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Bright Etumuse,1 Majesty Greer,2 Jane Onyemachi,1 Youshaa El-Abed,3 Sai Kamma,1 Jay D Shah,4 Henry Tuan Tran,1 Nasir Hussain,5 Thomas P Pittelkow,6 Ryan S D’Souza6 1University of Texas Medical Branch School of Medicine, Galveston, TX, USA; 2Howard University College of Medicine, Washington, DC, USA; 3Kansas City University, Kansas City, MO, USA; 4Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA; 5Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 6Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USACorrespondence: Ryan S D’Souza, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic 200 First St. SW, Rochester, MN, 55905, USA, Email Dsouza.ryan@mayo.eduBackground: As cannabis legalization expands nationally and globally, its use for chronic pain increases, prompting people to seek information on social media platforms like YouTube. This study evaluates the accuracy and quality of information of popular YouTube videos on cannabis for chronic pain.Methods: Using search terms related to cannabis for pain, the top 66 videos by view count were selected. Each video was classified as useful, misleading, or neither. The quality and reliability of each video were assessed using the modified DISCERN, mDISCERN, score and the Global Quality Scale, GQS. The video characteristics, usefulness classification, mDISCERN scores, and GQS scores were summarized. Continuous and categorical outcomes were compared using t-test and chi-square, respectively.Results: Of the 66 videos, 22.73% (n=15) were classified as useful, and 77.27% (n=51) were classified as neither. Of useful videos, 40.00% (n=6) were uploaded by physicians, 40.00% (n=6) were uploaded by corporations, and 6.67% (n=1) were uploaded by an independent user. Of videos classified as neither useful nor misleading, news sources uploaded 27.45% (n=14) of these videos (P=0.02). Physicians uploaded 37.50% (n = 18) of videos with a GQS score ≥ 3 (P=0.04), while independent users uploaded significantly more videos with a mDISCERN score < 3 (22.20%, P=0.02). Useful videos had a mean GQS of 4.00 ± 0.65 compared to a mean GQS of 2.76 ± 0.86 for videos deemed neither (P< 0.0001).Conclusion: This study suggests a moderate quality of YouTube content on cannabis use for chronic pain. Given cannabis’s growing popularity and potential for misinformation on popular social media platforms, healthcare professionals and organizations should consider uploading educational videos on this topic on YouTube.Keywords: social media, cannabis, medical cannabis, analgesics, YouTube

Majesty Greer,1 Sai Kamma,2 Henry Tran,2 Bright Etumuse,2 Jay D Shah,3 Youshaa El-Abed,4 Jane O Onyemachi,2 Nasir Hussain,5 Thomas P Pittelkow,6 Ryan S D’Souza6 1Howard University College of Medicine, Washington, DC, USA; 2University of Texas Medical Branch School of Medicine, Galveston, TX, USA; 3Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA; 4College of Osteopathic Medicine, Kansas City University, Kansas City, MO, USA; 5Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 6Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USACorrespondence: Ryan S D’Souza, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA, Email Dsouza.ryan@mayo.eduIntroduction: Acupuncture is commonly used to treat chronic pain. Patients often access public social media platforms for healthcare information when querying acupuncture. Our study aims to appraise the utility, accuracy, and quality of information available on YouTube, a popular social media platform, on acupuncture for chronic pain treatment.Methods: Using search terms such as “acupuncture for chronic pain” and “acupuncture pain relief”, the top 54 videos by view count were selected. Included videos were > 1 minute duration, contained audio in English, had > 7000 views, and was related to acupuncture. One primary outcome of interest was categorizing each video’s usefulness as useful, misleading, or neither. Another primary outcome of interest was the quality and reliability of each video using validated instruments, including the modified DISCERN (mDISCERN) tool and the Global Quality Scale (GQS). The means were calculated for the video production characteristics, production sources, and mDISCERN and GQS scores. Continuous and categorical outcomes were compared using Student’s t-test and chi-square test, respectively.Results: Of the 54 videos, 57.4% were categorized as useful, 14.8% were misleading, and 27.8% were neither. Useful videos had a mean GQS and mDISCERN score of 3.77± 0.67 and 3.48± 0.63, respectively, while misleading videos had mean GQS and mDISCERN score of 2.50± 0.53 and 2.38± 0.52, respectively. 41.8% of the useful videos were produced by a healthcare institution while none of the misleading videos were produced by a healthcare institution. However, 87.5% of the misleading videos were produced by health media compared to only 25.8% of useful videos from health media.Discussion: As patients increasingly depend on platforms like YouTube for trustworthy information on complementary health practices such as acupuncture, our study emphasizes the critical need for more higher-quality videos from unbiased healthcare institutions and physicians to ensure patients are receiving reliable information regarding this topic.Keywords: acupuncture, chronic pain, social media, anesthesia, information dissemination, internet

Jonathan M Hagedorn, Nicholas Canzanello, Markus A Bendel, Thomas P Pittelkow, Tim J Lamer Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, 55905, USACorrespondence: Jonathan M HagedornDepartment of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, 55905, USAFax +1 507-266-7732Email jonhagedornmd@yahoo.comObjective: Surgical site infection in patients who undergo spinal cord stimulator implant surgery represents a significant concern in terms of increased health care costs and patient morbidity. The use of antibacterial envelopes in spinal cord stimulator implant surgeries has not been previously described. The aim of this retrospective review was to evaluate the effectiveness of the antibacterial envelope in reducing surgical site infection in spinal cord stimulator implant surgeries when used adjunctively to standard infection prevention measures.Materials and Methods: The study included 52 patients, all of whom were implanted with a spinal cord stimulator between January 2015 and November 2020. To be included, patients were required to have had an antibacterial envelope utilized at the time of surgery. Patient records were retrospectively reviewed. All patients who received an antibacterial envelope at the time of implant surgery were included.Results: Data was collected and analyzed on 52 permanent SCS implantations, including primary implantation (n=26) and revision surgery (n=26). All patients were at least three months post-operative from the implant surgery (average follow-up time period was 518.4 days). There were no surgical site infections reported in the 52 patient cohort.Conclusion: Antibiotic impregnated envelopes appear to be a safe and effective modality to decrease surgical site infection risk in spinal cord stimulation implant surgeries.Keywords: spinal cord stimulation, surgical site infection, outcomes, infection prevention

Jonathan M Hagedorn, Thomas P Pittelkow, Christine L Hunt, Ryan S D’Souza, Tim J Lamer Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USACorrespondence: Tim J LamerDepartment of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN 55905, USATel +1-507-284-2511Email Lamer.Tim@mayo.eduAbstract: Cancer and cancer treatment-related chronic pain affect a significant number of patients. The etiology of this pain is diverse and may include nociceptive and/or neuropathic characteristics. Treatment is often multifactorial and may require advanced interventional techniques, such as spinal cord stimulation (SCS). This narrative review provides a thorough overview of cancer-related pain mechanisms and the use of SCS for cancer-related pain. Additionally, a review of the precautions that should be considered when caring for this patient population is provided with recommendations for safe care when utilizing these techniques.Keywords: spinal cord stimulation, cancer pain, neuromodulation, radiation, chemotherapy, surgery

Background: Complex regional pain syndrome is a chronic pain condition characterized by autonomic dysfunction, changes in sympathetic and vasomotor activity, and sensory and motor changes. Complex regional pain syndrome is a clinical diagnosis and may occur after trauma or surgery. Complex regional pain syndrome-related pain may occur spontaneously and is out of proportion with the inciting event. We report herein the rare case of a man who developed concomitant painful generalized ulcerations after diagnosis of complex regional pain syndrome., Case Presentation: A 43-year-old Caucasian male with history of four-extremity complex regional pain syndrome type 2 secondary to right rotator cuff surgery performed at an outside hospital presented to a tertiary care center for treatment of generalized ulcerations on all extremities of unknown etiology. Dermatology performed an extensive work-up including laboratory evaluations and biopsies, which were relatively unremarkable. His ulcers were treated with vinegar-based dressings, hydrotherapy, and irrigation and debridements. He was started on methadone (replacing a home fentanyl patch), ketamine infusion, and amitriptyline in addition to his home adjuncts. He obtained good symptom control, improved sleep, and diminished cognitive slowing, compared with his fentanyl patches., Conclusion: This case report emphasizes an atypical case of generalized ulceration formation in the setting of complex regional pain syndrome. This case highlights the challenging nature of treating complex regional pain syndrome and using multimodal analgesia to target various nociceptive receptors to successfully reduce symptoms., (© 2022. The Author(s).)

Shoulder arthroplasty is a successful surgical procedure for several conditions when patients become refractory to conservative management modalities. Unfortunately, some patients experience persistent chronic pain after shoulder arthroplasty. These individuals should undergo a comprehensive evaluation by an orthopedic surgeon to determine whether structural pathology is responsible for the pain and to decide whether reoperation is indicated. At times, a surgical solution does not exist. In these circumstances, a thorough and specific plan for the management of persistent chronic pain should be developed and instituted. In this article, we review common reasons for persistent pain after shoulder arthroplasty and outline the evaluation of the painful shoulder arthroplasty. We then provide a thorough review of interventional pain management strategies. Finally, we hypothesize developments in our field that might provide better outcomes in the future for patients suffering with chronic intractable pain after shoulder arthroplasty., (© 2022 The Author(s).)

Objectives: The purpose of this single center, prospective randomized controlled trial was to compare clinical outcomes between an ultrasound-guided greater occipital nerve block (GONB) at the C2 vertebral level versus landmark-based GONB at the superior nuchal line., Methods: Patients with occipital neuralgia or cervicogenic headache were randomized to receive either a landmark-based GONB with sham ultrasound at the superior nuchal line or ultrasound-guided GONB at the C2 vertebral level with blinding of patients and data analysis investigators. Clinical outcomes were assessed at 30 minutes, 2 weeks, and 4 weeks postinjection., Results: Thirty-two patients were recruited with 16 participants in each group. Despite randomization, the ultrasound-guided GONB group reported higher numeric rating scale (NRS) scores at baseline. Those in the ultrasound-guided GONB group had a significant decrease in NRS from baseline compared with the landmark-based GONB group at 30 minutes (change of NRS of 4.0 vs. 2.0) and 4-week time points (change of NRS of 2.5 vs. -0.5). Both groups were found to have significant decreases in Headache Impact Test-6. The ultrasound-guided GONB had significant improvements in NRS, severe headache days, and analgesic use at 4 weeks when compared with baseline. No serious adverse events occurred in either group., Conclusions: Ultrasound-guided GONBs may provide superior pain reduction at 4 weeks when compared with landmark-based GONBs for patients with occipital neuralgia or cervicogenic headache., Competing Interests: J.M.H. reports personal fees from Abbott, Boston Scientific, and Nevro that are outside of the submitted work. M.J.P. reports participation on WAPMU Board of Directors, but outside the submitted work. N.R.K. serves on the editorial board for Pain Medicine also reports grant from Nevro Corporation and personal fees from UpToDate that are outside the submitted work. The remaining authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The field of neurostimulation for the treatment of chronic pain is a rapidly developing area of medicine. Although neurostimulation therapies have advanced significantly as a result of technologic improvements, surgical planning, device placement, and postoperative care are of equal importance to optimize outcomes. This Neurostimulation Appropriateness Consensus Committee (NACC) project intends to provide evidence-based guidance for these often-overlooked areas of neurostimulation practice., Materials and Methods: Authors were chosen based on their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from the last NACC publication in 2017 to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on evidence strength and consensus when evidence was scant., Results: This NACC project provides guidance on preoperative assessment, intraoperative techniques, and postoperative management in the form of consensus points with supportive evidence. These results are based on grade of evidence, strength of consensus, and expert opinion., Conclusions: The NACC has given guidance for a surgical plan that encompasses the patient journey from the planning stage through the surgical experience and postoperative care. The overall recommendations are designed to improve efficacy and the safety of patients undergoing these neuromodulation procedures and are intended to apply throughout the international community., (Copyright © 2021 International Neuromodulation Society. Published by Elsevier Inc. All rights reserved.)

Spinal cord and dorsal root ganglion stimulation are minimally invasive surgical techniques used to treat an array of chronic pain disorders. There is a paucity of data related to defining best practices in these specific patient populations, and historically, providers have relied on consensus committees to opine on the best techniques for patient safety and experience. The most efficacious mechanism of surgical closure-specifically a running suture closure compared to a surgical staple closure-is debated. A retrospective review of 155 patients implanted with either a spinal cord or dorsal root ganglion stimulator between 2017 and 2019 was undertaken to determine if the type of surgical closure was related to degree of postoperative surgical site discomfort. The primary outcome showed no statistically significant difference on postoperative pain scores between the suture (6.0 (IQR 5.0-8.0)) and staple (7.0 (IQR 5.0-8.0)) cohorts at postoperative day (POD) #1 (adjusted β 0.17 (95% CI -0.61 to 0.95), P =0.670). This finding held for postoperative pain scores at POD #10 as well (staples (1.0 (IQR 0.0-4.0)) and suture (2.0 (IQR 0.0-5.0), adjusted β -0.39 (95% CI -1.35 to 0.58), P =0.432)). A regression analysis was performed to identify secondary factors impacting postoperative pain scores. Higher preoperative pain score ( β 0.50 (95% CI 0.09 to 0.92), P =0.019) and female gender ( β 1.09 (95% CI 0.15 to 2.02), P =0.023) were predictive of higher incisional pain scores at POD#10. Increasing age was associated with decreased incisional pain scores at POD#10 ( β -0.06 (95% CI -0.09 to -0.03), P < 0.001). These findings are of interest to the pain practitioner and may be valuable in preoperative discussions with prospective patients., Competing Interests: JMH is a consultant for Abbott, Boston Scientific, and Nevro. He serves on advisory boards for Boston Scientific and Nevro. MAB has funded research with Nevro. All the other authors declare that they have no conflicts of interest., (Copyright © 2021 Markus A. Bendel et al.)

Abstract: The primary aim of this randomized clinical trial is to investigate the effects of ultrasound-guided transversus abdominis plane (TAP) vs ultrasound-guided trigger point injections (TPIs) on numerical rating scale pain scores at month 3 follow-up in patients with a chronic abdominal wall pain. The primary outcome measure was the difference in mean numeric rating scale pain scores between the TAP and TPI groups at month 3 in an intent-to-treat (ITT) analysis. A total of 60 patients were randomized 1:1 to receive an ultrasound-guided TAP block (n = 30) or an ultrasound-guided TPI (n = 30). No significant group differences in baseline demographic or clinical characteristics were observed. The mean baseline pain score for the TAP and TPI groups was 5.5 and 4.7, respectively. In the ITT analysis at month 3, the between-group difference in pain scores was 1.7 (95% confidence interval, 0.3-3.0) favoring the TPI group. In a secondary per-protocol analysis, the between-group difference in pain scores was 1.8 (95% confidence interval, 0.4-3.2) favoring the TPI group. For the ITT and per-protocol analyses, the group differences in pain scores were consistent with a medium effect size. The main finding of this randomized clinical trial is that adults with chronic abdominal wall pain who received a TPI reported significantly lower pain scores at month 3 follow-up compared with patients who received a TAP block., (Copyright © 2021 International Association for the Study of Pain.)

Background/objective: Chronic pain is commonly reported in individuals with spinal cord injuries (SCIs), with recent prevalence reported as high as 80%. Uncontrolled pain is known to decrease quality of life, attenuate mood, and impact sleep. Spinal cord stimulation (SCS) for the treatment of refractory pain was first used in the SCI population in 1972. To date there have been no randomized controlled trials examining the effect of SCS on neuropathic pain post-SCI. A literature review in 2009 identified 27 studies, the majority prior to 2000, that included at least 1 patient with SCI. Given the significant advancements in the field of SCS, this review examines the updated evidence of SCS for the treatment of neuropathic pain in individuals with SCI and provides guidance on future investigations., Methods: MEDLINE and EMBASE databases were searched. All published reports, case series, and clinical trials reviewing SCS for neuropathic pain that included at least 1 individual with SCI were included., Results: The initial search identified 376 reports, of which 22 met inclusion criteria, for a total of 69 patients. All reports were of very low quality. A majority of the reported patients were male, underwent tonic stimulation, and reportedly experienced improvement in pain and spasticity, with decreased use of pain medication., Conclusions: The synthesized findings from primarily case studies support the safety of SCS in SCI with the suggestion of potential pain relief benefit; however, data from low-quality studies are insufficient for informing clinical practice. A well-designed, prospective clinical trial is proposed to further investigate this indication., (© 2019 World Institute of Pain.)

Objective: Spinal cord stimulation (SCS) is an evidence-based therapy for the treatment of refractory pain. Current American College of Graduate Medical Education requirements for pain medicine fellowship graduation include observation of five neuromodulation cases. Matriculating fellows have varying degrees of technical skill, training, and experience. The purpose of this study was to use an innovative skill-based assessment tool using the validated Zwisch scale to evaluate fellow surgical performance during SCS cases., Design: Cross-sectional survey SETTING: Mayo Clinic, Rochester, Minnesota., Subjects: Consultant faculty (10) in the Division of Pain Medicine and pain medicine fellows (5)., Methods: A list of faculty-driven neuromodulation surgical objectives was formed and a rubric was created that focused on technical approach, imaging, epidural access and wound closure. Consultants who perform surgical cases were instructed to use the Zwisch scale as a guide to evaluate fellow surgical performance during a neuromodulation case. Faculty and fellows were surveyed before and after implementation of the tool to determine their satisfaction with use of the skill assessment tool., Results: The consultants reported they were more satisfied, consistent, and efficient with feedback provided to the trainee on every aspect of neuromodulation surgical cases. The improvement was most significant during the fellows' intraoperative skill assessment. The fellows indicated increased satisfaction, improved communication, and increased efficiency of feedback when the tool was utilized. The fellows reported greater intraoperative skill assessment and consistency of feedback provided., Conclusions: The diverse nature of primary specialty backgrounds observed in pain medicine fellowship training offers a unique opportunity to assess and improve fellow skill and surgical competence in the field of neuromodulation. Both faculty and fellows reported improved satisfaction, consistency and efficiency with feedback provided. Importantly, this pilot project observed that implementation of a skill assessment tool was beneficial for both the faculty and fellow as the feedback received was viewed as strongly beneficial to the educational experience., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Pain is one of the most commonly experienced and feared symptoms faced by patients with a serious illness. For these patients, intrathecal drug delivery systems (IDDSs) provide greater potency and/or few systemic side effects. However, despite these benefits, the integration and management of IDDS for patients receiving hospice care has not been previous studied. An electronic, 18-question survey was sent to 200 hospice practitioners (physicians, nurse practitioners and nurses) in the state of Minnesota to explore their experience, confidence, and the perceived barriers to caring for patients with IDDS while being cared for on hospice. Providers were identified though mailing lists from the Minnesota Network of Hospice and Palliative Care organization. The survey was administered by the Mayo Clinic Survey Research Center with institutional review board approval. Slightly more than 50% of respondents have ever cared for a patient with an intrathecal pump. If a patient had a pump in place, only 28% of providers expressed confidence in managing their pain. Additionally, only 3 of 10 respondents felt that adjusting an intrathecal pump should be the first option when a patient with an IDDS in place had increased pain. Indeed, the vast majority (over 80%) of respondents preferred the use of systemic therapies for primary pain management. Access to IDDS vendors for changes/refills in the home is identified as another barrier with over 50% of respondents either unaware of an available vendor or reporting no vendor available. There are numerous self-reported barriers to ongoing use of IDDS with patients receiving hospice care.

Objectives: Exploratory research quantifying the change of spasticity among patients who underwent baclofen intrathecal drug delivery system (IDDS) implantation., Patients and Methods: 88 patients with a baclofen IDDS were identified. Patient characteristics, spasticity scores pre/post intrathecal baclofen test dose, and IDDS perioperative implantation records were collected. The primary outcome was to quantify the extent to which there was a change in Modified Ashworth Scores (MAS) pre/post-intrathecal baclofen test dose administration. Secondary outcomes included the prevalence of perioperative IDDS implantation complications., Results: The mean age at IDDS implant was 44.2 years (range, 19-71), and 62.5% were male. 45.5% had spasticity of spinal cord origin, 9% of cerebral origin, and 45.5% of other upper motor neuron dysfunction. Reduction of MAS in the spinal cord origin group was 2.6 (mean, 3.5 to 0.9), cerebral origin group was 2.9 (mean, 3.3 to 0.4), and other origin group was 2.5 (mean, 3.6 to 1.1). In all patients, post dural puncture headache was the most commonly reported complication at 22.7%., Conclusion: This report offers novel findings documenting a quantifiable change of at least two points on the MAS before and after intrathecal baclofen test dose as statistically significant and could prove to be useful information to enhance the decision making process to proceed with intrathecal baclofen beyond assessment of functional abilities., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Accurate diagnosis of musculoskeletal disorders relies heavily on the physical examination, including accurate palpation of musculoskeletal structures. The literature suggests that there has been a deterioration of physical examination skills among medical students and residents, in part due to increased reliance on advanced imaging. It has been shown that knowledge of musculoskeletal anatomy and physical examination skills improve with the use of ultrasound; however, the literature is limited., Objective: To determine whether ultrasound can improve the ability of physicians in training (residents) to palpate the long head of the biceps tendon (LHBT) in the bicipital groove., Design: Prospective study design., Setting: Tertiary care center., Participants: Ten physical medicine and rehabilitation residents served as subjects. Exclusion criteria included the presence of any condition that precluded their ability to palpate. Three volunteers were used as models. Model exclusion criteria included anything that distorted normal shoulder anatomy or inhibited examiner palpation. Three investigators with experience performing diagnostic musculoskeletal ultrasound were used to confirm palpation attempts., Methods: Subjects attempted to palpate the LHBT bilaterally in the bicipital groove of each model. Investigators assessed the accuracy of the palpation attempt using real-time ultrasonography. Subjects participated in a 30-minute ultrasound-assisted training session learning how to palpate the LHBT in the bicipital groove with ultrasound confirmation. After the ultrasound training session, subjects again attempted to palpate the LHBT in the bicipital groove of each model with investigator confirmation., Main Outcome Measurements: LHBT palpation accuracy rates preintervention versus postintervention., Results: Pretraining LHBT palpation accuracy was 20% (12/60 attempts). Post-ultrasound training session accuracy was 51.7% (31/60 attempts; P ≤ .001)., Conclusions: Our findings demonstrate that palpation accuracy improves after ultrasound assisted LHBT palpation training. These data suggest that the use of ultrasound may be beneficial when teaching musculoskeletal palpation skills to health care professionals., Level of Evidence: II., (Copyright © 2018 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objective: The goal of this study was to determine the frequency and clinical indications associated with implantation of single vs. dual percutaneous lead spinal cord stimulator (SCS) systems and to look further into how these leads are utilized for treatment., Materials and Methods: A retrospective cohort analysis of all patients undergoing SCS implantation between January 2001 and December 2013 with a minimum of 2 years of clinical follow-up was performed. Number of trial leads and implanted leads was recorded. For patients with dual-lead systems, it was noted if and when the second lead was used, along with the clinical indication for lead activation., Results: In the 259-patient cohort, 15.8% (n = 41) patients underwent placement of a single-lead system, 83.0% (n = 215) underwent placement of a dual-lead system, and 1.2% (n = 3) underwent placement of 3-lead systems. Placement of dual-lead systems was similar among all indication groups. Of those patients with a dual-lead system in place, 88.1% utilized both leads and average time to programming of the second lead was 2.3 months. The most common reason to activate the second lead was inadequate stimulation coverage. Five of the 41 patients with single-lead systems underwent an additional surgery to implant a second lead due to inadequate stimulation with 1 lead., Conclusions: To our knowledge this is the first descriptive analysis of the frequency of single- and dual-lead SCS systems. This report indicates that dual-lead systems are most often placed and both leads are required for optimal patient therapy., (© 2017 World Institute of Pain.)

Introduction: Surgical site infection is a potential complication of spinal cord stimulator (SCS) implantation. Current understanding of the epidemiology, diagnosis, and treatment of these infections is based largely on small clinical studies, many of which are outdated. Evidence-based guidelines for management of SCS-related infections thus rely instead on expert opinion, case reports, and case series. In this study, we aim to provide a large scale retrospective study of infection management techniques specifically for SCS implantation., Methods: A multicenter retrospective study of SCS implants performed over a seven-year period at 11 unique academic and non-academic institutions in the United States. All infections and related complications in this cohort were analyzed., Results: Within our study of 2737 SCS implant procedures, we identified all procedures complicated by infection (2.45%). Localized incisional pain and wound erythema were the most common presenting signs. Laboratory studies were performed in the majority of patients, but an imaging study was performed in less than half of these patients. The most common causative organism was Staphylococcus aureus and the IPG pocket was the most common site of an SCS-related infection. Explantation was ultimately performed in 52 of the 67 patients (77.6%). Non-explantation salvage therapy was attempted in 24 patients and was successful in resolving the infection in 15 patients without removal of SCS hardware components., Discussion: This study provides current data regarding SCS related infections, including incidence, diagnosis, and treatment., (© 2017 International Neuromodulation Society.)

Background: Occipital neuromodulation is a promising treatment modality for refractory headache, but lead migration remains a frequent surgical complication., Objectives: The primary objective was to identify surgical techniques that may minimize adverse events, particularly lead migration. We hypothesized that a surgical technique employing 2-point anchoring of stimulator leads designed to provide a tension-relief loop and the use of ultrasound for lead placement would decrease the complication rate., Study Design and Setting: A retrospective analysis was performed through electronic medical record chart review in a tertiary referral center., Methods: Institutional Review Board (IRB) approval was obtained. Eighteen patients had a trial and subsequent permanent occipital nerve stimulator (ONS) implantation between 2004 and 2011 and were included. Adverse events were recorded and efficacy outcome variables analyzed for significance., Results: The cohort was a median (IQR) 45 (37 - 58) in age and 9 (50%) were women. Tension-relief loops placed via a 2-point anchoring technique and ultrasound use for occipital lead placement were evident in 16 (89%) and 13 (72%), respectively. There was one (6%) clinically insignificant lead position change, not definitively a lead migration, which could have been an artifact of fluoroscope positioning. Adverse events included one (6%) battery malfunction, one (6%) lead malfunction, and 2 (12%) post-implantation infections. Following ONS, there were significant reductions in numeric rating scale (NRS) pain scores from a median (IQR) of 9.5 (8.25 - 10) to 2.5 (1 - 4.75) (P < 0.0001), headache days per week from 7 (7 - 7) to 1.5 (0.375 - 1.75) (P = 0.0005), and the number of daily headache medication from 3 (2.25 - 4) to 2.5 (2 - 3.75) (P = 0.0112)., Limitations: Limitations include retrospective study design, investigator bias, and non-standardized intervals of headache burden assessment., Conclusions: In ONS, utilization of a 2-point anchoring technique with a tension-relief loop may significantly minimize the risk of lead migration, based on the absence of definitive lead migration in our series. Ultrasound use may improve the anatomic accuracy of lead placement with the possibility of improved efficacy. ONS was associated with significantly decreased headache pain, frequency, and medication use., Key Words: Occipital neuromodulation, occipital nerve stimulation, surgical technique, lead migration, tension-relief loop.

Objective: To distinguish which patients with bone metastases are at risk for near-term disablement in order to assist clinicians in assessing the appropriateness of referrals for rehabilitation services., Design: Prospective cohort study., Setting: National Cancer Institute-designated comprehensive cancer center imbedded in a tertiary medical center., Participants: Data were collected from members (n=78) of a patient cohort (N=311) with stage IIIB or IV non-small-cell lung cancer or extensive-stage small-cell lung cancer who developed new or progressive imaging-confirmed bone metastases during the 2-year course of the study., Interventions: Not applicable., Main Outcome Measures: Functional capabilities were assessed at 3- to 4-week intervals over the study's 2-year duration with the Activity Measure for Post-Acute Care Computer Adaptive Testing., Results: Seventy-eight participants developed new or progressive bone metastases during the study. Most were men, and 83% had non-small-cell lung cancer. Metastases were most frequently located in the ribs (n=62), pelvis (n=49), or the thoracic (n=60) and lumbar spine (n=44). While neither the number of bone metastases nor their specific location was associated with near-term changes in patient mobility, their association with pain or a focal neurologic deficit was strongly associated with large declines in mobility. Similarly, patients whose imaging studies revealed new metastases and the expansion of established metastases were more likely to lose mobility., Conclusions: The total burden, specific locations, and overall distribution of bone metastases did not predict disablement. Patients with lung cancer-associated bone metastases are at markedly increased risk for declining mobility when their metastases are expanding in size and increasing in number, or are associated with pain or with new neurologic deficits., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Cigarette smoking is common among adults with chronic pain. The primary objective of this study was to determine the period prevalence of smoking in patients with chronic pain. A secondary objective was to determine the prevalence of smoking among patients with commonly occurring pain diagnoses including fibromyalgia, low back pain, and headache., Methods: This population study included 5350 patients (1256 smokers, 4094 nonsmokers) admitted to the Mayo Comprehensive Pain Rehabilitation Center from January 1998 through December 2012. Smoking status was determined using a self-report questionnaire., Results: During the 15 year study period, the overall prevalence of smoking was 23.5 % (95 % CI 22.4 - 24.6). The prevalence of smoking in 2000, 2005, and 2010 was 24.2, 25.7, and 28.3 % respectively. The overall prevalence of smoking in patients with fibromyalgia, low back pain, and headache was 25.2 % (95 % CI 22.8 - 28.3), 22.8 % (95 % CI 21.3 - 25.9), and 21.2 % (95 % CI 17.9 - 24.7), respectively. In a multiple variable logistic model adjusted for age and sex, opioid use was significantly associated with status as a current smoker., Conclusion: The prevalence of smoking in patients with chronic pain has not declined when compared to the general population. The higher prevalence of smoking was consistently observed in commonly occurring pain diagnoses including fibromyalgia, back pain, and headache. Further research is needed to identify the potential factors that contribute to the high prevalence of smoking in this patient population.