An overview of treatment approaches for chronic pain management

Pain which persists after healing is expected to have taken place, or which exists in the absence of tissue damage, is termed chronic pain. By definition chronic pain cannot be treated and cured in the conventional biomedical sense; rather, the patient who is suffering from the pain must be given the tools with which their long-term pain can be managed to an acceptable level. This article will provide an overview of treatment approaches available for the management of persistent non-malignant pain. As well as attempting to provide relief from the physical aspects of pain through the judicious use of analgesics, interventions, stimulations, and irritations, it is important to pay equal attention to the psychosocial complaints which almost always accompany long-term pain. The pain clinic offers a biopsychosocial approach to treatment with the multidisciplinary pain management programme; encouraging patients to take control of their pain problem and lead a fulfilling life in spite of the pain. © 2016 Springer-Verlag Berlin Heidelber

The clinical prediction rule for whiplash-associated disorders

Letter to the Editor-in-Chief of JOSPT as follows: •“MedRisk's Cross-Cultural Adaptation: Brazilian Version” •“The Clinical Prediction Rule for Whiplash-Associated Disorders” with Author's Response •“Regarding Ankle and Midfoot Mobilization” with Author's Respons

Late-developing infection following posterior fusion for adolescent idiopathic scoliosis

This study is a retrospective case series review of patients with adolescent idiopathic scoliosis (AIS) who were revised more than 1 year after the index procedure, due to a late-developing deep wound infection, to determine onset, bacteriology, possible influence of implant alloy (titanium vs. stainless-steel) and treatment outcome of patients. From a total of 540 patients who underwent posterior-only fusion for AIS from 1993 through 2005 at our institution, 15 cases (2.77%) were revised due to a late-developing post-operative infection: there were six males and nine females, with an average age at initial surgery of 15.8 years (range 12–18). Late infections occurred at a mean of 70 months (15–95) after the index procedure. The implant alloy used was a stainless-steel instrumentation in 11 patients (4.56% of 241) and a titanium one in 4 patients (1.33% of 299): there was an higher incidence of late infections in stainless-steel alloy group of patients (P < 0.0001). Complete removal of instrumentation was performed in nine patients, obtaining in all cases wound healing and no symptoms of infection, at a minimum 3 years follow-up. In the other six patients, presenting less severe clinical signs of infections, an attempt to save/replace the previous instrumentation was performed, but a complete instrumentation removal had to be performed 11.6 months later (range 3–24) for the persistence or recurrence of infection: all patients healed uneventfully at a minimum 3 years follow-up. Intraoperative cultures were obtained in all 15 cases, being positive in 13 cases (S. epidermidis in 5 patients, S. aureus in 3, Propionibacterium acnes in 1, Serratia marcescens in 1, Propionibacterium acnes + S. epidermidis in 1, S. aureus + S. epidermidis in 1 and coagulase-negative Staphylococci in 1). None presented at latest follow-up scoliosis progression: there was no statistically significant difference between final and pre-operative revision surgery values (P = 0.17). In conclusion, treatment of late-developing post-operative infection in AIS surgery required complete removal of the implant, continuous drain and adequate antibiotic therapy based on intraoperative swab antibiogram. Titanium alloy instrumentations resulted less subject to late post-operative infections, when compared to stainless-steel ones (P < 0.0001)

Quantitative analysis in outcome assessment of instrumented lumbosacral arthrodesis

The outcome assessment in instrumented lumbosacral fusion mostly focuses on clinical criteria, complications and scores, with a high variability of imaging means, methods of fusion grading and parameters describing degenerative changes, making comparisons between studies difficult. The aim of this retrospective evaluation was to evaluate the interest of quantified radiographic analysis of lumbar spine in global outcome assessment and to highlight the key biomechanical factors involved. Clinical data and Beaujon–Lassale scores were collected for 49 patients who underwent lumbosacral arthrodesis after prior lumbar discectomy (mean follow-up: 5 years). Sagittal standing and lumbar flexion-extension X-ray films allowed quantifying vertebral, lumbar, pelvic and kinematic parameters of the lumbar spine, which were compared to reference values. Statistics were performed to assess evolution for all variables. At long-term follow-up, 90% of patients presented satisfactory clinical outcomes, associated to normal sagittal alignment; vertebral parameters objectified adjacent level degeneration in four cases (8%). Clinical outcome was correlated (r = 0.8) with fusion that was confirmed in 80% of cases, doubtful in 16% and pseudarthrosis seemed to occur in 4% (2) of cases. In addition to clinical data (outcomes comparable to the literature), quantitative analysis accurately described lumbar spine geometry and kinematics, highlighting parameters related to adjacent level’s degeneration and a significant correlation between clinical outcome and fusion. Furthermore, criteria proposed to quantitatively evaluate fusion from lumbar dynamic radiographs seem to be appropriate and in agreement with surgeon’s qualitative grading in 87% of cases