Category: Statistics

Pain Physician. 2023 Oct;26(6):E725-E736.

ABSTRACT

BACKGROUND: Chronic back pain is a long-lasting disorder, whose main source of pain is often the intervertebral disc that undergoes a degenerative process associated with low-grade inflammation, leading to a reduced quality of life.

OBJECTIVES: The aim of our study was to assess the efficacy of intradiscal and epidural injections of plasma rich in growth factors (PRGF) in patients with chronic clinical symptoms due to intervertebral disc (IVD) degeneration.

STUDY DESIGN: Prospective observational study.

SETTING: A single spine unit in a private clinic.

METHODS: Thirty-two patients with cervical and lumbar chronic pain due to IVD degeneration were treated with 2 or 3 series of intradiscal and epidural PRGF infiltrations with 2 weeks between each procedure. The procedures were performed under fluoroscopic guidance and grade 3 sedation in an operating theater. Treatment efficacy was evaluated using the Spine Tango Core Outcome Measure Index questionnaire, Numeric Rating Scale for back pain, and the Oswestry Disability Index questionnaire. In addition, the number of patients who successfully achieved the minimal clinically important change was also determined. These assessments were evaluated at pretreatment (baseline) and at one, 3, and 6 months posttreatment.

RESULTS: The Oswestry Disability Index, COMI Spine Tango Core Outcome Measure Index total score, and Numeric Rating Scale showed a statistically significant reduction from the baseline level to the posttreatment first month, third month, and sixth month (P < 0.001). Moreover, 78.1% of the patients reached a pain reduction superior to 30% one month posttreatment, and 87.5% at 6 months posttreatment, which is considered as a clinically significant improvement.

LIMITATIONS: This study was prospective and did not have a control group. Only patient-reported outcomes were evaluated.

CONCLUSIONS: This observational, prospective study of patients with chronic back pain showed that 2-3 intradiscal and epidural injections of PRGF significantly decreased pain and disability at one month posttreatment and this improvement was maintained, and in some patients even improved, at 3, and 6 months posttreatment.

PMID:37847927

Pain Physician. 2023 Oct;26(6):E719-E724.

ABSTRACT

BACKGROUND: Extracranial nonsemilunar ganglion radiofrequency thermocoagulation in the treatment of postherpetic trigeminal neuralgia has significant clinical effects. However, the related risk factors for its recurrence have not been studied.

OBJECTIVE: This study aimed to investigate the risk factors for the recurrence of postherpetic trigeminal neuralgia after extracranial nonsemilunar ganglion radiofrequency thermocoagulation, and to construct a recurrence prediction model.

STUDY DESIGN: This is a single-center, retrospective observational study.

SETTING: The study was conducted in the Department of Pain, Affiliated Hospital of Jiaxing College, Jiaxing, People’s Republic of China.

METHODS: A total of 76 patients with postherpetic trigeminal neuralgia admitted to the First Hospital of Jiaxing from July 2013 through October 2021 were retrospectively analyzed. All patients were treated with computed tomography-guided extracranial nonsemilunar segment radiofrequency therapy. The Kaplan-Meier method was used for survival analysis, the log-rank test was used, and the Cox proportional hazards regression model was used to analyze the clinical factors affecting postherpetic trigeminal neuralgia recurrence after extracranial nosemilunar ganglia radiofrequency thermocoagulation; in addition, a recurrence prediction model was established.

RESULTS: Patients were followed-up for 12 months. A univariate analysis showed that age and disease duration are the factors affecting postherpetic trigeminal neuralgia recurrence after extracranial nonsemilunar ganglion radiofrequency thermocoagulation (P < 0.05). A multivariate Cox proportional hazards regression analysis showed that age and disease duration were independent influencing factors. The recurrence risk function model is expressed as follows. H (t) = h0exp (1.116 X1 + 1.340 X2), where X1 and X2 represent age and disease duration, respectively. The likelihood ratio of the model was tested, and the likelihood ratio was 195.776, showing statistical significance.

LIMITATIONS: We look forward to increasing the sample size in subsequent studies and exploring relevant conclusions in randomized controlled trials.

CONCLUSION: A short disease duration and young age can reduce the risk of recurrence after extracranial nonsemilunar ganglia radiofrequency thermocoagulation in patients with postherpetic trigeminal neuralgia. Our established recurrence prediction model can provide a reference for clinical diagnosis and treatment.

PMID:37847926

Pain Physician. 2023 Oct;26(6):E713-E717.

ABSTRACT

BACKGROUND: Following disc herniations, fragments migrate into the anterior epidural space within the lumbar spine. Although the volume of this area has been previously described in the adult population, the volume is relatively unknown within children.

OBJECTIVES: Investigate the relative volume in the lumbar anterior epidural space within the growing spine by using imaging studies.

STUDY DESIGN: Retrospective chart review.

SETTING: University Medical Center in Lubbock Texas. A teaching hospital affiliated with Texas Tech University Health Sciences Center.

METHODS: We conducted a retrospective review of the charts of pediatric patients seen at our institution from 2018 through 2020. Charts chosen for our investigation contained computed tomography imaging of the lumber spine, showing no deformities. Thirty patients were stratified equally among 3 age groups, 2-5 years old, 10-12 years old, and 16-18 years old. The anterior epidural space was measured in each patient 3 times using the previously reported method used by Teske et al (1). Results were compared with a combination of analysis of variance (ANOVA) and single tail paired t test.

RESULTS: There was a statistically significant difference in the anterior epidural space size among age groups at all levels of the lumbar spine. When comparing only 2 groups together, the younger age group had anterior epidural space sizes significantly smaller than the other age group for all levels of the lumbar spine. The 10-12 age group had a significantly smaller space in the anterior epidural space than the 16-18-year olds only at the level of L2, L4, and L5 (P = 0.048,0.039, and 0.031, respectively). Within the 16-18-year age group, the anterior epidural space was significantly different between L4 and L3 and L2 and L3 (P < 0.001 and P = 0.019, respectively).

LIMITATIONS: Our study is limited by its retrospective nature and the sample size of the patient groups. Furthermore, the use of computed tomography imaging and not making physical measurements limits our accuracy.

CONCLUSION: The volume of the anterior epidural space is smaller in the pediatric population than the adult population. The inability of herniated discs to fit within the epidural space in children and adolescents could potentially be the cause of the increased failure of conservative treatment for pediatric lumbar disc herniations.

PMID:37847925

Pain Physician. 2023 Oct;26(6):E703-E711.

ABSTRACT

BACKGROUND: Radiofrequency thermocoagulation of genicular nerves is an effective treatment for chronic pain due to knee osteoarthritis. The procedure can be performed under fluoroscopic or ultrasonographic guidance.

OBJECTIVES: The aim of this study was to fluoroscopically check the final location of the needle in ultrasound-guided genicular nerve radiofrequency thermocoagulation and evaluate the treatment’s success in patients with knee pain.

STUDY DESIGN: A 2-center, prospective study.

SETTING: A private clinic and a tertiary care health center.

METHODS: Thirty-two patients who had unilateral knee pain, and grade 3-4 knee osteoarthritis according to the Kellgren-Lawrence classification were included. Following diagnostic genicular nerve blocks in patients whose knee pain was relieved by >= 50%, radiofrequency thermocoagulation was applied to these nerves. The final position of the needle was checked via fluoroscopy in anteroposterior and lateral planes.

RESULTS: The needle was located in the one-third anterior portion of the bone shaft in 69 of 96 patients (71.9%), between one-third and two-thirds in 21 (21.9%), and in the one-third posterior portion in 6 (6.3%). The mean Numeric Rating Scale score for pain was 7.69 ± 0.99 before treatment, 4.03 ± 1.26 at one week, 2.53 ± 1.24 at one month, and 2.19 ± 1.71 at 3 months, indicating a statistically significant decrease (P < 0.001).

LIMITATIONS: The lack of a study group in which genicular nerve radiofrequency thermocoagulation was performed under fluoroscopy guidance could be cited among the limitations of this clinical study.

CONCLUSIONS: The final position of the needle tip in radiofrequency thermocoagulation of genicular nerves can exist at the one-third anterior of the bone shaft, without a need for further advancing the needle to the posterior portion. Although performed more distally compared to fluoroscopy guidance, ultrasound-guided genicular nerve radiofrequency thermocoagulation still provides effective analgesia.

PMID:37847924

Pain Physician. 2023 Oct;26(6):E687-E693.

ABSTRACT

BACKGROUND: Gabapentin is one of the most common medications employed in Pain Medicine, specifically targeting the management of neuropathic pain. We are most familiar with the incremental dosing strategy where a ceiling dose is eventually attained guided by efficacy and patient tolerance, after which a fixed dosing regimen is prescribed. We propose that autonomous short-term dose variations per patient could have rapid clinically significant effects in the management of chronic pain.

OBJECTIVES: This study examines the frequency at which patients take gabapentin on a fixed vs variable schedule and how the pattern of gabapentin use correlates with efficacy, side effects, and patient satisfaction.

STUDY DESIGN: Single institution, cross-sectional observational survey study with data collection performed over 2 phases as a pilot for proof of concept.

SETTING: Remote contact via telephone with researchers calling from a quiet, private location within the hospital complex conducive for confidential conversation.

METHODS: Patients recently prescribed gabapentin were queried on the patterns of use and self-perceived efficacy, satisfaction, and side effects in accordance to a standardized oral script. Patients selected met the criteria of being new patients freshly prescribed gabapentin who have been consistently on the medication for at least a month, while having chronic pain symptoms for over 3 months. Responses were collected in the form of a 5-point Likert scale. Statistical analyses were performed using GraphPad Prism.

RESULTS: Of the 222 patients, 92 patients agreed to participate in the survey for a response rate of 41.4. Of these, 51% had terminated the medication for various reasons. Of the patients still taking gabapentin, 73% were on a fixed schedule, while 27% were on a variable dosing schedule. Variable dosing cohort reported better efficacy (P = 0.027) and satisfaction (P = 0.036), while the side-effect profile between the 2 groups was similar.

LIMITATIONS: The study is limited by its nature of being a pilot, single-institution study performed on a relatively small sample size. None of the patients we surveyed had been given the autonomy to adjust gabapentin doses by their providers and this could significantly reduce the proportion of patients who would be encouraged to run a variable dosing regimen.

CONCLUSIONS: This pilot study suggests that a significant portion of patients choose to administer variable doses of gabapentin and associate this with better efficacy and satisfaction. A larger study is needed to confirm this supposition. Based upon this pilot study, the variable dosing option may be an option for improved therapeutic efficacy or as an alternative to those whose lifestyles do not allow for fixed dosing regimens. Discussion of the risks of gabapentin, including respiratory depression, and clear dosage parameters of use, would need to be outlined when considering a variable dose regimen.

PMID:37847922

Pain Physician. 2023 Oct;26(6):E679-E685.

ABSTRACT

BACKGROUND: Ultrasound-guided serratus anterior plane block (SAPB) is an efficient perioperative analgesic modality for breast surgeries. SAPB does not block the anterior cutaneous branches of the intercostal nerves; thus, it does not provide adequate analgesia for the parasternal region and the medial side of the breast. A new parasternal block, the pectointercostal fascial plane block (PIFB) has been developed to overcome this issue.

OBJECTIVES: The study aimed to evaluate the perioperative analgesic effect of using PIFB in addition to SAPB. The primary outcome was to evaluate the postoperative pain score. The secondary outcomes were to assess perioperative opioid requirements, hemodynamic stability, and the satisfaction of the patient and surgeon.

STUDY DESIGN: The current study was a prospective, double-blinded, randomized controlled study. The current study was registered at the Pan-African Clinical Trials Registry (PACTR202001789968542) and was designed after obtaining ethical institutional approval (Institutional Review Board No 00012098, Federalwide Assurance No 00018699).

SETTING: The study involved 60 women between 21 and 69 years old with breast cancer who were scheduled for modified radical mastectomy or conservative breast surgeries in a university hospital.

METHODS: After verbal and informed written consent, the patients were allocated to Group 1, which received SAPB, and Group 2, which received SAPB with PIFB. We assessed the Visual Analog Scale (VAS), perioperative opioid requirements, intraoperative hemodynamic stability, rescue analgesia, and complications. Patient and surgeon satisfaction were surveyed using a questionnaire where one is very dissatisfied and 5 is very satisfied.

RESULTS: Intraoperative mean arterial blood pressure (MABP) and heart rate were significantly lower in Group 2 (SAPB+PIFB). The number of patients who needed intraoperative fentanyl was also significantly lower in Group 2 (SAPB+PIFB) (P value = 0.010). Postoperative VAS showed no significant difference in both groups. The number of patients who needed postoperative rescue morphine, time for the first rescue analgesia, first morphine dose (mg), and total opioid consumption were also comparable for both groups. Patient satisfaction and surgeon satisfaction were comparable for both groups (P values = 1.000 and 0.496, respectively).

LIMITATIONS: VAS was not recorded during movements and no follow-up was done to detect the potential effect on chronic postmastectomy pain. Moreover, after reviewing the literature, there was no efficient data about adding PIFB with different regional blocks for breast surgery.

CONCLUSIONS: The number of patients who needed intraoperative fentanyl, as well as the MABP and heart rate were significantly lower in Group 2 (SAPB+PIFB). Postoperative vital signs, VAS, postoperative analgesic requirements, and opioid consumption were comparable for both groups. Patient satisfaction was comparable for both groups, while surgeon satisfaction was higher in Group 2 (SAPB+PIFB) but statistically not significant.

PMID:37847921

Pain Physician. 2023 Oct;26(6):E671-E677.

ABSTRACT

BACKGROUND: The mechanism of pain control with pulsed radiofrequency (PRF) is unclear.

OBJECTIVES: We aimed to compare the efficacy of combined PRF on dorsal root ganglion (DRG) with transforaminal epidural steroid injection (TFESI) vs TFESI-alone on pain improvement and serum tumor necrosis factor-alpha (TNF-a) level in lumbar disc-related radicular pain.

STUDY DESIGN: Prospective, randomized, controlled trial.

SETTING: Neurology and Pain Management clinics.

METHODS: A total of 80 patients with lumbar disc prolapse were divided into 2 groups: combined PRF on DRG with TFESI group and TFESI-alone group. The Numeric Rating Scale (NRS-11), Oswestry Disability Index (ODI), and Functional Rating Index (FRI) before intervention and at 2 weeks, 1 month, and 3 months after the intervention were observed. Serum TNF-a level was assessed pre- and post-intervention at 3 months.

RESULTS: The scores of NRS-11, ODI, and FRI showed a significant improvement at 2 weeks, 1 month, and 3 months following intervention in both combined PRF & TFESI group and TFESI-alone group (P < 0.001 in all comparisons), with no significant difference between the 2 groups. Serum TNF-a levels showed a statistically significant reduction, 3 months following intervention in the combined PRF & TFESI group (P < 0.001), but not in the TFESI-alone group (P = 0.297) (P between groups < 0.001).

LIMITATIONS: The main limitation of this study is that TNF-a level was not assessed earlier to see how long the steroids might reduce TNF-a. On the other hand, further study with extended follow-up periods is needed to confirm the long-term lowering effect of TNF-a provided by PRF.

CONCLUSIONS: Combined PRF on DRG with TFESI showed similar outcomes to TFESI-alone in relieving pain in patients with lumbar disc prolapse. However, PRF on DRG caused a significant decrease in TNF-a serum levels at 3 months.

PMID:37847920

Pain Physician. 2023 Oct;26(6):E651-E660.

ABSTRACT

BACKGROUND: Regional anesthesia for an upper limb provides many advantages over general anesthesia, especially in orthopedic surgery.

OBJECTIVES: This trial aimed to compare a retroclavicular approach to the infraclavicular brachial plexus with a costoclavicular approach in term of needle time, image time, and procedure time, and comparing both with the classic technique for upper limb surgeries guided by ultrasound.

STUDY DESIGN: Prospective, randomized, single-blinded controlled trial.

SETTING: Minia University, Faculty of Medicine, Anesthesia and Intensive Care Department.

METHODS: Sixty patients of both sees with an American Society of Anesthesiologists Classification of I and II, a BMI (kg/m2) of 20-35, aged from 18-60 years who were scheduled for a forearm or hand surgery under infraclavicular brachial plexus block were divided into 3 parallel equal groups. Group I (RC) received a retroclavicular approach. Group II (CC)received a costoclavicular approach. Group III (CT) received the classic technique. Procedure time, the sum of the imaging and needling times, was our primary outcome. Secondary outcomes were the motor and sensory block success rate 30 minutes postinjection of local anesthesia, duration of motor and sensory block, Visual Analog Score, first analgesic need, total analgesia requirements during the first postoperative 24 hours, and any complications.

RESULTS: The procedure and needle times were significantly decreased in the retroclavicular group due to better needle visibility. There was no significant difference regarding sensory and motor block data. The VAS score in the first postoperative 24 hours showed no statistical significance. Regarding analgesic data and patient satisfaction, there was no statistical significance among the 3 studied groups. There were no complications in any of the used approaches.

LIMITATION: Our trial did not include patients with a BMI > 35.

CONCLUSIONS: The retroclavicular approach is superior because of its decreased procedure time and needle time than both the costoclavicular approach and classic approach.

PMID:37847918

Pain Physician. 2023 Oct;26(6):E627-E633.

ABSTRACT

BACKGROUND: Percutaneous radiofrequency thermocoagulation (RFT) through the foramen rotundum (FR) is a new approach for the treatment of V2 trigeminal neuralgia (TN). Some studies have shown the novel method seems to have advantages over traditional RFT through the foramen ovale (FO). The optimal interventional surgical strategy for isolated V2 TN remains controversial.

OBJECTIVES: The purpose of our study was to perform a systematic review and meta-analysis to evaluate the clinical results of RFT through the FR and the traditional FO puncture approach.

STUDY DESIGN: A systematic review of randomized controlled trials for thermocoagulation through the foramen rotundum versus the foramen ovale for V2 primary trigeminal neuralgia.

METHODS: Randomized controlled trials or nonrandomized controlled trials published from January 2000 through October 2022 that compared RFT through the FR and the FO for V2 primary TN were found through a comprehensive search in 3 electronic databases (PubMed, EMBASE, Cochrane library). A total of 3 studies (105 patients) were included in this systematic review and meta-analysis.

RESULTS: The results indicate that there are no statistically significant differences between the FR group and the FO group in terms of postoperative immediate effect rate (postoperative one week) (P > 0.1; standardized mean difference [SMD] = 0.67 [0.26- 1.71]) and recurrence rate (P > 0.1; SMD = 0.67 [0.26 – 1.71]). The long-term effect rate (postoperative one year) was significantly higher in the FR group (P < 0.05; SMD = 0.12 [0.01 – 0.22]). The FO group had a significantly higher total complication rate compared with the FR group (P < 0.01; SMD = 0.12 [0.03 – 0.53]).

LIMITATIONS: The limitations of this systematic review and meta-analysis include the small range of study populations. Heterogeneity caused by inconsistent follow-up time, outcome measurements, and RF parameters are other limitations.

CONCLUSION: In conclusion, RFT of the maxillary nerve through the FR for the treatment of primary V2 TN had a better long-term effect rate and fewer complications in comparison with thermocoagulation of the Gasserian ganglion through the FO. No differences were found between both interventions in terms of immediate effect rate and recurrence rate.

PMID:37847916

Pain Physician. 2023 Oct;26(6):E617-E626.

ABSTRACT

BACKGROUND: There have been no recent meta-analysis studies on specific psychological symptoms (depression and anxiety) according to the type of primary headache disorder in children and adolescents.

OBJECTIVES: We performed a meta-analysis of various psychodiagnostic scales. Psychological symptoms of primary headache disorders have been reported in previous studies.

STUDY DESIGN: A systematic review and meta-analysis.

METHODS: We conducted systematic reviews using the PubMed, Embase, Cochrane Library, and Scopus databases up to October 19, 2022. Ten studies were selected by applying the inclusion criteria. The psychological symptoms (depression and anxiety) of children and adolescents with migraine and tension-type headache (TTH) were compared with those of healthy controls using scale scores. All statistical analyses of the pooled data were performed using RevMan 5.3 software.

RESULTS: Psychodiagnostic tools to assess depression scored higher in patients with migraine than in healthy controls; however, most anxiety-related scores were not significantly different between the migraine and control groups. In contrast, anxiety-related scores were higher in patients with TTH than in healthy controls, but the score to measure the degree of depressive symptoms was not significantly different from the control group in patients with TTH.

LIMITATIONS: A limited number of studies for each scale were included. In addition, each scale has different sensitivities and specificities, which may have affected the results. In addition, we did not evaluate the differences in psychological symptoms according to the frequency and severity of headaches.

CONCLUSIONS: Depression is more associated with migraine; whereas, anxiety is more associated with TTH than healthy controls. Therefore, the screening and assessment of psychological symptoms should be performed in children and adolescents with primary headache disorders.

PMID:37847915