Skip to main content
NCBI home page
British Journal of Pain logoLink to British Journal of Pain
. 2015 Nov;9(4):196–202. doi: 10.1177/2049463714561564

Posters presented at annual scientific meeting of Interventional Pain SIG of British Pain society on 17th October, 2014, Manchester

PMCID: PMC4616985

Protocol For Pilot RCT To Test The Effectiveness And Cost Effectiveness Of Facet-Joint Injections For Selected People With Persistent Non-Specific Low Back Pain (Fis) – The Protocol

Cairns M1, Mars T2, Haywood K3, Lega C2,4, Sandhu H2, Ellard D2, Keohane S2, Antrobus JH5 and Underwood M2

1Department of Allied Health Professions and Midwifery,

2School of Health and Social Work,

3University of Hertfordshire, UK

4Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School,

5The University of Warwick, UK

6Royal College of Nursing Research Institute, Division of Health Sciences, Warwick Medical School, The University of Warwick, UK

7School of Psychology, University of Bologna, Italy

8South Warwickshire NHS Foundation Trust

On behalf of the FIS Team

Background

Between 5-15% of people with chronic LBP are believed to have disease of one or more facet joints contributing to their pain yet there is considerable uncertainty on how to identify and treat such people.

This pilot RCT will test the hypothesis that, for people with suspected facet joint pain contributing to persistent LBP, adding facet joint injections, with local anaesthetic and corticosteroids, to best usual non-invasive care available from the NHS is both clinically and cost effective.

Method

Patients referred to secondary care with persistent non-specific LBP will be screened. Those meeting the eligibility criteria will receive a 1 hour assessment with a physiotherapist to confirm diagnosis and collect baseline data. All participants (n=150) will be offered a bespoke package of physical and behavioral rehabilitation. Those randomized into the intervention arm (n=75) will, in addition, receive facet joint injections. Primary outcome data will be collected using daily and then weekly text messaging service for a pain score on a 0-10 scale. Questionnaire follow up will be at 3, 6, and 12 months.

Results

To inform the ‘diagnosis’ and ‘best usual care’ package two systematic reviews have been undertaken

  1. non-invasive ‘diagnosis’ of suspected facet joint pain

  2. the physical therapy management of patients with ‘facet joint pain’ including psychological or cognitive behavioral approaches delivered by non-psychologists. MEDLINE, EMBASE, CINAHL, AMED and BIOSIS have been searched alongside the grey literature, hand searching and narrative evidence synthesis from seminal texts of physical therapy.

Conclusion

Recruitment will start in four sites in November 2014.

Footnotes

Funding: (Facet-joint injections for people with persistent non-specific low back pain (FIS); National Institute for Health Research/ Health Technology Assessment Programme funded project: 11/31/01)

Br J Pain. 9(4):196–202.

Article

Spinal Cord Stimulation For Patients With Chronic Neuropathic Pain (Failed Back Surgery Syndrome): Survey Results Of North England Pain Group’s 6th Annual Meeting, 2014

M Sharma1, S Gupta2, A Blythman3

1The Walton Centre for Neurology and Neurosurgery NHS Foundation Trust, Liverpool, 2Bradford Teaching Hospitals NHS Foundation Trust, Bradford, 3Medtronic Limited, Watford, Hertfordshire

Background

Spinal cord stimulation is an established treatment for failed back surgery syndrome as supported by Randomised controlled trial and from NICE Technology Appraisal Guidance 159. This treatment should be routinely available to patients who have uncontrolled neuropathic pain of more than six month’s duration, 50/100 on visual analogue pain scale and refractory to standard care. However there is considerable variation in uptake of this treatment and reasons are unclear. The purpose of this survey was to explore views of the attendees of this Chronic Pain Meeting in North of England.

Method

Survey was distributed to 110 delegates attending annual meeting of North England Pain Group. 41 completed forms were received. Some of the questions asked of the attendees are as below. What percentage of your workload are patients with chronic neuropathic leg and back pain? Please select your preferred treatment approach for a patient with failed back surgery syndrome where further spinal surgery is not an option and they continue with intractable Chronic Neuropathic pain? Please indicate which phrase best describes your current attitude towards Spinal Cord Stimulation (SCS) as a treatment for patients with FBSS. In your own words please state the type of patient you believe would be appropriate for SCS? Please rate the potential barriers to treating/referring appropriate candidates with chronic neuropathic leg and back pain that could be investigated for further treatment with SCS? The completed survey data was analyzed and responses were pooled in groups for purpose of comparison.

Results

For the most of responders very significant part of the workload was assessing and treating patients with FBSS. In terms of preferred first and second choice options for FBSS patients, treatment with nerve root blocks, long term opioids and other neuropathic pain medications were preferred over spinal cord stimulation. Key barriers for spinal cord stimulation seems to be lack of Knowledge of Level 1 RCT evidence, understanding of NICE Guidance/TAG 159, concern over funding (this may reflect the understanding between a NICE Guidance and a NICE TAG and mandatory funding), patient’s selection criteria for spinal cord stimulation and access to a service offering neurmodulation.

Conclusion

There seems to be considerable variation in application of treatment options for patients with FBSS. This is despite level 1 evidence from RCT for Spinal Cord stimulation and NICE TAG 159. For attendees of North England Pain meeting there appears to be lack of clarity on patient selection criteria, funding concerns and service access issues. This also seems to be the case supported from other published data. More education and awareness of this treatment is desirable to increase early uptake of spinal cord stimulation as there is evidence to support more success with early use.

References

  • 1. NICE. Technology Appraisal Guidelines 159: spinal cord stimulation for chronic pain of neuropathic or ischaemic origin, 2008. (updated Oct 2008). http://www.nice.org.uk/TA159
  • 2. Vyawahare B, Hallas N, Brookes M, Taylor R S, Eldabe S. Impact of the National Institute for Health and Care Excellence (NICE) guidance on medical technology uptake: analysis of the uptake of spinal cord stimulation in England 2008–2012. BMJ Open 2014; 4: e004182 doi: 10.1136/bmjopen-2013-004182 (accessed on line on 3rd September, 2014). [DOI] [PMC free article] [PubMed] [Google Scholar]
Br J Pain. 9(4):196–202.

Article

Failure To Remove Fractured Dorsal Root Ganglion Electrodes During Revision Surgery – A Report Of Two Cases

R Guru, R Srivastava, S Kapur

Department of Pain Management, Department of Radiodiagnosis*, Dudley NHS Foundation Trust, Russells Hall Hospital, Dudley,West Midlands, DY1 2HQ

Background

Dorsal root ganglion (DRG) stimulation is an effective treatment for neuropathic pain conditions that may not respond to conventional spinal cord stimulation (SCS). It involves inserting an electrode into the epidural space and then steering it laterally into the neural foramen to stimulate the dorsal root ganglion. Reported complications with DRG electrodes include infection, cerebrospinal fluid leak, electrode migration, fracture and breakage during removal. We report two cases of inability to remove fractured DRG stimulator electrodes.

Methods

Case 1: Patient had a DRG stimulation electrode inserted for neuropathic pain in the left groin and testicle. He reported 90% relief from the pain and was able to come off most of his medications. Unfortunately the DRG stimulator malfunctioned after the patient sustained a fall. X-rays revealed the DRG electrode was fractured proximal to the anchor site.

Case 2: Patient presented with severe neuropathic pain in his right foot refractory to conventional management and DRG stimulation was undertaken. To circumvent epidural access problems via the interlaminar route because of the presence of spinal fusion metalwork, a caudal approach was chosen to insert the DRG stimulator electrode. Unfortunately, after 6 months, he lost stimulation completely and X-rays revealed an electrode fracture.

Results

Case 1: Patient required revision surgery and a fresh DRG electrode was inserted. Attempts to remove the old fractured electrode were unsuccessful because of tissue adhesions. To avoid the risk of the old fractured electrode breaking and potentially leaving the fragment lying epidurally, we abandoned it in its existing pocket.

Case 2: Patient underwent revision surgery but we were unable to remove the DRG electrode from the right L5 neural foramen. The unfavourable anatomy meant we had to abandon the electrode in situ and explant the battery,

Conclusion

There have been other reports of inability to remove DRG electrodes. The manufacturer (Spinal Modulation®) has issued a field safety alert with advice/instructions on the method of removal of DRG electrodes. These instructions were followed during the unsuccessful attempts at removal of electrodes in both patients. Inability to remove fractured electrodes could lead to complications like electrode migration in the epidural space and breakage of the electrode. In our opinion, potential solutions could include a modification of the electrode architecture by the manufacturer to improve its tensile strength.

Footnotes

Funding: Dudley NHS Foundation Trust, West Midlands, DY1 2HQ, UK

Br J Pain. 9(4):196–202.

Article

A Survey Of Pain Practice In The North Of England

Dr A Natarajan1, Dr S Jayaseelan1, Dr P K Ganty2, Dr M Sharma3, Dr S Gupta4

1Pain Fellow, Department of Pain Management, Walton Centre, Liverpool

2Consultant, Department of Pain Management, Walton Centre, Liverpool

3Consultant & Clinical Director, Department of Pain Management, Walton Centre, Liverpool

4Consultant in Pain medicine & Anaesthesia, Bradford Teaching Hospital NHS Foundation trust

Background

This survey was done at the annual meeting of the North England pain medicine group. The aim of the study was to find out the pain problems with which patients presented in the pain clinic, time taken to see the new and follow up patients, the management of neuropathic pain in the community and the pain team’s perception of this management. We also wanted to determine if there is a need for a fast track service for radicular pain.

Methods

The annual meeting of the North England pain medicine group was attended by 108 delegates in June 2014. Each of these delegates was given a questionnaire. The questionnaire had questions regarding the delegate’s role in their pain team, type of patient seen in their clinic, time taken to see each patient, percentage of patients presenting with nociceptive or neuropathic pain, quality of management of neuropathic pain in the community, and the need for a fast track acute radicular pain service in the NHS.

Results

46 responses were received. Among the respondents, 57% were consultants, 21% were specialty doctors, 19% were registrars, nurse specialist and others 3%. Regarding the type of patient seen in the clinic, 57% had lower back pain, 14% had neck pain/ upper limb radicular pain, 8% had Rheumatologic conditions, 7% had chronic postsurgical pain, 5% had CRPS, 4% had thoracic pain, 4% had pelvic pain and 3% had facial pain. 30% had nociceptive, 30% had neuropathic and 40% had both nociceptive and neuropathic . 20 respondents answered that the neuropathic pain was managed well in the community, 23 thought that it was not managed well and 3 of them had no opinion. 30 delegates wanted a fast track service for radicular pain, 5 of them did not see a need and 3 had no opinion1. Average time taken for new consultation was 47+/- (SD) minutes2 and the time taken for follow up consultation was 19 +/- (SD) minutes3.

Conclusion

Low back pain and neck and upper limb radicular pain were the most common presentations to the pain clinic. The perception about the quality of primary care management of neuropathic pain seems to be divided equally among secondary care providers. This survey provides a reference template for young pain practitioners to compare their practice. There seems to be an overwhelming positive response to the need for a fast track pain service for the management of acute radicular pain in the NHS.

References

Br J Pain. 9(4):196–202.

Article

Blockage Of Vertebroplasty Needle By Radio Opaque Bead-Labelled Bone Cement

Balazs Bartos, Rahul Guru, Kumar Vasappa, Hirachand Mutagi, Aabha Sinha*, Sandeep Kapur

Department of Pain Management, Department of Radiodiagnosis*, Dudley NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, DY1 2HQ

Background

Percutaneous vertebroplasty (PVP) is a minimally invasive procedure in which polymethylmethacrylate (PMMA) cement is injected percutaneously into a vertebral body through a needle positioned using a transpedicular approach. This ‘internal casting’ alleviates pain and allows increased mobility in a significant percentage of patients suffering from vertebral compression of different origin. During unipedicular approach an access needle is inserted under fluoroscopic guidance through the pedicle into the vertebral body on one side and cement material is injected into the collapsed vertebral body to provide reinforcement. After introducing sufficient amount of cement any remnant from the needle is emptied into the vertebral body before the cement sets to prevent possible complications. We report a case where the use of a radio opaque bead-labelled cement caused obstruction of the vertebroplasty needle during a vertebral cement augmentation procedure that could have led to potential serious complications.

Methods

An 84 year old female with osteoporotic vertebral collapse underwent T11 vertebroplasty using a 13G NeuroTherm Parallax® vertebral access needle inserted via a right-sided unipedicular approach under fluoroscopic guidance in the hospital’s digital subtraction angiography suite. Propofol and Remifentanil target controlled infusion (TCI) and standard monitoring were instituted. We used the NeuroTherm Parallax® EZFlow Cement Delivery System to deliver a proprietary bead-labeled PMMA bone cement (NeuroTherm Parallax Acrylic Resin with TRACERS®). This cement material contains tantalum disks to create visible dots that clearly show the flow of cement within the bone cavity for improved visibility under x-ray.

Results

After successful positioning of the access needle approximately 1.3 ml of cement was injected into the vertebral body through the vertebroplasty needle, at which point unusually high resistance to delivery was perceived. When the cement delivery system was disconnected, the cement was noted to flow freely, indicating it had not ‘set’ prematurely, leading us to suspect an obstruction within the needle. Our inability to reinsert the stylet into the needle also indicated an intraluminal mechanical obstruction. This was confirmed when ex-vivo x-rays of the needle revealed a sludge of beads within it. Usually, once adequate cement augmentation is confirmed by fluoroscopy, the stylet is re-inserted into the needle to ‘push out’ any residual cement from the needle before it is withdrawn from the vertebra. This is done to prevent a formation of a ‘tail’ of cement protruding out of the vertebra into the paraspinal muscles and causing myofascial pain afterwards.

Conclusion

In our case, the needle obstruction meant that cement column formed by the needle was about 2cm long and extended into the pedicle. We recognized the risk and therefore rotated the needle continuously while withdrawing it, thereby ‘cutting off’ the cement column within the pedicle, with no bony spicule protruding into paraspinal muscles. The patient did well following the procedure and on the 4 weeks follow up. To the best of our knowledge, the above complication has not been reported previously. To prevent a recurrence of this event, we now use a bigger lumen vertebroplasty needle when injecting bead-labeled PMMA bone cement.

References

  • 1. Ohen JE, Lylyk P, Ceratto R : Percutaneous vertebroplasty: technique and results in 192 procedures. Neurol Res. 2004; 26: 41–49 [DOI] [PubMed] [Google Scholar]
  • 2. Jensen ME, Evans AJ, Mathis JM, et al. : Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures. technical aspects Am J Neuroradiol. 1997; 18:1897–1904 [PMC free article] [PubMed] [Google Scholar]
  • 3. Hadjipavlou AG, Tzermiadianos MN, Katonis PG, Szpalski M :Percutaneous vertebroplasty and balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures and osteolytic tumours. J Bone Joint Surg Br. 2005; 87:1595–1604 [DOI] [PubMed] [Google Scholar]
  • 4. Hu YC, Hart DJ. Complications of vertebroplasty and kyphoplasty. Techniques in Regional Anesthesia & Pain Management. 2007; 11 (3): 164–170 [DOI] [PMC free article] [PubMed] [Google Scholar]
Br J Pain. 9(4):196–202.

Article

Pain relief following interventional procedures for common chronic pain conditions - service evaluation

T. Bendinger¹, S Puppalwar², S Gupta³

1Advanced Pain Trainee, Sheffield Teaching Hospitals, Sheffield

2Pain Fellow, Sheffield Teaching Hospitals, Sheffield

3Consultant in Anaesthesia and Pain Medicine, Sheffield Teaching Hospitals, Sheffield

Background

Chronic pain conditions like lower back pain or radiculopathy are dramatically increasing problem in Western countries which cost billions of dollars to health providers. There are many different treatment options available like pharmacological therapy, invasive procedures or pain management programs. However there is lack of unequivocal evidence supporting superiority of one over another. Moreover the lack of clear national or international guidelines leaves medical practitioners without support during decision making process.

Increasing number of interventional procedures that are being done every year, and the associated cost with it, drives significant interest in evaluation of effectiveness of invasive techniques. Multiple recent meta-analysis or literature reviews have not delivered an unequivocal evidence of benefit. There is an increasing body of opinion that randomized double blinded controlled trails should not be considered as the only sources of evidence in pain medicine.

We are aiming to present our results of routine interventional practice within our clinic to support this method of treatment.

Methods

The data was collected prospectively after 815 episodes of invasive procedures done in a single Teaching Hospital Multidisciplinary Pain Clinic between 09/2011 and 04/2013 for patients suffering from one of three simplified diagnosis: mechanical lower back pain (LBP), radicular pain to lower limb and shoulder pain. It represents more than 85% of our patient cohort. Following procedures were performed for treatment of:

  • mechanical LBP - facet joints injection, sacroiliac joint injection and radiofrequency nerve ablation to medial branch;

  • radiculopathy - interlaminar epidural, transformaninal epidural and pulse radiofrequency to nerve root;

  • shoulder pain - radiofrequency suprascapular nerve ablation or steroid injection around the nerve.

Every procedure performed as a day case is recorded into a database. At the time of procedure, an informed verbal consent was obtained. Patients were followed up at 6 and 12 weeks by a nurse via telephone. Data was entered at 12 week review. Data related to duration and percentage of pain relief, improvement in sleep, activity, analgesia requirement and global perception of improvement were collected. Patients with any degree of pain relief at 12 weeks were considered to have benefitted from the intervention.

Results

815 procedures were performed for 391 patients with lower back pain, 370 with radiculopathy and 54 with shoulder pain. Mean age of group was 63.57 years. Gender distribution M:F was almost 1:2.

Out of 245 facet joints injections 154 (62.8%) provided some pain relief at 12 weeks follow up. Success in terms of pain relief for 96 radiofrequency ablations of medial branch nerve was achieved for 68 patients (70.8%). Sacroiliac joint injections were helpful for 19 (47.5%) patients out of 40 performed. Transforaminal epidural improved pain for 111 (47%) out of 234 patients at 12 weeks time, very similar to 112 interlaminal epidurals - 54 patients (48.2%). 30 pulsed radiofrequency procedures performed provided some pain relief to 19 (63.3%) patients. 25 patients (46.3%) of shoulder pain group benefited from total of 54 suprascapular nerve interventions.

Conclusion

Despite ambiguous results in the literature, the interventional therapy is effective for at least 12 weeks for about half of our patients who were diagnosed with mechanical lower back pain, radiculopathy or shoulder pain within our clinic setting.

Br J Pain. 9(4):196–202.

Article

Successful Symptom Management Of Sunct Syndrome By Cervical Medial Branch Radiofrequency Neurotomy

Kumar Vasappa, Rahul Guru, Balazs Bartos, Sandeep Kapur

Department of Pain Management, Dudley NHS Foundation Trust, Russells Hall Hospital, Dudley, West Midlands, DY1 2HQ

Background

SUNCT syndrome (Short lasting Unilateral Neuralgiform Headache attacks with Conjunctival injection and Tearing) is a rare chronic headache condition characterised by attacks of moderate to severe, strictly unilateral head pain lasting seconds to minutes, occurring at least once a day and usually associated with prominent lacrimation and redness of the ipsilateral eye. 1 The mean age of onset is around 50 years with a male predominance2. It is difficult to treat and management usually involves multimodal therapies that have variable efficacy2. Lamotrigine is the most effective preventive agent, with topiramate and gabapentin also being useful3. Intravenous lidocaine may be helpful as an acute therapy3. Limited reports exist on greater occipital nerve (GON) block for acute attacks4. Microvascular decompression (MVD) of the trigeminal nerve (in the presence of an aberrant vessel) and occipital nerve stimulation (ONS) have been reported to be effective treatment options for refractory SUNCT syndrome in the presence of an aberrant vessel5, 6

Methods

We report a case of SUNCT syndrome who had a partial response to pharmacological treatment, but gained further symptom relief from C2, 3 medial branch Radiofrequency neurotomy. A 47 years old male patient diagnosed with left sided SUNCT headache was referred to our MDT pain clinic. Previous to our consultation his pharmacotherapy was limited by side effects and a GON block had provided benefit for two weeks. The pain was significantly affecting his quality of life and causing low mood. Given the history of short-term benefit from GON blocks, we decided to offer left C2,3 Medial Branch blocks as a diagnostic intervention. If this proved to be beneficial we intended to proceed to Radiofrequency neurotomy of C2,3 medial branches.

Result

As documented on a procedure evaluation questionnaire completed by the patient, left C2, 3 median branch blocks decreased the patient’s VAS pain score from 75/100 to 15/100 for two weeks, with gradual regression to baseline pain scores thereafter. Radiofrequency (RF) neurotomy of left C2,3 medial branch nerves was thereafter undertaken under fluoroscopic guidance, local anaesthesia and light sedation. This procedure provided good benefit from his SUNCT headache symptoms for more than 3 months, with pain scores returning to pre-procedure levels gradually thereafter. A second RF procedure was therefore performed out 6 months later, with further tangible symptom reduction.

Conclusion

SUNCT syndrome is difficult to treat. The GON arises from the medial branch (MB) of the dorsal ramus of C2 and the third occipital nerve (TON) arises from the MB of dorsal ramus of C3. As ONS has been shown to be an effective treatment for intractable SUNCT syndrome6 we decided to do a diagnostic block of the medial branches of C2 and C3 (that give rise to the occipital nerves) followed by RF neurotomy. Our experience demonstrates that C2,3 medial branch blocks & RF neurotomy could help reduce the sensory nociceptive input from cervical spine to the trigeminal complex, thereby aiding symptom management in intractable SUNCT.

References

  • 1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalgia; 2013; 33(9): 629–808 [DOI] [PubMed] [Google Scholar]
  • 2. Pareja JA, Alvarez M, Montojo T.SUNCT and SUNA: Recognition and Treatment. Curr Treat Options Neurol. 2013. February;15(1):28–39. doi: 10.1007/s11940-012-0211-8 [DOI] [PubMed] [Google Scholar]
  • 3. May A, Leone M, Afra J, et al. : EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalagias. Eur J Neurol. 2006; 13:1066–1077. [DOI] [PubMed] [Google Scholar]
  • 4. Porta-Etessam J, Cuadrado ML, Galan L, Sampedro A, Valencia C. Temporal response to bupivacaine bilateral great occipital block in a patient with SUNCT syndrome. J Headache Pain. 2010;11:179. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5. Sebastian S, Schweitzer D, Tan L, Broadley SA. Role of trigeminal microvascular decompression in the treatment of SUNCT and SUNA. Curr Pain Headache Rep. 2013;17:332. Review of the evidence for MVD for SUNCT and SUNA. [DOI] [PubMed] [Google Scholar]
  • 6. Lambru G, Shanahan P, Watkins L, Matharu MS. Occipital nerve stimulation in the treatment of medically intractable SUNCT and SUNA. Pain Phys. 2014;17:29–41. [PubMed] [Google Scholar]
Br J Pain. 9(4):196–202.

Article

A Survey Of Pain Interventional Procedures

Dr A Natarajan1, Dr S Jayaseelan1, Dr P K Ganty2, Dr M Sharma3, Dr S Gupta4

1Pain Fellow, Department of Pain Management, Walton Centre, Liverpool

2Consultant, Department of Pain Management, Walton Centre, Liverpool

3Consultant & Clinical Director, Department of Pain Management, Walton Centre, Liverpool

4Consultant in Pain medicine & Anaesthesia, Bradford Teaching Hospital NHS Foundation trust

Background

The North of England pain group has a multi professional meeting every year. The group comprises of staff working in the department of pain management across different NHS trusts in the north of England. This included consultants, speciality doctors, physiotherapists, psychologists, nurses and other allied staff in the department of pain management. We utilised the opportunity to do a study of the pain practices regarding interventional pain procedures and the use of steroids across the region.

The aim of the study is to ascertain 1)the types and amount of steroids used, 2)the practices of avoiding injections in patients with recent infections, 3)pneumothorax and interventions, 4)surgery after injections and 5)injections following vaccinations.

Methods

The 6th annual meeting of the North of England pain group was attended by 108 delegates in 2014. Each of these delegates was given a questionnaire at the start of the meeting and the answers were collected after the meeting concluded. The questionnaire had questions regarding common clinical dilemmas such as the type and dose of steroid used for interventions; interventional procedures after a course of antibiotics; mild UTI and interventional procedures; pneumothorax and interventions particularly the lower cervical facet procedures; the interval between steroid injection and surgery and the interval between vaccination and steroid injection.

Results

On considering only the interventionists 59% said that the use Triamcinalone, 27% use Depomedrone, 11% said that they use both, and only 3% said that they use Dexamethosone1. On an average the practitioners used about 156mg of Triamcinolone per patient in a year. The duration after a course of antibiotics when the practitioner thought it safe to perform injections for the following procedures was as follows : Epidural steroid injections -Immediately 20% and after 4 weeks 54%, Median branch blocks with Local anaesthetics -immediately 48% and after 4 weeks 26%, Median branch block with steroid and local anaesthetic -immediately 30% and after 4 weeks 48%, Facet joint radiofrequency denervation- Immediately 38% and after 4 weeks 38%, Lumbar sympathetic block with local anaesthetic and steroid –Immediately 23% and after 4 weeks 52%, SI joint block with local anaesthetic - Immediately 40% and after 4 weeks 31%, SI joint block with local anaesthetic and steroid- Immediately 28% and after 4 weeks 47%. Would you differ an interventional procedure if the elderly patient has mild UTI and is not on antibiotics – 28% said yes, 50% said no and 22% had no comments. When asked if they warn regarding the complications of pneumothorax in patients who have lower cervical facet procedures- 37% said yes, 39% said no and 24% did not comment2. 10 interventionists said that they will advise their patients not to fly and avoid changes in atmospheric pressure after a lower cervical facet procedure and 14 of them said that they would give no such advice. When asked about the minimum interval after steroid injection and elective general or orthopaedic surgery 20% said next day and 50% said 4 weeks. And for performing a steroid injection after a flu vaccination 23% said that it can be done the next day and 38% said a minimum duration of 4 weeks is needed.

Conclusion

The survey shows a snapshot of the interventional pain practice across the northern region. There are important questions with no clear cut answer. This may tempt us to do more work on the required areas and produce robust guidelines.

References

  • 1. Role of neuraxial steroids in interventional pain management. Manchikanti L et al, Pain Physician. 2002. Apr;5(2): 182–99 [PubMed] [Google Scholar]
  • 2. Injury and Liability Associated with Cervical Procedures for Chronic Pain. Rathmell, James P et al, Anesthesiology: April 2011. - Volume 114 - Issue 4 - pp 918–926 [DOI] [PubMed] [Google Scholar]
Br J Pain. 9(4):196–202.

Article

Audit of Sacral Nerve Stimulation (SNS) For Bowel or Bladder Instability And Pelvic Pain

A. Stockley, B. Hammersley, S. Johnson, M. Draper, J. Farah, A. Baird, R. Chawla and M. Sharma

The Walton Centre NHS Foundation Trust and Aintree University Hospital NHS Trust, Liverpool.

Background

Sacral nerve stimulation is the application of barely perceptible electrical current to the S3/S4 nerve via a percutaneously inserted electrode. The aim is to produce paraesthesia in the perineum/pelvic floor. Stimulation is indicated for urinary urge incontinence, urgency-frequency and faecal incontinence for patients who have failed non-invasive conservative treatment (National Institute for Health and Care Excellence (NICE) IPG 64 and 99). Patient assessment and selection within a multidisciplinary setup is important. An established diagnosis is necessary and all patients should have attempted lifestyle modifications, behavioural techniques and drug therapies prior to being considered for sacral nerve stimulation. The Walton centre began using this modality in line with NICE recommendations in March 2011. All patients first undergo a two week trial employing a temporary monode. Following a successful trial, a quadrode is implaneted and connected to an internal battery. Our criteria for a positive trial is at least 50% improvement of symptoms (pain reduction and/or improved continence/urge/frequency).

Method

This case series is a retrospective audit (follow up = 6-36 months) that consisted of all patients who underwent a permanament SNS (Medtronic Interstim) between March 2011 and March 2014. We recorded retrospective information from a combination of regular outpatient consultations, case note review and questionnaires. The outcome measures reviewed were patient perceived global impression of change (7 point scale: very much improved to very much worse), urge/incontinence measures (descriptors of frequency and degree) and pain scores (NRS: 0= no pain and 10= worst pain imaginable).

Results

Our 14 patients comprised of neuropathic perineum pain (n=6), urinary incontinence and frequency syndromes with associated pain (n=6) and faecal incontinence (n=2). Mean age was 54yrs (18-78) and 57% were male. In the neuropathic perineum pain group (n=6, FU = 6 to 36 months) 3 had improved pain (30% to 90% relief), one of which reported 80% pain improvement at 3 years. However 2 reported early failure with no pain relief (FU = 6 to 12 months) and 1 patient reported 60% worse pain, due to falls secondary to neurological disease progression (FU = 12m). Interestingly patients reported: 2 patients. very much improved. 1 much improved and 3 minimally improved. In our urinary urge incontinence group, 5/6 patients. complained of associated pain (n=6, FU = 6 to 36 months). The urge/incontinence measures improvement ranged between 50 to 100% and pain score change ranged between 33-100% improvement. GIC, 4 ‘very much improved’, 2 ‘much improved’. In our two cases with faecal incontinence (FU = 6 to 18 months); both had complete resolution both in degree and frequency of incontinence episodes. GIC both 3 (very much improved). The 11 patients with successful outcomes reported clinically significant improvement in quality of life. e.g. allowing them to leave the house for extended periods of time, enjoy social occasions and leisure activities, avoiding need for self-catheterisation and use of incontinence pads and returning to paid employment. They also reported considerably improvements in anxiety and confidence. 13/14 patients reported 100% coverage at the time of last follow-up. IPG repositioning was needed in one case due to persistant pocket discomfort (resolved after repositioning IPG) and one superficial IPG infection resolved with four weeks of iv and oral antibiotics therapy. No further system revisions have been required.

Conclusion

Our case series of 14 patients implanted with SNS within an MDT set-up shows significant improvement in symptoms and quality of life and perceived global impression of change in 79% (11 pts) with a follow-up duration of 6-36 months. There were no late failures for faecal, bladder with assoiciated pain incontinence in this case series except for pelvic pain. Our series shows it is an effective treatment for appropriately selected patients. Urinary and faecal incontinence improvement was considerable and clinically relevant in all cases, resulting in patients reporting improvement of their quality of life, through effective symptom control. However, a larger number of patients would need to be prospectively studied to evaluate application of the relevance of sacral nerve stimulation for above indications.

References

  • 1. Fraser C, Glazener C, Grant A, et al. Systematic review of the efficacy and safety of sacral nerve stimulation for faecal incontinence. Aberdeen: Review Body for Interventional Procedures; 2004. [Google Scholar]
  • 2. ‘Brazzelli M, Murray A, Fraser C, Grant A. Systematic review of the efficacy and safety of sacral nerve stimulation for urinary urge incontinence and urgency-frequency. Aberdeen: Review Body for Interventional Procedures; 2003’ [Google Scholar]
  • 3. NICE interventional procedure guidance 64, June 2004 [Google Scholar]
  • 4. NICE interventional procedure guidance 99, November 2004 [Google Scholar]
  • 5. Dudding TC, Hollingshead JR, Nicholls RJ, et al. (2011) Sacral nerve stimulation for faecal incontinence: patient selection, service provision and operative technique. Colorectal Dis 13(8): e187–95 [DOI] [PubMed] [Google Scholar]
  • 6. Matzel KE. (2011a) The role of sacral nerve stimulation in treating faecal incontinence and refractory constipation. [DOI] [PubMed] [Google Scholar]
  • 7. Bosch R, Groen J. Complete 5-year follow-up of sacral (S3) segmental nerve stimulation with an implantable electrode and pulse generator in 36 consecutive patients with refractory detrusor [Google Scholar]
  • 8. overactivity incontinence. Neurourol Urodyn 2002; 21:390–391. [Google Scholar]
  • 9. Chen Y. (2010) Sacral nerve stimulation in patients with detrusor overactivity. Australian and Newzealand Contincence Journal. [Google Scholar]

Articles from British Journal of Pain are provided here courtesy of SAGE Publications

RESOURCES