Comprehensive Pain Management in the Rehabilitation Patient, 2017
While approximately 90% of headaches are considered primary or without an underlying secondary ca... more While approximately 90% of headaches are considered primary or without an underlying secondary cause to explain their etiology (see previous chapter), close to 10% of headaches are symptomatic of another condition. They are then referred to as secondary headaches. The actual percentage of one type versus the other is subject to referral bias; hence, the chance of finding an underlying headache-inducing pathologic process is far higher in the neurosurgeon’s clinic than it is in the primary care clinician’s facility. The possibility of missing an underlying cause creates anxiety in patients and clinicians alike. This chapter provides an overview of the approach to such workups and a summary of the more likely causes of head pain also touching upon anatomical findings that might incorrectly be assumed to be generating headaches. It is important to avoid unnecessary and especially invasive workups or treatments since risk may outweigh benefit in some cases. Imaging guidelines, etc., are provided, but for more detailed and newer options and overviews, please see the reading list at the end of the chapter.
The multiple mechanisms underlying the development of painful and nonpainful neuropathy associate... more The multiple mechanisms underlying the development of painful and nonpainful neuropathy associated with diabetes mellitus are not fully elucidated. Between 16% and 26% of diabetes patients experience chronic neuropathic pain, making diabetic peripheral neuropathic pain (DPNP) the most common neuropathic pain disorder. The use of antidepressants to treat DPNP is well established in clinical practice. Researchers performed a manufacturer-funded, multicenter, parallel, double-blind, randomized trial …
General practitioners (GPs) are often the first clinicians to encounter patients with trigeminal ... more General practitioners (GPs) are often the first clinicians to encounter patients with trigeminal neuralgia (TN). Given the gravity of the debilitating pain associated with TN, it is important for these clinicians to learn how to accurately diagnose and manage this illness. The objective of this article is to provide an up-to-date literature review regarding the presentation, classification, diagnosis, and the treatment of TN. This article also focuses on the long-term management of these patients under the care of GPs. GPs play an important role in the management of patients with TN by following the evidence-based management guidelines. The most important aspects of the management of TN are discussed in this review article. Categories: Family/General Practice, Neurology, Pain Management
Background: Antidepressants are prescribed in a wide range of doses to treat both depression and ... more Background: Antidepressants are prescribed in a wide range of doses to treat both depression and chronic pain, with optimal psychopharmacology individualized for each patient. In the past decade more antidepressants from different chemical classes have become available and are being used for the treatment of both chronic pain and depression. Objective: To review the utilization pattern changes and compare response rates of different classes and doses of antidepressants for various pain conditions in the context of multimodal therapies. Design: Chart review. Methods: We reviewed 5,916 records at an outpatient multidisciplinary pain center. Of these, 379 records were for patients diagnosed with cancer pain. Because the mechanisms and treatment approaches to cancer pain can differ greatly from non-cancer chronic pain, these records were excluded from the analysis. We assessed 1,506 medical records for patients with chronic non-caner pain who had used at least one antidepressant, with t...
Objectives: We aimed to prospectively evaluate the response and safety of pulsed and continuous r... more Objectives: We aimed to prospectively evaluate the response and safety of pulsed and continuous radiofrequecy lesioning of the dorsal root ganglion/segmental nerves in patients with chronic lumbosacral radicular pain. Methods: Seventy-six patients with chronic lumbosacral radicular pain refractory to conventional therapy met the inclusion criteria and were randomly assigned to one of 2 types of treatment, pulsed radiofrequency lesioning of the dorsal root ganglion/segmental nerve or pulsed radiofrequency followed immediately by continuous radiofrequency. Patients were carefully evaluated for neurologic deficits and side effects. The response was evaluated at 2 months and was then tracked monthly. A Kaplan-Meier analysis was used to illustrate the probability of success over time and a Box-Whisker analysis was applied to determine the mean duration of a successful analgesic effect. Results: Two months after undergoing radiofrequency treatment, 70% of the patients treated with pulsed ...
Background and Objective: Epidural steroid injections are commonly used to palliate the symptoms ... more Background and Objective: Epidural steroid injections are commonly used to palliate the symptoms of spinal stenosis. Deep tissue infection is a known potential complication of these injections. There have been no previous published cases of osteomyelitis without epidural abscess after such injections. We present a case in an elderly patient who presented only with persistent axial low back pain following a lumbar epidural steroid injection (LESI). We emphasize early patient evaluation, consideration of infectious predisposing factors, sterile technique, and skin disinfectant. Design: Open-label case report. Case description: A 77-year-old diabetic male with a history of radicular pain related to lumbar spinal stenosis was treated successfully several years prior with a series of lumbar epidural steroid injections (LESI) and was re-treated with LESIs for recurrent symptoms. Following his second epidural injection, he presented with back pain and induration at the injection site witho...
General practitioners (GPs) are often the first clinicians to encounter patients with trigeminal ... more General practitioners (GPs) are often the first clinicians to encounter patients with trigeminal neuralgia (TN). Given the gravity of the debilitating pain associated with TN, it is important for these clinicians to learn how to accurately diagnose and manage this illness. The objective of this article is to provide an up-to-date literature review regarding the presentation, classification, diagnosis, and the treatment of TN. This article also focuses on the long-term management of these patients under the care of GPs. GPs play an important role in the management of patients with TN by following the evidence-based management guidelines. The most important aspects of the management of TN are discussed in this review article.
Chronic pain is one of the most common and challenging medical problems facing our society. The s... more Chronic pain is one of the most common and challenging medical problems facing our society. The specialty of pain medicine has grown steadily in recent years, largely because of the recognition that multiple factors contribute to chronic pain. The practice of pain medicine is multidisciplinary in approach, incorporating modalities from various specialties to ensure the comprehensive evaluation and treatment of the pain patient. The integration of various specialties such as anesthesiology, neurology, neurologic surgery, orthopedic surgery, physical medicine, and psychiatry is essential to treating patients with chronic pain and to establishing continuity of care. Research in the last 30 years has developed a variety of alternatives or adjuncts to opiates for chronic pain, including neuroactive medications, counterstimulation methods, and cognitive-behavioral therapies. Pain medicine specialists have provided leadership in the development of the practice, with the application of a wide verity of central and peripheral nerve blocks, sympathetic and neurolytic blocks, intradiscal procedures, neuromodulation techniques, intrathecal infusion systems, and other technical procedures that are firmly linked to a biomedical model of pain.
Background and Objectives: The concept of radiofrequency denervation has recently come under ques... more Background and Objectives: The concept of radiofrequency denervation has recently come under question in light of several studies showing minimal to no benefit. One possibility proposed for these negative outcomes is poor selection criteria. Unlike virtually all other spine interventions, the factors associated with success and failure for cervical facet denervation have yet to be determined. The purpose of this study is to determine which demographic, clinical and treatment factors are associated with cervical facet radiofrequency denervation outcomes. Methods: Data were garnered from 3 academic medical centers on 92 patients with chronic neck pain who underwent radiofrequency denervation after a positive response to diagnostic local anesthetic blocks. Success was defined as at least 50% pain relief lasting at least 6 months. Variables evaluated for their association with outcome included age, sex, duration of pain, opioid use, pain referral pattern, paraspinal tenderness, pain exacerbated by extension/rotation, magnetic resonance image abnormalities, diabetes, smoking, scoliosis, obesity, prior surgery, and levels treated. Results: The only clinical variable associated with success was paraspinal tenderness. Factors associated with treatment failure included radiation to the head, opioid use, and pain exacerbated by neck extension and/or rotation. Conclusions: Selecting patients based on key clinical variables may increase the chance of treatment success for cervical facet radiofrequency denervation.
PAIN®, Volume 129, Issue 3, Pages 364-365, June 2007, Authors:Rami Burstein; Moshe Jakubowski; Pe... more PAIN®, Volume 129, Issue 3, Pages 364-365, June 2007, Authors:Rami Burstein; Moshe Jakubowski; Peter J. McAllister; Zahid H. Bajwa; Thomas N. Ward; Patty Smith.
The use of spinal cord stimulation (SCS) devices to treat chronic, refractory neuropathic pain co... more The use of spinal cord stimulation (SCS) devices to treat chronic, refractory neuropathic pain continues to expand in application. While device-related complications have been well described, inflammatory reactions to the components of these devices remain underreported. In contrast, hypersensitivity reactions associated with other implanted therapies, such as endovascular and cardiac rhythm devices, have been detailed. The purpose of this case series is to describe the clinical presentation and course of inflammatory reactions as well as the histology of these reactions. All patients required removal of the entire device after developing inflammatory reactions over a time course of 1-3 months. Two patients developed a foreign body reaction in the lead insertion wound as well as at the implantable pulse generator site, with histology positive for giant cells. One patient developed an inflammatory dermatitis on the flank and abdomen that resolved with topical hydrocortisone. "In vivo" testing with a lead extension fragment placed in the buttock resulted in a negative reaction followed by successful reimplantation of an SCS device. Inflammatory reactions to SCS devices can manifest as contact dermatitis, granuloma formation, or foreign body reactions with giant cell formation. Tissue diagnosis is essential, and is helpful to differentiate an inflammatory reaction from infection. The role of skin patch testing for 96 hours may not be suited to detect inflammatory giant cell reactions that manifest several weeks post implantation.
Journal of Manipulative and Physiological Therapeutics, 2005
Background: Lumbar pathologies may cause the perception of leg pain, but the character of this pa... more Background: Lumbar pathologies may cause the perception of leg pain, but the character of this pain has not been described. Diagnosis is often based on dermatomal charts, but observations reveal that the pain is not typically perceived on the skin. Objective: To document the incidence of superficial versus deep pain localization among patients with lumbar radicular pain. Methods: Twenty-five patients with lower limb radicular pain were questioned to determine the specific localization of their pain. The investigator categorized the pain location into general areas (eg, posterior thigh or anterior leg). Patients were asked if their pain was perceived as being on the skin or deep, as a forced choice question. These data were gathered in 2 conditions: at rest (spontaneous pain) and during a straight leg raise test (mechanically evoked pain). Data were recorded using a standardized form for later analysis. Results: In all cases, symptoms were reported to be in deep structures. Pain was typically reported at sites correlated with multiple spinal levels. Conclusion: Because radicular pain symptoms are perceived in deep structures rather than on the skin, the diagnostic value of dermatomal charts is questioned. Clinicians are advised to be specific when questioning patients with radicular pain symptoms and to refer to myotomal and sclerotomal charts when making diagnoses.
Headaches tend to improve in the majority of migraineurs during pregnancy, but some patients repo... more Headaches tend to improve in the majority of migraineurs during pregnancy, but some patients report a worsening of migraine and present a management challenge because of the restrictions of pharmacotherapy during pregnancy. Treatment options become even more limited for pregnant migraineurs who develop preeclampsia. Labetalol was tried successfully in reducing the frequency, duration, and intensity of migraine attacks in a pregnant woman with preeclampsia. There were no significant side effects and the patient delivered a healthy baby without complications.
Beta-blockers have proven effective in the treatment of migraine. Dermatologic side effects are e... more Beta-blockers have proven effective in the treatment of migraine. Dermatologic side effects are extremely rare. We report a patient with migraine who developed an acnelike dermatitis with two different beta-blockers with complete resolution of the acne upon discontinuation of each drug.
Objective.-We investigated in a sham-controlled trial the analgesic effects of a 4-week treatment... more Objective.-We investigated in a sham-controlled trial the analgesic effects of a 4-week treatment of transcranial direct current stimulation (tDCS) over the primary motor cortex in chronic migraine. In addition, using a high-resolution tDCS computational model, we analyzed the current flow (electric field) through brain regions associated with pain perception and modulation. Methods.-Thirteen patients with chronic migraine were randomized to receive 10 sessions of active or sham tDCS for 20 minutes with 2 mA over 4 weeks. Data were collected during baseline, treatment and follow-up. For the tDCS computational analysis, we adapted a high-resolution individualized model incorporating accurate segmentation of cortical and subcortical structures of interest. Results.-There was a significant interaction term (time vs group) for the main outcome (pain intensity) and for the length of migraine episodes (ANOVA, P < .05 for both analyses). Post-hoc analysis showed a significant improvement in the follow-up period for the active tDCS group only. Our computational modeling studies predicted electric current flow in multiple cortical and subcortical regions associated with migraine pathophysiology. Significant electric fields were generated, not only in targeted cortical regions but also in the insula, cingulate cortex, thalamus, and brainstem regions. Conclusions.-Our findings give preliminary evidence that patients with chronic migraine have a positive, but delayed, response to anodal tDCS of the primary motor cortex. These effects may be related to electrical currents induced in pain-related cortical and subcortical regions.
Purpose of review Neuropathic pain accounts for 25-50% of pain clinic visits with an estimated pr... more Purpose of review Neuropathic pain accounts for 25-50% of pain clinic visits with an estimated prevalence of 4 million. Neuropathic pain is often difficult to diagnose and treat with few pharmacologic options currently available. This review summarizes the latest research on the pathophysiology, diagnosis and treatment of neuropathic pain. Recent findings The diagnosis of neuropathic pain relies on an evaluation of information given by the patient and physical findings obtained by the health provider. There are several validated questionnaires that can be used. Neuropathic pain is associated with a number of different cellular and molecular mechanisms. These include abnormalities in ion channels; exaggerated responses to cytokines, enzymes and neuropeptides; and abnormal communications between large/small fibers and sympathetic/small fibers. An understanding of these mechanisms has led to mechanistic directed treatments including topical treatments, antiepileptics, antidepressants, opioids and other drugs in development that are more mechanistically driven. Summary Neuropathic pain is common, underdiagnosed and undertreated. Diagnosing and understanding the basic mechanisms of neuropathic pain will lead to better treatments of this difficult health care problem.
Objective: Based on evidence showing that electrical stimulation of the nervous system is an effe... more Objective: Based on evidence showing that electrical stimulation of the nervous system is an effective method to decrease chronic neurogenic pain, we aimed to investigate whether the combination of 2 methods of electrical stimulation-a method of peripheral stimulation [transcutaneous electrical nerve stimulation (TENS)] and a method of noninvasive brain stimulation [transcranial direct current stimulation (tDCS)]-induces greater pain reduction as compared with tDCS alone and sham stimulation. Methods: We performed a preliminary, randomized, shamcontrolled, crossover, clinical study in which 8 patients were randomized to receive active tDCS/active TENS (''tDCS/TENS'' group), active tDCS/sham TENS (''tDCS'' group), and sham tDCS/sham TENS (''sham'' group) stimulation. Assessments were performed immediately before and after each condition by a blinded rater. Results: The results showed that there was a significant difference in pain reduction across the conditions of stimulation (P = 0.006). Post hoc tests showed significant pain reduction as compared with baseline after the tDCS/TENS condition [reduction by 36.5% (± 10.7), P = 0.004] and the tDCS condition [reduction by 15.5% (± 4.9), P = 0.014], but not after sham stimulation (P = 0.35). In addition, tDCS/TENS induced greater pain reduction than tDCS (P = 0.02). Conclusions: The results of this pilot study suggest that the combination of TENS with tDCS has a superior effect compared with tDCS alone.
Tricyclic antidepressants (TCA) have been shown to provide analgesia for a variety of neuropathic... more Tricyclic antidepressants (TCA) have been shown to provide analgesia for a variety of neuropathic and headache pain syndromes regardless of the presence of depression. There is a high incidence of depression in patients with chronic pain, thereby making tricyclic antidepressants particularly suitable for chronic pain patients. We wanted to study patterns of use of tricyclic antidepressants in our Pain Management Center (Beth Israel Hospital, Boston, MA, U.S.A.) primarily to answer four questions: (1) What percentage of all patients were treated with tricyclic antidepressants? (2) How many patients were treated with each antidepressant, and what was the dose range used for individual antidepressants? (3) Were tricyclic antidepressants beneficial for chronic pain, and was that response dependent on a particular dose? (4) Did patients receive an adequate TCA trial, and what factors led to the discontinuation of a TCA trial? A total of 1,145 pain clinic patient charts were reviewed in alphabetical sequence. A total of 282 patients were identified as being treated with tricyclic antidepressants. Data were obtained from these 282 charts regarding the patient&#39;s age, diagnosis, tricyclic antidepressant use and dose, other pain treatments, response to treatment, and side effects. The existing diagnosis of depression was documented if possible. Tricyclic antidepressant doses were defined as low doses when the equivalent of 50 mg or less of amitriptyline was used, and as full doses when the equivalent of at least 150 mg of amitriptyline was used. Response to treatment was noted as mild, moderate, or marked improvement. Patients reporting mild improvement were considered nonresponders. Of 1,145 patients, 282 were treated with tricyclic antidepressants. A total of 205 (73%) of the patients were treated with low doses and only 34 (12%) with full doses. The remaining 43 (15%) received intermediate doses. Amitriptyline was the most commonly used drug (58%). Amitriptyline and doxepin appeared to be more effective than other tricyclic antidepressants. The rate of response to our treatment among the 31 patients with a coexisting diagnosis of depression was similar to the patients without documented depression. In patients with tricyclic antidepressants as the only treatment, there was only a trend toward greater response with full dose. In terms of side effects causing dose limitation or discontinuation of the drug, clomipramine, amitriptyline, and doxepin appeared to be worse than imipramine, desipramine, and nortriptyline. Tricyclic antidepressants were used in 25% of patients referred to a multidisciplinary pain center and were commonly used in low to intermediate doses, even in situations in which there were neither side effects nor optimal clinical response.
Background— Clinical observations of migraine headache symptoms in patients with a patent foramen... more Background— Clinical observations of migraine headache symptoms in patients with a patent foramen ovale (PFO), both of which conditions are highly prevalent, have raised the question of a possible pathophysiological relationship. We sought to evaluate the assumption of an association between migraine headaches and the presence of PFO by use of a large case-control study. Methods and Results— We conducted a case-control study to assess the prevalence of PFO in subjects with and without migraine. Case subjects were those with a history of migraine (diagnosed by neurologists at a specialty academic headache clinic). Control subjects were healthy volunteers without migraine 1:1 matched on the basis of age and sex with case subjects. Presence of PFO was determined by transthoracic echocardiogram with second harmonic imaging and transcranial Doppler ultrasonography during a standardized procedure of infused agitated saline contrast with or without Valsalva maneuver and a review of the res...
Comprehensive Pain Management in the Rehabilitation Patient, 2017
While approximately 90% of headaches are considered primary or without an underlying secondary ca... more While approximately 90% of headaches are considered primary or without an underlying secondary cause to explain their etiology (see previous chapter), close to 10% of headaches are symptomatic of another condition. They are then referred to as secondary headaches. The actual percentage of one type versus the other is subject to referral bias; hence, the chance of finding an underlying headache-inducing pathologic process is far higher in the neurosurgeon’s clinic than it is in the primary care clinician’s facility. The possibility of missing an underlying cause creates anxiety in patients and clinicians alike. This chapter provides an overview of the approach to such workups and a summary of the more likely causes of head pain also touching upon anatomical findings that might incorrectly be assumed to be generating headaches. It is important to avoid unnecessary and especially invasive workups or treatments since risk may outweigh benefit in some cases. Imaging guidelines, etc., are provided, but for more detailed and newer options and overviews, please see the reading list at the end of the chapter.
The multiple mechanisms underlying the development of painful and nonpainful neuropathy associate... more The multiple mechanisms underlying the development of painful and nonpainful neuropathy associated with diabetes mellitus are not fully elucidated. Between 16% and 26% of diabetes patients experience chronic neuropathic pain, making diabetic peripheral neuropathic pain (DPNP) the most common neuropathic pain disorder. The use of antidepressants to treat DPNP is well established in clinical practice. Researchers performed a manufacturer-funded, multicenter, parallel, double-blind, randomized trial …
General practitioners (GPs) are often the first clinicians to encounter patients with trigeminal ... more General practitioners (GPs) are often the first clinicians to encounter patients with trigeminal neuralgia (TN). Given the gravity of the debilitating pain associated with TN, it is important for these clinicians to learn how to accurately diagnose and manage this illness. The objective of this article is to provide an up-to-date literature review regarding the presentation, classification, diagnosis, and the treatment of TN. This article also focuses on the long-term management of these patients under the care of GPs. GPs play an important role in the management of patients with TN by following the evidence-based management guidelines. The most important aspects of the management of TN are discussed in this review article. Categories: Family/General Practice, Neurology, Pain Management
Background: Antidepressants are prescribed in a wide range of doses to treat both depression and ... more Background: Antidepressants are prescribed in a wide range of doses to treat both depression and chronic pain, with optimal psychopharmacology individualized for each patient. In the past decade more antidepressants from different chemical classes have become available and are being used for the treatment of both chronic pain and depression. Objective: To review the utilization pattern changes and compare response rates of different classes and doses of antidepressants for various pain conditions in the context of multimodal therapies. Design: Chart review. Methods: We reviewed 5,916 records at an outpatient multidisciplinary pain center. Of these, 379 records were for patients diagnosed with cancer pain. Because the mechanisms and treatment approaches to cancer pain can differ greatly from non-cancer chronic pain, these records were excluded from the analysis. We assessed 1,506 medical records for patients with chronic non-caner pain who had used at least one antidepressant, with t...
Objectives: We aimed to prospectively evaluate the response and safety of pulsed and continuous r... more Objectives: We aimed to prospectively evaluate the response and safety of pulsed and continuous radiofrequecy lesioning of the dorsal root ganglion/segmental nerves in patients with chronic lumbosacral radicular pain. Methods: Seventy-six patients with chronic lumbosacral radicular pain refractory to conventional therapy met the inclusion criteria and were randomly assigned to one of 2 types of treatment, pulsed radiofrequency lesioning of the dorsal root ganglion/segmental nerve or pulsed radiofrequency followed immediately by continuous radiofrequency. Patients were carefully evaluated for neurologic deficits and side effects. The response was evaluated at 2 months and was then tracked monthly. A Kaplan-Meier analysis was used to illustrate the probability of success over time and a Box-Whisker analysis was applied to determine the mean duration of a successful analgesic effect. Results: Two months after undergoing radiofrequency treatment, 70% of the patients treated with pulsed ...
Background and Objective: Epidural steroid injections are commonly used to palliate the symptoms ... more Background and Objective: Epidural steroid injections are commonly used to palliate the symptoms of spinal stenosis. Deep tissue infection is a known potential complication of these injections. There have been no previous published cases of osteomyelitis without epidural abscess after such injections. We present a case in an elderly patient who presented only with persistent axial low back pain following a lumbar epidural steroid injection (LESI). We emphasize early patient evaluation, consideration of infectious predisposing factors, sterile technique, and skin disinfectant. Design: Open-label case report. Case description: A 77-year-old diabetic male with a history of radicular pain related to lumbar spinal stenosis was treated successfully several years prior with a series of lumbar epidural steroid injections (LESI) and was re-treated with LESIs for recurrent symptoms. Following his second epidural injection, he presented with back pain and induration at the injection site witho...
General practitioners (GPs) are often the first clinicians to encounter patients with trigeminal ... more General practitioners (GPs) are often the first clinicians to encounter patients with trigeminal neuralgia (TN). Given the gravity of the debilitating pain associated with TN, it is important for these clinicians to learn how to accurately diagnose and manage this illness. The objective of this article is to provide an up-to-date literature review regarding the presentation, classification, diagnosis, and the treatment of TN. This article also focuses on the long-term management of these patients under the care of GPs. GPs play an important role in the management of patients with TN by following the evidence-based management guidelines. The most important aspects of the management of TN are discussed in this review article.
Chronic pain is one of the most common and challenging medical problems facing our society. The s... more Chronic pain is one of the most common and challenging medical problems facing our society. The specialty of pain medicine has grown steadily in recent years, largely because of the recognition that multiple factors contribute to chronic pain. The practice of pain medicine is multidisciplinary in approach, incorporating modalities from various specialties to ensure the comprehensive evaluation and treatment of the pain patient. The integration of various specialties such as anesthesiology, neurology, neurologic surgery, orthopedic surgery, physical medicine, and psychiatry is essential to treating patients with chronic pain and to establishing continuity of care. Research in the last 30 years has developed a variety of alternatives or adjuncts to opiates for chronic pain, including neuroactive medications, counterstimulation methods, and cognitive-behavioral therapies. Pain medicine specialists have provided leadership in the development of the practice, with the application of a wide verity of central and peripheral nerve blocks, sympathetic and neurolytic blocks, intradiscal procedures, neuromodulation techniques, intrathecal infusion systems, and other technical procedures that are firmly linked to a biomedical model of pain.
Background and Objectives: The concept of radiofrequency denervation has recently come under ques... more Background and Objectives: The concept of radiofrequency denervation has recently come under question in light of several studies showing minimal to no benefit. One possibility proposed for these negative outcomes is poor selection criteria. Unlike virtually all other spine interventions, the factors associated with success and failure for cervical facet denervation have yet to be determined. The purpose of this study is to determine which demographic, clinical and treatment factors are associated with cervical facet radiofrequency denervation outcomes. Methods: Data were garnered from 3 academic medical centers on 92 patients with chronic neck pain who underwent radiofrequency denervation after a positive response to diagnostic local anesthetic blocks. Success was defined as at least 50% pain relief lasting at least 6 months. Variables evaluated for their association with outcome included age, sex, duration of pain, opioid use, pain referral pattern, paraspinal tenderness, pain exacerbated by extension/rotation, magnetic resonance image abnormalities, diabetes, smoking, scoliosis, obesity, prior surgery, and levels treated. Results: The only clinical variable associated with success was paraspinal tenderness. Factors associated with treatment failure included radiation to the head, opioid use, and pain exacerbated by neck extension and/or rotation. Conclusions: Selecting patients based on key clinical variables may increase the chance of treatment success for cervical facet radiofrequency denervation.
PAIN®, Volume 129, Issue 3, Pages 364-365, June 2007, Authors:Rami Burstein; Moshe Jakubowski; Pe... more PAIN®, Volume 129, Issue 3, Pages 364-365, June 2007, Authors:Rami Burstein; Moshe Jakubowski; Peter J. McAllister; Zahid H. Bajwa; Thomas N. Ward; Patty Smith.
The use of spinal cord stimulation (SCS) devices to treat chronic, refractory neuropathic pain co... more The use of spinal cord stimulation (SCS) devices to treat chronic, refractory neuropathic pain continues to expand in application. While device-related complications have been well described, inflammatory reactions to the components of these devices remain underreported. In contrast, hypersensitivity reactions associated with other implanted therapies, such as endovascular and cardiac rhythm devices, have been detailed. The purpose of this case series is to describe the clinical presentation and course of inflammatory reactions as well as the histology of these reactions. All patients required removal of the entire device after developing inflammatory reactions over a time course of 1-3 months. Two patients developed a foreign body reaction in the lead insertion wound as well as at the implantable pulse generator site, with histology positive for giant cells. One patient developed an inflammatory dermatitis on the flank and abdomen that resolved with topical hydrocortisone. "In vivo" testing with a lead extension fragment placed in the buttock resulted in a negative reaction followed by successful reimplantation of an SCS device. Inflammatory reactions to SCS devices can manifest as contact dermatitis, granuloma formation, or foreign body reactions with giant cell formation. Tissue diagnosis is essential, and is helpful to differentiate an inflammatory reaction from infection. The role of skin patch testing for 96 hours may not be suited to detect inflammatory giant cell reactions that manifest several weeks post implantation.
Journal of Manipulative and Physiological Therapeutics, 2005
Background: Lumbar pathologies may cause the perception of leg pain, but the character of this pa... more Background: Lumbar pathologies may cause the perception of leg pain, but the character of this pain has not been described. Diagnosis is often based on dermatomal charts, but observations reveal that the pain is not typically perceived on the skin. Objective: To document the incidence of superficial versus deep pain localization among patients with lumbar radicular pain. Methods: Twenty-five patients with lower limb radicular pain were questioned to determine the specific localization of their pain. The investigator categorized the pain location into general areas (eg, posterior thigh or anterior leg). Patients were asked if their pain was perceived as being on the skin or deep, as a forced choice question. These data were gathered in 2 conditions: at rest (spontaneous pain) and during a straight leg raise test (mechanically evoked pain). Data were recorded using a standardized form for later analysis. Results: In all cases, symptoms were reported to be in deep structures. Pain was typically reported at sites correlated with multiple spinal levels. Conclusion: Because radicular pain symptoms are perceived in deep structures rather than on the skin, the diagnostic value of dermatomal charts is questioned. Clinicians are advised to be specific when questioning patients with radicular pain symptoms and to refer to myotomal and sclerotomal charts when making diagnoses.
Headaches tend to improve in the majority of migraineurs during pregnancy, but some patients repo... more Headaches tend to improve in the majority of migraineurs during pregnancy, but some patients report a worsening of migraine and present a management challenge because of the restrictions of pharmacotherapy during pregnancy. Treatment options become even more limited for pregnant migraineurs who develop preeclampsia. Labetalol was tried successfully in reducing the frequency, duration, and intensity of migraine attacks in a pregnant woman with preeclampsia. There were no significant side effects and the patient delivered a healthy baby without complications.
Beta-blockers have proven effective in the treatment of migraine. Dermatologic side effects are e... more Beta-blockers have proven effective in the treatment of migraine. Dermatologic side effects are extremely rare. We report a patient with migraine who developed an acnelike dermatitis with two different beta-blockers with complete resolution of the acne upon discontinuation of each drug.
Objective.-We investigated in a sham-controlled trial the analgesic effects of a 4-week treatment... more Objective.-We investigated in a sham-controlled trial the analgesic effects of a 4-week treatment of transcranial direct current stimulation (tDCS) over the primary motor cortex in chronic migraine. In addition, using a high-resolution tDCS computational model, we analyzed the current flow (electric field) through brain regions associated with pain perception and modulation. Methods.-Thirteen patients with chronic migraine were randomized to receive 10 sessions of active or sham tDCS for 20 minutes with 2 mA over 4 weeks. Data were collected during baseline, treatment and follow-up. For the tDCS computational analysis, we adapted a high-resolution individualized model incorporating accurate segmentation of cortical and subcortical structures of interest. Results.-There was a significant interaction term (time vs group) for the main outcome (pain intensity) and for the length of migraine episodes (ANOVA, P < .05 for both analyses). Post-hoc analysis showed a significant improvement in the follow-up period for the active tDCS group only. Our computational modeling studies predicted electric current flow in multiple cortical and subcortical regions associated with migraine pathophysiology. Significant electric fields were generated, not only in targeted cortical regions but also in the insula, cingulate cortex, thalamus, and brainstem regions. Conclusions.-Our findings give preliminary evidence that patients with chronic migraine have a positive, but delayed, response to anodal tDCS of the primary motor cortex. These effects may be related to electrical currents induced in pain-related cortical and subcortical regions.
Purpose of review Neuropathic pain accounts for 25-50% of pain clinic visits with an estimated pr... more Purpose of review Neuropathic pain accounts for 25-50% of pain clinic visits with an estimated prevalence of 4 million. Neuropathic pain is often difficult to diagnose and treat with few pharmacologic options currently available. This review summarizes the latest research on the pathophysiology, diagnosis and treatment of neuropathic pain. Recent findings The diagnosis of neuropathic pain relies on an evaluation of information given by the patient and physical findings obtained by the health provider. There are several validated questionnaires that can be used. Neuropathic pain is associated with a number of different cellular and molecular mechanisms. These include abnormalities in ion channels; exaggerated responses to cytokines, enzymes and neuropeptides; and abnormal communications between large/small fibers and sympathetic/small fibers. An understanding of these mechanisms has led to mechanistic directed treatments including topical treatments, antiepileptics, antidepressants, opioids and other drugs in development that are more mechanistically driven. Summary Neuropathic pain is common, underdiagnosed and undertreated. Diagnosing and understanding the basic mechanisms of neuropathic pain will lead to better treatments of this difficult health care problem.
Objective: Based on evidence showing that electrical stimulation of the nervous system is an effe... more Objective: Based on evidence showing that electrical stimulation of the nervous system is an effective method to decrease chronic neurogenic pain, we aimed to investigate whether the combination of 2 methods of electrical stimulation-a method of peripheral stimulation [transcutaneous electrical nerve stimulation (TENS)] and a method of noninvasive brain stimulation [transcranial direct current stimulation (tDCS)]-induces greater pain reduction as compared with tDCS alone and sham stimulation. Methods: We performed a preliminary, randomized, shamcontrolled, crossover, clinical study in which 8 patients were randomized to receive active tDCS/active TENS (''tDCS/TENS'' group), active tDCS/sham TENS (''tDCS'' group), and sham tDCS/sham TENS (''sham'' group) stimulation. Assessments were performed immediately before and after each condition by a blinded rater. Results: The results showed that there was a significant difference in pain reduction across the conditions of stimulation (P = 0.006). Post hoc tests showed significant pain reduction as compared with baseline after the tDCS/TENS condition [reduction by 36.5% (± 10.7), P = 0.004] and the tDCS condition [reduction by 15.5% (± 4.9), P = 0.014], but not after sham stimulation (P = 0.35). In addition, tDCS/TENS induced greater pain reduction than tDCS (P = 0.02). Conclusions: The results of this pilot study suggest that the combination of TENS with tDCS has a superior effect compared with tDCS alone.
Tricyclic antidepressants (TCA) have been shown to provide analgesia for a variety of neuropathic... more Tricyclic antidepressants (TCA) have been shown to provide analgesia for a variety of neuropathic and headache pain syndromes regardless of the presence of depression. There is a high incidence of depression in patients with chronic pain, thereby making tricyclic antidepressants particularly suitable for chronic pain patients. We wanted to study patterns of use of tricyclic antidepressants in our Pain Management Center (Beth Israel Hospital, Boston, MA, U.S.A.) primarily to answer four questions: (1) What percentage of all patients were treated with tricyclic antidepressants? (2) How many patients were treated with each antidepressant, and what was the dose range used for individual antidepressants? (3) Were tricyclic antidepressants beneficial for chronic pain, and was that response dependent on a particular dose? (4) Did patients receive an adequate TCA trial, and what factors led to the discontinuation of a TCA trial? A total of 1,145 pain clinic patient charts were reviewed in alphabetical sequence. A total of 282 patients were identified as being treated with tricyclic antidepressants. Data were obtained from these 282 charts regarding the patient&#39;s age, diagnosis, tricyclic antidepressant use and dose, other pain treatments, response to treatment, and side effects. The existing diagnosis of depression was documented if possible. Tricyclic antidepressant doses were defined as low doses when the equivalent of 50 mg or less of amitriptyline was used, and as full doses when the equivalent of at least 150 mg of amitriptyline was used. Response to treatment was noted as mild, moderate, or marked improvement. Patients reporting mild improvement were considered nonresponders. Of 1,145 patients, 282 were treated with tricyclic antidepressants. A total of 205 (73%) of the patients were treated with low doses and only 34 (12%) with full doses. The remaining 43 (15%) received intermediate doses. Amitriptyline was the most commonly used drug (58%). Amitriptyline and doxepin appeared to be more effective than other tricyclic antidepressants. The rate of response to our treatment among the 31 patients with a coexisting diagnosis of depression was similar to the patients without documented depression. In patients with tricyclic antidepressants as the only treatment, there was only a trend toward greater response with full dose. In terms of side effects causing dose limitation or discontinuation of the drug, clomipramine, amitriptyline, and doxepin appeared to be worse than imipramine, desipramine, and nortriptyline. Tricyclic antidepressants were used in 25% of patients referred to a multidisciplinary pain center and were commonly used in low to intermediate doses, even in situations in which there were neither side effects nor optimal clinical response.
Background— Clinical observations of migraine headache symptoms in patients with a patent foramen... more Background— Clinical observations of migraine headache symptoms in patients with a patent foramen ovale (PFO), both of which conditions are highly prevalent, have raised the question of a possible pathophysiological relationship. We sought to evaluate the assumption of an association between migraine headaches and the presence of PFO by use of a large case-control study. Methods and Results— We conducted a case-control study to assess the prevalence of PFO in subjects with and without migraine. Case subjects were those with a history of migraine (diagnosed by neurologists at a specialty academic headache clinic). Control subjects were healthy volunteers without migraine 1:1 matched on the basis of age and sex with case subjects. Presence of PFO was determined by transthoracic echocardiogram with second harmonic imaging and transcranial Doppler ultrasonography during a standardized procedure of infused agitated saline contrast with or without Valsalva maneuver and a review of the res...
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Papers by Zahid Bajwa