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Narouze S.N.,Anesthesiology and Pain Medicine | Narouze S.N.,Center for Pain Medicine Summa Western Reserve Hospital | Casanova J.,Neurocare Center | Souzdalnitski D.,Cleveland Clinic
Pain Practice | Year: 2014

Background Goals: Intrathecal drug delivery is an effective method to treat intractable pain. However, intrathecal catheter tip granuloma (ICTG) is a devastating complication of intrathecal drug delivery systems. It typically occurs in the thoracic region; particularly, in patients receiving high doses or high concentrations of intrathecal drug infusions. Materials and Methods: The PUBMED/MEDLINE and Cochrane databases were also systematically searched for all reports on ICTG published in any language. The key words included "intrathecal," "granuloma," and "spine surgery," and all related publications between the earliest available date (the first granuloma-related chronic complication of intrathecal infusion reported in PUBMED/MEDLINE in 1996) and June (week 1) of 2012 were searched. This case report is unique because it describes the formation of an intrathecal granuloma in the lumbar region of a patient who received a low-dose intrathecal infusion. Results and Conclusion: Cerebrospinal fluid flow dynamics within the spinal canal along with the physical, chemical, and immunological properties of intrathecal medications have been suggested to be responsible for the growth of inflammatory mass lesions at the tips of intrathecal drug delivery catheters. Our literature review supports the possible role of certain factors, specifically previous spine surgery or spinal injury, in granuloma formation. The rate of development of ICTG appears to be higher in patients who have had previous spine surgery or spinal injury (68%) than in a general cohort of patients (48%), with an intrathecal pump. Therefore patients with a history of spine surgery or injury may be at increased risk of ICTG when receiving chronic intrathecal analgesia. © 2013 World Institute of Pain. Source

Deer T.R.,Center for Pain Relief | Krames E.,Pacific Pain Treatment Center | Mekhail N.,University of Kentucky | Pope J.,Center for Pain Relief | And 15 more authors.
Neuromodulation | Year: 2014

Introduction The International Neuromodulation Society (INS) has determined that there is a need to provide an expert consensus that defines the appropriate use of neuromodulation technologies for appropriate patients. The Neuromodulation Appropriateness Consensus Committee (NACC) was formed to give guidance to current practice and insight into future developments. Methods The INS executive board selected members of the international scientific community to analyze scientific evidence for current and future innovations and to use clinical experience to fill in any gaps in information. The NACC used PubMed and Google Scholar to obtain current evidence in the field and used clinical and research experience to give a more complete picture of the innovations in the field. Results The NACC has determined that currently approved neurostimulation techniques and technologies have expanded our ability to treat patients in a more effective and specific fashion. Despite these advances, the NACC has identified several additional promising technologies and potential applications for neurostimulation that could move this field forward and expand the applicability of neuromodulation. Conclusions The NACC concludes that the field of neurostimulation is an evolving and rapidly changing one that will lead to improved patient access, safety, and outcomes. © 2014 International Neuromodulation Society. Source

Jaggers R.,Methodist Sports Medicine | Lewis H.,University of Missouri | Plackis A.,University of Missouri | Sim S.B.,Anesthesiology and Pain Medicine | Sherman S.L.,University of Missouri
Physician and Sportsmedicine | Year: 2014

Optimal pain management is critical after knee surgery to avoid adverse events and to improve surgical outcomes. Pain may affect surgical outcomes by contributing to limitations in range of motion, strength, and functional recovery. The causes of postoperative pain are multifactorial; therefore, an appropriate pain management strategy must take into account preoperative, intraoperative, and postoperative factors to create a comprehensive and individualized plan for the patient. Preoperative assessment includes management of patient expectations, recognition of conditions and early counseling for high-risk patients (ie, opioid dependence, psychiatric comorbidities), and use of preemptive analgesia techniques (ie, preoperative IV medications, peripheral nerve blocks, incisional field blocks). Intraoperative strategies include meticulous surgical technique, limiting the use of tourniquets (ie, duration and pressure), and using preventive analgesia methods (ie, postoperative field block, continuous nerve catheters, intra-articular injection). Postoperative analgesia may be facilitated by cryotherapy, early mobilization, bracing, and rehabilitation. Certain modalities (ie, continuous passive motion devices, transcutaneous electrical nerve stimulation units, iontophoresis) may be important adjuncts in the perioperative period as well. There may be an evolving role for alternative medicine strategies. Early recognition and treatment of exaggerated postoperative pain responses may mitigate the effects of complex regional pain syndrome or the development of chronic pain. © The Physician and Sportsmedicine. Source

Gopalakrishnan V.,Brain Tumor Center | Gopalakrishnan V.,University of Houston | Bie B.,Anesthesiology and Pain Medicine | Fuller G.N.,University of Houston | And 4 more authors.
Stem Cells | Year: 2010

Production of neurons from non-neural cells has farreaching clinical significance. We previously found that myoblasts can be converted to a physiologically active neuronal phenotype by transferring a single recombinant transcription factor, REST-VP16, which directly activates target genes of the transcriptional repressor, REST. However, the neuronal subtype of M-RV cells and whether they can establish synaptic communication in the brain have remained unknown. M-RV cells engineered to express green fluorescent protein (M-RV-GFP) had functional ion channels but did not establish synaptic communication in vitro. However, when transplanted into newborn mice cerebella, a site of extensive postnatal neurogenesis, these cells expressed endogenous cerebellar granule precursors and neuron proteins, such as transient axonal glycoprotein-1, neurofilament, type-III β-tubulin, superior cervical ganglia-clone 10, glutamate receptor-2, and glutamate decarboxylase. Importantly, they exhibited action potentials and were capable of receiving glutamatergic synaptic input, similar to the native cerebellar granule neurons. These results suggest that M-RV-GFP cells differentiate into glutamatergic neurons, an important neuronal subtype, in the postnatal cerebellar milieu. Our findings suggest that although activation of REST-target genes can reprogram myoblasts to assume a general neuronal phenotype, the subtype specificity may then be directed by the brain microenvironment. © AlphaMed Press. Source

Deer T.R.,Center for Pain Relief | Mekhail N.,Cleveland Clinic | Petersen E.,University of Arkansas for Medical Sciences | Krames E.,Pacific Pain Treatment Center | And 14 more authors.
Neuromodulation | Year: 2014

Introduction The International Neuromodulation Society (INS) has identified a need for evaluation and analysis of the practice of neurostimulation of the brain and extracranial nerves of the head to treat chronic pain. Methods The INS board of directors chose an expert panel, the Neuromodulation Appropriateness Consensus Committee (NACC), to evaluate the peer-reviewed literature, current research, and clinical experience and to give guidance for the appropriate use of these methods. The literature searches involved key word searches in PubMed, EMBASE, and Google Scholar dated 1970-2013, which were graded and evaluated by the authors. Results The NACC found that evidence supports extracranial stimulation for facial pain, migraine, and scalp pain but is limited for intracranial neuromodulation. High cervical spinal cord stimulation is an evolving option for facial pain. Intracranial neurostimulation may be an excellent option to treat diseases of the nervous system, such as tremor and Parkinson's disease, and in the future, potentially Alzheimer's disease and traumatic brain injury, but current use of intracranial stimulation for pain should be seen as investigational. Conclusions The NACC concludes that extracranial nerve stimulation should be considered in the algorithmic treatment of migraine and other disorders of the head. We should strive to perfect targets outside the cranium when treating pain, if at all possible. © 2014 International Neuromodulation Society. Source

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