AAPM Abstract Roundup (Part 4)

FEBRUARY 05, 2010
Abstract #124
The PAIN BLITZ Pilot Project: Improving Care for Pain Patients with Comorbid Pain and Substance Abuse
Karp J, Brancolini S, Douaihy A, Daley D, Cope D
Purpose: The Pain Blitz (PB) goals were to explore the feasibility of implementing multidisciplinary treatment using the electronic medical record (EMR). The PB team comprised pain and addiction physicians and psychiatrists. 12 patients at risk of continued pain problems were selected based upon: 1) no major pathology, 2) monthly ED visits over the past 6 months or 3 hospital admissions within the past 6 months, and/or 3) substance abuse and/or aggressive opioid-seeking behavior.
Results: 83% were female. The average age was 42. For the 12 months pre-PB, the average number of ED visits was 22.5 and hospitalizations were 16.25. The chief complaint of 92% was abdominal pain, 75% reported depression/anxiety, 83% used opioids, 75% tobacco, and 42% illicit drugs. During the 16 weeks of the PB, 2/12 dropped out of the health plan, 1/12 returned to work and stopped opioids, and 1/12 stopped ED visits/admissions.

Abstract #125
Dose Stability of Tapentadol Extended Release (ER) for the Relief of Moderate-to-Severe Chronic Osteoarthritic Knee Pain
Kelly K, Lange B, Kuperwasser B, et al
Purpose: Dose stability of tapentadol ER was evaluated in patients with moderate-to-severe chronic osteoarthritic knee pain. Randomized patients received tapentadol ER (100-250 mg bid), oxycodone HCl CR (20-50 mg bid), or placebo for a 12-week maintenance period, following a 3-week titration period. Efficacy was measured as change from baseline in average pain intensity (11-point NRS) using LOCF to impute missing values.
Results: Compared with placebo (n=336), patients who received tapentadol ER (n=344) had a significantly greater reduction from baseline in average pain intensity at Week 12 and throughout the maintenance period (least-squares mean difference versus placebo, −0.7 and P<0.001 for both); patients who received oxycodone CR (n=342) had a significantly greater reduction over the entire maintenance period (−0.3; P=0.049) but not at week 12 (−0.3; P=0.069). Mean(SD) TDDs at week 1 and week 11-12 of maintenance, respectively, were 344.0(112.16)mg and 366.2(118.60)mg with tapentadol ER and 67.5(21.99)mg and 72.8(24.20)mg with oxycodone HCl CR. Mean(SD) pain intensity scores were similarly stable after maintenance week 2 (week 2 and week 12, respectively: tapentadol ER, 4.5[2.41] and 4.4[2.48]; oxycodone CR, 4.7[2.18] and 4.7[2.35]). Fewer patients discontinued because of adverse events with tapentadol ER (19.2%) than with oxycodone CR (42.7%).
Funding: Study supported by Johnson & Johnson Pharmaceutical Research & Development, L.L.C. and Grünenthal GmbH

Abstract #130
Pain Outcomes in Failed Back Surgery Syndrome Patients Following Spinal Cord Stimulation and Conventional Medical Management
Kumar K, Eldabe S, Buchser E, Taylor R
Purpose: Failed back surgery syndrome patients FBSS) experience chronic pain. We detail changes in pain for patients receiving spinal cord stimulation (SCS) and conventional medical management (CMM) over a 24-month period.
Results: 48% of the SCS group experienced >50% leg pain relief at 6 months compared with 9% of the CMM group. 38% of the group achieved >30% back pain relief at 6 months compared with 14% of the CMM group. These effects were sustained at 24 months. 34% of the SCS group and 59% of the CMM group experienced back pain worsening. Back and leg pain tended to increase in both groups over the course of a day. However, no pattern of daily pain variation over the 4-day assessment period could be identified.
Funding: All logistical aspects of the PROCESS study were managed and funded by Medtronic Europe sàrl. Clinicians/investigators had independent access to all data. All authors were clinical investigators for the trial with the exception of Rod Taylor, PhD who is a consultant to Medtronic.

Abstract #134
Sympathetic Nerve Block for Treating Post-Amputation Stump Hyperhydrosis
Li S, Sukumaran H, Miller S, Green C
Purpose: When a limb is lost, a properly fitted prosthesis is essential for recovery.
Hyperhydrosis, excessive sweating in the affected limb is common following amputation and SF-36 affects most amputees. Excess moisture may cause skin irritation, poor prosthetic fit, and dermal breakdown. Current therapeutic modalities are often unsatisfactory (eg, prosthetic padding, ventilated sockets, topical powders, topical anticholinergics, botulinum toxin-A, and surgery). A novel approach for treating post-amputation stump hyperhydrosis using lumbar sympathetic blockade is presented.
Results: A 49-year-old male presented to a tertiary care pain center for right leg, post-amputation, stump hyperhydrosis. He reported excessive sweating, skin irritation, and discomfort from his amputation stump preventing proper fit of his prosthesis. A diagnostic and therapeutic lumbar sympathetic block was performed. Four weeks following the procedure, he continued to report excellent relief and was able to wear his prosthesis without excessive sweating. To our knowledge, this is the first reported case of using lumbar sympathetic blockade (blocking the sympathetic innervation to eccrine glands) to treat hyperhydrosis following amputation. Thus, sympathetic nerve block is an additional therapeutic modality for controlling residual limb hyperhydrosis. In this patient, it yielded significant improvements in his quality of life.

Abstract #136
Combined Radiofrequency Ablation within the Sacrococcygeal Disc and the Ganglion Impar for Mixed Somatic and Neuropathic Coccycynia
Malayil J, Shaparin S, Kaufman A
Purpose: This is a case report of long-term improvement of mixed component pain following combined radiofrequency ablation (RFA) within the sacrococcygeal disc and the ganglion impar.
Results: A 63-year-old female presented with a two year history of localized sharp coccydynia with sitting and burning perineal pain radiating into her lower extremities. A trans-sacroccygeal ganglion impar block under fluoroscopic guidance was performed. During placement of the needle sharp localized pain was reproduced. Triamcinolone 80 mg and 5 cc 0.5% bupivicaine was injected with almost 100% relief of her burning pain but minimum relief of her sharp pain. Upon follow-up for RFA, passage of the needle through the sacrococygeal disc again elicited sharp localized pain. Stimulation at 50Hz/0.2 volts within the ganglion impar replicated her diffuse burning pain and RFA was performed at 60 Celsius for 90 seconds. Subsequent stimulation within the sacrococcygeal disc at 50Hz/0.2 volts replicated her sharp pain, therefore RFA was done at 80°C for 60 seconds. She had 95% pain relief after the procedure and was able to sit comfortably without sharp or burning pain for about 6 months.

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