Chronic post-surgical pain (CPSP) is not limited to major surgeries and can develop after smaller procedures such as hernia repairs. While nerve injury has traditionally been thought to be the culprit for CPSP, it is evident that nerve-sparing surgical techniques are not completely preventative. Regional analgesia and agents such as ketamine, gabapentinoids, and COX-2 inhibitors have also been found to decrease the risks of developing chronic pain to varying degrees. Yet, given the correlation of central sensitization with the development of chronic pain, it is reasonable to utilize aggressive multimodal analgesia whenever possible. Development of chronic pain is typically a result of peripheral and central sensitization, with CPSP being one of the most common presentations. Using minimally invasive surgical techniques may reduce the risk of CPSP. Regional anesthetic techniques and preemptive analgesia should also be utilized when appropriate to reduce the intensity and duration of acute post-operative pain, which has been correlated with higher incidences of chronic pain.

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Moderate to severe pain occurs in many cancer patients during their clinical course and may stem from the primary pathology, metastasis, or as treatment side effects. Uncontrolled pain using conservative medical therapy can often lead to patient distress, loss of productivity, shorter life expectancy, longer hospital stays, and increase in healthcare utilization. Various publications shed light on strategies for conservative medical management for cancer pain and a few international publications have reviewed limited interventional data. Our multi-institutional working group was assembled to review and highlight the body of evidence that exists for opioid utilization for cancer pain, adjunct medication such as ketamine and methadone and interventional therapies. We discuss neurolysis via injections, neuromodulation including targeted drug delivery and spinal cord stimulation, vertebral tumor ablation and augmentation, radiotherapy and surgical techniques. In the United States, there is a significant variance in the interventional treatment of cancer pain based on fellowship training. As a first of its kind, this best practices and interventional guideline will offer evidenced-based recommendations for reducing pain and suffering associated with malignancy.

Purpose We have observed a higher rate of Lhermitte's syndrome (LS) after chemo-IMRT of head and neck cancer than the published rates after conventional radiotherapy. We hypothesized that the inhomogeneous spinal cord dose distributions produced by IMRT caused a “bath and shower” effect, characterized by low doses in the vicinity of high doses, reducing spinal cord tolerance. Methods and Materials 73 patients with squamous cell carcinoma of the oropharynx participated in a prospective study of IMRT concurrent with weekly carboplatin and taxol. 15 (21%) reported LS in at least 2 consecutive follow-up visits. Mean dose, maximum dose, partial (Vd) as well as the absolute volume (cc) of spinal cord receiving specified doses (≥10 Gy, 20 Gy, 30 Gy, 40 Gy), and the pattern of dose distributions at the “anatomical” (from the base of the skull to the aortic arch) and “plan-related” (from the top through the bottom of the PTV's) spinal cords were compared between LS and 34 non-LS patients. Results LS patients had significantly higher spinal cord mean doses, V30, V40, and volumes receiving ≥30 and ≥ 40 Gy compared to the non-LS patients (p < 0.05). Strongest predictors of LS were higher V40 and higher cord volumes receiving ≥40 Gy (p ≤ 0.007). There was no evidence of larger spinal cord volumes receiving low doses in the vicinity of higher doses (“bath and shower”) in LS compared to non-LS patients. Conclusions Greater mean dose, V30, V40, and cord volumes receiving ≥30 and ≥40 Gy characterized LS compared to non-LS patients. “Bath and shower” effects could not be validated in this study as a potential contributor to LS. The higher than expected rates of LS may be due to the specific concurrent chemotherapy agents, or to more accurate identification of LS in the setting of a prospective study.

The placement of thoracic epidural catheters is complicated by the layering of the vertebral lamina. Therefore, traditional blind palpation techniques require insertion of an epidural needle with likely contact of lamina with redirections into the epidural space. We discuss a safe and consistent technique using true real-time ultrasound visualization of the needle with a paramedian sagittal oblique view to improve the consistency of placing an epidural in the thoracic spine for postoperative analgesia. Successful epidural placement was achieved in every patient. All catheters were found to be effective for use in the postoperative phase.

Background and objectivesWith a growing need for non-opioid chronic pain treatments, pain physicians should understand the proper utilization of neuromodulation therapies to provide the most comprehensive care. We aimed to identify the unmet training needs that deter physicians from using spinal cord stimulation (SCS) devices.MethodsInternet-based surveys were fielded to fellows enrolled in pain fellowships during the 2016–2017 academic year accredited by the Accreditation Council for Graduate Medical Education and past pain fellows identified through pain medicine societies and SCS manufacturers.ResultsCurrent fellows were more likely to have received SCS training during fellowship compared with past fellows (100.0% vs 84.0%), yet there was variability in fellows’ SCS experiences with a wide range of trials and implants performed. Forty-six percent of current fellows felt there was an unmet training need regarding SCS. Deficiency in SCS case volume was the most common barrier that was noted (38.5%), followed by lack of SCS curriculum (30.8%) and lack of faculty with SCS expertise (23.1%). Lack of training was a predominant reason for past fellows choosing not to use SCS devices postfellowship. The majority of current and past fellows (79.5% and 55.4%, respectively) strongly supported direct training of fellows by SCS manufacturers.ConclusionsWhile SCS training during pain fellowship has become more universal, the experiences that fellows receive are highly variable, and most rely on industry-sponsored programs to supplement training deficiencies. Standardization of SCS procedures may also enable less experienced providers to navigate the SCS treatment algorithm.

Chronic intractable pain affects a significant percentage of the worldwide population, and it is one of the most disabling and expensive health conditions across the globe. Spinal cord stimulation (SCS) has been used to treat chronic pain for a number of years, but high-frequency SCS was not the US FDA approved until 2015. In this review, we describe the history and development of high-frequency SCS and discuss the benefits of the Omnia™ implantable pulse generator. We also provide a thorough literature review of the published work, highlighting the efficacy and safety profiles of high-frequency SCS for the treatment of multiple chronic pain conditions. Lastly, we offer our outlook on future developments with the Omnia SCS system.

BackgroundThere is no consensus regarding what volume of local anesthetic should be used to achieve successful supraclavicular block while minimizing hemidiaphragmatic paresis (HDP). This study investigated the dose–response relationship between local anesthetic volume and HDP after ultrasound-guided supraclavicular brachial plexus block.MethodsA dose escalation design was used to define the dose response curve for local anesthetic volume and incidence of HDP in subjects undergoing upper extremity surgery with supraclavicular block as the primary anesthetic. Dosing levels of 5, 10, 15, 20, 25, 30, 35 and 40 mL of local anesthetic were administered in cohorts of three subjects per dose. Diaphragm function was assessed with M-mode ultrasound before and after block. Secondary objectives included assessment of negative inspiratory force (NIF), oxygen saturation, subjective dyspnea and extent of sensory and motor blockade.ResultsTwenty-one subjects completed the study. HDP was present at all doses, with an incidence of 33% at 5 mL to 100% at 30–35 mL. There was a significant decrease in NIF (7.5 cmH2O, IQR (22,0); p=0.01) and oxygen saturation on room air (1%, IQR (2,0); p=0.01) 30 min postblock in subjects experiencing HDP but not in those without HDP. There was no increase in dyspnea in subjects with or without HDP. No subject required respiratory intervention. Motor and sensory block improved with increasing dose, and subjects with HDP exhibited denser blocks than those without (p<0.01).ConclusionsThere is no clinically relevant volume of local anesthetic at which HDP can be avoided when performing a supraclavicular block. In our subject population free of respiratory disease, HDP was well tolerated.Trial registration numberNCT03138577.