Chronic Widespread Pain Drawn on a Body Diagram is a Screening Tool for Increased Pain Sensitization,Psycho‐Social Load,and Utilization of Pain Management Strategies

The aim of this study was to investigate the hypothesis that chronic widespread pain, (CWP) drawn by patients on a body diagram, could be used as a screening tool for increased pain sensitization, psycho‐social load, and utilization of pain management strategies. The triage questionnaires of 144 adults attending a chronic pain outpatients' clinic were audited and the percentage pain surface area (PPSA) drawn on their body diagrams was calculated using the “rule of nines” (RON) method for burns area assessment. Outcomes were measured using the painDETECT Questionnaire (PD‐Q) and other indices and compared using a nonrandomized, case–control method. It was found that significantly more subjects with CWP (defined as a PPSA ≥ 20%) reported high (≥ 19) PD‐Q scores (suggesting pain “sensitization” or neuropathic pain) (P = 0.0002), “severe” or “extremely severe” anxiety scores on the Depression, Anxiety and Stress Scale‐21 Items Questionnaire (P = 0.0270), ≥ 5 psycho‐social stressors (P = 0.0022), ≥ 5 significant life events (P = 0.0098), and used ≥ 7 pain management strategies (PMS) (P < 00001), compared to control subjects with a lower PPSA. A Widespread Pain Index score ≥ 7 (OR = 11.36), PD‐Q score ≥ 19 (OR = 4.46) and use of ≥ 7 PMS (OR = 5.49) were independently associated with CWP. This study demonstrates that calculating PPSA on a body diagram (using the RON method) is a valid and convenient “snapshot” screening tool to identify patients with an increased likelihood of pain sensitization, psycho‐social load, and utilizing pain management resources.     

Pain management and quality in healthcare

Management of pain in the acute peri-operative setting still leaves a significant number of patients suffering from moderate to severe pain. In order to improve this, it is important to understand the underlying mechanisms of pain perception, and be able to apply this to clinical settings. Effective assessment of pain is needed, with re-assessment to detect treatment efficacy. Meta-analyses and systematic reviews are available for many of the analgesic therapies used, and this can be used as a basis for formulating an effective management plan. By optimizing pain management in the peri-operative period, and utilizing this, it should be possible to minimize resultant disability and hospital stay.     

A Cadaveric and in vitro Controlled Comparative Investigation of Percutaneous Spinal Cord Lead Anchoring

Spinal cord stimulator lead migration is a common problem. Anchor design may be a factor in its prevention. We have undertaken a cadaveric and in vitro comparative investigation of the force required to cause lead migration with a variety of anchor types. Thirty‐eight spinal cord stimulator leads were anchored with short silastic (N = 8), long silastic (N = 16) and titanium (N = 10) devices in cadavers. Twenty‐eight further spinal cord stimulator lead anchorings were undertaken on the bench with the titanium anchor and three different octrode leads. The median force to cause lead movement in cadavers was 0.55 Newtons (N) for short silastic anchors, 0.81 N and 0.63 N for two types of long silastic anchor, and 1.3 N for the titanium anchor. There was a significant difference between long and short silastic anchors (p < 0.01) and a significant difference between the titanium anchor and the silastic anchors (p < 0.003). There was an insignificant difference in the force required to cause lead movement repeated by the same operator (p = 0.36). There was no significant difference between inexperienced and experienced operators (p = 0.88). There was no significant difference between the different leads using the titanium anchor (p = 0.06). The titanium anchor prevents simulated lead movement at greater forces that the silastic anchors with a variety of leads. For silastic anchors, movement occurred at median force below that simulated with spinal movement; for the titanium anchor, movement occurred at a median force above that simulated with spinal movement. Further in vivo investigations are warranted to assess the potential of titanium anchoring to significantly reduce spinal cord stimulator lead migration.     

Does epidural analgesia delay the diagnosis of lower limb compartment syndrome in children?

One of the cardinal symptoms of compartment syndrome is pain. A literature review was undertaken in order to assess the association of epidural analgesia and compartment syndrome in children, whether epidural analgesia delays the diagnosis, and to identify patients who might be at risk. Evidence was sought to offer recommendations in the use of epidural analgesia in patients at risk of developing compartment syndrome of the lower limb. Increasing analgesic use, increasing/breakthrough pain and pain remote to the surgical site were identified as important early warning signs of impending compartment syndrome in the lower limb of a child with a working epidural. The presence of any should trigger immediate examination of the painful site, and active management of the situation (we have proposed one clinical pathway). Avoidance of dense sensory or motor block and unnecessary sensory blockade of areas remote to the surgical site allows full assessment of the child and may prevent any delay in diagnosis of compartment syndrome. Focusing on excluding the diagnosis of compartment syndrome rather than failure of analgesic modality is vital. In the pediatric cases reviewed there was no clear evidence that the presence of an epidural had delayed the diagnosis.