Clinical Uses of Intrathecal Therapy and Its Placement in the Pain Care Algorithm.

Intrathecal drug delivery is an effective treatment option for patients with severe chronic pain who have not obtained adequate analgesia from more conservative therapies (eg, physical therapy, systemic opioids, nonsteroidal anti-inflammatory drugs, antidepressants, and anticonvulsants). This review focuses on, but is not limited to, the 2 agents currently approved by the U.S.

Results From the Partnership for Advancement in Neuromodulation Registry: A 24-Month Follow-Up.

Objective: This longitudinal, clinical outcome study was a multicenter, prospective, observational, registry with a 24-month assessment of patients implanted with spinal cord stimulation (SCS) systems for the management of chronic pain of the trunk and/or limbs.

Methods: On informed consent and institutional review board approval, 614 patients from 39 sites were enrolled within 30 days following permanent SCS system implantation. Medication usage, patient-reported pain relief (PRP), categorical ratings of pain relief, pain disability index scores (PDI), quality of life (QoL), and patient satisfaction were assessed at enrollment, 3-, 6-, 12-, 18-, and 24-month postimplant.

The Pharmacology of Spinal Opioids and Ziconotide for the Treatment of Non-Cancer Pain.

Background: Intrathecal drug delivery has undergone a revitalization following a better understanding of this delivery route and its pharmacokinetics. Driven by patient safety and outcomes, clinicians are motivated to rethink the traditional spinal infusion pump patient selection criteria and indications. We review the current understanding of the pharmacology of commonly employed intrathecal agents and the clinical relevance.

Advanced Innovations for Pain.

Chronic pain represents one of the most important public health problems in terms of both the number of patients afflicted and health care costs. Most patients with chronic pain are treated with medications as the mainstay of therapy, and yet most medically treated patients continue to report ongoing pain. Additionally, adverse effects from pain medications represent a major challenge for clinicians and patients.

Prospective, Multicenter, Randomized, Double-Blinded, Partial Crossover Study to Assess the Safety and Efficacy of the Novel Neuromodulation System in the Treatment of Patients With Chronic Pain of Peripheral Nerve Origin.

Introduction: Currently available central nervous system treatment strategies are often insufficient in management of peripheral neuropathic pain, prompting a resurgence of neuromodulation focused on peripheral pain. A new peripheral nerve stimulation device was investigated in a prospective, randomized, double blind, crossover study, looking specifically at efficacy and safety, with Food and Drug Administration oversight.

Methods: Prospective, multicenter, randomized, double-blind, partial crossover study to assess safety and efficacy.

Multimodal Treatment of Chronic Pain.

Most patients with chronic pain receive multimodal treatment. There is scant literature to guide us, but when approaching combination pharmacotherapy, the practitioner and patient must weigh the benefits with the side effects; many medications have modest effect yet carry significant side effects that can be additive. Chronic pain often leads to depression, anxiety, and deconditioning, which are targets for treatment.

The Proper Use of Neurostimulation for Hand Pain.

Upper extremity neuropathic pain states greatly impact patient functionality and quality of life, despite appropriate surgical intervention. This article focuses on the advanced therapies that may improve pain care, including advanced treatment strategies that are available. The article also surveys therapies on the immediate horizon, such as spinal cord stimulation, peripheral nerve stimulation, and dorsal root ganglion spinal cord stimulation.

An International Survey to Understand Infection Control Practices for Spinal Cord Stimulation.

Objectives: Surgical site infections (SSIs) are associated with significant healthcare costs and morbidity. Limited research exists specific to the prevention of spinal cord stimulation (SCS) SSIs. The objectives of this international survey were to examine current infection control practices for SCS trials and implants and to compare reported responses with evidence-based recommendations.

Factors to consider in the choice of intrathecal drug in the treatment of neuropathic pain.

Medication selection for neuropathic pain follows a path of evidence, with respect to appreciating the patient's entry into the pain care algorithm. As we decide how to approach neuropathic pain, the considerations for intrathecal therapy medication selection are bound by catheter location, region of pain, and patient selection, to name a few. Future research and the 2016 polyanalgesic consensus conference may further provide patient care through a mindful eye on the improvement of patient safety and a reduction of the societal needs of opioids.

Nonopioid medications for pain.

Evidence of nonopioid analgesic effectiveness exceeds that for long-term opioids in chronic noncancer pain (CNCP), most with lower risk. Non-drug therapies such as cognitive behavioral therapy and physical activation are safer and also effective. Nonsteroidal antiinflammatory drugs are useful for inflammatory and nociceptive pain, share renal and variable gastrointestinal, bleeding and cardiovascular side effects.

Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain.

Interventional spine and pain procedures cover a far broader spectrum than those for regional anesthesia, reflecting diverse targets and goals. When surveyed, interventional pain and spine physicians attending the American Society of Regional Anesthesia and Pain Medicine (ASRA) 11th Annual Pain Medicine Meeting exhorted that existing ASRA guidelines for regional anesthesia in patients on antiplatelet and anticoagulant medications were insufficient for their needs. Those surveyed agreed that procedure-specific and patient-specific factors necessitated separate guidelines for pain and spine procedures.

Advanced waveforms and frequency with spinal cord stimulation: burst and high-frequency energy delivery.

In recent years, software development has been key to the next generation of neuromodulation devices. In this review, we will describe the new strategies for electrical waveform delivery for spinal cord stimulation. A systematic literature review was performed using bibliographic databases, limited to the English language and human data, between 2010 and 2014.

Blood testing in chronic pain management.

Blood testing is quickly becoming a useful laboratory tool for opioid prescribers who wish to document and assess patient tolerance, more objectively monitor patient safety, and evaluate patient compliance using information that is not available with traditional urine drug testing (UDT). Blood testing does not need to be performed as frequently as UDT but provides extremely valuable information which can be used to more accurately evaluate patient compliance and assist with interpreting blood toxicology results commonly used in impairment or overdose cases. This narrative review presents the current evidence supporting the use of blood testing within the chronic pain management setting.

Intrathecal Pharmacology Update: Novel Dosing Strategy for Intrathecal Monotherapy Ziconotide on Efficacy and Sustainability.

Introduction: Intrathecal drug delivery is a well-defined strategy to treat malignant and nonmalignant pain. Ziconotide is a well-studied intrathecal medicine option that has many attractive qualities, as it is non-granulomagenic, overdose or underdose is not associated with cardiopulmonary compromise or death, and is a non-opoid analgesic. However, it has had slow adoption into pain care algorithms because it has been historically plagued with the connotation of having a narrow therapeutic window and a low sustainability rate.

Neurostimulation for the treatment of axial back pain: a review of mechanisms, techniques, outcomes, and future advances.

Introduction: The use of spinal cord stimulation (SCS) is well established in the treatment of neuropathic pain. This procedure has been approved in the United States for neuropathic pain of the trunk and limbs from various conditions. International use is variable based on governmental policy.

Risk and Resilience in Pediatric Chronic Pain: Exploring the Protective Role of Optimism.

Objective: Fear of pain and pain catastrophizing are prominent risk factors for pediatric chronic pain-related maladjustment. Although resilience has largely been ignored in the pediatric pain literature, prior research suggests that optimism might benefit youth and can be learned. We applied an adult chronic pain risk-resilience model to examine the interplay of risk factors and optimism on functioning outcomes in youth with chronic pain.

Analysis of adverse events in the management of chronic migraine by peripheral nerve stimulation.

Objective: In this study, we analyze device- and procedure-related adverse events (AEs) from a recent prospective, multicenter, double-blinded controlled study that utilized peripheral nerve stimulation (PNS) of occipital nerves for management of chronic migraine.

Methods: PNS device characteristics (lead length and spacing), surgical techniques including lead orientation (parallel or perpendicular to the nerve), and implantable pulse generator (IPG) placement (upper buttock, abdomen, infraclavicular, or lower axilla) in 157 patients were analyzed to identify any relationship with the AE incidence rate. Number of prior PNS implants performed (NPPIP) by the implanter and its relationship with different AE categories (hardware-related, biological, and stimulation-related events) and frequently observed device/procedure-related AEs (lead migration/fracture/breakage, persistent pain at the lead/IPG location, unintended/undesirable changes in stimulation, infection) were also evaluated.

The appropriate use of neurostimulation: new and evolving neurostimulation therapies and applicable treatment for chronic pain and selected disease states. Neuromodulation Appropriateness Consensus Committee.

Introduction: The International Neuromodulation Society (INS) has determined that there is a need to provide an expert consensus that defines the appropriate use of neuromodulation technologies for appropriate patients. The Neuromodulation Appropriateness Consensus Committee (NACC) was formed to give guidance to current practice and insight into future developments.

Methods: The INS executive board selected members of the international scientific community to analyze scientific evidence for current and future innovations and to use clinical experience to fill in any gaps in information.