Stanford pain

[ostensibly]

1). Does Stanford have seperate ACGME pain fellowship and "Interventional spine" fellowship programs?

2). Does Derby train fellows?

-Thanks

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[ampaphb]

1). Does Stanford have seperate ACGME pain fellowship and "Interventional spine" fellowship programs?

2). Does Derby train fellows?

-Thanks

no and no

 

[Disciple]

#2 is yes.

Check here

www.aapmr.org/member/fellowship/fellsearchc.asp?mstate=CA

 

[drf]

Stanford used to have a regular pain fellowhip as well as a PM&R interventional spine fellowship with Raj Mitra. However, the spine fellow position was absorbed into the pain fellow pool. The latest news is that the ortho department (PM&R is under ortho) has taken the funds from that position back, cutting the fellowship numbers from 6 to 5.

 

[ampaphb]

#2 is yes.

Check here

www.aapmr.org/member/fellowship/fellsearchc.asp?mstate=CA

I had the chance to spend a week at Dr. Derby's practice. While he maintains a loose affiliation with the University, fellows did not rotate with him in Daly City when I was there, and when I spoke with his practice administrator today, she confirmed that remains the case.

 

[Disciple]

I misunderstood the question.

#2 is no in regards to Stanford, but I believe he has his own fellowship through his practice.

 

[ampaphb]

I misunderstood the question.

#2 is no in regards to Stanford, but I believe he has his own fellowship through his practice.

Dr. Derby takes on research fellows each year. He seems to have a preference for physicians from Korea for these positions. These fellows do not have clinical responsibilities.

 

[Disciple]

So is the fellowship advertised on the AAPMR website a research position?

It doesn't sound like that on the program description.

 

[ampaphb]

So is the fellowship advertised on the AAPMR website a research position?

It doesn't sound like that on the program description.

Feel free to call them directly and ask

 

[ampaphb]

Stanford used to have a regular pain fellowhip as well as a PM&R interventional spine fellowship with Raj Mitra. However, the spine fellow position was absorbed into the pain fellow pool. The latest news is that the ortho department (PM&R is under ortho) has taken the funds from that position back, cutting the fellowship numbers from 6 to 5.

Then again, with quality research like this, perhaps there is a reason the fellowship got swallowed up:

Pulsed radiofrequency for the treatment of chronic ilioinguinal neuropathy
Hernia 2007 Aug;11(4):369-71.
Mitra R, Zeighami A, Mackey S.

BACKGROUND: Ilioinguinal neuropathy is a rare but disabling condition. The condition may arise spontaneously or in the setting of pelvic surgery. To date, most therapeutic options have been limited to neuropathic pain medications, anti-inflammatory medications, nerve blocks with local anesthetics, or neurectomy. Long-term results of non-surgical interventions are fair at best. We present a case of chronic ilioinguinal neuropathy treated with pulsed radiofrequency.

OBJECTIVE: To examine the efficacy of pulsed radiofrequency (PRF) lesioning on pain in ilioinguinal neuropathy.

METHOD: A 58-year old man with chronic ilioinguinal neuropathy was treated with PRF and was followed for 3 months.

RESULTS: The patient had significant pain relief at 3 months follow up.

CONCLUSION: Pulsed radiofrequency lesioning may be a good treatment for chronic ilioinguinal neuropathy in cases refractory to conservative management.
​

Gee, lets use an unproven technology, obtain short-term, unquantified relief, and publish it in a journal no one in the pain world has ever heard of, even though a better case series looking at virtually the exact same topic has already been in the literature for more than a year:

Pulsed radiofrequency for the treatment of ilioinguinal neuralgia after inguinal herniorrhaphy
Mt Sinai J Med 2006 Jul;73(4):716-8
Rozen D, Ahn J.

BACKGROUND AND PURPOSE: Ilioinguinal neuralgia secondary to inguinal hernia repair is frequently a chronic, debilitating pain. It is most often due to destruction or entrapment of nerve tissue from staples, sutures, or direct surgical trauma. Treatment modalities, including oral analgesics, nerve blocks, mesh excision, and surgical neurectomy, have varied success rates. Pulsed radiofrequency (PRF) has recently been described as a successful method of treating chronic groin pain. Unlike conventional radiofrequency, PRF is non-neurodestructive and therefore less painful and without the potential complications of neuritis-like reactions and neuroma formation. Although the mechanism is unknown, it appears that the interaction of an electromagnetic field and c-fos proteins may alter normal transmission of painful impulses. Our study examines five patients treated with PRF for ilioinguinal neuralgia secondary to inguinal herniorrhaphy.

METHOD: Five patients were diagnosed with chronic ilioinguinal neuralgia secondary to inguinal hernia repair at our institution. Each patient was treated at vertebral T12, L1, and L2 with root PRF at 42 degrees C for 120 seconds per level.

RESULTS: Four out of five patients reported pain relief lasting from four to nine months on follow-up visits. Only one patient reported no pain relief whatsoever.

CONCLUSION: Ilioinguinal neuralgia is challenging to treat. We have demonstrated the successful use of PRF for four out of five patients seen in our office.

​

 

[drusso]

Well, the nice thing about Pain Medicine is that the research bar is not *too* high...

 

[nvrsumr]

Ive done US guided pRF of the ilioinguinal nerve 4-5 times and have had variable results. This is of course only done after other interventions have been tried.

 

[Tenesma]

i find that in patients with multiple hernia surgeries that US guided becomes useless because of all the scar tissue - so i do a fishing expedition with the RF needle until i capture... variable results so far... have tried the protocols for PRF of DRG and have been not impressed at all with the results -

 

[drrinoo]

Then again, with quality research like this, perhaps there is a reason the fellowship got swallowed up:

Pulsed radiofrequency for the treatment of chronic ilioinguinal neuropathy
Hernia 2007 Aug;11(4):369-71.
Mitra R, Zeighami A, Mackey S.

BACKGROUND: Ilioinguinal neuropathy is a rare but disabling condition. The condition may arise spontaneously or in the setting of pelvic surgery. To date, most therapeutic options have been limited to neuropathic pain medications, anti-inflammatory medications, nerve blocks with local anesthetics, or neurectomy. Long-term results of non-surgical interventions are fair at best. We present a case of chronic ilioinguinal neuropathy treated with pulsed radiofrequency.

OBJECTIVE: To examine the efficacy of pulsed radiofrequency (PRF) lesioning on pain in ilioinguinal neuropathy.

METHOD: A 58-year old man with chronic ilioinguinal neuropathy was treated with PRF and was followed for 3 months.

RESULTS: The patient had significant pain relief at 3 months follow up.

CONCLUSION: Pulsed radiofrequency lesioning may be a good treatment for chronic ilioinguinal neuropathy in cases refractory to conservative management.
​

Gee, lets use an unproven technology, obtain short-term, unquantified relief, and publish it in a journal no one in the pain world has ever heard of, even though a better case series looking at virtually the exact same topic has already been in the literature for more than a year:

Pulsed radiofrequency for the treatment of ilioinguinal neuralgia after inguinal herniorrhaphy
Mt Sinai J Med 2006 Jul;73(4):716-8
Rozen D, Ahn J.

BACKGROUND AND PURPOSE: Ilioinguinal neuralgia secondary to inguinal hernia repair is frequently a chronic, debilitating pain. It is most often due to destruction or entrapment of nerve tissue from staples, sutures, or direct surgical trauma. Treatment modalities, including oral analgesics, nerve blocks, mesh excision, and surgical neurectomy, have varied success rates. Pulsed radiofrequency (PRF) has recently been described as a successful method of treating chronic groin pain. Unlike conventional radiofrequency, PRF is non-neurodestructive and therefore less painful and without the potential complications of neuritis-like reactions and neuroma formation. Although the mechanism is unknown, it appears that the interaction of an electromagnetic field and c-fos proteins may alter normal transmission of painful impulses. Our study examines five patients treated with PRF for ilioinguinal neuralgia secondary to inguinal herniorrhaphy.

METHOD: Five patients were diagnosed with chronic ilioinguinal neuralgia secondary to inguinal hernia repair at our institution. Each patient was treated at vertebral T12, L1, and L2 with root PRF at 42 degrees C for 120 seconds per level.

RESULTS: Four out of five patients reported pain relief lasting from four to nine months on follow-up visits. Only one patient reported no pain relief whatsoever.

CONCLUSION: Ilioinguinal neuralgia is challenging to treat. We have demonstrated the successful use of PRF for four out of five patients seen in our office.

​

If he had published a case report like this:

Pain Management Consultation for the treatment of chronic ilioinguinal neuropathy
Hernia 2007 Aug;11(4):369-71.
Mitra R, Zeighami A, Mackey S.

BACKGROUND: Ilioinguinal neuropathy is a rare but disabling condition. The condition may arise spontaneously or in the setting of pelvic surgery. To date, most therapeutic options have been limited to neuropathic pain medications, anti-inflammatory medications, nerve blocks with local anesthetics, or neurectomy. Long-term results of non-surgical interventions are fair at best. We present a case of chronic ilioinguinal neuropathy treated by a visit with a pain management specialist.

OBJECTIVE: To examine the efficacy of a pain management consultation with a board certified pain physician on pain in ilioinguinal neuropathy.

METHOD: A 58-year old man with chronic ilioinguinal neuropathy was treated with advice from a pain management consultant and was followed for 3 months.

RESULTS: The patient had significant pain relief at 3 months follow up.

CONCLUSION: A pain management consult (cpt code 99243) may be a good treatment for chronic ilioinguinal neuropathy in cases refractory to conservative management.

What would you say...would you demand an RCT or is the above self evident, even though it is a case report

One can define a pain physician consult as a health care intervention (procedure) and use rhis as the basis for a case report or an RCT.

One could come to a nihilistic conclusion that a visit with a pain physician is not relevant, since the pain physician will inform the patient about the lack of RCT evidence to treat their pain or according to the case report...only 3 months of relief....in either case one could argue that a pain consult is not necessary.

Remember don't think EBM should limit its scope to procedures....it can be generalized to individual practitioners and their judgments.

At least Dr. Mitra tried to help a patient that might not have needed the index hernia operation in the first place.

Remember, chronic pain is unsolvable....you don't need a board certification or a livelihood as a physician to inform the patient rhat nothing can be done....ultimately, our entire practice of pain management is going to be skewed towards art more than science....and pain physicians above all have to develop a keen sense of judgment....over a microscopic analysis of data.

Here is one major problem with EBM in pain medicine.....the selection criteria for RCTs makes broad assumptions about the homogeneity of patients based exclusively on age range, absence or presence of prior surgery, and sex....

Actually, each group is very heterogeneous....and not generalizable.....this is actually the impetus for the entire field of pharmcogenomics....which recognizes that drugs have to be tailored to individual patients and not large cohorts....

Imagine, what happens with pain perception, pain behavior, and pain treatment which is far more complex....and almost non sensical to categorize broad categories of individuals and to make assumptions about their homogeneity.

 

[drrinoo]

I am going to take the criticism of case reports and case series to their logical extension.....

A case report originates as such:

a physician searches their patient records...may be thousands of patients....and identifies one patient that they would like to 'declassify' and send out for public commentary....they send this through peer review, so that other physicians can rate their care (ok, writing style as well)....then the physician peer group decides whether it is worthy of presenting this case to a larger physician group.....and then other physicians can debate the merits of this care on forums, like these....

So, arguably we should be able to 'declassify' all the patients we see and each episode of care and allow other physicians to rate our care....and each and every time....we could face this exhausting scrutiny of our practices by our own physician peer groups....

perhaps, eventually this will be a trend with 100% accountability and each payment we receive with each episode of care could be audited like we are doing with a case report....and then if we fail to provide EBM RCT evidence level of care....then may be we should refund the money.....

discrediting a case report is akin to discrediting using your own autonomous judgment to care for individual patients.....

 

[drrinoo]

discrediting a case report....is also making use of the selection bias heuristic...

we discredit a case report because of selection bias....

but the actual act of discrediting a case report is also making use of the selection bias heuristic....we should be prepared to similarly investigate every patient encounter to truly be free from using a selection bias when we criticize another provider for relying on the selection bias...

 

[ampaphb]

discrediting a case report....is also making use of the selection bias heuristic...

we discredit a case report because of selection bias....

but the actual act of discrediting a case report is also making use of the selection bias heuristic....we should be prepared to similarly investigate every patient encounter to truly be free from using a selection bias when we criticize another provider for relying on the selection bias...

I am going to take the criticism of case reports and case series to their logical extension.....

A case report originates as such:

a physician searches their patient records...may be thousands of patients....and identifies one patient that they would like to 'declassify' and send out for public commentary....they send this through peer review, so that other physicians can rate their care (ok, writing style as well)....then the physician peer group decides whether it is worthy of presenting this case to a larger physician group.....and then other physicians can debate the merits of this care on forums, like these....

So, arguably we should be able to 'declassify' all the patients we see and each episode of care and allow other physicians to rate our care....and each and every time....we could face this exhausting scrutiny of our practices by our own physician peer groups....

perhaps, eventually this will be a trend with 100% accountability and each payment we receive with each episode of care could be audited like we are doing with a case report....and then if we fail to provide EBM RCT evidence level of care....then may be we should refund the money.....

My only concern about your critique is that it is that it does not in anyway address my original criticism, which was:

Gee, lets use an unproven technology, obtain short-term, unquantified relief, and publish it in a journal no one in the pain world has ever heard of, even though a better case series looking at virtually the exact same topic has already been in the literature for more than a year:

Pulsed radiofrequency for the treatment of ilioinguinal neuralgia after inguinal herniorrhaphy
Mt Sinai J Med 2006 Jul;73(4):716-8
Rozen D, Ahn J.​

I was not criticizing Dr. Mitra and his colleagues for publishing a case report. My concern was that a more extensive case series already had been published on the very same subject.

My greater concern with your diatribe is that it diminishes the value of GOOD case reports. Case reports are useful to those of us in private practice when there is something unique about them - the diagnosis, technology, or application of commonly used technology to a new condition. The case report in question does none of those things, and to my mind is not worthy of an exalted medical institution such as Stanford.

To me, the value of a case report is as a canary in a coal mine. It indicates a potential new useful tool or useful application. While an overly broad generalization, these tend to come from the world of private practices, while academics typically then run with these and produce the case series or RCTs.

The Stanford case report I derided did nothing to inform those of us in the trenches of day to day private practice. It did nothing to advance the science of pain. It replicated information already in print, likely so a fellow could fulfill his or her research obligation, and so Stanford staff physicians could claim one more publication for their CV's. If the paper had come out of a third world country, or BFE University, we would have rolled our collective eyes, dismissed it as irrelevant, and moved on to the next article. I would suggest we do the same here.

 

[drrinoo]

I didn't to be critical of your post, but rather chose to use it as spring board.

With the recent APS/ACP guidelines and the Clinical Crossroads in JAMA (on post lami syndrome)....it is clear that the guiding principle in medicine is that pain treatments have to pass an exhaustingly high threshold in EBM...and that the current medical climate doesn't distinguish GOOD vs. BAD case reports....they just ignore it.

Case reports ironically are more reflective of individual physician judgment as compared to EBM. No doubt EBM with a high threshold is imperative for patient safety and clear cut outcome measures....such as death/survival.....but EBM with a high threshold is less use ful than case reports in providing guidance about patient care for ill defined problems with a high intra individual variance such as chronic pain.

For instance, chronic pain is strongly correlated with fear avoidance and anger....how could we study an intervention in an RCT fashion to reduce the burden of chronic anger and chronic fear...since anger and fear vary significantly between individuals independent of age, sex, health status....

I recognize that from our previous posts that you have been an advocate of the judicious use of interventional procedures---but we are in current climate...wherein it is simply a conflict between high threshold EBM (all case reports are discarded--as in the reference section in the APS/ACP reference list and the JAMA clinical crossroads) and individual physician judgment.

Another argument is that 5000 case reports from 5000 practitioners attesting to the efficacy of a pain procedure would be defeated by a good RCT with placebo enrolling only 100 patients.

 

[drusso]

drrinoo,

Can you send the link for the JAMA Clinical Cross Roads post-lami article?

I think that one methodology that has been under-utilized in Pain Medicine is N=1 studies. These aren't mere case reports, but prospectively planned, longitudinal single case interventions using validated pre-post measurements. This is a methodology that *every* pain practitioner could implement in their practice starting tomorrow.

It could begin with agreeing upon a set of general and disease specific outcome measures that have adequate psychometrics to detect *individual* changes on a repeated measures basis, using an already consensus validated selection/treatment paradigm (for example ISIS algorithm for lumbar MBB/neurotomy), and prospectively following single patients with repeated measures over a sufficient period of time or to some pre-specified endpoint.

If, say, 5 pain practitioners each agreed to do this for 1 patient and then "linked" their studies into a series, it would be interesting. It would not move the earth as far as EBM goes, but it would begin to help gather systematic information about the efficacy of interventional pain procedures without the tremendous burden and cost of RCT's.

BTW, medical oncologists have been using this paradigm with respect to chemotherapy for decades...

 

[ampaphb]

Another argument is that 5000 case reports from 5000 practitioners attesting to the efficacy of a pain procedure would be defeated by a good RCT with placebo enrolling only 100 patients.

The problem there is, no one publishes their failures, so if there were 500 successes, how many didn't work. Case reports allow physicians to cherry pick only those patients who fit their expectations and agenda.

Nothing diminishes glowing case reports like 100% follow-up (can you say IDET?)

 

[jump1]

in regards to the case report from stanford, i have to disagree with previous post from ampaphb regarding the stanford report from dr mitra; i did find the information useful- i had a patient that did not respond to conventional treatment for ilioinguinal neuropathy and the case report helped me with some guidelines for RFL treatment, the patient responded well and has been pain free.

take that however you'd like it, but Dr Mitra's paper was very helpful to me clinically. I also had a related question and received a response from dr mitra's office immediately.