Philip Chan, MD, FRCPC (Anesthesiology, Pain Medicine), FIPP,

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Abstract: There is increasing concern in Canada about the overuse and misuse of opioids. While there are no simple answers to this complex societal problem, adequate and timely access to proper multidisciplinary chronic pain care is important in decreasing the reliance on opioids when treating chronic pain in Canada. Neuromodulation therapy, especially spinal cord stimulation (SCS), offers patients the potential for pain relief without repeated injections or ongoing medication use. SCS is effective in the treatment of persistent postoperative neuropathic pain and complex regional pain syndrome. Prospective SCS candidates should undergo a full multidisciplinary assessment to evaluate both physical and psychological factors that may adversely affect results.

Key Words: chronic pain, spinal cord stimulation, opioids, neuropathic pain, persistent postoperative neuropathic pain.

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The best studied indications for SCS are persistent postoperative neuropathic pain (so-called failed back surgery syndrome [FBSS]) and complex regional pain syndrome (CRPS).

The key to success with SCS is to generate a pattern of paresthesia that overlaps with the patient’s area of pain while avoiding extraneous paresthesia that may cause discomfort.

SCS is a cost-effective treatment, whereby the long-term savings in terms of diagnostic imaging, physician visits, medications, and rehabilitative services outweighed the higher upfront cost.

Contraindications for SCS implantation include: systemic infection, cognitive impairment, and low platelet counts.

Well-accepted positive predictive factors for long-term success with SCS include: patients whose etiology of pain have a predominately peripheral neuropathic pain component, treatment early in the course of the pain syndrome, and the presence of allodynia and other features suggestive of neuropathic pain. Significantly depressed mood, low energy levels, somatization, anxiety, and poor coping skills are important predictors of poor outcome.

SCS is a non-destructive procedure; the device can be explanted at any point if it no longer provides pain relief, and it does not preclude other treatment modalities, including spinal surgery, in the future.

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John D. Markman, M.D., Director, Translational Pain Research, Department of Neurosurgery, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA.
Maria E. Frazer, B.S., Health Project Coordinator, Translational Pain Research, Department of Neurosurgery, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA.
Pierre S. Girgis, M.D., Assistant Professor, Department of Neurosurgery, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA.
Kevin R. McCormick, M.D., Ph.D, Associate Professor, Department of Medicine, University of Rochester School of Medicine & Dentistry, Rochester, NY, USA.

Lumbar spinal stenosis (LSS) is the leading cause of spinal surgery among older Americans, yet more than one-third do not gain significant relief from surgical treatment. The distinct pattern of lower back and leg pain induced by standing and walking associated with LSS is known as neurogenic intermittent claudication (NIC). Various treatment options for NIC include surgical interventions as well as pharmacological, biomechanical and conservative therapy (i.e., physical therapy). No specific treatment is associated with guaranteed outcome, which underscores the need to further evaluate the diagnosis and symptoms associated with LSS.
Key words: lumbar spinal stenosis, neuropathic pain, treatment, treadmill testing, epidural steroid injection.

Jackie Gardner-Nix, MB BS, PhD, MRCP(UK), Assistant Professor, University of Toronto; Chronic Pain Consultant, Department of Anesthesia, St Michael’s Hospital; and Pain Management Programme, Sunnybrook Health Sciences Centre, Toronto, ON.

The management of neuropathic pain at any age is aimed at the relief of suffering rather than focusing on decreasing pain scores, and it should involve even simple measures that affect pain and coping. Addressing physical stressors—poor diet, hydration, and sleep quality and quantity—is particularly relevant in older adults. Medications relieving neuropathic pain may be adjunctive to initial interventions and need to be carefully assessed for efficacy and side effects to ensure they relieve, rather than add to, suffering.
Key words: neuropathic pain, analgesics, older adults, mindfulness, psychological interventions.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Hsiupei Chen, MD, Carolina Pain Consultants and Critical Health Systems, Raleigh, North Carolina, USA.
Randall P. Brewer, MD, The Spine Institute, Willis Knighton Health System, Shreveport, Louisiana, USA.

Neuropathic pain (NP) results from injury or dysfunction in the processing of sensory information in the nervous system. It occurs in a wide array of disease processes and may involve complex management strategies. A comprehensive approach utilizing proven pharmacologic and nonpharmacologic therapies can be used to return function and improve quality of life that has been lost because of pain. In the older population, age-related physiologic and pharmacodynamic alterations, coexisting diseases, and the prevalence of polypharmacy must be considered when selecting therapies for neuropathic pain.
Key words: neuropathic pain, older adults, neuropathy, pain, analgesics.

D'Arcy Little, MD, CCFP, Director of Medical Education, York Community Services; Lecturer and Academic Fellow, Department of Family and Community Medicine, University of Toronto; 2002-3 Royal Canadian Legion Fellow in Care of the Elderly, Toronto, ON.

Neuropathic pain is a relatively common and challenging entity in the elderly, with a wide differential diagnosis and numerous treatments available. In general, damage to peripheral nerves via an injury or as a result of abnormal functioning is thought to trigger a cascade of events in sensory neurons that is responsible for the generation of pain. Potential treatments include tricyclic antidepressants, serotonin re-uptake inhibitors, venlafaxine, ion channel blockers, opioids, capsaicin and the Lidocaine patch. This article reviews the relative efficacy of these treatments, with specific reference to considerations in the elderly.
Key words: neuropathic pain, peripheral neuropathy, treatment, anticonvulsant, antidepressant.