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In JoVE (1)
Other Publications (24)
- Pain Medicine (Malden, Mass.)
- The Journal of Pain : Official Journal of the American Pain Society
- Pain Medicine (Malden, Mass.)
- Journal of Anesthesia
- Anesthesiology
- Anesthesia and Analgesia
- Expert Review of Neurotherapeutics
- Anesthesiology
- Pain Practice : the Official Journal of World Institute of Pain
- Pain Practice : the Official Journal of World Institute of Pain
- Pain Practice : the Official Journal of World Institute of Pain
- Pain Medicine (Malden, Mass.)
- Journal of Anesthesia
- Journal of Anesthesia
- Pain Practice : the Official Journal of World Institute of Pain
- Pain Practice : the Official Journal of World Institute of Pain
- Anesthesia and Analgesia
- Pain Practice : the Official Journal of World Institute of Pain
- European Spine Journal : Official Publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society
- Anesthesiology
- Journal of Cardiothoracic and Vascular Anesthesia
- Lancet
- Pain Medicine (Malden, Mass.)
- Spine
Articles by Alex Cahana in JoVE
JoVE Clinical and Translational Medicine
An Experimental Paradigm for the Prediction of Post-Operative Pain (PPOP)
Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine
Diffuse noxious inhibitory control, temporal summation and wound hyperalgesia testing are demonstrated in the obstetric patient. These tests evaluate inhibitory and excitatory mechanisms of pain processing and are here utilized to evaluate endogenous analgesia at different time-points during pregnancy and the peripartum period to help reveal individual s risk for persistent pain.
Other articles by Alex Cahana on PubMed
Acute Differential Modulation of Synaptic Transmission and Cell Survival During Exposure to Pulsed and Continuous Radiofrequency Energy
Pulsed radiofrequency, in which short bursts of radiofrequency energy are applied to nervous tissue, has been recently described as an alternative technique devoid of nerve injury, a subsequent side effect of thermal lesions created by continuous radiofrequency lesioning. Yet the mechanism of this effect remains unclear. In this study we compared the acute effects of pulsed versus continuous radiofrequency energy on impulse propagation and synaptic transmission in hippocampal slice cultures and on cell survival in cortical cultures. A differential effect was observed on both systems, with pulsed radiofrequency producing a transient and continuous radiofrequency a lasting inhibition of evoked synaptic activity. In addition, although both continuous radiofrequency and pulsed radiofrequency treatments induced a distance-dependent tissue destruction under the stimulating needle, the effect was more pronounced in the continuous radiofrequency group. These findings suggest that the acute effects of pulsed radiofrequency are more reversible and less destructive in nature than the classic continuous radiofrequency mode, even in normothermal conditions. This model might help elucidate the importance of various parameters for the clinical application of radiofrequency lesioning and might open new horizons for the role of pulsed radiofrequency lesioning in cases of neuropathic pain.
The Long-term Effect of Repeated Intravenous Lidocaine on Central Pain and Possible Correlation in Positron Emission Tomography Measurements
Functional neuroimaging suggests that similar brain regions are involved in the processing of pain in healthy subjects and in patients with chronic neuropathic central pain. We present a patient with chronic neuropathic central pain due to a unique lesion to the trigeminal and spinothalamic pathway who had persistent pain relief after repeated IV lidocaine infusions. Positron emission tomography scan results showed a relative hypoactivity of the left posterolateral thalamus before treatment which disappeared after therapy. This case may suggest a stereo-selective analgesic effect of lidocaine accompanied by regional cerebral blood flow changes in the thalamus, indicating that sodium channels could, in fact, be highly expressed or modified in the thalamus after thalamic deafferentation. IMPLICATIONS: We present a case of persistent central pain after encephalitis in a patient who had long-term pain relief after a series of IV lidocaine infusions. A positron emission tomography scan study, done before and after treatment, suggested that lidocaine for the diagnosis of chronic neuropathic pain may have a specific site of action in the brain.
Do Minimally Invasive Procedures Have a Place in the Treatment of Chronic Low Back Pain?
Chronic low back pain is the leading cause of disability in the industrialized world. Medical and surgical treatments remain costly despite limited efficacy. The field of 'interventional pain' has grown enormously and evidence-based practice guidelines are systematically developed. In this article, the vast, complex and contradictory literature regarding the treatment of chronic low back pain is reviewed. Interventional pain literature suggests that there is moderate evidence (small randomized, nonrandomized, single group or matched-case controlled studies) for medial branch neurotomy and limited evidence (nonexperimental one or more center studies) for intradiscal treatments in mechanical low back pain. There is moderate evidence for the use of transforaminal epidural steroid injections, lumbar percutaneous adhesiolysis and spinal endoscopy for painful lumbar radiculopathy, and spinal cord stimulation and intrathecal pumps mostly after spinal surgery. In reality, there is no gold standard for the treatment of chronic low back pain, but these results appear promising.
Ethical and Epistemological Problems when Applying Evidence-based Medicine to Pain Management
Epistemology, or the theory of knowledge, is a branch in philosophy concerned with the definitions of knowledge and evidence. Although evidence-based medicine (EBM) has a strong ethical imperative behind it, rooted in the concern to do no harm, to do one's best for one's patients, and by doing so--eliminating waste, it still harbors within it serious epistemological limits. These include methodological and ethical limits to perform randomized controlled trials, the idea of "hierarchy of evidence" which may provide conclusions well short of medical knowledge, and the unique use of a single particular theory of statistical inference which is far from consensual. In this article, we review these difficulties and suggest that EBM is at best a methodological solution to some clinical phenomena, but remains blind to mechanisms of explanation and causation needed, in order to advance our knowledge. Further research in the theory of evidence and inference, causation and correlation, clinical judgment and collective knowledge, the structure of medical theory, and the nature of clinical effectiveness are needed.
Percutaneous Vertebroplasty in Octogenarians: Results and Follow-up
To determine pain relief, performance status, morbidity, and mortality associated with percutaneous vertebroplasty for spinal pain in patients aged 80 years and older.
Pulsed Radiofrequency: Current Clinical and Biological Literature Available
Pulsed radiofrequency, where short bursts of radiofrequency energy are applied to nervous tissue, has been used by pain practitioners as a non- or minimally neurodestructive technique, alternative to radiofrequency heat lesions. Clinical advantages and mechanisms of this treatment remain unclear. The objective of this study was to review current clinical and laboratory data.
The Story of Vioxx--no Pain and a Lot of Gain: Ethical Concerns Regarding Conduct of the Pharmaceutical Industry
Not All Placebos Are the Same: a Debate on the Ethics of Placebo Use in Clinical Trials Versus Clinical Practice
Attitudes and Beliefs Regarding the Role of Interventional Pain Management at the End-of-life Among Caregivers: a 4-year Perspective
Intrathecal and epidural opioid analgesia represents a major advance in the management of cancer pain, adding a new dimension to opioid therapy by allowing prolonged analgesia through the use of significantly lower doses than those required for systemic administration. However, myths, misconceptions, and apprehension continue to serve as major barriers to effective cancer pain management, and concerns regarding safety, efficacy, and relative ease of utilization still prevail. This, in turn, results in unnecessary suffering, depression, diminished cognitive function, sleep disturbance, functional disability, and compromised quality of life. We conducted a survey to systematically explore medical and paramedical attitudes prior to and 4 years after the introduction an interventional pain program and attempted to qualitatively analyze what appeared as main facilities or difficulties following end-of-life clinical experiences. In general we found that all caregivers were satisfied from using interventional pain relief techniques at the end-of-life; more so among caregivers directly involved in patient care. Although nearly half of the responders initially found "technical manipulations" moderately difficult to difficult, after a simple hands-on instruction all found these techniques to be "helpful, simple and feasible." "When all went well," caregivers found implantable devices as a useful tool to relieve pain, to increase the ability of patients to complete personal endeavors, notably mobilization, but also noted an increased patient anxiety at the end-of-life. "When all went wrong," caregivers evoked the paradoxical attitude of patients to having a "high-tech" treatment at the end-of-life, causing them eventually to have "false hope," as well as the phenomenon of "interdisciplinary hyperactivity," creating what was referred to as therapeutic futility. In summary, this study suggests the importance on insisting to introduce novel techniques into practice despite initial apprehension, however, quality improvement by detecting and overcoming attitudinal barriers remain primordial and requires narrative research.
Percutaneous Pulsed Radiofrequency Reduces Mechanical Allodynia in a Neuropathic Pain Model
Neuropathic pain is a result of a primary lesion or dysfunction of the peripheral or central nervous system, and its treatment is challenging. Animal models have been helpful in understanding mechanisms of neuropathic pain and in developing new treatment strategies. In this study, we examined the effect of percutaneous pulsed radiofrequency (PRF), which is a minimally invasive pain treatment method, on mechanical allodynia in a neuropathic pain rat model.
Voluntary Informed Consent in Research and Clinical Care: an Update
Informed consent is important: in research, it allows subjects to make an informed and voluntary choice to participate--or refuse to participate--in a project where they will be asked to take risks for the benefit of others. In both research and clinical care, informed consent represents a permission to intervene on a person's private sphere. The elements of informed consent are usually described as disclosure, understanding, decision-making capacity, and voluntariness. Each poses distinct difficulties, and can be amenable to improvements. However, research on the quality of informed consent and on strategies intended to improve it have only become the object of research relatively recently. In this article, we describe some results of this research, and outline how they can be relevant to informed consent in research and clinical care. Although much of the data suffers from limitations, it does suggest that disclosure has improved, but is still uneven, comprehension is often poor, for both patients and research subjects. Moreover, trust is a motivating factor for research participation, and thus we run risks if we allow false expectations and prove ourselves unworthy of this trust. Although improving consent forms does not have a clear effect on understanding, improving the consent process may help. Finally, better information may decrease anxiety and seems to have at most a small negative effect on research recruitment.
Injection Therapy and Denervation Procedures for Chronic Low Back Pain: a Systematic Review--clinical Value?
Target-controlled Dosing of Remifentanil During Cardiac Surgery Reduces Postoperative Hyperalgesia
One of the strategies to attenuate opioid-induced hyperalgesia (OIH) may be to decrease intraoperative doses of opioids by using target-controlled infusion (TCI).
Treatment of Chronic Non-cancer Pain
Chronic pain is a pervasive problem that affects the patient, their significant others, and society in many ways. The past decade has seen advances in our understanding of the mechanisms underlying pain and in the availability of technically advanced diagnostic procedures; however, the most notable therapeutic changes have not been the development of novel evidenced-based methods, but rather changing trends in applications and practices within the available clinical armamentarium. We provide a general overview of empirical evidence for the most commonly used interventions in the management of chronic non-cancer pain, including pharmacological, interventional, physical, psychological, rehabilitative, and alternative modalities. Overall, currently available treatments provide modest improvements in pain and minimum improvements in physical and emotional functioning. The quality of evidence is mediocre and has not improved substantially during the past decade. There is a crucial need for assessment of combination treatments, identification of indicators of treatment response, and assessment of the benefit of matching of treatments to patient characteristics.
Chronic Low Back Pain: a Heterogeneous Condition with Challenges for an Evidence-based Approach
"Chronic" low back pain (LBP), defined as present for 3 or more months, has become a major socioeconomic problem insufficiently addressed by five major entities largely working in isolation from one another - procedural based specialties, strength based rehabilitation, cognitive behavioral therapy, pain management and manipulative care. As direct and indirect costs continue to rise, many authors have systematically evaluated the body of evidence in an effort to demonstrate the effectiveness (or lack thereof) for various diagnostic and therapeutic interventions. The objective of this Spine Focus issue is not to replicate previous work in this area. Rather, our expert panel has chosen a set of potentially controversial topics for more in-depth study and discussion. A recurring theme is that chronic LBP is a heterogeneous condition, and this affects the way it is diagnosed, classified, treated, and studied. The efficacy of some treatments may be appreciated only through a better understanding of heterogeneity of treatment effects (i.e., identification of clinically relevant subgroups with differing responses to the same treatment). Current clinical guidelines and payer policies for LBP are systematically compared for consistency and quality. Novel approaches for data gathering, such as national spine registries, may offer a preferable approach to gain meaningful data and direct us towards a "results-based medicine." This approach would require more high-quality studies, more consistent recording for various phenotypes and exploration of studies on genetic epidemiologic undertones to guide us in the emerging era of "results based medicine."
