Moeschler, Susan M.

Background: The principle aim of this study was to investigate the associations between heat pain (HP) perception, pain catastrophizing, and pain-related anxiety in a heterogenous cohort of community-dwelling adults with chronic pain admitted to a 3-week outpatient pain rehabilitation program. Methods: All adults consecutively admitted to an outpatient pain rehabilitation program from July 2009 through January 2011 were eligible for study recruitment (n=574). Upon admission, patients completed the Pain Catastrophizing Scale (PCS), the short version of the Pain Anxiety Symptoms Scale (PASS-20), and HP perception was assessed using a standardized quantitative sensory testing (QST) method of levels. Results: Greater PCS scores were significantly correlated with lower standardized values of HP threshold (HP 0.5) (P=0.006) and tolerance (HP 5) (P=0.003). In a multiple variable model adjusted for demographic and clinical factors known to influence HP perception, every 10-point increase in the PCS was associated with a −0.124 point change in HP 0.5 (P=0.014) and a −0.142 change in HP 5 (P=0.014) indicating that participants with higher PCS scores had lower HP thresholds and tolerances, respectively. Similarly, greater PASS-20 scores significantly correlated with lower standardized values of HP 0.5 and HP 5. In a multiple variable model, every 10-point increase in the PASS-20 was associated with a −0.084 point change in HP 0.5 (P=0.005) and a −0.116 point change in HP 5 (P=0.001) indicating that participants with higher PASS-20 scores had lower HP thresholds and tolerances, respectively. Conclusions: The findings of this study extend the use of a standardized method for assessing HP in a heterogenous sample of adults with chronic pain. Although pain catastrophizing shares significant variance with pain-related anxiety, our findings suggest that either measure would be appropriate for use in future studies that incorporate the QST method of levels.

AbstractIntroductionSpinal cord stimulators (SCS) are used to treat various chronic pain states. Establishing patient outcomes in terms of pain control, opioid medication use, and overall satisfaction is vital in maintaining SCS's role in clinical practice.MethodsAll patients who underwent SCS implantation between January 2001 and December 2011 at a tertiary academic pain medicine center were included if he or she underwent permanent cervical or thoracolumbar dorsal column SCS implantation and age was 18 or greater. For the 199 patients who met inclusion criteria, data were collected retrospectively. Preimplant information included indication for implantation, Numeric Rating Scale (NRS) score, and dose in oral morphine equivalents (OME). Postimplant NRS score was recorded at 6 months and 1 year. OME requirement and patient satisfaction were determined at 1 year postimplantation.ResultsThis data set showed an overall decrease in OME requirements and NRS scores at both 6 months and 1 year. These differences were statistically significant (P < 0.01) compared to preimplantation values. Additionally, 84.27% of patients were satisfied with their implants at 1 year. Patient outcomes were analyzed further in respect to implant indication; groups included failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS), angina, and other. For all groups, there were statistically significant (P < 0.01) decreases in NRS scores at 6 months and 1 year. In the FBSS and CRPS groups, statistically significant (P < 0.02) decreases in OME usage existed.ConclusionRetrospective review of patients with spinal cord stimulators revealed OME reduction at 1 year for those patients in the FBSS and CRPS groups; patient satisfaction at 1 year and NRS score reduction at 6 months and 1 year were statistically significant for all groups.

AbstractAcute pain following amputation can be challenging to treat due to multiple underlying mechanisms and variable clinical responses to treatment. Furthermore, poorly controlled preoperative pain is a risk factor for developing chronic pain. Evidence suggests that epidural analgesia and peripheral nerve blockade may decrease the severity of residual limb pain and the prevalence of phantom pain after lower extremity amputation. We present the perioperative analgesic management of a patient with gangrene of the bilateral upper and lower extremities as a result of septic shock and prolonged vasopressor administration who underwent four‐limb amputation in a single procedure. A multimodal analgesic regimen was utilized, including titration of preoperative opioid and neuropathic pain agents, perioperative intravenous, epidural and peripheral nerve catheter infusions, and postoperative oral medication titration. More than 8 months postoperatively, the patient has satisfactory pain control with no evidence for phantom limb pain. To our knowledge, there have been no publications to date concerning analgesic regimens in four‐limb amputation.

We present the case of a 34-year-old woman with Klippel-Feil syndrome who developed progressive generalized dystonia of unclear etiology, resulting in intractable pain despite aggressive medical and surgical interventions. Ultimately, palliative sedation was required to relieve suffering. Herein, we describe ethical considerations including defining sedation, determining prognosis in the setting of an undefined neurodegenerative condition, and use of treatments that concurrently might prolong or alter end-of-life trajectory. We highlight pertinent literature and how it may be applied in challenging and unique clinical situations. Finally, we discuss the need for expert multidisciplinary involvement when implementing palliative sedation and illustrate that procedures and rules need to be interpreted to deliver optimal patient-centered plan of care.

AbstractIntrathecal drug delivery systems (IDDSs) are used to treat resistant pain states as well as intractable spasticity via medication delivery into the spinal fluid. Risks associated with implantation of these devices include infection, bleeding, intrathecal granuloma formation, and neurologic sequelae similar to other neuraxial procedures. Intrathecal catheter placement creates the additional risk of persistent spinal fluid leak, which can lead to postdural puncture headaches as well as seroma formation and may require subsequent surgical exploration or explantation. This retrospective case series examines 3 patients at a single institution with persistent spinal fluid leak after IDDS placement (and explantation in one case) resulting in headache and/or seroma formation that were treated with epidural fibrin glue.Three patients underwent IDDS implantation with baclofen for spasticity. In 1 patient, a cerebral spinal fluid leak developed at 1‐week postoperatively. After several unsuccessful epidural blood patches and surgical exploration with a catheter revision, she was ultimately treated successfully with a fibrin glue patch. The second patient received an IDDS and did well until a seroma developed 1 year later. He was likewise treated with an epidural fibrin glue patch after 2 failed blood patches. In a third patient, a spinal fluid leak developed after explantation of an IDDS and was treated with an epidural fibrin glue patch as initial therapy.