BACKGROUND:Cancer-related pain remains one of the most debilitating symptoms in patients with advanced malignancy, with a significant proportion experiencing pain refractory to standard medical therapy. Percutaneous cordotomy is an established intervention targeting the spinothalamic pathway and can provide meaningful relief in appropriately selected patients; however, its use has declined and is typically performed in awake patients. CASE PRESENTATION:A 54-year-old woman with metastatic gallbladder carcinoma presented with severe, unilateral, nociceptive abdominal pain refractory to medical and interventional treatments. Given her limited life expectancy and persistent symptoms, she underwent percutaneous cervical cordotomy. At the patient's request, the procedure was performed under general anesthesia. We achieved excellent localization for safe ablation using intraoperative CT and neuromonitoring guidance. Postoperatively, she reported complete resolution of her primary pain (8-10/10 to 0/10) on postoperative Day 1. She developed expected contralateral "mirror pain," which was less severe and manageable. Pain relief was sustained during early follow-up, although later recurrence was attributed to disease progression rather than procedural failure. CONCLUSION:This case demonstrates that percutaneous cordotomy can be performed safely and effectively under general anesthesia with the aid of intraoperative CT and neuromonitoring. This approach may expand the applicability of cordotomy in carefully selected patients with refractory cancer pain, particularly when patient comfort is a priority.
INTRODUCTION:Transforaminal epidural steroid injection (TFESI) is commonly applied for lumbar radicular pain. High-level evidence supports the use in disc-related radiculopathy, while evidence for TFESI in neuroforaminal stenosis remains consensus-based. METHODS:A retrospective repeated cross-sectional study was conducted covering January 2013-December 2022. The dataset comprised 11,208 unique patients reimbursed for TFESI. Trends in clinical indications were analyzed using automated keyword-based text recognition. Representative cohorts from 2014 (n = 266) and 2022 (n = 299) were randomly selected for clinical and radiologic reviews. Imaging was reassessed according to established grading systems. Pain intensity and global perceived effect were evaluated approximately 6 weeks post-injection. Parametric and non-parametric statistics, linear regression, and ordinal logistic regression were applied. A two-sided p < 0.05 was considered statistically significant. RESULTS:Mean patient age and the proportion of stenosis-related indications both increased steadily between 2013 and 2022 (p < 0.001). In the studied cohorts, short-term pain decreased significantly after TFESI across all phenotypical subcategories, except for moderate-to-severe central canal compression in 2014. Neuroforaminal stenosis predicted greater pain improvement regardless of its nature in 2014 (p = 0.006), whereas disco-osteophyte abnormalities and chronic or recurrent symptoms were associated with less pain reduction in 2022 (p < 0.05). Female patients showed less short-term improvement than males. At one-year follow-up, central canal stenosis predicted a lower likelihood of being pain-free (OR = 0.63, p = 0.022). CONCLUSIONS:This retrospective study found an upward trend in patient age and a growing proportion of non-discogenic neuroforaminal stenosis as indications for TFESI. While modest short-term pain reduction was observed, outcomes were slightly negatively influenced by central compression, disco-osteophyte abnormalities, chronic symptoms, and female sex.
BACKGROUND:Several studies point towards the involvement of the immune system (especially the monocyte-macrophage system) in the pathophysiology of Complex Regional Pain Syndrome (CRPS), as shown by increased levels of the cytokines tumor necrosis factor (TNF)-α and interleukin (IL)-6. These cytokines are primarily released from pro-inflammatory M1 macrophages, but are difficult to measure in a clinical setting. Investigating the activity of tissue-resident macrophages by measuring soluble CD163 (sCD163) in serum is much more clinically applicable. sCD163 could potentially be a biomarker for determining inflammation in CRPS and would have direct consequences for the choice of therapy. The aim of this study is to investigate the tissue-resident macrophage activation in CRPS with sCD163 and explore the relationship between soluble IL-2R, which is a marker for T-cell activation, and sCD163. METHODS:The sCD163 levels were determined in this retrospective cohort study (MEC-2020-0716) in serum of CRPS patients (n = 22) and healthy controls (n = 27). ELISA kits were used to measure the levels of these markers. Data on demographics, pain scores (11-point Numeric Rating Scale: NRS), sIL-2R levels, signs and symptoms, and CRPS disease severity were also recorded. RESULTS:The median serum sCD163 level was significantly higher in CRPS patients (CRPS 960.5 pg/mL [Q3-Q1: 1211.5-623.9] than in healthy controls 677.0 pg/mL [Q3-Q1: 828.0-469.5], p = 0.008). There was a statistically significant positive correlation between sCD163 and sIL-2R in the CRPS group (rs = 0.577; p = 0.005), but not in the healthy control group (rs = 0.359; p = 0.066). CONCLUSION:Our findings indicate that pro-inflammatory activation of tissue-resident macrophages and thus the monocyte-macrophage system is part of CRPS pathogenesis. The monocyte-macrophage system is an interesting new target for future research into the pathogenesis of CRPS, but also has potential for diagnosis, particularly for assessing the involvement of the immune system and choice of therapy in the individual CRPS patient. Measurement of the sCD163 could be a potential biomarker for inflammation in CRPS. TRIAL REGISTRATION:This retrospective cohort study was approved by the Medical Ethics Committee of the Erasmus MC University Medical Center (MEC-2020-0716).
INTRODUCTION:Despite advancements in pharmacological and intrathecal treatment of oncological pain, it remains a significant challenge, affecting 44.5% of patients with cancer, with 30.6% experiencing moderate-to-severe pain. METHODS:This scoping review provides a summary of the literature from 2016 to 2024, focusing on percutaneous cordotomy techniques and clinical outcomes for the treatment of unilateral pain in patients with cancer. A literature search (in Medline and Embase) was performed from inception up to September 9, 2024, in collaboration with a medical information specialist. RESULTS:A comprehensive multidimensional assessment is essential when considering cordotomy. Ideal candidates have unilateral pain unresponsive to more conservative measures, localized below the C4 level. A detailed neurological examination is crucial for intra-procedural assessment and to evaluate potential post-procedural muscle weakness and sensory deficits. Our search identified 18 studies, half of which were retrospective and half prospective, including 596 patients in total. Studies varied regarding imaging technique and included fluoroscopy, CT-guided, or via microendoscopy. Excellent immediate pain relief was reported in between 86% and 98% of patients. Of patients surviving 6 months, the majority still experienced sustained pain relief. There is no consensus regarding optimal lesion temperature and duration. The reported rate of permanent complications such as paresis is low. The reported incidence of mirror pain is highly variable. CONCLUSIONS:Cancer pain should ideally be managed in a multidisciplinary and multimodal manner. When conservative treatment fails, a percutaneous cordotomy can be considered for refractory unilateral pain.
BACKGROUND:Although modern medicine provides multimodal approaches to treating pain, pain remains undertreated in 30% of pediatric palliative patients. PROCEDURE:In this single center retrospective cohort study, our aim was to ascertain how pediatric palliative phase pain was managed at a tertiary university hospital during the years 2013-2022. The medical records of patients with childhood cancer were reviewed for palliative diagnosis, demographics, duration of palliative period, pain medication or other treatment modality, effects and adverse effects, pain assessment, and death location. RESULTS:We identified 35 patients aged 1 to 19 years (median 9.0 years), of which 24 were female. Twenty-three patients had the ICD10 diagnosis for palliative care in their diagnoses. The palliative phase lasted from 1 to 491 days and took place at home in 15 cases. Fifteen patients had tumors of the central nervous system. Other diagnoses included sarcoma, neuroblastoma, acute lymphoblastic leukemia, and hepatocellular cancer. All patients were given acetaminophen and opioids. Non-steroidal anti-inflammatory drugs were given to 24 patients, anticonvulsants to 14, tricyclic antidepressants to 9, corticosteroids to 21, interventional pain procedures to 3, radiation therapy for analgesia to 10, and 5 patients underwent a procedure to alleviate pain and discomfort. Thirty-one patients used patient-controlled analgesia. CONCLUSIONS:Patient data concerning analgesics' effects and adverse effects were heterogeneous. We followed the WHO analgesic ladder during palliative care. Use of opioids was beneficial; the outcome for other classes of drugs was uncertain based on our limited data.
INTRODUCTION:Persistent spinal pain syndrome (PSPS) with predominant low-back pain (LBP) is difficult to manage when conservative and surgical treatments fail. Dorsal root ganglion stimulation (DRG-S) offers segmental, focal neuromodulation that may be particularly suited for managing axial LBP, yet long-term evidence from real-world practice remains limited. This study evaluated the effectiveness, safety, and impact on medication use of bilateral T12 DRG-S in patients with intractable LBP, using prospectively collected registry data. METHODS:Of 33 consecutive patients with chronic LBP assessed for DRG-S, 20 underwent trial stimulation after multidisciplinary evaluation. Eighteen (90%) proceeded to permanent implantation following ≥ 50% pain reduction during trial. Patients were followed via a digital platform at 3, 6, 12, and 24 months. Outcomes included pain intensity (NRS), quality of life (PROMIS-29), pain catastrophizing (PCS), satisfaction, medication use, and adverse events. Statistical comparisons were made between baseline and follow-up time points using paired tests. RESULTS:Pain intensity decreased substantially and significantly across all follow-up assessments: mean NRS declined from 8.0 ± 1.8 at baseline to 3.6 ± 1.6 at 3 months, 3.2 ± 1.8 at 6 months, 3.6 ± 1.7 at 12 months, and 2.9 ± 1.6 at 24 months (all p < 0.001). At 24 months, 100% of patients achieved ≥ 30% pain reduction and 70% achieved ≥ 50% reduction. Patient-reported outcomes demonstrated broad improvements. PROMIS-29 domains showed significant gains in physical function, pain interference, fatigue, and sleep disturbance, with consistent improvements also observed in anxiety and depression. Pain catastrophizing (PCS) scores decreased markedly, with total scores reduced by 47%-62% across follow-ups (all p < 0.001), reflecting improvements across helplessness, magnification, and rumination subdomains. Medication use declined over time. Mean opioid dose fell from 27 mg/day at baseline to 11.25 mg/day at 1 year and 4.44 mg/day at 2 years (p = 0.019 and 0.011, respectively). Paracetamol use also decreased significantly, whereas gabapentinoid use remained variable. Seven hardware-related complications were recorded (lead migration n = 3, lead fracture/damage n = 4), all successfully managed with revision surgery. Kaplan-Meier analysis estimated mean time to complication at 1080 days. Two patients discontinued therapy (EOT), both for reasons unrelated to device failure. CONCLUSIONS:In this prospective registry, bilateral T12 DRG-S provided durable reduction in pain intensity, improved physical, psychosocial, and cognitive outcomes, and facilitated meaningful opioid-sparing effects over 2 years. Complications were limited to correctable hardware issues, and therapy discontinuation was rare. Although larger multicentre studies are warranted, these findings add important real-world evidence supporting DRG-S as a valuable therapeutic option for refractory axial LBP.
INTRODUCTION:Percutaneous vertebral augmentation is widely used to provide symptom relief for patients with painful vertebral compression fractures (VCFs), but adjacent fractures remain a known complication. This retrospective study evaluated the risk of adjacent vertebral fractures following different percutaneous vertebral augmentation techniques. METHODS:A total of 985 encounters from 878 patients who underwent vertebroplasty, kyphoplasty, or bone tumor radiofrequency ablation (BT-RFA) with cement augmentation were included. The primary outcome was incidence of postprocedural adjacent fractures. Associations with demographic and clinical factors including age, sex, BMI, pathologic fractures, bone density, imaging guidance, and number of treated levels were assessed. Statistical analyses included a generalized linear mixed model and Cox proportional hazards models clustered by patient. RESULTS:Adjacent fracture occurred in 17.8% of encounters. BT-RFA was associated with a significantly lower risk of adjacent fractures compared with kyphoplasty (HR: 0.54, 95% CI:0.36-0.81; p = 0.003) and vertebroplasty (HR: 0.40, 95% CI: 0.27-0.60; p < 0.0001). Multilevel vertebral augmentations increased fracture risk by 1.42-fold, while pathologic fractures lowered the odds of adjacent fracture. No significant associations were found for age, BMI, sex, cement extravasation, or bone density. CONCLUSION:BT-RFA combined with cement augmentation significantly reduced the risk of adjacent fractures compared to kyphoplasty or vertebroplasty.
INTRODUCTION:Spinal cord stimulation (SCS) is an established therapy for chronic pain. While hardware complications such as lead migration or infection are well-documented, biological responses such as fibrotic encapsulation are rare and underrecognized. Prior reports of fibrosis related to SCS have been limited to the epidural space, primarily involving paddle leads. We report the first known case of intradural fibrotic scarring following percutaneous SCS implantation, resulting in delayed spinal cord compression and progressive neurologic decline. CLINICAL PRESENTATION:A 69-year-old woman with a history of thoracic percutaneous SCS placement presented with progressive lower extremity sensory loss, weakness, and urinary retention 7 years after implantation. MRI demonstrated a spinal cord signal change centered around a T9-10 lesion at the level of the leads. During surgery, dense fibrotic tissue was noted both epidurally and intradurally, tightly encasing and tethering the spinal cord. No distinct dural plane was observed at the site of maximal compression. A durotomy was required to perform microsurgical dissection intradurally and release the spinal cord. Histopathological analysis revealed dense hyalinization, chronic lymphohistiocytic infiltration, and focal metallic material deposition, consistent with a chronic foreign body reaction. CONCLUSION:This represents the first documented case of SCS-associated fibrosis extending intradurally, highlighting a novel and serious complication. Clinicians should maintain vigilance for delayed neurologic decline in patients with long-standing SCS systems and consider open decompression when percutaneous explantation is not feasible.
OBJECTIVE:Chronic pain affects up to 21% of pediatric patients and significantly impairs function and quality of life. Although spinal neuromodulation, including spinal cord stimulation (SCS) and dorsal root ganglion stimulation (DRG-S), has demonstrated efficacy in adults, evidence in children remains limited. This scoping review aims to systematically evaluate current evidence on spinal neuromodulation for pediatric chronic pain patients, focusing on clinical indications, outcomes, and safety. METHODS:A structured scoping review was conducted using PubMed/MEDLINE and Scopus databases on June 8, 2025. Studies were included if they reported on patients under 21 years undergoing SCS or DRG-S for chronic pain. Two independent reviewers screened articles and extracted data on demographics, diagnoses, interventions, outcomes, and follow-up. RESULTS:Out of 706 references, 17 studies met inclusion criteria. Of those, 16 reported on SCS and 1 reported on DRG-S. complex regional pain syndrome (CRPS) was the most common indication, with most patients reporting substantial pain reduction, improved functional outcomes, and decreased medication use. Erythromelalgia was another frequent diagnosis treated successfully with SCS, demonstrating significant reductions in pain, swelling, and erythema. Other conditions included recurrent tethered cord syndrome, neurogenic thoracic outlet syndrome, lymphangioma, postoperative neuropathic pain, and genetic syndromes. Overall, most patients experienced meaningful improvements in pain and daily functioning, with few major complications reported. CONCLUSIONS:Spinal neuromodulation, predominantly SCS, appears to be a promising adjunctive therapy for refractory chronic pain in pediatric patients, particularly for CRPS and erythromelalgia. Despite encouraging findings, the evidence remains limited to small series and case reports. High-quality prospective studies are needed to establish long-term safety, efficacy, and optimal patient selection in this vulnerable population.
INTRODUCTION:Evidence-based practice relies on accurate measurement of healthcare conditions. However, measurement of phantom limb pain after amputation can be challenging due to the varying intensity, duration, and quality of pain episodes. Standard measurement of phantom limb pain involves patient recall during clinic appointments and therefore may provide biased information. The purpose of this study was to compare recalled average and maximum ratings of phantom limb pain intensity with real-time ratings. METHODS:Participants (n = 17, 59% male, age 32-76) with lower limb amputation completed momentary ratings of phantom limb pain intensity on a 0-10 scale via ecological momentary assessment surveys on their mobile devices three times per day for 40 days. Momentary average and maximum ratings were compared to participants' recalled ratings on a 0-10 scale using standard clinical questions. RESULTS:Average recalled phantom limb pain intensity ratings were significantly higher than average momentary ratings when including zeros in the momentary average calculation (6.53 vs. 1.99; p < 0.001) and when including only nonzero momentary ratings (6.53 vs. 5.08; p = 0.001). Additionally, maximum recalled phantom limb pain intensity ratings were significantly higher than maximum momentary ratings (9.06 vs. 7.59; p = 0.001). CONCLUSIONS:These results suggest that momentary ratings of phantom limb pain intensity may yield more accurate information than standard recalled ratings. Assessment of phantom limb pain in a clinical setting could benefit from more frequent, real-time measurement to better track changes in pain and evaluate treatment effects.
BACKGROUND:Although there is little evidence that very long-term (> 1 year) prescription opioid use is effective for non-cancer pain management, many patients continue prescription opioid use for many years. Interest in quitting and beliefs about opioid risks and benefits have not been measured in this patient population. METHODS:Semi-structured interviews were conducted with 20 non-cancer chronic pain patients who reported using daily prescription opioid use for > 1 year and either discontinued (n = 10) or continued use (n = 10) within the past 2 years. Grounded theory analysis was utilized to identify themes and to develop a theoretical model using the health beliefs model as a framework. RESULTS:Patients who continued to use opioids tended to perceive themselves as not vulnerable to addiction, had pronounced fear of pain, and perceived opioids as the best option for pain control. Patients who quit reported concerns about becoming addicted, had experience with medication for addiction treatment, and valued non-opioid pain management. CONCLUSIONS:Educating patients about the numerous physical and psychiatric consequences of chronic opioid use is warranted. Additional research is needed to measure physician beliefs about the risks and benefits of very long-term opioid use among adherent patients.
BACKGROUND:Peripheral neuropathic pain (PNP) results from damage to peripheral nerves, leading to intractable or exaggerated pain. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive therapeutic method that modulates cortical neuronal activity and can promote endogenous opioid release, with a potential analgesic effect. This meta-analysis evaluates the efficacy and safety of rTMS use in PNP patients. METHODS:We systematically searched PubMed, Web of Science, Scopus, and the Cochrane Library for randomized controlled trials (RCTs) evaluating rTMS in PNP. The primary outcome was pain intensity. Statistical analysis was performed using Review Manager version 5.4.1. Risk of bias was assessed using the Cochrane RoB 2 tool, and a random-effects model was used to compute pooled estimates, expressed as standardized mean differences (SMD), mean differences (MD), and risk ratios (RR) with 95% confidence intervals (CI). RESULTS:Nine studies with 435 patients were included. rTMS significantly improved pain intensity (SMD = -1.11, 95% CI: [-1.72, -0.49]; p = 0.0004) and achieved a 30% reduction in pain (RR = 3.31, 95% CI: [0.98, 11.20]; p = 0.05). Improvements in sleep quality (SMD = -1.02, p = 0.26) and Patient Global Impression of Change were not statistically significant (RR = 1.70, p = 0.13). Safety analysis showed no significant increase in adverse events such as headache (RR = 1.32, p = 0.1), dizziness, pain at the stimulation site, sleep disturbances, or cognitive complaints. CONCLUSION:rTMS significantly reduces pain in PNP patients without major safety concerns. While findings support its clinical utility, high heterogeneity and limited long-term data suggest further standardized trials are warranted. PROSPERO REGISTRATION:CRD42024628350.
INTRODUCTION:Supraneural transforaminal epidural steroid injections (TFESI) at the L5 level are widely used to manage lumbosacral radiculopathy. However, fluoroscopic barriers such as prominent osteophytes and altered transverse process morphology can complicate needle advancement and reduce the likelihood of optimal injectate delivery. Despite these procedural challenges, no standardized grading system currently exists to objectively quantify anatomical complexity or predict technical difficulty during L5 supraneural TFESI. METHODS:This study included 584 L5 supraneural TFESI cases performed in 273 L5 radicular lesions aged above 60. All procedures were performed under standardized fluoroscopic guidance by a single experienced pain physician using a consistent supraneural approach. The LTDS comprises six fluoroscopic criteria reflecting anatomical barriers at the L5/S1 level. The patients were stratified into three LTDS groups (Low, 0-3; Middle, 4-6; High, 7-10). Procedural outcomes were assessed based on needle position and the pattern of contrast spread. Receiver operating characteristic (ROC) analysis was performed to assess the discriminative performance of the LTDS for predicting epidurogram failure. RESULTS:Higher LTDS scores were significantly associated with longer procedure times and lower rates of optimal TFESI execution. Each one-point increase in LTDS decreased the odds of successful injection by approximately 40%. ROC analysis demonstrated fair discriminative ability (AUC = 0.707; 95% CI, 0.651-0.764; p < 0.001). While an LTDS threshold of ≥ 5.5 provided the optimal balance between sensitivity and specificity, higher thresholds showed markedly increased specificity, indicating that the LTDS preferentially identifies cases with a high likelihood of technical difficulty rather than serving as a sensitive screening tool. The inter- and intra-rater reliabilities of the LTDS were high (Cronbach's α = 0.886 and 0.891, respectively). CONCLUSIONS:The LTDS demonstrates meaningful discriminative performance and high reliability for stratifying technical difficulty in L5 supraneural TFESI. Rather than functioning as a rigid predictor of failure, the LTDS serves as a practical decision-support tool that may assist in preprocedural planning, approach selection, and operator training in patients with advanced lumbar degeneration.
