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Wondwossen Y, Patzkowski MS, Amoako MY, Lawson BK, Velosky AG, Soto AT, Highland KB. Spinal Cord Stimulator Inequities Within the US Military Health System. Neuromodulation 2024; 27:916-922. [PMID: 38971583 DOI: 10.1016/j.neurom.2023.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/20/2023] [Accepted: 03/13/2023] [Indexed: 07/08/2024]
Abstract
OBJECTIVES Although studies have described inequities in spinal cord stimulation (SCS) receipt, there is a lack of information to inform system-level changes to support health care equity. This study evaluated whether Black patients exhaust more treatment options than do White patients, before receiving SCS. MATERIALS AND METHODS This retrospective cohort study included claims data of Black and non-Latinx White patients who were active-duty service members or military retirees who received a persistent spinal pain syndrome (PSPS) diagnosis associated with back surgery within the US Military Health System, January 2017 to January 2020 (N = 8753). A generalized linear model examined predictors of SCS receipt within two years of diagnosis, including the interaction between race and number of pain-treatment types received. RESULTS In the generalized linear model, Black patients (10.3% [8.7%, 12.0%]) were less likely to receive SCS than were White patients (13.6% [12.7%, 14.6%]) The interaction term was significant; White patients who received zero to three different types of treatments were more likely to receive SCS than were Black patients who received zero to three treatments, whereas Black and White patients who received >three treatments had similar likelihoods of receiving a SCS. CONCLUSIONS In a health care system with intended universal access, White patients diagnosed with PSPS tried fewer treatment types before receiving SCS, whereas the number of treatment types tried was not significantly related to SCS receipt in Black patients. Overall, Black patients received SCS less often than did White patients. Findings indicate the need for structured referral pathways, provider evaluation on equity metrics, and top-down support.
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Affiliation(s)
- Ysehak Wondwossen
- School of Medicine, Uniformed Services University, Bethesda, MD, USA
| | - Michael S Patzkowski
- Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, TX, USA; Department of Anesthesiology, Uniformed Services University, Bethesda, MD, USA
| | - Maxwell Y Amoako
- Enterprise Intelligence and Data Solutions program office, Program Executive Office, Defense Healthcare Management Systems, San Antonio, TX, USA; Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA
| | - Bryan K Lawson
- Department of Orthopedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Alexander G Velosky
- Enterprise Intelligence and Data Solutions program office, Program Executive Office, Defense Healthcare Management Systems, San Antonio, TX, USA; Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA
| | - Adam T Soto
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD, USA; Department of Anesthesiology, Tripler Army Medical Center, Honolulu, HI, USA
| | - Krista B Highland
- Department of Anesthesiology, Uniformed Services University, Bethesda, MD, USA.
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Umeh UO. Examining disparities in regional anaesthesia and pain medicine. Br J Anaesth 2024; 132:1033-1040. [PMID: 38508942 DOI: 10.1016/j.bja.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 02/20/2024] [Accepted: 02/24/2024] [Indexed: 03/22/2024] Open
Abstract
In high-resource countries, health disparities exist in both treatment approaches and health outcomes. Race and ethnicity can serve as proxies for other socioeconomic factors and social determinants of health such as income, education, social support, and residential neighbourhood, which strongly influence health outcomes and disparities. In regional anaesthesia and pain medicine, disparities exist across several surgical specialties including obstetrics, paediatrics, and orthopaedic surgery. Understanding these disparities will facilitate development of solutions aimed at eliminating disparities at the patient, physician/provider, and healthcare system levels.
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Affiliation(s)
- Uchenna O Umeh
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA.
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Crimmel S, Hu L, D'Souza RS, Wang EJ. Treatment Disparities in Hispanic Patients with Chronic Pain: An Evidence-Based Narrative Review. Curr Pain Headache Rep 2024; 28:271-278. [PMID: 38358442 DOI: 10.1007/s11916-024-01220-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 02/16/2024]
Abstract
PURPOSE OF REVIEW The purpose of this narrative review is to summarize healthcare disparities experienced by Hispanic and Latino/Latinx patients with chronic pain, evaluate the existing literature exploring the specific therapeutic inequities affecting this patient population, and identify gaps in the literature requiring future study. RECENT FINDINGS Hispanic and Latino/Latinx patients experience disparities in chronic pain management. They are less likely to be prescribed pharmacologic therapies, including non-steroidal anti-inflammatory drugs and opioids. Hispanic and Latino/Latinx patients are also less likely to receive spinal cord stimulators and may be charged higher costs for them. There are no published studies specifically assessing Hispanic and Latino/Latinx patients' utilization and outcomes from other common interventional pain procedures (e.g., epidural steroid injections, radiofrequency ablation). Limited data suggest non-pharmacologic treatments, such as cognitive behavioral therapy and complementary/integrative health modalities, might have more benefit for this population, potentially because of greater utilization. Hispanic and Latino/Latinx patients experience disparities in chronic pain management. There is a paucity of data available pertaining specifically to pain-related outcomes and the utilization of pain treatment modalities, especially in regard to interventional procedures. Additional research is urgently needed in order to understand the full extent of these disparities and develop solutions to provide more equitable care.
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Affiliation(s)
- Stephanie Crimmel
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Lizbeth Hu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Eric J Wang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Krishnan S, Brovman EY, Jones MR, Manzi JE, Kim JS, Rao N, Urman RD. Racial and socioeconomic disparities in kyphoplasty among the Medicare population. Pain Pract 2024; 24:76-81. [PMID: 37606504 DOI: 10.1111/papr.13286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 05/02/2023] [Accepted: 08/04/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Kyphoplasty is a minimally invasive treatment for chronic refractory pain secondary to spinal compression fracture. This study investigates racial and socioeconomic disparities in kyphoplasty among the Medicare population. MATERIALS AND METHODS This study utilized data from the Medicare Limited Data Sets (LDS), a CMS administrative claims database. Patients aged 18 and older with ICD code consistent with spinal pathology and compression fractures were included. Outcome was defined as kyphoplasty by race and socioeconomic status (SES) with low SES defined by dual enrollment in Medicare/Medicaid. RESULTS There was a total of 215,502 patients gathered from CMS data, and 717 (0.33%) of these patients underwent kyphoplasty during the study period. Of these patients, 458 (63.8%) were female, the average age was 76.5 years old, 655 (91.3%) were White, 20 (2.7%) were Black, 9 (1.3%) were Hispanic, and 98 (13.7%) were Medicare/Medicaid dual eligible. White patients (32,317/157,177 [20.6%]) were less likely to be dual enrollment eligible in Medicare and Medicaid than Black (5407/13,522 [39.9%]), Hispanic (2833/3675 [77.1%]), Asian (2087/3312 [63.0%]), or North American Native patients (778/1578 [49.1%]). Multivariate regression (MVR) analysis was performed and showed that Blacks were less likely than Whites to have a kyphoplasty performed (OR 0.46 [95% CI: 0.29-0.72], p-value <0.001). Although Hispanics (OR 0.95 [0.49-1.86]), North American Native (OR 0.82 [0.3-2.19]), and unknown race had a decreased odd of undergoing kyphoplasty, it was not statistically significant. CONCLUSION Our study showed after adjustment for pertinent comorbidities, Medicare/Medicaid dual-eligible patients and Black patients were significantly less likely to receive kyphoplasty than White patients with Medicare.
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Affiliation(s)
- Sindhu Krishnan
- Department of Anesthesiology, Perioperative and Pain Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ethan Y Brovman
- Department of Anesthesiology, Perioperative and Pain Medicine, Tufts Medical Center/Tufts Medical School, Boston, Massachusetts, USA
| | - Mark R Jones
- Pain Medicine of the South, Knoxville, Tennessee, USA
| | - Joseph Emanuele Manzi
- Pain Division, Department of Anesthesiology, Weill Cornell School of Medicine and NewYork-Presbyterian Hospital, New York, New York, USA
| | | | | | - Richard D Urman
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Fisher LE, Lempka SF. Neurotechnology for Pain. Annu Rev Biomed Eng 2023; 25:387-412. [PMID: 37068766 DOI: 10.1146/annurev-bioeng-111022-121637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
Neurotechnologies for treating pain rely on electrical stimulation of the central or peripheral nervous system to disrupt or block pain signaling and have been commercialized to treat a variety of pain conditions. While their adoption is accelerating, neurotechnologies are still frequently viewed as a last resort, after many other treatment options have been explored. We review the pain conditions commonly treated with electrical stimulation, as well as the specific neurotechnologies used for treating those conditions. We identify barriers to adoption, including a limited understanding of mechanisms of action, inconsistent efficacy across patients, and challenges related to selectivity of stimulation and off-target side effects. We describe design improvements that have recently been implemented, as well as some cutting-edge technologies that may address the limitations of existing neurotechnologies. Addressing these challenges will accelerate adoption and change neurotechnologies from last-line to first-line treatments for people living with chronic pain.
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Affiliation(s)
- Lee E Fisher
- Rehab Neural Engineering Labs, Department of Physical Medicine and Rehabilitation, and Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA;
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Scott F Lempka
- Department of Biomedical Engineering, Biointerfaces Institute, and Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA;
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Nguyen LH, Dawson JE, Brooks M, Khan JS, Telusca N. Disparities in Pain Management. Anesthesiol Clin 2023; 41:471-488. [PMID: 37245951 DOI: 10.1016/j.anclin.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Health disparities in pain management remain a pervasive public health crisis. Racial and ethnic disparities have been identified in all aspects of pain management from acute, chronic, pediatric, obstetric, and advanced pain procedures. Disparities in pain management are not limited to race and ethnicity, and have been identified in multiple other vulnerable populations. This review targets health care disparities in the management of pain, focusing on steps health care providers and organizations can take to promote health care equity. A multifaceted plan of action with a focus on research, advocacy, policy changes, structural changes, and targeted interventions is recommended.
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Affiliation(s)
- Lee Huynh Nguyen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Jessica Esther Dawson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Meredith Brooks
- Department of Anesthesiology, Cook Children's Health Care System, Texas Christian University School of Medicine, Fort Worth, TX, USA
| | - James S Khan
- Department of Anesthesia and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Natacha Telusca
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA.
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Corriere MA, Dickson AL, Daniel LL, Nepal P, Hall K, Plummer WD, Dupont WD, Murray KT, Stein CM, Ray WA, Chung CP. Duloxetine, Gabapentin, and the Risk for Acute Myocardial Infarction, Stroke, and Out-of-Hospital Death in Medicare Beneficiaries With Non-Cancer Pain. Clin J Pain 2023; 39:203-208. [PMID: 37094085 PMCID: PMC10127144 DOI: 10.1097/ajp.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 02/11/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVE Duloxetine is a serotonin-norepinephrine reuptake inhibitor prescribed for musculoskeletal and other forms of chronic pain. Its dual pharmacologic properties have the potential to either raise or lower cardiovascular risk: adrenergic activity may increase the risk for acute myocardial infarction (AMI) and stroke, but antiplatelet activity may decrease risk. Gabapentin is another nonopioid medication used to treat pain, which is not thought to have adrenergic/antiplatelet effects. With the current emphasis on the use of nonopioid medications to treat patients with chronic pain, assessing cardiovascular risks associated with these medications among high-risk patients is important. MATERIALS AND METHODS We conducted a retrospective cohort study among a 20% sample of Medicare enrollees, aged 65 to 89, with chronic pain who were new users between 2015 and 2018 of either duloxetine (n = 34,009) or gabapentin (n = 233,060). We excluded individuals with cancer or other life-threatening conditions at study drug initiation. The primary outcome was a composite of AMI, stroke, and out-of-hospital mortality. We adjusted for comorbidity differences with time-dependent inverse probability of treatment weighting. RESULTS During 115,668 person-years of follow-up, 2361 patients had the composite primary outcome; the rate among new users of duloxetine was 16.7/1000 person-years compared with new users of gabapentin (21.1/1000 person-years), adjusted hazard ratio = 0.98 (95% CI: 0.83, 1.16). Results were similar for the individual components of the composite outcome as well as in analyses stratified by demographic and clinical characteristics. DISCUSSION In summary, cohort Medicare patients with non-cancer pain beginning treatment with duloxetine had rates of AMI, stroke, and out-of-hospital mortality comparable to those who initiated gabapentin.
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Affiliation(s)
| | | | - Laura L Daniel
- Departments of Medicine
- Department of Medicine, University of Miami, Miami, FL
| | - Puran Nepal
- Departments of Medicine
- Department of Medicine, University of Miami, Miami, FL
| | | | | | | | | | | | - Wayne A Ray
- Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Cecilia P Chung
- Departments of Medicine
- Department of Medicine, University of Miami, Miami, FL
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Beletsky A, Liu C, Alexander E, Hassanin SW, Vickery K, Loomba M, Winston N, Chen J, Gabriel RA. The Association of Psychiatric Comorbidities With Short-Term and Long-Term Outcomes Following Spinal Cord Stimulator Placement. Neuromodulation 2023:S1094-7159(22)01432-5. [PMID: 36720669 DOI: 10.1016/j.neurom.2022.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/28/2022] [Accepted: 12/19/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Outcomes after spinal cord stimulator (SCS) placement are affected by psychologic comorbidities. It is part of routine practice to do psychologic assessments prior to SCS trials to assess for the presence of maladaptive behavioral patterns. However, few studies have sought to quantify the effect of psychiatric comorbidities on complications, reoperation, and readmission rates. The purpose of this study was to assess the association of psychiatric comorbidities with postprocedural outcomes after SCS implantation. MATERIALS AND METHODS Inclusion criteria included SCS placement between 2015 and 2020 (percutaneous approach or an open laminectomy-based approach) using Healthcare Corporation of America National Database. Data on psychiatric comorbidities present at the time of SCS implantation surgery were collected. Outcomes of interest included complication rates (defined as lead migration, fracture, malfunction, battery failure, postoperative pain, infection, dural puncture, or neurological injury), reoperation rates (defined as either revision or explant [ie, removal]), and readmission rates within 30-day and 1-year time after SCS implantation. We measured the association between psychiatric comorbidities and outcomes using multivariable regression and reported odds ratio (OR) and respective 95% confidence intervals. RESULTS A total of 12,751 cases were included. The most common psychiatric comorbidities were major depressive disorder (16.1%) and anxiety disorder (13.4%). In unadjusted univariate analysis, patients with any psychiatric comorbidity had heightened rates of any complication (27.1% vs 19.4%), infection (5.9% vs 1.9%), lead displacement (2.2% vs 1.3%), surgical pain (2.1% vs 1.2%), explant (14.7% vs 8.8%), and readmission rates at one year (54.2% vs 33.8%) (all p < 0.001). In multivariable logistic regression, with each additional psychiatric comorbidity, a patient had increased odds of experiencing any complication (OR = 1.5, 95% CI = 1.36-1.57, p < 0.001), requiring a reoperation (OR = 1.5, 95% CI = 1.37-1.6, p < 0.001), and requiring readmission (OR = 1.7, 99% CI = 1.6-1.8, p < 0.001). CONCLUSIONS The presence of psychiatric comorbidities was found to be associated with postoperative complication rates, reoperation, and readmission rates after SCS placement. Furthermore, each consecutive increase in psychiatric comorbidity burden was associated with increased odds of complications, reoperation, and readmission. Future studies might consider examining the role of presurgical mental health screening (ie, patient selection, psychologic testing) and treatment in optimizing outcomes for patients with psychiatric comorbidities.
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Affiliation(s)
- Alexander Beletsky
- Department of Anesthesiology, Riverside Community Hospital, HCA Healthcare, Riverside, CA, USA.
| | - Cherry Liu
- Department of Anesthesiology, Riverside Community Hospital, HCA Healthcare, Riverside, CA, USA
| | - Evan Alexander
- Department of Anesthesiology, Riverside Community Hospital, HCA Healthcare, Riverside, CA, USA
| | - Samir W Hassanin
- Rutgers Robert Wood Johnson Medical School, School of Medicine, Rutgers the State University of New Jersey, Picataway, NJ, USA
| | - Kim Vickery
- Department of Anesthesiology, Riverside Community Hospital, HCA Healthcare, Riverside, CA, USA
| | - Munish Loomba
- Department of Anesthesiology, Riverside Community Hospital, HCA Healthcare, Riverside, CA, USA
| | - Nutan Winston
- Department of Anesthesiology, Riverside Community Hospital, HCA Healthcare, Riverside, CA, USA
| | - Jeffrey Chen
- Division of Pain, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Division of Pain, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA; Division of Regional Anesthesia, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA; Division of Biomedical Informatics, Department of Medicine, University of California San Diego, San Diego, CA, USA
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Spirollari E, Vazquez S, Ng C, Naftchi AF, Graifman G, Das A, Greisman JD, Dominguez JF, Kinon MD, Sukul VV. Comparison of Characteristics, Inpatient Outcomes, and Trends in Percutaneous vs Open Placement of Spinal Cord Stimulators. Neuromodulation 2022:S1094-7159(22)01253-3. [DOI: 10.1016/j.neurom.2022.08.456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/18/2022] [Accepted: 08/23/2022] [Indexed: 11/06/2022]
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10
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Health Care Disparity in Pain. Neurosurg Clin N Am 2022; 33:251-260. [DOI: 10.1016/j.nec.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Peripheral Nerve Stimulation: A Review of Techniques and Clinical Efficacy. Pain Ther 2021; 10:961-972. [PMID: 34331668 PMCID: PMC8586305 DOI: 10.1007/s40122-021-00298-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/19/2021] [Indexed: 12/21/2022] Open
Abstract
Chronic pain is a common source of morbidity in many patient populations worldwide. There are growing concerns about the potential side effects of currently prescribed medications and a continued need for effective treatment. Related to these concerns, peripheral nerve stimulation has been regaining popularity as a potential treatment modality. Peripheral nerve stimulation components include helically coiled electrical leads, which direct an applied current to afferent neurons providing sensory innervation to the painful area. In theory, the applied current to the peripheral nerve will alter the large-diameter myelinated afferent nerve fibers, which interfere with the central processing of pain signals through small-diameter afferent fibers at the level of the spinal cord. Multiple studies have shown success in the use of peripheral nerve stimulation for acute post-surgical pain for orthopedic surgery, including post total knee arthroplasty and anterior cruciate ligament surgery, and chronic knee pain. Many studies have investigated the utility of peripheral nerve stimulation for the management of chronic shoulder pain. Peripheral nerve stimulation also serves as one of the potential non-pharmacologic therapies to treat back pain along with physical therapy, application of transcutaneous electrical neurostimulation unit, radiofrequency ablation, epidural steroid injections, permanently implanted neurostimulators, and surgery. Studies regarding back pain treatment have shown that peripheral nerve stimulation led to significant improvement in all pain and quality-of-life measures and a reduction in the use of opioids. Further studies are needed as the long-term risks and benefits of peripheral nerve stimulation have not been well studied as most information available on the effectiveness of peripheral nerve stimulation is based on shorter-term improvements in chronic pain.
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