Pain – and how we approach it – is a perpetual puzzle for all member of our health-care system. Physicians scratch their heads in finding ways to prevent pain and treat that which persists after their patients leave the hospital, but this is an uphill battle. Those who continue to experience pain have earned contracts for a lifelong journey with their pain. Chronic pain, especially back pain, contributes more than $500 billion to annual health-care costs [1] and disables more than 20% of the workforce [2]. However, many potential solutions are themselves expensive puzzle pieces that can be misunderstood or incompatible with the patients they attempt to treat.

Prescription painkillers, or “opioids,” while touted as a cheap and effective therapy for many different kinds of pain, have consistently made headlines because of the rapid increase in narcotic-related deaths over the past decade. [3] However, they are not without their side effects, which are not uncommon – more than 20% of patients will experience constipation, nausea, and itching, and over-sedation. Higher-risk patients may experience breathing issues, especially if they have been receiving similar medications or have medical problems that prolong the effects of these pills. A recent CDC survey reported that a quarter of patients with legitimate prescriptions are incorrectly using or storing these medications, increasing the risk for overdose or harm to their loved ones in close proximity. [4]

The crisis has called for physicians and researchers to work ever so closely together to produce alternative treatments that are effective in patients that are nowadays living longer with more complex medical problems.

One of these therapies include deep brain stimulation (DBS) therapy, a treatment modality that has long been studied and evaluated for use in several brain-related disorders. Since the 1970s, scientists have discovered specific “targets” within the brain that conduct irregular patterns of brain electrical activity, and these patterns have been associated with different pain syndromes. Initial interest in this technology focused on the use of DBS to treat movement disorders, including Parkinson’s Disease. Many movement disorders are associated with pain itself, and patients reported an increase in their quality of life and pain control with further improvements in the procedure over time.

In the past 30 years, collaborations between neurosurgeons, pain specialists, and researchers led to its use in patients with chronic pain syndromes, with significant success with patients with cluster headaches and back pain. [5] Current research is exploring its use in pain after stroke or loss or a limb (e.g. phantom limb pain) [6]. Treatment effect is even more significant with patients who have previously failed to realize adequate pain relief with escalating conventional treatments methods, including:

1) over-the counter medications (e.g. Tylenol, Advil)

2) prescription opioid therapy

3) neuropathic pain treatments (e.g. Neurontin, Lyrica)

4) complementary therapies (e.g. acupuncture),

5) interventional pain therapies (e.g. injections for nerve block, radiofrequency and chemical denervation).

It is natural to have questions about the overall safety and approach of this “brain surgery.” After a referral to a neurosurgeon with specialized experience, patients receive routine pre-operative medical and surgical evaluations, including a thorough review of pain complaints, triggers, and expectations for eventual relief. On the day of the procedure, the patient is placed under general anesthesia, and a small device called a pulse generator (e.g. neurostimulator) in is placed in the neck or abdomen. Leads connect the generator to the “target” areas in the brain, and the integrity of the connections and the generator are tested before the end of the procedure. Recovery in the hospital lasts a few days, and the patient may receive closer (i.e. around-the-clock) monitoring for the first 24 hours for unlikely complications including bleeding, infection and seizures. After leaving the hospital, a few patients may report slight changes in mood and personality. DBS lead placement may be responsible for the majority of these complaints, and it is very important to follow-up with the surgeon within 1-2 weeks after the initial procedure.

DBS has proven to be beneficial for patients with the most recalcitrant types of pain. In combination with conventional and alternative treatments (e.g. multimodal therapy), DBS provides an essential piece of the pain puzzle that may be beneficial with other pain syndromes and clinical disorders syndromes in the future.


References

[1] Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011. http://books.nap.edu/openbook.php?record_id=13172&page=1.

[2] Peter D. Hart Research Associates. Page 3. KEY FINDINGS. Americans in Pain. Much of America is hurting: the majority of adults (57%) in this country have … http://www.researchamerica.org/uploads/poll2003pain.pdf

[3] Vivolo-Kantor AM, Seth P, Gladden RM, et al. Vital Signs: Trends in Emergency Department Visits for Suspected Opioid Overdoses — United States, July 2016–September 2017. MMWR Morb Mortal Wkly Rep 2018;67:279–285. DOI: http://dx.doi.org/10.15585/mmwr.mm6709e1

[4] QuickStats: Percentage of Emergency Department Visits That Had an Opioid Ordered or Prescribed, by Age Group — National Hospital Ambulatory Medical Care Survey, United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2018;67:344. DOI: http://dx.doi.org/10.15585/mmwr.mm6711a8

[5] Lempka SF, Malone DA, Hu B, Baker KB, Wyant A, Ozinga JG, Plow EB., Pandya M, Kubu CS, Ford PJ, Machado AG. Randomized clinical trial of deep brain stimulation for poststroke pain. Ann Neurol. 2017 May;81(5):653-663. doi: 10.1002/ana.24927.

[6] Bittar, RG. et al. Deep brain stimulation for pain relief: A meta-analysis. J Clin Neurosci. 2005 Jun;12(5):515-9. DOI:10.1016/j.jocn.2004.10.005

A Promising Treatment for Neurological Disease and Psychiatric Disorders

Neuromodulation or Neurostimulation is a promising modality for treating neurological disease (Parkinson’s disease, Tremors, Chronic Pain, seizures) as well as psychiatric disorders (Major Depression, OCD). The basic premise of neuromodulation is that by stimulating deep brain structures, it is possible to disrupt abnormal patterns of brain activity (in people with neurologic disease) and thereby restore normal brain electrical rhythms resulting in improvement and even resolution of symptoms. While the exact mechanism of how Neuromodulation works is not completely understood, it is believed that restoring normal brain electrical activity is essential to improve disease symptoms. Contrary to what many in the general public would think, a typical neurostimulating system is relatively simple in that it consists of only three components: an implantable stimulator generator/pulse generator (IPG), a lead, and extension wiring. Traditional Neuromodulation consists of continuous high-frequency stimulation (known as an open-loop system). While effective in minimizing some symptoms, this method of neuromodulation comes with the drawbacks of causing potential tissue damage from the constant stimulation as well as shortening generator (IPG) battery life to 2-5 years.

In continuous pursuit of a cure, neuromodulation companies/labs are developing increasingly sophisticated brain stimulators. Building off the success of the open-loop system, researchers have developed next generation systems that make stimulation more targeted not only in terms of where, but when stimulation occurs. This new targeted type of therapy where stimulation occurs in response to specific changes in a patient’s electrical brain activity is known as closed-loop neuromodulation. These implantable devices are able to record the electrical activities of many neurons continuously and as a result, determine patterns in the overall neural activity. The specific neural patterns are then able to be utilized as an input signal to the processor in the device that can sync neurostimulation with a specific event.

Consider that an early usage for neuromodulation was treating refractory epilepsy, an event that occurs spontaneously and unpredictably (much like that of a life-threatening cardiac arrhythmia). One could see the similarities between a neuromodulator and Automated Implantable Cardioverter Defibrillator (AICD), and thus the benefits provided by a closed-loop system. Much like how an AICD delivers a shock to stop an abnormal heart rhythm only when it occurs, an implantable closed loop neurostimulator can halt an epileptic seizure by delivering stimulation when it senses the beginning of seizure activity in the brain. While only an analogy, it makes sense that a device that only as beneficial in specific situations would be better to be triggered for that purpose alone.

The transformational benefit of closed loop neuromodulation clearly is a targeted therapy specific to an individual’s electrical brain activity, but other benefits of a closed loop system are still impressive such as a potential decrease in tissue damage as well as an overall decrease in power consumption leading to increased battery life (and subsequently avoiding frequent surgical IPG replacement). The benefits of the closed loop system are now starting to be quantified with early studies are demonstrating promising results with the treatment of epilepsy. A 2018 FDA approved study demonstrated that patients with a closed loop system experienced a 70% median seizure reduction after five years of therapy. This finding as well as numerous other promising ones are validating the benefits of a closed loop system. As a result of its individualization, closed loop neuromodulation can and is now being applied to all types of neuropathology. As the technology continues to be refined the benefits to those suffering will only increase.

Spine imaging for chronic neck pain: a brief review

It is estimated that at least 15% of the US adult population suffer from chronic neck pain. While cervical intervertebral discs, cervical facet joints, atlanto-axial and atlanto-occipital joints, ligaments, fascia, muscle, and dura have all been shown to be potential causes for neck pain, it is often difficult to identify the exact cause of the pain. Spine imaging is often helpful in identifying targets for intervention.

Plain radiographs, MRI and CT scans have all been utilized as imaging modalities for diagnosing neck pain. Indications for radiographic imaging include age >50 with new symptoms, constitutional symptoms such as fevers or unexplained weight loss, moderate to severe pain lasting more than six weeks, progressive neurologic findings, infectious risk such as IVDA or immunosuppression, and history of malignancy.

Plain films often include a cervical series of seven views, including odontoid, lateral, AP, two oblique views, lateral view in flexion, and lateral view in extension. However, as the flexion and extension views have not been shown to lead to findings that changed clinical management, often they are excluded. Lateral views demonstrate vertebral alignment, screens for osteoarthritis and disc space narrowing, and may demonstrate bony pathology such as compression fracture. Oblique views are used to diagnose foraminal encroachment. AP views best show lateral spine deviation, while odontoid views are appropriate in acute trauma.

MRI and CT are more sensitive than plain films for diagnosing disc herniation, spinal cord compression, infection and malignancy. While MRI is preferred for soft tissue processes such as tumor, central stenosis, and disc herniation, CT is better for facet osteoarthrisis or other osseous changes. CT scans are not able to identify intramedullary pathology such as spinal cord tumors, and have the downside of significant radiation exposure.

In addition to spine imaging, fluroscopically guided diagnostic procedures such as cervical facet joint block have been shown to be helpful in establishing the etiology of neck pain. By injecting local anesthetic into the facet joint, the amount of immediate relief experienced by the patient is useful in determining if the facet joint is the source of pain. Cervical facet joint interventions such as therapeutic cervical medial branch blocks and radiofrequency neurotomy of medial branches in the cervical spine have fair evidence in terms of efficacy of pain relief. Intraarticular injections, on the other hand, had limited evidence for efficacy.

Fluroscopically guided epidural steroid injections have also been shown to be effective in providing short term relief of cervical radicular pain. Long term benefits are less certain, with few studies comparing the intervention to a true placebo group.

Spine imaging for chronic neck pain is helpful in both diagnosis and, when coupled with fluoroscopically guided pain procedures, provides therapeutic relief of this prevalent condition. Even general anesthesia providers should have a basic understanding of these concepts, as many of our patients are likely to have undergone similar evaluations and procedures.


References:

Falco FJ, Manchikanti L, Datta S, Wargo BW, Geffert S, Bryce DA, Atluri S, Singh V, Benyamin RM, Sehgal N, Ward SP, Helm S 2nd, Gupta S, Boswell MV. Systematic review of the therapeutic effectiveness of cervical facet joint interventions: an update. Pain Physician. 2012 Nov-Dec;15(6):E839-68.

House LM, Barrette K, Mattie R, McCormick ZL. Cervical Epidural Steroid Injection: Techniques and Evidence. Phys Med Rehabil Clin N Am. 2018 Feb;29(1):1-17. doi: 10.1016/j.pmr.2017.08.001. Epub 2017 Oct 16.

Isaac, Z. (2018). Evaluation of the patient with neck pain and cervical spine disorders. In Sullivan, DJ and Lee, SI (Ed), UpToDate.

Managing and Monitoring Pediatric Pain with a Mobile App

Pain management is a crucial component of surgical recovery for any patient, but there are unique concerns and challenges that comes with managing pain in pediatric patients. While the inherent vulnerability of children is deeply felt by clinicians and families alike, postoperative pain is nevertheless undertreated in this population. A major driver of this issue is that many common procedures require little time in the hospital, leaving most of the recovery to happen at home. Neglected postoperative pain creates short-term issues of sleep disruption, stress, and delayed recovery but can also lead to serious long-term consequences, or even disability.1

A central barrier to effectively managing pain following a procedure is reliably assessing a young patient’s pain level.2 This task most often falls to parents and other caregivers, and is deceptively difficult. Research reveals two major challenges in pain reporting: a child’s ability to identify and name their pain, and the reliability of measurement instruments to consistently guide a clinical response. Opioids are unsurprisingly a central tool for effectively treating pain in children. For acute pain in particular, they are a powerful option that can provide uniquely immediate relief. However, there are known risks and side effects associated with opioid use that merit heightened caution when opiods are being used by children. Understanding a child’s experience of pain is key to responding with the appropriate balance of analgesics, and this can place an immense amount of pressure on caregivers at home.

Self-reporting is the clinically preferred way to assess pain in children.3 However, this approach to pain measurement can be difficult among children for reasons that any parent could probably guess—a child may be afraid that sharing about their pain will cause them to return to the hospital, for example, or their social environment might cause them to overstate or understate their pain level. Commonly used instruments take various forms of visual and verbal rating scales, but the evidence is mixed on which tools are the most rigorous and widely applicable across the many developmental stages of childhood.


What if there was a way to solicit a child’s experience of pain through a familiar, less clinical and engaging instrument? This is where the recently developed Panda pain management mobile app is poised to make a difference. The Panda app seeks to improve pediatric postoperative pain management through an engaging and easy-to-use platform. Parents or other caregivers use the app’s walkthrough design to assess and record important aspects of their child’s pain. Then, the app guides them in making decisions about when and how to administer pain medication, tracking when medication is administered to keep families on schedule for future dosages. Users receive medication alerts directly from their phone, much like the many apps families already use to schedule and track their commitments and routines.

 

Panda was developed by researchers at the University of British Columbia and has already seen promising results in the controlled setting of in-hospital use. Parents piloting the app with the guidance of clinical staff reported that the app was easy to use and could see themselves using it in the home setting.4 The app is currently being evaluated for in-home use.

Providing families with an easy-to-navigate tool to not just identify pain in children following surgery, but also connect those pain measurements to a medication schedule, could be an important step in better addressing this neglected area of pain management. Pain management is a complex aspect of clinical care for patients regardless of age, and the special concerns of pediatric patients demand innovation beyond merely adapting adult guidelines for younger patients. There are exciting possibilities for the use of smartphone apps like Panda in better describing and alleviating pain in children. Tools that fit neatly into a familiar routine, like a smartphone app, may reduce some of the stress parents face in managing complex pain without clinical support.


References

[1] Porter FL, Grunau RE, Anand KJ: Long-term effects of pain in infants. J Dev Behav Pediatr 1999; 20:253–61Porter, FL Grunau, RE Anand, KJ

[2] Chou, Roger, et al. “Management of Postoperative Pain: a clinical practice guideline from the American pain society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ committee on regional anesthesia, executive committee, and administrative council.” The Journal of Pain 17.2 (2016): 131-157.

[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3983412/

[4] https://www.researchgate.net/publication/316853501_Feasibility_of_Panda_a_Smartphone_Application_Designed_to_Support_Pediatric_Postoperative_Pain_Management_at_Home

Herniated Lumbar Disc

Herniated Lumbar Disc also known as Lumbosacral Radiculopathy (“slipped disc”, “ruptured disc”) is a medical term for the pain (lower back and legs), numbness, tingling and weakness associated with a herniated disc in the lumbar (lower back) region. Patients often undergo significant suffering and reduction in quality of life with this condition. It is the most common type of disc herniation. Lumbosacral disc herniation occurs in the lower back region, typically between the fourth and fifth lumbar (L4-L5) or fifth lumbar and first sacral (L5-S1) vertebral bodies but can occur in any disc of the lumbar spine. The essence of the condition is a tear in the fibrous outer ring of the disc between vertebrae which then allows for the central component (nucleus pulposus) to protrude out. This nucleus pulposus carries a cascade of inflammatory chemicals that often irritate and compress lumbar spinal nerves causing symptoms. This can occur spontaneously or from trauma, lifting, and straining of the lower back.

Symptoms of this condition depend on the location and severity of the herniation. In terms of location, there are five lumbar vertebral bodies with discs between them (these are the ones that can herniate) with 2 spinal nerves exiting at each level. Vertebral discs provide support and mobility for the lower back region. Severity is often caused by how much of the disc has herniated and subsequently compressed the surrounding lumbar spinal nerve. Patients’ symptoms can range from mild sensory changes in the lower back, buttock, thigh, foot or toe to numbness, tingling, paresthesia, sharp shooting pain, muscle weakness, and leg paralysis. Severe symptoms, including loss of bowel or bladder function, should warrant immediate medical evaluation.

Diagnosis and Management

Diagnosis of lumbar disc herniation is a clinical one often resulting from the history provided by the patient along with specific physical examination findings. Examination includes a thorough neurological examination to uncover motor, reflex, and sensory changes. This will often lead to the “culprit” lumbar nerve root that is affected by a lumbar disc herniation. Other signs include diminished leg reflexes and a positive straight leg raise. There is no “gold standard” for diagnosing lumbar disc herniation but often imaging, specifically MRI, is very helpful. Imaging may point to the existence of a specific location of disc protrusion. A positive correlation with symptoms may aid in the diagnoses. There is a high degree of variability in the symptoms experienced by patients. Most concerning is worsening pain and weakness in the leg. Other possible diagnoses for back/leg symptoms are lumbar facet syndrome, myofascial pain syndrome, and spinal stenosis.

Generally, lumbar disc herniations will heal on their own with conservative measures (including rest, ice, heat, anti-inflammatory medications). If symptoms do resolve, they often do in a period of weeks to a couple of months. Initial treatment involves conservative measures including education, light exercise, medications (a short course of anti-inflammatories), physical therapy, body mechanics, lumbar traction, and weight control. More invasive treatments include interventional pain injections (lumbar epidural steroid injections, spinal cord stimulation) and/or surgery (most commonly lumbar decompression or laminectomy). Lumbar epidural steroid injections involve depositing a small quantity of steroid and local anesthetic mediation, using X-ray image guidance, onto the affected lumbar spine nerve. These may often be repeated every 3-6 months depending on the symptoms. Indications for surgery include patients with ongoing leg pain despite 6-8 weeks of conservative treatment along with signs of motor or saddle weakness.

Herniated Cervical Disc

Background/description

Herniated Cervical Disc also known as Cervical Radiculopathy (“slipped disc”, “ruptured disc”) is a medical term for the pain (neck and arms), numbness, tingling and weakness associated with a herniated disc in the cervical (neck) region. Patients often undergo significant suffering and reduction in quality of life with this condition. It is the second most common type of disc herniation, following lumbar (back) disc herniation. Cervical disc herniation occurs in the neck region, usually between the lower cervical vertebral bodies but can occur in any disc of the cervical spine. The essence of the condition is a tear in the fibrous outer ring of the disc between vertebrae which then allows for the central component (nucleus pulposus) to protrude out. This nucleus pulposus carries a cascade of inflammatory chemicals that often irritate and compress cervical spinal nerves causing symptoms. This can occur spontaneously or from trauma, lifting, and straining of the neck.

Symptoms of this condition depend on the location and severity of the herniation. In terms of location, there are seven cervical vertebral bodies with discs between them (these are the ones that can herniate) with 2 spinal nerves exiting at each level. Vertebral discs provide support and mobility for the neck region. Severity is often caused by how much of the disc has herniated and subsequently compressed the surrounding cervical spinal nerve. Patients’ symptoms can range from mild sensory changes in the neck and arms: numbness, tingling, paresthesia to sharp shooting pain, muscle weakness, and arm paralysis. Severe symptoms should warrant immediate medical evaluation.

Neck Pain

Diagnosis and Management

Diagnosis of cervical disc herniation is a clinical one often resulting from the story (history) provided by the patient and the physical examination findings. Examination includes a thorough neurological examination to uncover motor and sensory changes. This will often lead to the “culprit” cervical nerve root that is impingement by a cervical disc herniation. Other signs include increase in arm reflexes and a maneuver known as Spurling’s, where downward pressure is applied by a physician on a patient’s neck to recreate arm tingling and numbness. There is no “gold standard” for diagnosing cervical disc herniation but often imaging, specifically MRI, is very helpful. Imaging may point to the existence of specific locations of disc protrusion and if correlating with the symptoms may aid in the diagnoses. There is a high degree of variability in the symptoms experienced by patients. Most concerning as worsening pain and weakness in arm. Other possible diagnoses for neck/arm symptoms are nerve entrapment medical conditions such as carpal tunnel (median nerve) syndrome and cubital tunnel (ulnar nerve) syndrome. These can often be diagnosed clinically with the support of a nerve conduction study.

Most cervical disc herniations will heal on their own with conservative measures (include rest, ice, heat, anti-inflammatory medications). Most of the time the symptoms involve pain, numbness, and weakness in the arm. If symptoms do resolve, they often do so in a period of weeks to a couple of months. Otherwise, initial treatment often begins with conservative measures including education, light exercise, medications (short course of anti-inflammatories), physical therapy, body mechanics, cervical traction, and weight control. More invasive treatments include interventional pain injections (cervical epidural steroid injections) and/or surgery (most commonly anterior cervical discectomy and fusion – ACDF). Cervical epidural steroid injections involve depositing a small quantity of steroid and local anesthetic mediation, using X-ray image guidance, onto the affected cervical spine nerve. These may often be repeated every 3-6 months depending on the symptoms. Indications for surgery include patients with ongoing arm pain despite 6-8 weeks of conservative treatment along with signs of motor weakness.

Sacroiliac Disease

Background/Description

Sacroiliac (SI) disease (also known as SI joint dysfunction, SI syndrome) is an inflammation in the joint connecting the pelvis (iliac bones) to the sacrum. It is often caused by a dysfunction in the mobility of the joint (too much movement, too little movement). This dysfunction can be a debilitating source of back pain and suffering for patients. This highly complex joint is surrounded by numerous muscles, ligaments, and cartilage that intricately function with one another to provide stability in normal everyday movements. Symptoms include lower back or buttock pain, groin or hip pain. This pain can be sharp or dull and often worsens with activity and movement. Some patients also complain of tingling and numbness in the pelvic region. Standing, sitting, lying in a prolonged position often worsens this numbness and pain. If symptoms are severe and chronic enough this can often lead to depression, social isolation, and insomnia.

Diagnosis and Management

Often overlooked as a source of pain, sacroiliac disease is part of many possible sources of lower back/buttock pain or dysfunction. Imaging studies (X-ray, CT, MRI) are often not specific enough to diagnose SI disease. More commonly, it is diagnosed by a physician with a series of physical examination signs known as provocative testing. A detailed history relayed by the patient is also an important part of diagnosis. The most specific way of diagnosing this joint disease is to undergo a diagnostic Sacroiliac joint injection (X-ray, ultrasound) by a physician with additional training in pain medicine. A substantial relief in pain from this injection is a specific indicator of pathology in the Sacroiliac joint.

Management of sacroiliac disease and treating its resultant back pain includes conservative and invasive treatments. Conservative measures include anti-inflammatory medications, ice/heat, rest, and physical therapy. Manipulative, massage, and manual therapy are additional measures in this category. More invasive treatments include steroid injections and in severe cases, surgery. Steroid injections are low risk procedures (with image guidance) that deposit strong anti-inflammatory medication directly into the joint. This is often followed by a series of physical and manual therapy sessions to encourage adequate movement and mobility of the joint. Periodic steroid injections are often adequate in providing patients with significant pain relief and in improving quality of life. New technologies have emerged in the field of neuromodulation in cases where injections and surgery have not sufficiently reduced pain. These interventions utilized low and high frequency signals to provide a means of overriding the SI joint pain generator. A patient should ask her physician questions about all these possible treatments in order to start the path of healing and recovery.