Survey of Variation in The Practice of Interventional Management of Facet Joint Pain
S. Manickam1, S. Krishna2, S. Kapur2
1Pain Fellow, 2Consultant, Pain Management
Dudley Pain Management & Neuromodulation Centre, Russells Hall Hospital, DY1 2HQ, West Midlands
Background
Facet joint injections and medial branch blocks are the most commonly performed interventions for spinal pain. There is no consensus on the number of diagnostic medial branch blocks performed before considering radiofrequency denervation. Multiple diagnostic blocks decrease the false positive responses but increase false negatives(1), and also costs(2). It has been suggested that increasing the threshold of pain relief obtained to 80% (from the conventionally used 50%) would decrease false positives(3) but this has been challenged by others(4).
The histological basis of intra-articular steroid injections has been studied (5) but there is no literature on the effects of injecting corticosteroids around nerves. The use of corticosteroids in medial branch blocks is a widely prevalent practice. Given this lack of consensus, we conducted a survey to look at the variations in practice across the United Kingdom.
Methods
A web based survey using survey methods was conducted amongst pain consultants who routinely perform these procedures. The survey link was sent to members of an interactive forum of Pain specialists. The responses were anonymous. The survey questions included site and frequency of diagnostic blocks for facet joint pain, usage of steroids in injections, follow up methods and criteria for eligibility for radiofrequency denervation.
Results
A total of 87 Consultants responded to the survey.
The responses were as follows:
Site of injection- medial branch block -58(67%) compared to periarticular or intra-articular injection 29(33%).
Purpose of inital injection -Diagnostic -34(39%),Therapeutic-12(13%), Therapeutic & diagnostic-41(47%)
Number of diagnostic blocks performed -one-37(46%), two-41(51%), more than three-2(2.5%).10(12%) didn’t offer denervation.
Percentage Pain relief required for consideration of RF denervation-50 percent -28(35%), 50-70 percent -32(40%), more than 70 percent -21(26%).
Injection of steroid along with local anaesthetic-Not used-23(27%), steroid used-71(78%)
Duration of pain relief considered adequate after each diagnostic block- immediate to 24 hours-34(41%), 24 hours to one week-22(27%), one to six weeks-14(17%), greater than six weeks-12(15%).
Method of follow up after diagnostic injections- pain evaluation questionnaire-28(33%), clinic follow up-35(42%), telephonic follow up- 38(45%), assessment in recovery-5(6%).
61% would consider denervation if patients showed functional improvement even if there was less than 50% decrease in pain scores.
Conclusion
As there are still many controversies surrounding the interventions for facet joint pain it will be difficult to achieve a consensual view on all aspects of the conduct of the injections. However it may be useful to develop a framework for minimal standards to be adhered to while performing the injections and also to assess the effectiveness of diagnostic blocks. This will enable us to look at outcome measures to demonstrate benefit and support the continuing performance of these injections.
References
Van Zundert J, Vanelderen P, Kessels A, van Kleef M. Radiofrequency Treatment of Facet-related Pain: Evidence and Controversies. Curr. Pain Headache Rep. 2012 Feb;16(1):19–25.
Cohen SP, Williams KA, Kurihara C, Nguyen C, Shields C, Kim P, et al. Multicenter, Randomized, Comparative Cost-effectiveness Study Comparing 0, 1, and 2 Diagnostic Medial Branch (Facet Joint Nerve) Block Treatment Paradigms before Lumbar Facet Radiofrequency Denervation. Anesthesiology. 2010 Aug;113(2):395–405.
Manchikanti L, Pampati S, Cash KA. Making sense of the accuracy of diagnostic lumbar facet joint nerve blocks: an assessment of the implications of 50% relief, 80% relief, single block, or controlled diagnostic blocks. Pain Physician. 2010 Apr;13(2):133–43.
Cohen SP, Stojanovic MP, Crooks M, Kim P, Schmidt RK, Shields CH, et al. Lumbar zygapophysial (facet) joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks: a multicenter analysis. Spine J. Off. J. North Am. Spine Soc. 2008 Jun;8(3):498–504.
Habib GS, Saliba W, Nashashibi M. Local effects of intra-articular corticosteroids. Clin. Rheumatol. 2010 Apr;29(4):347–56.
Anatomy of Abdominal Cutaneous Nerves: A Study in Adult Human Cadavers
E Welsh1, S Muthukrishnan2, S Kanakarajan3
1Department of Anatomy, University of Aberdeen, 2Advanced Pain Trainee, 3Consultant, Department of Anaesthesia, Aberdeen Royal Infirmary, Aberdeen
Background
Abdominal Cutaneous Nerve Entrapment Syndrome (ACNES) is one of the common causes of abdominal wall pain. The diagnosis is established by local anaesthetic blockade of abdominal cutaneous nerves (ACN). Ultrasound guided nerve injections have improved the accuracy of the diagnosis1. In addition to local injections, radiofrequency lesioning and surgical release are considered as treatment option for this condition. However, there is paucity of literature about the anatomical topography of these nerves. A micro-anatomical study has revealed ischemic changes as possible mechanism2. But there is no consensus about the number of nerves traversing the muscle plane between internal oblique and transverse abdominus to reach the rectus. There is a general agreement that these nerves enter the rectus abdominus near its lateral border. Clinical experience suggested that this might not be true. Also there may be more than one nerve entering at a given level and more than 5 nerves (T8 to T12) were identifiable under ultrasound. Hence we undertook a human cadaveric study to identify the number of nerves, locate accessory branches and evaluate the location of nerves in relation to the anatomical landmarks.
Methods
After local departmental approval, we dissected abdominal walls of 5 embalmed adult human cadavers. After exposing the rectus sheath, we counted the number of nerves piercing through the rectus muscle. We measured the distance of exit point from linea semilunaris. We also identified the number of accessory branches. Rectus muscle was exposed from lateral border in one specimen and from the midline in subsequent specimens. The distance from midline and lateral border of rectus sheath was measured (entry point). 2 authors verified the number of nerves.
Results
Both sides of all cadavers were dissected making a total of 10 specimens. We identified 45 nerves in total. The nerves corresponded to T8 to T12 pattern in 7 specimens. T12 could not be identified in 2 specimens and T8 and T9 in another specimen. We also identified 4 nerves corresponding to T7 in 4 specimens. There were accessories present in at least 18 occasions. There was a difference of more than 2 mm between entry and exit point in more than 38 nerves implying that nerve traverses obliquely rather than vertical.
Conclusion
Our anatomical study shows wide variation in the course of ACN in relation to rectus muscle. There may be more that 5 nerves (T8 to T12) present in a given individual contributing to ACNES. The nerve may continue as abdominal cutaneous nerve or divide into medial and lateral branches before entering the rectus muscle. The course of the nerve is oblique. This has clinical implications while performing the block under ultrasound guidance.
References
Kanakarajan S, High K, Nagaraja N. Chronic Abdominal Wall Pain and ultrasound-guided Abdominal Cutaneous Nerve infiltration – A case series. Pain Medicine 2011; 12: 382–386.
Applegate WV, Buckwalter NR. Microanatomy of the structures contributing to Abdominal Cutaneous Nerve Entrapment Syndrome. J Am Board Fam Pract 1997; 10: 329–32.
Initial Experience Using Dorsal Root Ganglion Stimulation: A Small Case Series
S. Johnson, R Chawla, A. Cox, M. Draper, B Hammersley, P. Eldridge, J. Farah, B. Frank, A. Goebel, T. Nurmikko, A Stockley, and M. Sharma
The Walton Centre NHS Foundation Trust, Liverpool, UK and the Pain Research Institute, Liverpool, UK.
Introduction
Despite good reported efficacy some patients do not receive adequate pain relief from traditional spinal cord stimulation (SCS) (Kumar et al 2008). One of the challenges of SCS is that it can be difficult to target paraesthesia’s to specific anatomical locations. Initial work with Dorsal Root Ganglion (DRG) stimulation has suggested it to be an effective alternative treatment with the ability to discretely target specific areas of pain with minimal overspill and position related stimulation changes (Liem et al 2013, Deer et al 2012).
Our initial justification of DRG treatment was to use it in cases were pain was localized to a specific area and hard to reach with traditional SCS i.e. foot or groin.
Methods
A case series of 8 patents trialled with DRG stimulation between June 2012 and April 2013 was reviewed. Outcomes were collected prospectively and case notes audited. Outcomes comprised of measures of pain intensity, disability and function, mood, patients perceived impression of change and degree of stimulation coverage and overspill, additional information was collected regarding symptom profile, demographics and implant details. Outcomes were recorded pre-trial, 1 month post implant and a further outcome review.
Results
8 patients were trialled during this period. Patient diagnosis and area of pain included: 4 CRPS (3x foot, 1x shoulder), 2 neuropathic groin pain, 2 phantom limb pain (1x toe, 1x groin). 3/8 of patents were considered to have already failed SCS. 7/8 patients were implanted. 5/7 reported significant pain relief at 1 month follow up (p=0.002) and later follow up (p=0.02). Average length of follow up at later follow up was 6.1 months (range 3-11).
Mean pain intensity (NRS 0-10) was 8.4 (range 5-10) pre-implant compared to 6.8 (range 1-10) at follow-up. Average pain reduction was 35% (n=8, range 0-80%). Mean percentage of stimulation coverage was 71.4% (range 0-100%, n=8) and for those who reported on-going efficacy 100% (n=5). No change was evident for measures of disability or mood. Functional data was incomplete.
Conclusion
The results show DRG stimulation within this small sample to be comparable to SCS in terms of pain relief. This is encouraging especially given 3/8 of the current sample had already failed traditional SCS prior to DRG. It was disappointing we were unable to report change in other domains. Obvious limitations to the current audit are small numbers and a relatively short follow up. However our results do support our original thoughts regarding utility; DRG stimulation can provide discrete coverage of hard to treat dermatomes, patients reported minimal overspill and position related changes in stimulation.
References
Deer TR, Grigsby E, Weiner RL, Wilcosky B, Kramer JM 2013. A prospective study of dorsal root ganglion stimulation for the relief of chronic pain. Neuromodulation.Jan-Feb;16(1):67–71.
Kumar K, Taylor RS, Jacques L, Eldabe S, Meglio M, Molet J, Thomson S, O’Callaghan J, Eisenberg E, Milbouw G, Buchser E, Fortini G, Richardson J, North RB. 2008. The effects of spinal cord stimulation in neuropathic pain are sustained: a 24-month follow-up of the prospective randomized controlled multicenter trial of the effectiveness of spinal cord stimulation. Neurosurgery.Oct;63(4):762–70.
Liem L, Russo M, Huygen FJ, Van Buyten JP, Smet I, Verrills P, Cousins M, Brooker C, Levy R, Deer T, Kramer J. 2013.A Multicenter, Prospective Trial to Assess the Safety and Performance of the Spinal Modulation Dorsal Root Ganglion Neurostimulator System in the Treatment of Chronic Pain. Neuromodulation. May 2013.
Learning Priorities of the UK Pain Physicians Training In Ultrasound Guided Pain Management Procedures
M Tavakkolizadeh, A Krol
St George’s Hospital, Pain Management Department, London
Background
Use of real-time ultrasound imaging in performing different regional blocks has been widely advocated by different authorities including American and European Societies of Regional Anaesthesia and Pain Medicine as well as UK National Institute for Clinical Excellence. More recently, ultrasound guided procedures in chronic pain management have gained popularity by introducing new dimensions to some commonly performed fluoroscopy-guided interventions. This eliminates the risks of radiation exposure, facilitates performing the procedures in an outpatient setting and improves safety and precision. However, its commonplace use has been limited by training, availability, and financial and technical factors within the UK National Health System.
Methods
We performed an online survey of the expectations from a training course in “using ultrasound guidance for performing chronic pain management procedures” in the UK.
An online survey (Surveymonkey) was emailed to physicians registered with British Pain Society or Regional Anaesthesia UK (ESRA) using their members’ contact databases. We used this data in designing the curriculum for our training courses. This data can also be used as a reference point in further development and monitoring of this practice.
Results
There were 71 respondents out of which 42 were interested in such a course. This group of 42 Pain physicians were hoping to learn to perform the following procedures under ultrasound; Sacroiliac joint (74%), Stellate ganglion, Suprascapular, Pudendal, Occipital nerves and Piriformis (71%).
Joint injections (71%), Lumbar facets and Median Branch blocks (69%), Paravertebral and Intercostal blocks (67%), Caudal (62%), Cervical Median Branch blocks (62%), Trigger point injections (52%) and finally Cervical root blocks (50%).
We used this data in developing our course curriculum. In our course feedback, being hands-on was identified as the major positive feedback while lectures were overall discouraged unless being short introductions coupled with interactive live model scanning by the faculty.
Conclusions
An estimated half of the UK Pain specialists use Ultrasound routinely. This indicates a growing interest in the Ultrasound use. The feedback from our cadaveric/ hands-on course following utilizing the above results in the course planning, confirmed these findings. We believe further developments in this field will depend on high quality scientific evidence, availability of training opportunities, reduced costs and improved technology.
This curriculum design exercise supported by Regional Anaesthesia UK, was the first of its kind. Given the constantly changing training requirements in this field, similar surveys are advised at timely intervals.
References
Neal et al. “The ASRA Evidence-Based Medicine Assessment of Ultrasound-Guided Regional Anesthesia and Pain Medicine”; Regional Anesthesia & Pain Medicine: March/April 2010 - Volume 35(2)
Tavakkolizadeh M, Anandakrishnan S, Krol A. “Current UK practice of ultrasound guided pain management procedures”; Poster presentation, NWAC World Anesthesia Convention in Istanbul: April 2012
Ultrasound Guided Neurolytic Coeliac Plexus Block ( Ncpb) By Anterior Approach In Patient With Cholestasis And Advanced Pancreatic Cancer
M But1, A Król2
1Oddział Anestezjologii i Intensywnej Terapii,Szpital Wojewódzki im M. Kopernika w Koszalinie, Poland. 2Department of Anesthesia and Chronic Pain Service St. George’s Hospital,London, UK
Background
Coeliac plexus neurolysis is well established and commonly performed procedure for upper abdominal pain. Most common indications are upper abdominal malignacy within coeliac plexus innervation (pancreas, kidneys, suprarenal glands, stomach, liver) and hronic pancreatitis. Many different approaches and visualization techniques has been used. Posterior approach uder fluoroscopy or computed tomography has been widely described and is most popular among pain specialists. Severe complications are rare - 1/683 according to Davies studies and include paraplegia, retroperineal bleeding, aortic dissection, pneumothorax, and infections. Anterior approach under US guidance is an alternative and can avoid neurological complications.
Case report: A 58 year-old women with pancreatic tumor, metastasis to the liver and cholestasis which appeared a week before procedure and tend to increase was referred for management of severe epigastric and midback pain described as 8 on VAS. Previous oral treatment with strong opioids were ineffective and caused typical side effects: nausea, constipation and drowsiness.
Methods and results
The patient was placed in supine position, typical monitoring of vital functions was used . The procedure was performed in aseptic conditions Using ultrasound system SONOSITE M –turbo with convex transducer 2-6MHz.The edge of the liver was found and needle trajectory was designed. Optimal transducer position for visualization of coeliac trunk base, superior mesenteric artery, providing the best trajectory to by pass the liver was obtained . In designed trajectory, almost parallel to the aorta, the distance from the base of the coeliac trunk to the needle entry point was measured. A path for the needle was calculated to avoid liver puncture to reduce the risk of fistula formation in patient with cholestasis. The skin was infiltrated with 2% Lidocaine . Under ultrasound guidance with longitudal transducer position, the 21G x 110 SONO TAP PAJUNK needle was introduced “in plane “under the liver targeting a coeliac plexus. 10 ml of 1%Lignocaine with 10 µg/ml epinephrine was injected to anaesthetise coeliac plexus and exclude intravascular position of a needle at the same time. Complete pain relief was obtained without any heart rate alteration.Total of 30 ml. of 70% etanol with 80mg of Depo-Medrol ( methylprednisolone) was instilled uneventfully. Patient experienced complete pain relieve . Consequently patient underwent surgery for insertion of bile duct prosthesis.
Conclusion
Coeliac plexus neurolysis is safe and effective technique for visceral upper abdominal pain caused by cancer. Precise needle placement and adequate medication diffusion over the target area are the main indicators of success. A technique under fluoroscopy guidance, which rely on bony landmarks, does not take into account anatomic variations of the celiac trunk in relation to the aorta and the vertebral body. An anterior in plane approach provides better needle control and the possibility of precise deposition of neurolytic agent. In comparison to the CT guided techiniques it is faster, far less expensive, more accessible and does not involve exposure to the harmful radiation.
References
Yuen TS, Ng KF, Tsui SL. Neurolytic celiac plexus block for visceral abdominal malignancy: is prior diagnostic block warranted? Anaesth Intensive Care 2002;30:442–8.
Eisenberg E, Carr BD, Chalmers TC, Neurolitic celiac plexus block for treatment of cancer pain: A metaanalisys Anesth Analg 1995;80:290–295.
Atlas of Ultrasound-Guided Procedures in Interventional Pain Management Samer N. Narouze, MD, MSc, DABPM, FIPP Springer 2010
Davies DD. Incidence of major complications of neurolytic coeliac plexus block. J R Soc Med. 1993; 86:264–6.
James P. Rathmell, M.D., Janice M. Gallant, M.D., David L. and Brown, M.D. Computed Tomography and the Anatomy of Celiac Plexus Block Regional Anesthesia and Pain Medicine Vol. 25 No. 4 July–August 2000;411–416
Spinal Cord Ischemia a Complication After Celiac Plexus Block, case report Josephine N Lo M. D. Regional Anesthesia & Pain Medicine 7(2):66–68, April/May/June 1982.
Radiofrequency Neurotomy of The Third Occipital Nerve For Management of Occipital Neuralgia In A Patient with Arnold Chiari Malformation and Ventriculo-Peritoneal Shunt In Situ
A. Puttappa1, A. Behura1, H. Mutagi2, S. Kapur2
1Clinical Fellow, 2Consultant
Dudley Pain Management & Neuromodulation Centre, Russells Hall Hospital, DY1 2HQ, West Midlands
Background
We describe a case where Radiofrequency lesioning (RFL) of the third occipital nerve offered effective management of occipital neuralgia in a patient with Arnold Chiari malformation and ipsilateral ventriculo-peritoneal (VP) shunt.
Case Report
A 40yrs old female presented with right sided occipital neuralgia following posterior fossa decompression surgery and multiple VP shunt procedures for Arnold Chiari malformation and idiopathic intracranial hypertension. Her symptoms proved refractory to conventional medical management. We performed RFL of C2-C3 medial branches after successful diagnostic blocks, resulting in significant pain relief for 9-12 months. The procedure was successfully repeated thereafter.
Discussion
RFL of the third occipital nerve is an established treatment in occipital neuralgia. However, the presence of ipsilateral VP shunt and post-surgery scar tissue presented technical challenges in performing the RFL procedure. The VP shunt catheter closely overlapped the target zone for the procedure. Moreover there was a risk of the heat generated from the RF electrode tip causing damage to the silastic VP shunt catheter. Furthermore repeated surgeries had resulted in significant scar tissue formation, which in turn presented further technical challenges. However, these proved to be surmountable and procedure has resulted in significant, reproducible pain relief for the patient.
Conclusion
Cervical zygapophyseal joint RF neurotomy can result in significant reduction in cervicogenic headaches and Occipital neuralgia. Govind et al showed that 88% patients achieved a successful outcome following this procedure, and the median duration of relief in these patients was 297 days though relief is not permanent as the nerve regenerates. Although the relief of headache is limited in duration, it is profound and can be reinstated by repeat neurotomy.
Reference
Govind J, King W, Bailey B, et al. Radiofrequency neurotomy for the treatment of third occipital headache. J Neurol Neurosurg Psychiatry 2003;74:88–9
Sub-optimal outcome of lumbar radiofrequency sympathectomy – hampered by incomplete lesion?
A. Puttappa1, A. Behura1, H. Mutagi2, S. Kapur2
1Clinical Fellow, 2Consultant
Dudley Pain Management & Neuromodulation Centre, Russells Hall Hospital, DY1 2HQ, West Midlands
Background
Sympathetic mediated neuropathic pain is well documented, often diagnosed following a diagnostic sympathetic block. However, the currently available evidence does not support the logical therapeutic avenue of radiofrequency sympathectomy. We hypothesize a potentially improved outcome by using a bipolar technique to ablate lumbar sympathetic ganglion as demonstrated by the presented case. This is similar to Kang SS et al reporting sustained improved perfusion of lower limb following a sequential Bipolar RF for Raynaud’s disease.1
Case Report
A 49yr old female presented with a 7 year history of pain in left knee. She was diagnosed to have a combined nociceptive arthritic pain and post-surgical neuropathic pain following multiple arthroscopic knee procedures. Conservative measures that included weak opioids, gabapentin and antidepressants did not provide much relief. The neuropathic features of the knee pain completely resolved transiently following a diagnostic left lumbar sympathetic block undertaken at L3 level. A radiofrequency sympathectomy was contemplated to prolong the benefit. At 6 weeks follow-up, she reported significant resolution of neuropathic component of her left knee pain. Telephonic review at 4 months revealed near complete resolution of neuropathic pain.
Discussion
A bipolar technique of Radiofrequency was hypothesized to ensure complete sympathectomy as the standard technique involves placing the RF probe perpendicular rather than aligned along the long axis of the ganglion. A single bipolar RF lesion was created without any immediate complications.
Conclusion
Bipolar RF creates a continuous strip lesion that potentially improves outcome in comparison to well recognized unipolar technique of lumbar sympathectomy as the RF probe cannot be placed along the long axis of the sympathetic ganglions.
References
Kang SS, Shin KM et al Sequential bipolar radiofrequency lumbar sympathectomy in Raynaud’s disease -A case report- Korean J Anesthesiol. 2010; 59:286–289.
Wang YG, Lu ZY et al A comparative study of radiofrequency ablation in unipolar and bipolar fashion. J Tongji Med Univ. 1995; 15:73–76.
Spinal Cord Stimulation and Fatigue
T McCormick1 and S Thomson2
1Pain Relief Unit, Oxford University Hospitals, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE. 2Pain Management Centre, Basildon and Thurrock University Hospitals, Orsett Hospital, Rowley Road, Grays, Essex, RM16 3EU.
Background
The use of spinal cord stimulation (SCS) is an established modality for the treatment of chronic neuropathic pain (1). SCS has been shown to reduce pain scores (2), but pain permeates all aspects of a patient’s life and if pain scores are used as a sole outcome measure, they underestimate the benefits of a therapy, as improved function and quality of life go unmeasured. An outcome measure of increasing prominence is fatigue. Fatigue, as a complaint, is rated as similar to pain by patients with rheumatoid arthritis and patients’ feel unsupported in its management(4). It differs from normal tiredness; although both share physical and cognitive components, these are predictable, less profound and temporary in tiredness (3). The aim of this pilot study was to investigate the levels of fatigue amongst the population of patients selected for spinal cord stimulation and establish the effects of SCS on fatigue.
Methods
Fifteen sequential patients, scheduled for spinal cord stimulation, from May 2013 to August 2013 were asked to complete the FACIT-fatigue questionnaire pre-implantation, at the end of the trial period, and at three months. All implants were performed by a single implanter (SJT) using Boston Scientific Precision Plus system with MICC (multiple independent current control) technology.
The FACIT-fatigue questionnaire is a thirteen item questionnaire that assesses self reported fatigue and its impact on function. It has been employed in over 70 published studies and in a number of conditions. It is valid as a “standalone” questionnaire. The recall period for the questionnaire is over the previous seven 7 days. The range of possible scores is 0-52 with higher numbers reflecting less fatigue and a cut off point of 34 for diagnosis of fatigue (5,6).
Results
Fifteen patients underwent SCS for a variety of conditions (FBSS, CRPS, Brachial Plexus avulsion, Angina and Phantom limb/stump pain).
The prevalence of fatigue was high at 93% (14/15). Fatigue scores ranged from 5-45 and the average score of 19 (< 34 indicates significant fatigue) represents a greater degree of fatigue than seen in other musculoskeletal conditions (RA, SLE, Sjogren’s) (4). The prevalence of fatigue reduced after SCS insertion, to 33% (5/15). The average fatigue score post SCS was 36. This represents a significant improvement. Only one patient did not go on to have a full implant. The correlation between decreased pain scores and decreased fatigue levels was weakly positive (R2=0.28). This is in keeping with previous statements that the relationship between pain reports and functional behaviour is only modest (7). Improvements in levels of fatigue appeared sustained at three month follow up.
Conclusion
This pilot study is limited by its small size, but it would suggest that SCS has a positive effect on fatigue that is not entirely due to a reduction in pain scores. Levels of fatigue dropped from 93% to 33% after SCS. The average fatigue score went from 19 (significant fatigue) to 36 (not fatigued). On average, patients were no longer reporting significant fatigue after SCS. Further research, with larger numbers and longer follow up, would be required to draw any meaningful conclusions although the initial results are encouraging.
There were insufficient numbers of patients with different conditions to draw conclusions about certain conditions or if fatigue scores would be a useful tool in assisting in patient selection.
References
Spinal cord stimulation versus conventional medical management for neuropathic pain:A multi centre randomised controlled trial in patients with failed back surgery. Kumar et al Pain 132 (2007) 179–188
A qualitative investigation of fatigue among healthy working adults. Aaronson et al. West J Nurs Res 2003;25(4):419–33
Fatigue in Musculoskeletal conditions. Hewlett et al Topical Reviews Autumn 2008 (1)
Comparison of proposed diagnostic criteria with FACT-F and VAS for cancer-related fatigue: proposal for use as a screening tool Support Care Cancer (2005) 13:246–254
Clinical Effectiveness and Cost-Effectiveness of Treatments for Patients with Chronic Pain. Turk D. The Clinical Journal of Pain 18:335–365
Management of CRPS Hand With Topical 8% Capsaicin Patch- A Case Report
A. Behura1, A. Puttappa1, H. Mutagi2, S. Kapur2
1Clinical Fellow, 2Consultant
Dudley Pain Management & Neuromodulation Centre, Russells Hall Hospital, DY1 2HQ, West Midlands
Background
The high concentration capsaicin patch (8%W/W) is a unique topical treatment for peripheral neuropathic pain in non-diabetic adults. Complex Regional Pain syndrome (CRPS) is a disabling condition with neuropathic pain out of proportion to inciting trauma. Most studies on treatments of neuropathic conditions by capsaicin patch exclude CRPS cases. We present a CRPS patient refractory to conventional management and report her response to capsaicin patch therapy.
Case Report
A 36yr old female presented with severe CRPS1 of right hand following K wire fixation of fractured ring finger. Her symptoms proved refractory to pharmacological management with opioids and anti-neuropathic medications2. An ultrasound-guided stellate ganglion block followed by intensive physiotherapy also proved unsuccessful. Our multidisciplinary team considered her unsuitable for a Spinal Cord Stimulation trial in view of psychosocial barriers. In spite of contradictory anecdotes in literature, we opted to undertake a trial of 8% Capsaicin patch (Qutenza®, Astellas Pharma UK) application as per the standard recommended technique to cover the predominant symptomatic area. She underwent the trial as a day case procedure. She reported marked reduction in symptoms following initial transient exacerbation of symptoms. On review 4 months later, her CRPS symptoms continued to be in remission; with pain, cutaneous sensitivity and colour changes markedly reduced (VAS 9/10 down to 4/10).
Discussion
Capsaicin selectively binds to a protein (TRPV 1) that resides on the membranes of pain and heat sensing neurons. Prolonged activation of these neurons by capsaicin results in defunctionalization and constituted by reduced spontaneous activity and a loss of responsiveness to a wide range of sensory stimuli. This is caused by multiple mechanisms like Inactivation of voltage gated Na+channnels, direct pharmacological desensitization of TRPV1 receptors, activation of Ca++dependant proteases and direct inhibition of electron chain transport.3
Conclusion
8% Capsaicin cutaneous patch has been approved for treatment of peripheral neuropathic pain, excluding painful diabetic neuropathy. But little has been published about its use in CRPS. We suggest a novel approach in treatment of refractory cases of CRPS.
References
Harden RN, Bruehl S, Perez RS et al: Validation of proposed diagnostic criteria (the “Budapest Criteria”) for Complex Regional Pain Syndrome: Pain. 2010 August; 150(2): 268–274.
NICE clinical guideline (CG96)- Neuropathic pain: The pharmacological management of neuropathic pain in adults in non-specialist settings: issued March 2010
Topical capsaicin for pain management: therapeutic potential and mechanisms of action of the new high- concentration capsaicin 8% patch; Anand P. and K. Bley; British Journal of Anaesthesia 107 (4); 490–502 (2011)