Publications by authors named "William D Mauck"

32 Publications

Pre-operative assessment of patients undergoing spinal cord stimulation for refractory angina pectoris.

Pain Med 2021 Mar 18. Epub 2021 Mar 18.

Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN.

Spinal cord stimulation (SCS) is used to treat a variety of chronic pain conditions refractory to more conservative management including refractory angina pectoris. We identified thirty-one patients who underwent SCS implantation for the indication of refractory angina at a single institution from 2003 through 2018. Sixteen patients were male and fifteen were female. Average age was 53.9 years. Prior to SCS implantation, all patients had at least one coronary angiogram. Ten patients (32.3%) had undergone percutaneous coronary intervention and four (12.9%) had undergone coronary artery bypass grafting. Thirty patients (96.7%) were currently using anti-angina medications. Twenty-six patients (83.9%) were on antiplatelet or anticoagulant agents at the time of SCS evaluation. Spinal cord stimulation implanters must perform a comprehensive evaluation incorporating appropriate multidisciplinary care particularly in patients with refractory angina given their cardiovascular comorbidities. It is important to have baseline data (e.g. pain scores, nitroglycerin consumption, frequency of angina episodes, and a questionnaire, such as the Seattle Angina Questionnaire) in order to compare to follow-up data to help define treatment success. We report a single institution's pre-operative experience for patients undergoing SCS for refractory angina to illustrate unique pre-operative SCS considerations in this chronic pain population.
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http://dx.doi.org/10.1093/pm/pnab105DOI Listing
March 2021

The Use of the Seattle Angina Questionnaire in Patients Who Underwent Spinal Cord Stimulation for Refractory Angina Pectoris.

Pain Med 2021 Apr;22(4):1005-1009

Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Background: The Seattle Angina Questionnaire (SAQ) is a self-administered questionnaire used in cardiac patients to quantify angina based on five scales: physical limitation scale, anginal stability scale, anginal frequency scale, treatment satisfaction scale, and the disease perception scale. Here we report the use of the SAQ to assess angina symptoms in 18 patients who underwent spinal cord stimulation (SCS) for refractory angina pectoris (RAP) at the Mayo Clinic.

Methods: Electronic health records were searched to find patients who underwent SCS for the treatment of RAP at a single institution from 2003 to 2018. Eligible patients were asked to participate in a phone survey that included the SAQ.

Results: Out of 13 patients who still had their implant, six (46%) had minimal physical limitations. Ten patients (76.9%) had favorable anginal frequency scores, defined as minimal or mild. Out of the five patients who had their device removed, one (20%) had minimal physical limitations and three (60%) had favorable anginal frequency scores. There was a high treatment satisfaction score for both those with their implant in place and those with the device removed.

Conclusion: The SAQ is useful as a comprehensive measure specific to patients with RAP assessing function, pain, and satisfaction. The utilization of this tool pre- and post-operatively may provide additional information to analyze the effectiveness of SCS for RAP.
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http://dx.doi.org/10.1093/pm/pnaa447DOI Listing
April 2021

Analyzing Spinal Cord Stimulator Explants in Refractory Angina Pectoris Patients.

Pain Med 2021 Feb 24. Epub 2021 Feb 24.

Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.

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http://dx.doi.org/10.1093/pm/pnaa456DOI Listing
February 2021

Examining Use of Low-Dose Ketamine Infusions During the Postoperative Period: A Retrospective Study Comparing Opioid-Tolerant and Nonopioid-Tolerant Patients.

AANA J 2021 Feb;89(1):19-25

is chair of the Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota, and an assistant professor of anesthesiology, Mayo Clinic College of Medicine and Science.

Ketamine is a well-known anesthetic that has been used since the 1970s. Despite its ubiquitous use as a postoperative analgesic, no studies have described dosing differences between opioid-tolerant (OT) and nonopioid-tolerant (NOT) patients or determined optimal dosing. The primary aim of this study was to assess whether OT and NOT patients had significant differences in ketamine infusion dosing requirements. We also aimed to measure the overall incidence of psychotomimetic adverse effects associated with low-dose ketamine infusions. We hypothesized that NOT patients would have lower ketamine infusion dosing requirements and a higher incidence of psychotomimetic adverse effects compared with OT patients. We performed a retrospective chart review and showed that the percentages of OT and NOT patients experiencing psychotomimetic adverse effects were similar (15.5% vs 15.3%; P=.93) and that increasing age was the only factor associated with increased odds of experiencing a psychotomimetic adverse effect potentially associated with ketamine (odds ratio, 1.29 [95% CI, 1.11-1.50]; P=.001). Optimal subanesthetic ketamine infusion dosing could not be established, and further research in this area may be warranted.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7850169PMC
February 2021

Sex-Related Differences in Symptoms and Psychosocial Outcomes in Patients With Fibromyalgia: A Prospective Questionnaire Study.

Mayo Clin Proc Innov Qual Outcomes 2020 Dec 10;4(6):767-774. Epub 2020 Dec 10.

Department of Pain Medicine, Mayo Clinic, Jacksonville, FL.

Objective: To investigate sex-related differences in patients with fibromyalgia (FM) in terms of demographic characteristics and clinical features, including tender point count (TPC), mood disorders, sleep problems, FM symptom severity, fatigue, cognitive dysfunction, and quality of life (QOL).

Patients And Methods: We studied 668 consecutive patients with FM (606 women) from May 1, 2012, to November 30, 2013. Validated questionnaires assessed outcomes of depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), sleep problems (Medical Outcomes Study Sleep Scale), FM symptom severity (Revised Fibromyalgia Impact Questionnaire), fatigue (Multidimensional Fatigue Inventory), cognitive dysfunction (Multiple Ability Self-report Questionnaire), and QOL (36-Item Short Form Health Survey). Nonparametric Mann-Whitney and Pearson χ tests were used to compare continuous and categorical outcome measures, respectively, between men and women. Linear regression models were performed for all continuous dependent variables, adjusting for age, body mass index, ethnicity, marital status, and highest education level completed. <.05 was considered statistically significant. The Benjamini-Hochberg procedure was used to adjust for multiple comparisons.

Results: Multiple linear regression analysis revealed a significant association of female sex and greater TPC (<.001), lower overall FM symptom severity (lower overall Revised Fibromyalgia Impact Questionnaire score; =.03), and higher QOL subscale score for vitality (36-Item Short Form Health Survey vitality subscale score; =.02). After adjustment for multiple comparisons, only the association between female sex and greater TPC remained significant. There were no sex-related differences in demographic characteristics, depression, anxiety, sleep problems, FM symptom severity, cognitive dysfunction, and QOL.

Conclusion: A higher TPC may be associated with female sex in patients with FM. The assumption of other sex-based differences in the clinical presentation of FM was not supported in our study.
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http://dx.doi.org/10.1016/j.mayocpiqo.2020.06.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7749234PMC
December 2020

Peripheral Nerve Stimulation and Clinical Outcomes: A Retrospective Case Series.

Pain Pract 2021 Apr 10;21(4):411-418. Epub 2020 Dec 10.

Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A.

Purpose: Peripheral nerve stimulation (PNS) is a rapidly expanding field within neuromodulation; however, there is limited data on therapeutic efficacy. This study describes the indications and clinical outcomes for patients undergoing PNS for chronic pain states.

Patients And Methods: This is a retrospective case series of adults undergoing PNS implantation from 2004 to 2017 at an academic medical center. The primary outcomes were changes in numeric rating scale (NRS) pain scores, opioid utilization in oral morphine milligram equivalent (MME), and self-reported patient functioning at 6 months postoperatively. Infectious and device-related complications were also assessed.

Results: A total of 72 patients underwent PNS implantation, including 59 patients that received a preceding PNS trial (59/78; 76% progression rate) and 13 that did not receive a PNS trial. The most common indication for stimulation was occipital neuralgia (47%) followed by lower-extremity neuropathies (17%). PNS implantation was associated with 6-month reductions in pain scores (7 [6, 8] baseline vs. 4 [2, 5] 6 months; P < 0.001) and opioid utilization (eg, median 60 [31, 104] vs. 18 [0, 52] MME among those with baseline opioid use; P < 0.001). Median functional improvement was 73% (50%, 88%). Seven patients (10%) suffered a postoperative surgical site infection at a median of 50 (30, 124) days, of which five devices were removed.

Conclusion: Peripheral nerve stimulation was associated with reduced pain scores, lower opioid utilization, and improved patient function at 6 months. These data support PNS as a potentially effective nonopioid analgesic modality in chronic pain, though prospective multicenter evaluation is warranted to evaluate longer-term outcomes.
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http://dx.doi.org/10.1111/papr.12968DOI Listing
April 2021

Peripheral Nerve Stimulation: A New Treatment for Meralgia Paresthetica.

Pain Med 2021 02;22(1):213-216

Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Background: Meralgia paresthetica is a condition caused by entrapment of the lateral femoral cutaneous nerve that leads to paresthesia along the anterolateral portion of the thigh. Because of advancements in neuromodulation, peripheral nerve stimulation (PNS) has been considered a new treatment option for meralgia paresthetica. Newer PNS technology targets peripheral nerves directly yet in a minimally invasive manner. We report a case in which a PNS device provided more than 12 months of complete pain relief in a patient with meralgia paresthetica and helped the patient avoid a neurolysis procedure.

Case Presentation: A 57-year-old male presented to clinic with a 6-year history of "painful numbness [and] burning" along the right lateral thigh. He rated his pain as 8 out of 10, which decreased to a rating of 2 out of 10 with the use of gabapentin, but unwanted side effects motivated him to seek alternative treatment. On the basis of his history, physical exam, and imaging results, he was diagnosed with meralgia paresthetica. He was offered neurolysis; however, after seeing a pain specialist, he agreed to the implantation of a SPRINT peripheral nerve stimulator. After the implantation procedure, his pain reduced to 0 out of 10, and his quality of life improved, with better sleep and less somnolence. The device was removed after 60 days, as planned. He continued to have complete resolution of pain at 12 months after the date of device implantation.

Conclusion: With recent advancements, PNS can be used to treat meralgia paresthetica in an effective yet minimally invasive manner. As newer PNS technology becomes more familiar to physicians and pain specialists, it is likely to be used as a mainstay treatment for meralgia paresthetica.
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http://dx.doi.org/10.1093/pm/pnaa326DOI Listing
February 2021

A three-dimensional computed tomography study to determine the ideal method for fluoroscopically-guided bone marrow aspiration from the iliac crest.

Bosn J Basic Med Sci 2020 May 11. Epub 2020 May 11.

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA; Department of Pain Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Bone marrow aspiration (BMA) through the iliac crest is potentially unsafe due to the vicinity of neurovascular structures in the greater sciatic notch. Our objective was to investigate the safety of a recently described BMA technique, specifically a trajectory from the posterior superior iliac spine (PSIS) to the anterior inferior iliac spine (AIIS). We conducted a chart review of 260 patients, analyzing three-dimensional reconstructed computed tomography images of the pelvis and sacrum to validate that this new approach offers a wide safety margin from the greater sciatic notch. Analysis of three-dimensional computed tomography scans demonstrated that the PSIS to AIIS trajectory never crossed the greater sciatic notch. The trajectory was noted to be at least one cm away from the greater sciatic notch in all measurements. The new trajectory entered the PSIS at 25.29 ± 4.34° (left side) and 24.93 ± 4.15° (right side) cephalad from the transverse plane, and 24.58 ± 4.99° (left side) and 24.56 ± 4.67° (right side) lateral from the mid-sagittal plane. The area of bone marrow encountered with the new approach was approximately 22.5 cm2. Utilizing the same CT scans, the trajectory from the traditional approach crossed the greater sciatic notch in all scans, highlighting the potential for violating the greater sciatic notch boundary and damaging important neurovascular structures. Statistically significant sex-related differences were identified in needle trajectory angles for both approaches. We conclude that based on this three-dimensional computed tomography study, a trajectory from the PSIS to the AIIS for BMA may offer a wide safety margin from the greater sciatic notch.
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http://dx.doi.org/10.17305/bjbms.2020.4744DOI Listing
May 2020

Advancement in Neuromodulation Technology with the Innovation of Design-Specific Peripheral Nerve Stimulators: Sural Nerve Stimulation for Radiculopathy.

Pain Med 2020 06;21(6):1297-1300

Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Background: Peripheral nerve stimulation (PNS) is a form of neuromodulation that is used to treat chronic and refractory neuropathic pain. Peripheral nerve stimulation was first described in the early 1960s when Shelden implanted a PNS device for trigeminal neuralgia. Despite PNS being known since the 1960s, technology designed specifically for PNS was lacking. Within the past few years, design-specific PNS devices have become widely available, with favorable efficacy and safety profiles. Here we report a case of design-specific PNS that provided two years of pain relief in a patient with lower extremity neuropathic pain.

Case Presentation: A 53-year-old female with a history of congenital lumbar meningocele status post-L4-L5 laminectomy presented to the Mayo Clinic for treatment of foot pain that began three days after her laminectomy. She experienced a 6/10 burning, tingling sensation in the lateral dorsal portion of her right foot and posterolateral calf in addition to allodynia that prevented her from wearing shoes. She failed gabapentin, amitriptyline, cannabis, transforaminal epidural steroid injections, and two spinal cord stimulator trials. The patient ultimately underwent implantation of a right sural nerve stimulator, resulting in a 50% improvement in pain and functionality at two-year follow-up.

Conclusions: This report emphasizes the recent development of design-specific PNS devices and their successful use in this patient. Peripheral nerve stimulation technology and applications have diminished the role of spinal cord stimulation devices used for the periphery. Peripheral nerve stimulation should be considered for patients with isolated extremity pain, especially in those with spinal abnormalities (e.g., arachnoid cyst).
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http://dx.doi.org/10.1093/pm/pnaa077DOI Listing
June 2020

Fibromyalgia Symptom Severity and Psychosocial Outcomes in Fibromyalgia Patients with Hypovitaminosis D: A Prospective Questionnaire Study.

Pain Med 2020 12;21(12):3470-3478

Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA.

Objective: To evaluate the association between hypovitaminosis D and outcomes of symptom severity, mood disorders, fatigue, and quality of life in fibromyalgia (FM) patients.

Methods: Five hundred ninety-three FM patients were surveyed from May 2012 to November 2013. Patients with serum vitamin D <25 ng/mL were considered to have hypovitaminosis D. The primary outcome was FM symptom severity (FIQ-R questionnaire). Secondary outcomes included quality of life (SF-36), fatigue (MFI-20), anxiety (GAD-7), and depression (PHQ-9). Independent t tests and chi-square tests were performed for continuous and categorical variables, respectively. Regression analysis was performed adjusting for age, gender, body mass index, ethnicity, and season. A post hoc analysis examined for correlation between outcomes and serum vitamin D (ng/mL) as a continuous variable.

Results: One hundred twenty-two patients (20.6%) had hypovitaminosis D. In our adjusted regression analysis, the total FIQ-R score in patients with hypovitaminosis D was higher compared with control patients with adequate serum vitamin D (57.85 ± 18.09 vs 62.79 ± 18.10, P = 0.04). Adjusted regression analysis revealed higher total GAD-7 (P = 0.01) and higher total PHQ-9 scores (P = 0.04) in patients with hypovitaminosis D compared with control patients. There were no differences based on severity of depression or anxiety. No differences in fatigue or quality of life were identified. Unadjusted post hoc analysis revealed that as serum vitamin D increased, there was an association with lower total FIQ-R (β coefficient = -0.11, P = 0.02) and lower SF-36 subscale scores of role-physical (β coefficient = -0.10, P = 0.03). Adjusted post hoc analysis revealed no significant associations.

Conclusions: Hypovitaminosis D may be a risk factor for worse symptom severity, anxiety, and depression in FM patients.
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http://dx.doi.org/10.1093/pm/pnz377DOI Listing
December 2020

Tobacco Use in Fibromyalgia Is Associated With Cognitive Dysfunction: A Prospective Questionnaire Study.

Mayo Clin Proc Innov Qual Outcomes 2019 Mar 26;3(1):78-85. Epub 2019 Feb 26.

Department of Anesthesiology, Pain Division, Mayo Clinic, Rochester, MN.

Objective: To evaluate the association between smoking and cognitive function in patients with fibromyalgia.

Patients And Methods: We surveyed 668 patients with fibromyalgia from May 1, 2012 through November 30, 2013 at a major tertiary referral center. Patients were categorized by smoking status. Primary outcome of interest was cognitive function (MASQ questionnaire), and secondary outcomes included fibromyalgia symptom severity (FIQ-R questionnaire), quality of life (SF-36 questionnaire), fatigue (MFI-20 questionnaire), sleep (MOS-sleep scale), anxiety (GAD-7 questionnaire), and depression (PHQ-9 questionnaire). Independent Students' -tests and χ tests were performed for continuous and categorical variables, respectively. Univariate regression analysis identified variables predictive of outcomes, adjusting for age, gender, body mass index, marital status, and educational level.

Results: Ninety-four (14.07%) patients self-identified as smokers. There was an association of lower education level, unmarried status, and younger age in smokers compared with nonsmokers. In the adjusted univariate regression analysis, fibromyalgia smokers reported greater perceived total cognitive dysfunction (=.009) and greater subscale scores of perceived difficulty in language (=.03), verbal memory (=.003), visual-spatial memory (=.02), and attention (=.04) compared with nonsmokers with fibromyalgia. For secondary outcomes, smokers with fibromyalgia reported greater severity of fibromyalgia-related symptoms (=.006), worse quality-of-life index in the mental component scale (=.02), greater sleep problems (=.01), and increased anxiety (=.001) compared with nonsmokers who had fibromyalgia.

Conclusion: In patients with fibromyalgia, smoking is a risk factor for cognitive dysfunction. Moreover, smokers with fibromyalgia were more likely to report increased severity of fibromyalgia symptoms, worse quality of life, more sleep problems, and increased anxiety compared with nonsmokers with fibromyalgia.
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http://dx.doi.org/10.1016/j.mayocpiqo.2018.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6408684PMC
March 2019

Procedural predictors of epidural blood patch efficacy in spontaneous intracranial hypotension.

Reg Anesth Pain Med 2019 Jan 13. Epub 2019 Jan 13.

Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA

Background And Objective: Epidural blood patch (EBP) is a safe and effective treatment for spontaneous intracranial hypotension (SIH), but clinical and procedural variables that predict EBP efficacy remain nebulous.

Methods: This study is an institutional review board-approved retrospective case series with dichotomized EBP efficacy defined at 3 months. The study included 202 patients receiving 604 EBPs; iatrogenic cerebrospinal fluid leaks were excluded.

Results: Of the EBPs, 473 (78%) were single-level, 349 (58%) lumbar, 75 (12%) bilevel, and 56 (9%) multilevel (≥3 levels). Higher volume (OR 1.64; p<0.0001), bilevel (3.17, 1.91-5.27; p<0.0001), and multilevel (117.3, 28.04-490.67; p<0.0001) EBP strategies predicted greater efficacy. Only volume (1.64, 1.47-1.87; p<0.0001) remained significant in multivariate analysis. Site-directed patches were more effective than non-targeted patches (8.35, 0.97-72.1; p=0.033). Lower thoracic plus lumbar was the most successful bilevel strategy, lasting for a median of 74 (3-187) days.

Conclusions: In this large cohort of EBP in SIH, volume, number of spinal levels injected, and site-directed strategies significantly correlated with greater likelihood of first EBP efficacy. Volume and leak site coverage likely explain the increased efficacy with bilevel and multilevel patches. In patients with cryptogenic leak site, and either moderate disability, negative prognostic brain MRI findings for successful EBP, or failed previous lumbar EBP, a low thoracic plus lumbar bilevel EBP strategy is recommended. Multilevel EBP incorporating transforaminal administration and fibrin glue should be considered in patients refractory to bilevel EBP. An algorithmic approach to treating SIH is proposed.
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http://dx.doi.org/10.1136/rapm-2018-000021DOI Listing
January 2019

Office-Based Mesenchymal Stem Cell Therapy for the Treatment of Musculoskeletal Disease: A Systematic Review of Recent Human Studies.

Pain Med 2019 08;20(8):1570-1583

Physical Medicine and Rehabilitation.

Background: The use of mesenchymal stem cells (MSCs) in clinical applications for the treatment of musculoskeletal disease is steadily increasing in office-based practice. The so-called "first generation" of MSCs is defined as autologous stem cells that have undergone minimal manipulation and are used for a homologous purpose. Systematic reviews of the clinical trials completed to date of such MSCs enable practitioners to better understand what is currently known about the outcomes and side effects of such treatments.

Study Design: A systematic review of human clinical studies of office-based MSC therapy for the treatment of painful degenerative musculoskeletal conditions.

Methods: A search of the Ovid MEDLINE, EMBASE, and Scopus databases was conducted from 2006 through September 2016. Seven hundred sixty-one records were identified from database searching, and two records from reference review of included papers. Studies with human subjects that evaluated treatment of musculoskeletal disease with minimally manipulated MSCs were included.

Results: Eight studies were included in this review based on selection criteria. A total of 941 patients were included, 841 of whom received cellular products, and no significant adverse events were reported. Symptomatology generally improved, though no differences were seen over controls where present.

Conclusion: Support in the literature is strongest for the use of bone marrow aspirate concentrate (BMAC) injections for the treatment of knee pain, but applications of the use of BMAC and peripheral blood-derived MSCs for the treatment of hip pain, tendon pain, and disc pain have all been reported. Further research is required, with large randomized controlled trials.
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http://dx.doi.org/10.1093/pm/pny256DOI Listing
August 2019

Combined Celiac Ganglia and Plexus Neurolysis Shortens Survival, Without Benefit, vs Plexus Neurolysis Alone.

Clin Gastroenterol Hepatol 2019 03 12;17(4):728-738.e9. Epub 2018 Sep 12.

Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota.

Background & Aims: Pancreatic cancer produces debilitating pain that opioids often ineffectively manage. The suboptimal efficacy of celiac plexus neurolysis (CPN) might result from brief contact of the injectate with celiac ganglia. We compared the effects of endoscopic ultrasound-guided celiac ganglia neurolysis (CGN) vs the effects of CPN on pain, quality of life (QOL), and survival.

Methods: We performed a randomized, double-blind trial of patients with unresectable pancreatic ductal adenocarcinoma and abdominal pain; 60 patients (age 66.4±11.6 years; male 66%) received CPN and 50 patients (age 66.8±10.0 years; male 56%) received CGN. Primary outcomes included pain control and QOL at week 12 and survival (overall median and 12 months). Secondary outcomes included morphine response, performance status, secondary neurolytic effects, and adverse events.

Results: Rates of pain response at 12 weeks were 46.2% for CGN and 40.4% for CPN (P = .84). There was no significant difference in improvement of QOL between the techniques. The median survival time was significantly shorter for patients receiving CGN (5.59 months) compared to (10.46 months) (hazard ratio for CGN, 1.49; 95% CI, 1.02-2.19; P = .042), particularly for patients with non-metastatic disease (hazard ratio for CGN, 2.95; 95% CI, 1.61-5.45; P < .001). Rates of survival at 12 months were 42% for patients who underwent CPN vs 26% for patients who underwent CGN. The number of adverse events did not differ between techniques.

Conclusion: In a prospective study of patients with unresectable pancreatic ductal adenocarcinoma and abdominal pain, we found CGN to reduce median survival time without improving pain, QOL, or adverse events, compared to CPN. The role of CGN must be therefore be reassessed. Clinicaltrials.gov no: NCT01615653.
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http://dx.doi.org/10.1016/j.cgh.2018.08.040DOI Listing
March 2019

Reply to Dr de Cassai et al.

Reg Anesth Pain Med 2018 07;43(5):557

Department of Anesthesiology Mayo Clinic Minnesota Rochester, MN.

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http://dx.doi.org/10.1097/AAP.0000000000000809DOI Listing
July 2018

Epidural Hematoma Following Interlaminar Epidural Injection in Patient Taking Aspirin.

Reg Anesth Pain Med 2018 Apr;43(3):310-312

From the Pain Division, Mayo Clinic Department of Anesthesiology and Perioperative Medicine, Rochester, MN.

Objective: We present a case report of a patient who developed an epidural hematoma following an interlaminar epidural steroid injection with no risk factors aside from old age and aspirin use for secondary prevention.

Case Report: A 79-year-old man developed an epidural hematoma requiring surgical treatment following an uncomplicated interlaminar epidural steroid injection performed for neurogenic claudication. In the periprocedural period, he continued aspirin for secondary prophylaxis following a myocardial infarction.

Conclusions: For patients taking aspirin for primary or secondary prophylaxis, the American Society of Regional Anesthesia and Pain Medicine antiplatelet and anticoagulation guidelines for spine and pain procedures recommend a shared assessment and risk stratification when deciding to hold the medication for intermediate-risk neuraxial procedures. Cases such as this serve to highlight the importance of giving careful consideration to medical optimization of a patient even when a low- or intermediate-risk procedure is planned.
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http://dx.doi.org/10.1097/AAP.0000000000000730DOI Listing
April 2018

Bleeding and Neurologic Complications in 58,000 Interventional Pain Procedures.

Reg Anesth Pain Med 2017 Nov/Dec;42(6):782-787

From the *Department of Anesthesiology and Divisions of †Pain Medicine and ‡Critical Care Medicine, Mayo Clinic, Rochester, MN.

Background And Objectives: Interventional pain procedures are commonly performed on patients receiving antiplatelet therapy. However, there is limited evidence to support or refute the safety of this practice. The goal of this investigation was to assess the rate of bleeding complications in a large cohort of patients undergoing intermediate- and low-risk pain procedures, with a specific focus on antiplatelet and anticoagulant medication use and baseline coagulation abnormalities.

Methods: This is a retrospective cohort study of adult patients undergoing low- and intermediate-risk pain procedures from 2005 through 2014 by the division of pain medicine at a single academic tertiary care center. Baseline characteristics, antiplatelet and anticoagulant medication use, coagulation parameters, and procedural details were extracted from the electronic medical record. The primary outcome was a bleeding-related complication requiring emergency medicine, neurology, or neurosurgical evaluation within 31 days. The secondary outcome was the presence or absence of a periprocedural red blood cell transfusion occurring within 72 hours of needle placement.

Results: A total of 58,066 procedures were performed on 24,590 unique patients. Preprocedural aspirin or nonsteroidal anti-inflammatory drug therapy was present for 17,825 procedures (30.7%). Sixteen procedures were associated with perioperative red blood cell transfusion (0.03%), with no difference based on preprocedural nonsteroidal anti-inflammatory drug, including aspirin, or other anticoagulation use (P = 0.107). Five patients (0.009%) had a neurologic complication requiring further evaluation, of which 2 were likely related to procedural bleeding.

Conclusions: Bleeding complications are rare in patients undergoing low- or intermediate-risk pain procedures even in the presence of antiplatelet medications. This is consistent with recently released guidelines.
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http://dx.doi.org/10.1097/AAP.0000000000000672DOI Listing
September 2018

Bleeding Complications in Patients Undergoing Intrathecal Drug Delivery System Implantation.

Pain Med 2017 Dec;18(12):2422-2427

Departments of Anesthesiology.

Introduction: Intrathecal drug delivery systems (IDDSs) have dramatically improved analgesia and the functional status of cancer patients and those with chronic pain states. However, given the close proximity to the neuraxis and frequent concomitant use of antiplatelet or anticoagulant medications, this intervention is not without risk. The goal of this investigation was to determine the incidence of bleeding complications following IDDS placement.

Methods: This is a retrospective review from 2005 through 2014 of adult patients undergoing IDDS implantation or revision at a tertiary care center. The primary outcome was a bleeding-related neurological complication requiring emergency medicine, neurology, or neurosurgical evaluation within 31 days.

Results: A total of 247 procedures were performed on 216 unique patients. Patients received aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) within seven days of needle placement for 64 procedures (25.9%). A preprocedural platelet count or international normalized ratio (INR) was available within 30 days for 138 procedures (55.9%). Of these, two patients had a platelet count lower than 100 x 109/L and one patient had an INR of 1.5 or higher at the time of the procedure. One neurological complication was identified (0.4%) that was not related to procedural bleeding. Similarly, three patients (1.2%) received a periprocedural red blood cell transfusion, none of which were related to procedural bleeding.

Conclusion: No cases of bleeding-related neurological complications were identified following IDDS placement or revision, including in those receiving aspirin or NSAIDs. Future investigations with larger numbers are needed to further explore the safety of antithrombotic therapy continuation or discontinuation periprocedurally.
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http://dx.doi.org/10.1093/pm/pnw363DOI Listing
December 2017

Erratum to: Efficacy of epidural blood patch with fibrin glue additive in refractory headache due to intracranial hypotension: preliminary report.

Springerplus 2016 4;5(1):960. Epub 2016 Jul 4.

Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 USA.

[This corrects the article DOI: 10.1186/s40064-016-1975-1.].
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http://dx.doi.org/10.1186/s40064-016-2451-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932001PMC
July 2016

Bleeding Complications in Patients Undergoing Percutaneous Spinal Cord Stimulator Trials and Implantations.

Pain Med 2016 11 12;17(11):2076-2081. Epub 2016 Jun 12.

Departments of *Anesthesiology.

Introduction: Spinal cord stimulators (SCS) are indicated for the management of multiple pain states with strong evidence. Recent guidelines recommend discontinuing aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) for the described procedures. The goal of this investigation is to assess the rate of bleeding and neurologic sequelae in patients undergoing SCS trials and implantation.

Methods: This is a retrospective review from 2005 through 2014 of all patients 18 years or older undergoing the following procedures: Percutaneous SCS implantations, SCS revisions, and SCS trials. Baseline characteristics, antiplatelet and anticoagulation medications, coagulation parameters, and procedural details were extracted. The primary outcome was the presence of a bleeding complication within 31 days of the procedure requiring emergency medicine, neurology, or neurosurgical evaluation. The neurological complication was independently categorized for its potential relationship to procedural bleeding, and periprocedural red blood cell transfusion requirements were analyzed as a secondary outcome.

Results: A total of 642 percutaneous SCS procedures were performed on 421 unique patients, including 346 SCS trials, 255 SCS implantations, and 41 revision surgeries. Patients had received aspirin or NSAIDs within 7 days of needle placement for 101 procedures (15.7%). There were no bleeding or neurological complications identified in this cohort.

Conclusion: Although the incidence of epidural hematoma is low, the development of bleeding complications following SCS lead placement can be devastating. In the present investigation, we identified no cases of epidural hematoma following percutaneous SCS lead placement, including more than 100 patients receiving aspirin or NSAIDs. Future investigations with larger numbers are needed to better define the relationships between periprocedural aspirin and NSAID utilization and bleeding complications.
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http://dx.doi.org/10.1093/pm/pnw124DOI Listing
November 2016

Bleeding Complications in Patients Undergoing Celiac Plexus Block.

Reg Anesth Pain Med 2016 Jul-Aug;41(4):488-93

From the *Department of Anesthesiology, †Division of Pain Medicine, and Departments of ‡Neurology and §Critical Care Medicine, Mayo Clinic, Rochester, MN.

Background And Objectives: Celiac plexus blockade has known risks including bleeding and neurologic injury because of the close proximity of vascular and neuraxial structures. The aim of this study was to determine the incidence of bleeding complications in patients undergoing celiac plexus block (CPB), with an emphasis on preprocedural antiplatelet medication use and coagulation status.

Methods: This is a retrospective study from 2005 to 2014 of adult patients undergoing CPB by the pain medicine division at a tertiary care center. The primary outcome was red blood cell (RBC) transfusion within 72 hours of needle placement, with a secondary outcome of bleeding complications requiring emergency medicine, neurology, or neurosurgical evaluation within 31 days.

Results: A total of 402 procedures were performed on 298 unique patients, with 58 patients (14.4%) receiving aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) preoperatively. Five patients (1.2%) received RBC transfusion within 72 hours, of which one had received preprocedure NSAIDs. A platelet count measured within 30 days was available for 268 patients, with 7 patients (2.6%) having platelet counts of 100 × 10/L or less at the time of needle placement. A total of 187 patients had a valid preoperative international normalized ratio (INR), with 9 (4.8%) having an INR of 1.5 or higher (range, 1.5-2.6). One patient (11.1%) required RBC transfusion compared with an RBC transfusion rate of 2.3% (4 of 178) in those with normal INR (P = 0.221). We identified no bleeding complications requiring emergency medicine, neurology, or neurosurgical evaluation.

Conclusions: This study suggests that CPBs may be safely performed in patients receiving aspirin and/or NSAID therapy.
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http://dx.doi.org/10.1097/AAP.0000000000000409DOI Listing
March 2017

Efficacy of epidural blood patch with fibrin glue additive in refractory headache due to intracranial hypotension: preliminary report.

Springerplus 2016 11;5:317. Epub 2016 Mar 11.

Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 USA.

Background: Injection of fibrin glue mixed with blood into the epidural space to reliably and effectively treat medically refractory orthostatic headache caused by spinal cerebrospinal fluid (CSF) leaks and subsequent intracranial hypotension has recently been described. The study described in this article utilizes an analogous technique to gauge the therapeutic reproducibility of this novel technique.

Methods: Eight patients with medically refractory headache resulting from intracranial hypotension caused by spinal CSF leaks received epidural injections of combined fibrin glue, autologous blood, and Isovue contrast at the L1-2 vertebral level using intermittent fluoroscopic guidance. Pre-procedure, 1-week post-procedure, and 3-month post-procedure headache pain scores were collected and used for comparison.

Results: Three out of 8 patients reported relief at 1 week, although 1 of these 3 patients had returned to their baseline pain intensity at 3 months. Four patients reported no change at 1 week, though 2 of these patients had reduction of their chronic headache pain at 3 months. A single patient reported increased pain 1 week after the procedure, which persisted at 12 weeks. Overall, 4 out of the 8 patients had decreased pain scores at 3-month follow-up.

Conclusions: We did not achieve a similar frequency of headache resolution as reported in prior original studies. However, a subset of patients did appear to receive substantial benefit from the combined fibrin glue-blood patching procedure. This technique may prove to be useful in medically refractory cases, including those patients who continue to have symptoms despite the prior administration of conventional epidural blood patches.
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http://dx.doi.org/10.1186/s40064-016-1975-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4788675PMC
April 2016

Safety of Lumbar Spine Radiofrequency Procedures in Patients Who Have Posterior Spinal Hardware.

Pain Med 2016 09 13;17(9):1634-7. Epub 2016 Jan 13.

*Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota.

Objective: The purpose of this study was to determine whether the energy generated by an active radiofrequency (RF) cannula adjacent to lumbar spine hardware could result in heating of the hardware.

Design: Prospective study.

Setting: Tertiary care medical center.

Subjects: Six patients with lumbar facet joint pain at the level adjacent to lumbar spine fusion hardware were studied.

Methods: A total of 10 lumbar medial branch nerve radiofrequency lesion procedures were performed on six patients. A temperature probe was placed on the fusion hardware to continuously monitor the temperature of the hardware throughout the RF procedure.

Results: The temperature of the fusion hardware increased in six of the 10 RF lesion procedures. During two of the procedures, the temperature rose rapidly to 42°C, at which time the procedure was ceased at that level.

Conclusion: This study demonstrated that radiofrequency lesioning to treat symptomatic facet joint pain in patients who have adjacent posterior lumbar fusion hardware may result in heat energy being transferred to the adjacent hardware. This may increase the risk of injury to the patient. Monitoring for a temperature increase is easily accomplished by inserting a temperature probe onto the surface of the hardware.
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http://dx.doi.org/10.1093/pm/pnv078DOI Listing
September 2016

Implementing an Electronic Health Record Medical Device Module-A Critical Patient Safety Enhancement.

J Am Coll Radiol 2016 Jun 21;13(6):705-8. Epub 2015 Nov 21.

Department of Radiology, Mayo Clinic, Rochester, Minnesota.

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http://dx.doi.org/10.1016/j.jacr.2015.10.009DOI Listing
June 2016

Efficacy of intervertebral disc regeneration with stem cells - a systematic review and meta-analysis of animal controlled trials.

Gene 2015 Jun 19;564(1):1-8. Epub 2015 Mar 19.

Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA; Department of Anesthesiology Pain Division, Mayo Clinic, Rochester, MN 55905, USA; Spine Center, Mayo Clinic, Rochester, MN 55905, USA. Electronic address:

Management of intervertebral disc (IVD) degenerative disease is challenging, as it is accompanied by irreversible loss of IVD cells. Stem cell transplantation to the disc has shown promise in decelerating or arresting the degenerative process. Multiple pre-clinical animal trials have been conducted, but with conflicting outcomes. To assess the effect of stem cell transplantation, a systematic review and meta-analysis was performed. A comprehensive literature search was conducted through Week 3, 2015. Inclusion criteria consisted of controlled animal trials. Two reviewers screened abstracts and full texts. Disagreements were resolved by a third reviewer. Random effects models were constructed to pool standardized mean difference (SMD). Twenty two studies were included; nine of which were randomized. Statistically significant differences were found with the stem cell group exhibiting increased disc height index (SMD=3.64, 95% confidence interval (CI): 2.49, 4.78; p<0.001), increased MRI T2 signal intensity (SMD=2.28, 95% CI: 1.48, 3.08; p<0.001), increased Type II collagen mRNA expression (SMD=3.68, 95% CI: 1.66, 5.70; p<0.001), and decreased histologic disc degeneration grade (SMD=-2.97, 95% CI: -3.97, -1.97; p<0.001). There was statistical heterogeneity between studies that could not be explained with pre-planned subgroup analyses based on animal species, study designs, and transplanted cell types. Stem cells transplanted to the IVD in quadruped animals decelerate or arrest the IVD degenerative process. Further studies in human clinical trials will be needed to understand if such benefit can be translated to bipedal humans.
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http://dx.doi.org/10.1016/j.gene.2015.03.022DOI Listing
June 2015

Incidence of clinically significant percutaneous spinal cord stimulator lead migration.

Neuromodulation 2015 Feb 5;18(2):123-5; discussion 125. Epub 2014 May 5.

Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA.

Objective: To examine the incidence of percutaneous spinal cord stimulator lead migration, given current hardware and surgical technique.

Materials And Methods: We retrospectively reviewed records of patients who underwent spinal cord stimulator implantation with percutaneous leads at our institution from 2008 through 2011. We determined the number of patients who required surgical revision for clinically significant lead migration.

Results: Clinically significant lead migration requiring surgical revision occurred in three of 143 patients (2.1%) with primary SCS system implants utilizing percutaneous-type leads.

Conclusions: The rate of lead migration observed in our practice was considerably lower than previously published estimates of clinically significant lead migration or revision for lead migration (13%-22%). However, our study did not determine the reason for the decreased rate, which may be influenced by current hardware and implant techniques.
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http://dx.doi.org/10.1111/ner.12184DOI Listing
February 2015

Incidence of neuropathic pain after radiofrequency denervation of the third occipital nerve.

J Pain Res 2014 10;7:195-8. Epub 2014 Apr 10.

Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA.

The purpose of this study was to identify the incidence of neuropathic pain occurring after radiofrequency neurotomy of the third occipital nerve (TON). This study was conducted at a teaching hospital from January 1, 2008, to March 31, 2010. With institutional review board approval, Current Procedural Terminology codes were used to identify patients who received radiofrequency ablation (RFA) of the nerves supplying the C2-3 facet joint and the TON. The C3 dorsal ramus provides innervation to the C2-3 facet joint and the suboccipital cutaneous region, and procedures that included ablation to this region were reviewed for complications. Postprocedural data were collected by reviewing follow-up appointment notes and telephone calls. Included were patients who had new neuropathic pain in the distribution of the TON after RFA. They described what they were feeling as burning, tingling, or numbness. All patients who presented with complaints had normal neurologic findings and no secondary cause for their symptoms. The included patient medical records were then reviewed for severity and duration of symptoms and the need for treatment with pain medication. Sixty-four patients underwent C2-3 RFA or TON RFA, and 12 patients were identified as experiencing ablation-induced third occipital neuralgia, an incidence rate of 19%. This finding suggests that patients undergoing RFA of the nerves supplying the C2-3 joint or TON are at risk for postprocedural third occipital neuralgia. This possibility may affect providing informed consent as well as anticipating and managing postprocedural pain.
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http://dx.doi.org/10.2147/JPR.S60925DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3986282PMC
April 2014

Dual-epidural catheter technique and perioperative outcomes after Ivor-Lewis esophagectomy.

Reg Anesth Pain Med 2013 Jan-Feb;38(1):3-8

Department of Anesthesiology and Division of Thoracic Surgery, Mayo Clinic, Rochester, MN 55905, USA.

Background: Ivor-Lewis esophagectomy is associated with significant postoperative analgesic requirements and perioperative complications. A dual-epidural technique may improve perioperative outcomes compared with single thoracic epidural analgesia.

Methods: This study identified all cases of Ivor-Lewis esophagectomy over a 3-year period. Eighty-one patients undergoing Ivor-Lewis esophagectomy who received general anesthesia supplemented by neuraxial analgesia with dual-epidural catheters (DECs) were matched 1:1 with patients who received general anesthesia and a single thoracic epidural catheter. Primary outcomes included quality of analgesia at rest and with movement on each of the first 3 postoperative days. Secondary outcomes included adverse events and the incidence of 4 major postoperative complications (anastomotic leak, pulmonary complications, atrial fibrillation, and sepsis).

Results: A DEC technique significantly improved analgesia (evidenced by reduced pain with movement on each of the first 3 postoperative days) when compared with a single epidural catheter technique. The placement of DECs did not increase catheter-related adverse events. A DEC technique was associated with a 50% reduction in the combined rate of major postoperative complications (36% vs. 18%; odds ratio, 0.40; P = 0.01) and increased number of hospital-free days measured at day 28 (21.2 vs. 22.3; P = 0.04).

Conclusions: The DEC technique improved postoperative analgesia and reduced the incidence of major postoperative complications and hospital length of stay in patients undergoing Ivor-Lewis esophagectomy. Future studies should evaluate the efficacy of this technique in a controlled randomized clinical trial.
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http://dx.doi.org/10.1097/AAP.0b013e318276a714DOI Listing
August 2013

An exploratory pilot study of palliative medicine compared to anesthesia-pain consultation for pain in patients with cancer.

J Support Oncol 2011 May-Jun;9(3):113-9

Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Oncologists often manage cancer-associated symptoms including pain. When symptoms are severe, anesthesia-pain medicine (APM) and/or palliative medicine (PM) can effectively treat symptoms. Nevertheless, symptom management may be suboptimal, leading to diminished quality of life (QOL). We assessed the value of PM vs. APM consultation in cancer patients referred for pain management alone. Patients referred to an APM-based Cancer Pain Clinic (CPC) over an 8-month period were evaluated by PM or APM based on the first available appointment. Symptoms and QOL were assessed by the MD Anderson Symptom Inventory and Linear Analog Self-Assessment at baseline and 4-6 weeks after initial encounter. Data were analyzed on an available-case basis. Sixty-two patients (37 PM, 25 APM) completed the initial survey, with 48 patients (31 PM, 17 APM) completing followup. Mean pain score improved from 7.97 to 5.47 in the PM group (P < 0.0001) and from 7.1 to 4.5 (P = 0.29) in the APM group. The PM group demonstrated a clinically significant improvement in 8/19 symptoms vs. 3/19 in the APM group and in 3/5 QOL parameters in the PM group vs. 1/5 in the APM group. Our small sample size weakens our power and ability to detect significant differences between the groups. Only one follow-up symptom-assessment point was obtained. PM consultation is as effective as APM in improving cancer pain but may be more effective with symptom management and improving QOL.
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http://dx.doi.org/10.1016/j.suponc.2011.01.006DOI Listing
July 2011

Preoperative gabapentin for acute post-thoracotomy analgesia: a randomized, double-blinded, active placebo-controlled study.

Pain Pract 2012 Mar 16;12(3):175-83. Epub 2011 Jun 16.

Department of Anesthesiology, College of Medicine Mayo Clinic, Rochester, Minnesota, USA.

Background: The role of preoperative gabapentin in postoperative pain management is not clear, particularly in patients receiving regional blockade. Patients undergoing thoracotomy benefit from epidural analgesia but still may experience significant postoperative pain. We examined the effect of preoperative gabapentin in thoracotomy patients.

Methods: Adults undergoing elective thoracotomy were enrolled in this prospective, randomized, double-blinded, placebo-controlled study, and randomly assigned to receive 600 mg gabapentin or active placebo (12.5 mg diphenhydramine) orally within 2 hours preoperatively. Standardized management included thoracic epidural infusion, intravenous patient-controlled opioid analgesia, acetaminophen and ketorolac. Pain scores, opioid use and side effects were recorded for 48 hours. Pain was also assessed at 3 months.

Results: One hundred twenty patients (63 placebo and 57 gabapentin) were studied. Pain scores did not significantly differ at any time point (P = 0.53). Parenteral and oral opioid consumption was not significantly different between groups on postoperative day 1 or 2 (P > 0.05 in both cases). The frequency of side effects such as nausea and vomiting or respiratory depression was not significantly different between groups, but gabapentin was associated with decreased frequency of pruritus requiring nalbuphine (14% gabapentin vs. 43% control group, P < 0.001). The frequency of patients experiencing pain at 3 months post-thoracotomy was also comparable between groups (70% gabapentin vs. 66% placebo group, P = 0.72).

Conclusions: A single preoperative oral dose of gabapentin (600 mg) did not reduce pain scores or opioid consumption following elective thoracotomy, and did not confer any analgesic benefit in the setting of effective multimodal analgesia that included thoracic epidural infusion.
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http://dx.doi.org/10.1111/j.1533-2500.2011.00480.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3200555PMC
March 2012