Orhurhu, Vwaire

Abstract Background Context Surgical decompression is the definitive treatment for managing symptomatic lumbar spinal stenosis; however, select patients are poor surgical candidates. Consequently, minimally invasive procedures have gained popularity, but there exists the potential for failure of therapy necessitating eventual surgical decompression. Purpose To evaluate the incidence and characteristics of patients who require surgical decompression following minimally invasive procedures to treat lumbar spinal stenosis. Study Design/Setting Retrospective review. Patient Sample Patients who underwent minimally invasive procedures for lumbar spinal stenosis (Percutaneous Image‐guided Lumbar Decompression [PILD] or interspinous spacer device [ISD]) and progressed to subsequent surgical decompression within 5 years. Outcome Measures The primary outcome was the rate of surgical decompression within 5 years following the minimally invasive approach. Secondary outcomes included demographic and comorbid factors associated with increased odds of requiring subsequent surgery. Methods Patient data were collected using the PearlDiver‐Mariner database. The rate of subsequent decompression was described as a percentage while univariable and multivariable regression analysis was used for the analysis of predictors. Results A total of 5278 patients were included, of which 3222 (61.04%) underwent PILD, 1959 (37.12%) underwent ISD placement, and 97 (1.84%) had claims for both procedures. Overall, the incidence of subsequent surgical decompression within 5 years was 6.56% (346 of 5278 patients). Variables associated with a significantly greater odds ratio (OR) [95% confidence interval (CI)] of requiring subsequent surgical decompression included male gender and a prior history of surgical decompression by 1.42 ([1.14, 1.77], p = 0.002) and 2.10 times ([1.39, 3.17], p < 0.001), respectively. In contrast, age 65 years and above, a diagnosis of obesity, and a Charlson Comorbidity Index score of three or greater were associated with a significantly reduced OR [95% CI] by 0.64 ([0.50, 0.81], p < 0.001), 0.62 ([0.48, 0.81], p < 0.001), and 0.71 times ([0.56, 0.91], p = 0.007), respectively. Conclusions Minimally invasive procedures may provide an additional option to treat symptomatic lumbar spinal stenosis in patients who are poor surgical candidates or who do not desire open decompression; however, there still exists a subset of patients who will require subsequent surgical decompression. Factors such as gender and prior surgical decompression increase the likelihood of subsequent surgery, while older age, obesity, and a higher Charlson Comorbidity Index score reduce it. These findings aid in selecting suitable surgical candidates for better outcomes in the elderly population with lumbar spinal stenosis.

Peripheral nerve stimulation (PNS) has been utilized for over 50 years with accumulating evidence of efficacy in a variety of chronic pain conditions. The level and strength of evidence supporting the use of PNS for peripheral neuropathic pain remains unclear. The purpose of this review is to synthesize data from prospective studies on the efficacy of PNS for neuropathic pain as it pertains to pain intensity, neurological deficits/neuropathy (e.g., weakness, sensory deficits, gait/balance), and other secondary outcomes (quality of life, satisfaction, emotional functioning, and adverse events). In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, this review identified articles from MEDLINE(R), EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. Overall, per the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, pooled results demonstrate very low quality or low quality of evidence supporting modest to substantial improvement in pain and neurological function after PNS implantation for treatment of peripheral neuropathic pain. PNS for phantom limb pain was the only indication that had moderate level evidence. Future prospective and well-powered studies are warranted to assess the efficacy of PNS for peripheral neuropathic pain.

Background: Hypertension (HTN) control rate is a core clinical quality measure. It is presently assessed by manual review of a random sample of patients with HTN billing claims. There is an increasing push by regulators towards the use of electronic medical records (EMR) to assess quality of care. Purpose: To use EMR to obtain a more in-depth assessment of quality of hypertension care. Methods: Cross sectional study involving adults with HTN seen at 2 or more office visits in 2009 by eligible primary or specialist providers at a large medical group practice. We measured the proportion of HTN patients with blood pressure (BP) at goal (BP < 140/90 mm Hg) at their last hypertension visit (LHV). Results: Of a total of 10,401 patients, 5970 (57%) were controlled and 1959 (19%) were uncontrolled at their LHV. Control could not be assessed in 2472 (24%) as BP values were unavailable from the vital signs section of the visit notes in the EMR. Of a random sample of 250 patients with unavailable BP, only 94 (37.6%) had BP values documented in other parts of the visit note. In 29 patients (11.6%) billing for HTN was done without adequate evidence that it was addressed at that visit. Control rates were highest for primary care providers where measurement and documentation of BP was a focus - Family Medicine 77% controlled, 1% unavailable; Primary Care Internal Medicine 71% controlled, 4% unavailable. A considerable proportion of patients in the other four provider groups did not have BP available from their last hypertension visit - Cardiology 59% controlled, 22% unavailable; Nephrology 38% controlled, 47% unavailable; Preventive Medicine 48% controlled, 39% unavailable; General Internal Medicine 41% controlled, 45% unavailable. Control rates were similar across provider groups when patients with unavailable BP were excluded: Family Medicine 78%, Primary Care 74%, Cardiology 75%, Nephrology 73%, Preventive Medicine 79%, and General Medicine 75%. Conclusions: Up to a quarter of HTN patients did not have properly documented BP in the EMR at their LHV. For those with measurements recorded, control rates were similar across primary care and specialty clinics, but measurement rates were higher for primary care practices. Use of the EMR facilitates efficient and granular assessment of the measurement process and control rates for HTN among various provider groups.

AbstractObjectivesSpinal cord stimulation (SCS) therapies are used in the management of patients with complex regional pain syndrome I (CRPS I) and failed back surgery syndrome (FBSS). The purpose of this study was to investigate the racial and health insurance inequalities with SCS therapy in patients with chronic pain who had CRPS I and FBSS.MethodsPatients with chronic pain who had a discharge diagnosis of FBSS and CRPS I were identified using the National Inpatient Sample database. Our primary outcome was defined as the history of SCS utilization by race/ethnicity, income quartile, and insurance status. Multivariable logistic regression was used to determine the variables associated with utilization of SCS therapy.ResultsBetween 2011 and 2015, 40,858 patients who were hospitalized with a primary diagnosis of FBSS and/or CRPS I were identified. Of these patients, 1,082 (2.7%) had a history of SCS therapy. Multivariable regression analysis revealed that compared to White patients, Black and Hispanic patients had higher odds of having SCS therapy (Black patients: odds ratio [OR] = 1.41; 95% confidence interval [CI], 1.12 to 1.77; P = 0.003; Hispanic patients: OR = 1.41; 95% CI, 1.10 to 1.81; P = 0.007). Patients with private insurance had significantly higher odds of having SCS therapy compared with those with Medicare (OR = 1.24; 95% CI, 1.08 to 1.43; P = 0.003). Compared to patients with Medicare, Medicaid patients had lower odds of having SCS therapy (OR = 0.50; 95% CI, 0.36 to 0.70; P < 0.001).ConclusionsOur study suggests that socioeconomic disparities may exist in the utilization of SCS among hospitalized patients with CRPS I and FBSS the United States. However, confirming these data from other administrative databases, in the outpatient setting, may shed more insight.

AbstractTotal knee arthroplasty is a common and successful treatment modality for knee arthritis that is refractory to conservative management strategies. Over 600,000 arthroplasties are performed per year in the United States, and this number is expected to increase in the coming years. Unfortunately, 8% to 34% of patients experience chronic pain after having a total knee arthroplasty. These patients should undergo an appropriate work‐up by the orthopedic surgeon, but many times a surgical problem is not uncovered. In these situations, a thorough and specific plan for pain management should be sought. In this article, we outline the work‐up of a painful total knee arthroplasty. Then we provide a thorough review of interventional pain management strategies and highlight the pertinent literature. Lastly, we hypothesize future developments in the field that may provide better outcomes for patients suffering from painful total knee arthroplasty.

Abstract Objective To evaluate the association between hypovitaminosis D and outcomes of symptom severity, mood disorders, fatigue, and quality of life in fibromyalgia (FM) patients. Methods Five hundred ninety-three FM patients were surveyed from May 2012 to November 2013. Patients with serum vitamin D &lt;25 ng/mL were considered to have hypovitaminosis D. The primary outcome was FM symptom severity (FIQ-R questionnaire). Secondary outcomes included quality of life (SF-36), fatigue (MFI-20), anxiety (GAD-7), and depression (PHQ-9). Independent t tests and chi-square tests were performed for continuous and categorical variables, respectively. Regression analysis was performed adjusting for age, gender, body mass index, ethnicity, and season. A post hoc analysis examined for correlation between outcomes and serum vitamin D (ng/mL) as a continuous variable. Results One hundred twenty-two patients (20.6%) had hypovitaminosis D. In our adjusted regression analysis, the total FIQ-R score in patients with hypovitaminosis D was higher compared with control patients with adequate serum vitamin D (57.85 ± 18.09 vs 62.79 ± 18.10, P = 0.04). Adjusted regression analysis revealed higher total GAD-7 (P = 0.01) and higher total PHQ-9 scores (P = 0.04) in patients with hypovitaminosis D compared with control patients. There were no differences based on severity of depression or anxiety. No differences in fatigue or quality of life were identified. Unadjusted post hoc analysis revealed that as serum vitamin D increased, there was an association with lower total FIQ-R (β coefficient = –0.11, P = 0.02) and lower SF-36 subscale scores of role-physical (β coefficient = –0.10, P = 0.03). Adjusted post hoc analysis revealed no significant associations. Conclusions Hypovitaminosis D may be a risk factor for worse symptom severity, anxiety, and depression in FM patients.