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Biomedical subjects

Mark V Boswell

Publications and source records attributed to Mark V Boswell.

At least 19 recordsLinked to original sources
PubMed2006

Opioid guidelines in the management of chronic non-cancer pain.

BACKGROUND: Opioid abuse has increased at an alarming rate. However, available evidence suggests a wide variance in the use of opioids, as documented by different medical specialties, medical boards, advocacy groups, and the Drug Enforcement Administration (DEA). OBJECTIVES: The objective of these opioid guidelines by the American Society of Interventional Pain Physicians (ASIPP) is to provide guidance for the use of opioids for the treatment of chronic non-cancer pain, to bring consistency in opioid philosophy among the many diverse groups involved, to improve the treatment of chronic non-cancer pain, and to reduce the incidence of drug diversion. DESIGN: A policy committee evaluated a systematic review of the available literature regarding opioid use in managing chronic non-cancer pain. This resulted in the formulation of the essentials of guidelines, a series of potential evidence linkages representing conclusions, followed by statements regarding relationships between clinical interventions and outcomes. METHODS: Consistent with the Agency for Healthcare Research and Quality (AHRQ) hierarchical and comprehensive standards, the elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentations, formal endorsement by the Board of Directors of the American Society of Interventional Pain Physicians (ASIPP), and blinded peer review. Evidence was designated based on scientific merit as Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), or Level V (indeterminate). RESULTS: After an extensive review and analysis of the literature, the authors utilized two systematic reviews, two narrative reviews, 32 studies included in prior systematic reviews, and 10 additional studies in the synthesis of evidence. The evidence was limited. CONCLUSION: These guidelines evaluated the evidence for the use of opioids in the management of chronic non-cancer pain and recommendations for management. These guidelines are based on the best available scientific evidence and do not constitute inflexible treatment recommendations. Because of the changing body of evidence, this document is not intended to be a "standard of care."

Analgesics, Opioid↗
PubMed2006

A comparison of pulsed radiofrequency and continuous radiofrequency on thermocoagulation of egg white in vitro.

BACKGROUND: Clinical studies have demonstrated the efficacy of pulsed radiofrequency (PRF). PRF energy is delivered to neural structures via specifically designed, percutaneously placed needles to treat some chronic pain states. PRF was introduced as a non-destructive alternative to destructive lesioning produced by continuous radiofrequency (CRF) energy. However, there is an ongoing controversy regarding the potential tissue-destructive effects of PRF used for pain management. OBJECTIVE: To evaluate the ability of PRF to coagulate egg white at various temperatures used clinically and to compare with CRF. METHODS: A commercially available (TYCO-Radionics Labs) 5 cm, 22G (0.7 mm) SMK needle with 5 mm active tip was inserted into a 10 mL test tube containing raw egg white at 37 degrees C and the tip was heated up to 80 degrees C. The photographic patterns of thermocoagulation of egg white in vitro produced by continuous and pulsed radiofrequency (RF) were compared and the lowest temperature at which PRF produced thermocoagulation was determined. RESULTS: Pulsed RF produced barely detectable thermocoagulation at 60 degrees C. Above 60 degrees C, the pattern of coagulation produced by PRF resembled that observed with CRF. However, the density and size of the coagulation ball appeared somewhat greater with CRF. CONCLUSION: PRF coagulated egg white at temperatures above 60degrees C in a manner similar to CRF. Monitoring needle tip temperature using the thermode supplied with the needle during PRF and keeping the recorded tip temperature below 60degrees C may minimize unwanted thermal destruction of tissue.

Cardiac Catheterization↗
PubMed2005

[ISRCTN 16558617] A randomized, controlled trial of spinal endoscopic adhesiolysis in chronic refractory low back and lower extremity pain.

BACKGROUND: Postoperative epidural fibrosis may contribute to between 5% to 60% of the poor surgical outcomes following decompressive surgery. Correlations have been reported between epidural scarring and radicular pain, poor surgical outcomes, and a lack of any form of surgical treatment. The use of spinal endoscopic adhesiolysis in recent years in the management of chronic refractory low back and lower extremity pain has been described. METHODS: A prospective, randomized, double-blind trial was conducted to determine the outcome of spinal endoscopic adhesiolysis to reduce pain and improve function and psychological status in patients with chronic refractory low back and lower extremity pain. A total of 83 patients were evaluated, with 33 patients in Group I and 50 patients in Group II. Group I served as the control, with endoscopy into the sacral level without adhesiolysis, followed by injection of local anesthetic and steroid. Group II received spinal endoscopic adhesiolysis, followed by injection of local anesthetic and steroid. RESULTS: Among the 50 patients in the treatment group receiving spinal endoscopic adhesiolysis, significant improvement without adverse effects was shown in 80% at 3 months, 56% at 6 months, and 48% at 12 months. The control group showed improvement in 33% of the patients at one month and none thereafter. Based on the definition that less than 6 months of relief is considered short-term and longer than 6 months of relief is considered long-term, a significant number of patients obtained long-term relief with improvement in pain, functional status, and psychological status. CONCLUSION: Spinal endoscopic adhesiolysis with targeted delivery of local anesthetic and steroid is an effective treatment in a significant number of patients with chronic low back and lower extremity pain without major adverse effects.

Journal Article↗
PubMed2005

Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines.

BACKGROUND: The lifetime prevalence of spinal pain has been reported as 54% to 80%, with as many as 60% of patients continuing to have chronic pain five years or longer after the initial episode. Spinal pain is associated with significant economic, societal, and health impact. Available evidence documents a wide degree of variance in the definition and the practice of interventional pain management. OBJECTIVE: To develop evidence-based clinical practice guidelines for interventional techniques in the management of chronic spinal pain, with utilization of all types of evidence, applying an evidence-based approach, with broad representation of specialists from academic and clinical practices. DESIGN: A systematic review of diagnostic and therapeutic interventions applied in managing chronic spinal pain by a policy committee. Design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions, and statements about relationships between clinical interventions and outcomes. METHODS: The elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentation, formal endorsement by the Board of Directors of the American Society of Interventional Pain Physicians (ASIPP), and blinded peer review. Methodologic quality evaluation criteria utilized included AHRQ criteria, QUADAS criteria, and Cochrane review criteria. The designation of levels of evidence was from Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), to Level V (indeterminate). RESULTS: The accuracy of facet joint nerve blocks was strong in the diagnosis of lumbar and cervical facet joint pain, whereas, it was moderate in the diagnosis of thoracic facet joint pain. The evidence was strong for lumbar discography, whereas, the evidence was limited for cervical and thoracic discography. The evidence was moderate for transforaminal epidural injections or selective nerve root blocks in the preoperative evaluation of patients with negative or inconclusive imaging studies. The evidence was moderate for sacroiliac joint injections in the diagnosis of sacroiliac joint pain. The evidence for therapeutic lumbar intraarticular facet injections of local anesthetics and steroids was moderate for short-term improvement and limited for long-term improvement, whereas, it was negative for cervical facet joint injections. The evidence for lumbar and cervical medial branch blocks was moderate. The evidence for medial branch neurotomy was moderate to strong for relief of chronic low back and neck pain. The evidence for caudal epidural steroid injections was strong for short-term relief and moderate for long-term relief in managing chronic low back and radicular pain, and limited in managing pain of postlumbar laminectomy syndrome. The evidence for interlaminar epidural steroid injections was strong for short-term relief and limited for long-term relief in managing lumbar radiculopathy, whereas, for cervical radiculopathy the evidence was moderate. The evidence for transforaminal epidural steroid injections was strong for short-term and moderate for long-term improvement in managing lumbar nerve root pain, whereas, it was moderate for cervical nerve root pain and limited for lumbar post laminectomy syndrome and spinal stenosis. The evidence for percutaneous epidural adhesiolysis was strong. For spinal endoscopic adhesiolysis, the evidence was strong for short-term relief and moderate for long-term relief. For sacroiliac intraarticular injections, the evidence was moderate for short-term relief and limited for long-term relief. The evidence for radiofrequency neurotomy for sacroiliac joint pain was indeterminate. The evidence for intradiscal electrothermal therapy was strong for short-term relief and moderate for long-term relief in managing chronic discogenic low back pain, whereas, for nucleoplasty, the evidence was limited. The evidence for spinal cord stimulation in failed back surgery syndrome and complex regional pain syndrome was strong for short-term relief and moderate for long-term relief. The evidence for implantable intrathecal infusion systems was moderate to strong. CONCLUSION: These guidelines included the evaluation of evidence for diagnostic and therapeutic procedures in managing chronic spinal pain and recommendations for managing spinal pain. However, these guidelines do not constitute inflexible treatment recommendations. These guidelines do not represent "a standard of care".

Journal Article↗
PubMed2005

Therapeutic facet joint interventions in chronic spinal pain: a systematic review of effectiveness and complications.

BACKGROUND: Facet joint interventions are used frequently for managing chronic spinal pain. Evidence continues to accumulate supporting the clinical effectiveness of these procedures and defining potential complications. OBJECTIVE: To evaluate the effectiveness of three types of facet joint interventions (facet joint injections, medial branch blocks and facet joint neurotomy) in managing spinal pain. STUDY DESIGN: A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials and Cochrane Musculoskeletal Review Group for randomized trials. METHODS: Data sources included relevant literature of the English language identified through searches of MEDLINE and EMBASE (January 1966 to November 2004), manual searches of bibliographies of known primary and review articles, and abstracts from scientific meetings within the last 2 years. Analyses were performed for the different modes of facet joint interventions of cervical, thoracic and lumbar spine, to determine short- and long-term outcome measurements and complications associated with the procedures. OUTCOME MEASURES: The primary outcome measure was pain relief. For facet joint injections and medial branch blocks, short-term pain relief was defined as relief less than 6 weeks, and long-term as 6 weeks or longer. For medial branch radiofrequency neurotomy, short-term relief was defined as pain relief of less than 3 months, and long-term as 3 months or longer. Other outcome measures included functional improvement, improvement of psychological status, and return to work. RESULTS: For lumbar intraarticular facet joint injections, there was moderate evidence for short-term improvement, and limited evidence for long-term improvement. The evidence was negative for cervical intraarticular facet joint injections. For cervical and lumbar medial branch blocks with local anesthetics and steroids, the evidence was moderate. The evidence for pain relief with radiofrequency neurotomy of medial branch nerves was moderate to strong. CONCLUSION: The evidence for facet joint interventions ranged from negative to strong.

Journal Article↗
PubMed2004

Prevalence of facet joint pain in chronic spinal pain of cervical, thoracic, and lumbar regions.

BACKGROUND: Facet joints are a clinically important source of chronic cervical, thoracic, and lumbar spine pain. The purpose of this study was to systematically evaluate the prevalence of facet joint pain by spinal region in patients with chronic spine pain referred to an interventional pain management practice. METHODS: Five hundred consecutive patients with chronic, non-specific spine pain were evaluated. The prevalence of facet joint pain was determined using controlled comparative local anesthetic blocks (1% lidocaine or 1% lidocaine followed by 0.25% bupivacaine), in accordance with the criteria established by the International Association for the Study of Pain (IASP). The study was performed in the United States in a non-university based ambulatory interventional pain management setting. RESULTS: The prevalence of facet joint pain in patients with chronic cervical spine pain was 55% 5(95% CI, 49%-61%), with thoracic spine pain was 42% (95% CI, 30%-53%), and in with lumbar spine pain was 31% (95% CI, 27%-36%). The false-positive rate with single blocks with lidocaine was 63% (95% CI, 54%-72%) in the cervical spine, 55% (95% CI, 39%-78%) in the thoracic spine, and 27% (95% CI, 22%-32%) in the lumbar spine. CONCLUSION: This study demonstrated that in an interventional pain management setting, facet joints are clinically important spinal pain generators in a significant proportion of patients with chronic spinal pain. Because these patients typically have failed conservative management, including physical therapy, chiropractic treatment and analgesics, they may benefit from specific interventions designed to manage facet joint pain.

Adult↗
PubMed2004

The value of interdisciplinary pain management in complex regional pain syndrome type I: a prospective outcome study.

BACKGROUND: Complex regional pain syndrome (CRPS) type I is a symptom complex of severe, chronic limb pain, often associated with allodynia, vasomotor, and sudomotor changes. Optimal management of this condition is not well understood. The role of a traditional, comprehensive pain management program with long-term follow-up has not been evaluated. OBJECTIVE: To define the benefit of the interdisciplinary approach in patients with CRPS type I. DESIGN: Prospective, case series, outcomes evaluation. METHODS: Patients with a diagnosis of CRPS type I entering the University Pain Center's intensive, outpatient pain management program were enrolled in an objective assessment study through the duration of the program, with a follow-up of 2 years. This program involved 4 weeks of interdisciplinary management comprised of 20 sessions of physical therapy, 20 sessions of occupational therapy, 12 sessions of water therapy, 20 sessions of group psychotherapy, stellate ganglion blocks, and drug therapy. OUTCOME MEASURES: Specific objective measurements of upper extremity function, sensation and strength over time, and functional status 2 years after program completion. RESULTS: Upper extremity weight tolerance increased dramatically by 29-pounds (p<0.05). Function improved, with a 35 inch-pound gain in BTE (Baltimore Therapeutic Equipment) extension (p<0.005) and a 50 inch-pound increase in flexion (p<0.02). Jebsen-Taylor multifunctional testing (fine and gross motor skills) normalized from 72 to 48 seconds (p<0.04). Stable anxiety levels despite increased patient effort implied improved pain tolerance. At the 2-year follow up, 75% of the patients were employed. CONCLUSION: Patients with CRPS type I may benefit from a 4-week outpatient pain management program emphasizing rehabilitation.

Journal Article↗
PubMed2004

Plasma Beta-endorphin levels before and after relief of cancer pain.

BACKGROUND: Plasma Beta endorphin (BE) is an endogenous peptide opioid derived form pro-opiomelanocortin. Although the role of plasma BE in pain regulation is unclear, plasma BE levels have been reported to correlate inversely with pain levels in cancer pain. OBJECTIVE: To measure BE levels in patients with cancer before and after pain relief with different analgesic modalities, to evaluate the relationship between cancer pain, pain control and plasma BE levels. METHODS: Prospective interventional study conducted in a university hospital setting. Patients with intractable pain due to upper abdominal visceral malignancies (pancreatic, liver and gastric cancers) agreed to participate in the study. Pain relief was provided with one of four primary modalities: 1) oral continuous release morphine, 2) thoracic epidural morphine boluses, 3) alcohol celiac plexus blocks or 4) interpleural infusions of bupivacaine. Blood samples for plasma BE levels were taken before treatment and at the time of maximal pain relief obtained with the particular treatment modality. Pain levels were determined using a 10 cm visual analogue scale. BE levels were measured by competitive radioimmunoassay using 125I Beta endorphin. RESULTS: Average pain scores decreased from 7.3 +/- 1.27 (SD) before treatment to 1.2 +/- 1.18 (SD) after treatment (p<0.0001). Satisfactory pain relief was obtained with each of the four treatment modalities and was associated with a significant increase in plasma Beta levels. The mean plasma BE level for all groups before treatment was 18.9 +/- 5.4 pg/ ml (range 2.0 to 29.6 pg/ml) compared to 38.7 +/- 17.6 pg/ml (range 13.2 to 67.9 pg/ml) after pain relief (p < 0.0001). Plasma BE levels increased with improved pain control with each of the four analgesic modalities, including oral and epidural morphine. CONCLUSION: Plasma BE levels increased with improved pain control in patients with upper abdominal gastrointestinal malignancies. Although the role of plasma BE in pain pathophysiology is unclear, it appears that pain relief per se, and not the analgesic technique, modulates plasma BE levels. This suggests that plasma BE levels may serve as an objective measure of cancer pain severity and corroborate the patient's report of pain relief.

Journal Article↗
PubMed2004

Intrathecal cefazolin-induced seizures following attempted discography.

This report describes a 39 year-old woman who underwent attempted discography and intradiscal electrothermal therapy (IDET) of the L5/S1 intervertebral disc. The procedure was abandoned after multiple unsuccessful attempts to cannulate the disc. The case was complicated by at least two lumbar dural punctures, confirmed by injection of nonionic contrast that contained 12.5 mg/mL of cefazolin, included for prophylaxis of discitis. About 45 minutes later the patient developed severe back pain. Shortly thereafter she became progressively agitated and confused, and developed intractable seizures and coma. Despite aggressive treatment the patient could not be resuscitated and expired several hours later. Convulsions were initially attributed to an adverse reaction to meperidine and promethazine, given for the back pain, however this explanation proved to be untenable. In addition, the accidental administration of an ionic contrast agent, such as Hypaque(R), was excluded. Based on a detailed review of the case and the literature, it was concluded that the patient succumbed from an unintentional dose of intrathecal cefazolin, which had been diluted in the nonionic contrast agent that was used to confirm needle placement. Available evidence indicates that cefazolin is a potent epileptogenic agent when given intrathecally. The facts of the case and the evidence supporting the conclusion are presented. It is recommended that cefazolin not be mixed with the contrast agent used to document initial needle placement during discography.

Journal Article↗
PubMed2003

Paresthesiae during radiofrequency neurolysis of lumbar sympathetic trunk in CRPS: human evidence of a sympatho-sensory connection?

Radiofrequency heat lesioning has been advocated to prolong the duration of therapeutic effect of lumbar sympathetic block in Complex Region Pain Syndrome (CRPS) of the lower extremity. Prior to radiofrequency lesioning of the lumbar sympathetic trunk, sensory and motor stimulation may be used to verify that the active needle tip is not adjacent to a spinal nerve to avoid unwanted neural injury. However, the value of sensory stimulation to aid in precise needle positioning at the desired target remains controversial. In this report we describe our observations using sensory stimulation to aid in needle placement for radiofrequency lesioning. We confirm a novel observation that paresthesiae to the lumbar sympathetic trunk is possible and hypothesize on pathophysiologic meaning. Two representative patients are presented who underwent sensory stimulation of the lumbar sympathetic trunk during needle placement for lumbar sympathetic radiofrequency neurolysis. Sensory stimulation was elicited at the L3 or L4 vertebral level using a 15 cm insulated radiofrequency needle with a 5-mm active tip. During sensory stimulation, patients described paresthesiae to the ipsilateral buttock and lower extremity. Stimulation intensity was less than 0.8 V at 50 Hz at impedance of 300 Ohms or less. Motor stimulation did not occur up to the maximum voltage tested (2.0 V at 2 Hz) Sensory stimulation of the lumbar sympathetic trunk may be used to aid in localization of the active tip of the radiofrequency needle, in preparation for lesioning. A dermatomal sensory pattern was observed, suggesting that afferent sensory fibers travel in the lumbar sympathetic trunk. The implications of this observation for understanding the mechanism of CRPS-related pain are discussed.

Journal Article↗
PubMed2003

Accuracy of precision diagnostic blocks in the diagnosis of chronic spinal pain of facet or zygapophysial joint origin.

CONTEXT: Facet or zygapophysial joint blocks are used extensively in the evaluation of chronic spinal pain. However, there is a continuing debate about the value and validity of facet joint blocks in the diagnosis of chronic spinal pain. The value of diagnostic facet joint injections may have been overlooked in the medical literature. OBJECTIVES: To determine the accuracy of facet joint blocks in the diagnosis of chronic spinal pain of facet joint origin and also determine the rationale, principles, false-positive rate, and diagnostic utility of facet joint blocks as well as prevalence of facet joint pain. METHODS: Relevant literature was identified through searches of MEDLINE, EMBASE (Jan 1966- Mar 2003), manual searches of bibliographies of known primary and review articles, and abstracts from scientific meetings. Studies were selected if they were either placebo-controlled or comparative local anesthetic blocks and met 3 of the 5 criteria established by the Agency for Healthcare Research and Quality. Information extracted from each study included the details about the study, type, design, patient eligibility criteria, and statistical analysis. Studies were excluded from analysis if they were simply a review or descriptive or involved only a single-block. RESULTS: The data showed that there was conclusive evidence demonstrating that facet joints have a nerve supply and are capable of causing pain with provocation in normal volunteers that reproduces typical pain attribution clinically to facet joints. The studies demonstrated a prevalence of facet joint pain in chronic spinal pain patients of 15% to 45% in lumbar spine, up to 48% in thoracic spine, and 54% to 67% in the cervical spine. Single diagnostic blocks showed a false-positive rate of 27% to 63%. CONCLUSION: The diagnostic accuracy of controlled local anesthetic facet joint blocks is high in the diagnosis of chronic spinal pain.

Journal Article↗