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10 Articles in Volume 10, Issue #1
An Overview of CRPS
Balancing Evidence, Efficacy and Stakeholder Values in Practical Pain Care
Biopsychosocial Approach to Management of Total Joint Arthroplasty Patients
Dextrose Prolotherapy Injections for Chronic Ankle Pain
Genetic Influences on Pain Perception and Treatment
Headache in Children and Adolescents
Hormone Replacements and Treatments in Chronic Pain: Update 2010
Opioid Treatment 10-year Longevity Survey Final Report
Therapeutic Laser in the Treatment of Herpes Zoster
Use and Effectiveness of Spinal Cord Stimulation

Use and Effectiveness of Spinal Cord Stimulation

Spinal cord stimulation has been one of the major advances in the efficacious and cost-effective treatment of chronic pain patients with multiple different pain processes—particularly of cervical and lumbar spinal origin.
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I find it substantially helpful to use the stiffer stylets with curved tips. This will help to manipulate on the curvature. Another observation in these patients is that trying to align along the right or left of the midline in the spinous process is distorted despite the adjustments that we have made to the fluoroscope in order to position this to an AP view. I find frequently that a lead placed slightly to the right on the convex side is going to stimulate more to that side than anticipated. In other words, the leads need to be positioned more toward the concave side than what we are seeing anatomically on the AP positioning. This varies with all patients and is affected by the amount of spinal rotation. These simple suggestions can help to provide appropriate placement in the patient with rotoscoliosis.

Results for Those Told No Other Treatment Options Were Available or Surgery Was Their Only Treatment Option

As previously noted, prior to prolotherapy 14 (45%) patients were told no other treatment options were available for their wrist pain. As a group they suffered with pain an average of 66 months. Analysis of these patients revealed a starting average pain level of 6.2 and a post-prolotherapy pain level of 1.5. Wrist stiffness averaged 4.0 prior to prolotherapy treatments and improved to 1.5 after completing the treatments. Eleven out of fourteen (78%) achieved 50% or greater pain relief. Prior to prolotherapy only 36% of the patients could exercise longer than 30 minutes, but this increased to 78% after prolotherapy.

Five patients (16%) were told that surgery was the only option available to eliminate their wrist pain. Their average pain duration prior to prolotherapy was 39 months. Their starting average pain level was 4.8 before prolotherapy, which declined to 1.2 after prolotherapy. Reported wrist stiffness was 1.8 prior to prolotherapy and 1.0 after completing their prolotherapy treatments. All five patients (100%) exhibited 50% or greater pain relief. One out of five of the patients could exercise longer than 30 minutes prior to prolotherapy, but this number increased to four out of five after prolotherapy (see Table 2).

Spinal Arthrosis

Patients who have significant spinal arthrosis can present particular challenges as well. First, when identifying the EES, observation for substantial arthrosis can be helpful. One of the best things we can do to help our patients here is to note that if there is substantial arthrosis, then we may need to change our anticipated EES above or below by an appropriate number of levels. I suggest that if you have all of your angulations and specific alignment completed, and you are not able to find entry into the epidural space after a reasonable period of trial, then you should go to another level. It frequently does take a significant amount of manipulation and angulation of the needle in various directions in order to work through and weave your way through a patient with a significant amount of arthritis. It is not necessary to give up immediately, but be gentle and make sure that you slightly advance and then slightly withdraw and then advance the needle again. Also make sure that, if necessary, you provide additional subcutaneous local anesthesia so that the patient does not become overly apprehensive and uncomfortable and may want to abort the procedure. There is no specific recommendation that I can give in terms of how to manipulate a needle around an arthritic patient, other than to try angulating a little steeper on the AP and a little left or right on the oblique. In talking to other practitioners, I think the feeling is that you are kind of working your way through an area of arthritis. It is important that you do not force the needle when you contact bony material, but rather gently change angulation. I have found it also effective in many patients with arthritis that the SES is dropped down three levels below the EES, decreasing significantly the oblique angulation of approach. Again, you may need to use a longer needle and a longer lead. Basically, observe the spine on fluoroscopy prior to placement. Pick the best possible EES and gently manipulate the needle to achieve loss of resistance. If you have major resistance and difficulty, do not spend an excessive amount of time but, instead, try another level. You may have to go up or down quite a few levels to find an area where you can obtain access to the epidural space. Also, on occasion in an arthritic patient, I have found good loss of resistance in the epidural space, but have been unable or had difficulty advancing the leads. In many cases, the guidewire will pass, but the leads do not advance. What is occurring in these cases is that there is some arthritic bony obstruction to the epidural space—either posteriorly or anteriorly on the spine—that is inhibiting advancement of the lead. I find that intrusion can be overcome by simply manually manipulating the angulation of the needle. A gentle posterior movement half a centimeter or two while, at the same time, gently advancing the leads typically overcomes this arthritic obstruction. I frequently find that in order to advance or more easily manipulate the wire on arthritic patients, a similar gentle manual traction is necessary. The patient should not experience any increased pain or discomfort with this manipulation based on my experience.

Last updated on: January 5, 2012
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