To evaluate whether an epidural steroid injection or gabapentin is a better treatment for lumbosa... more To evaluate whether an epidural steroid injection or gabapentin is a better treatment for lumbosacral radiculopathy. A multicenter randomized study conducted between 2011 and 2014. Computer generated randomization was stratified by site. Patients and evaluating physicians were blinded to treatment outcomes. Eight military, Veterans Administration, and civilian hospitals. 145 people with lumbosacral radicular pain secondary to herniated disc or spinal stenosis for less than four years in duration and in whom leg pain is as severe or more severe than back pain. Participants received either epidural steroid injection plus placebo pills or sham injection plus gabapentin. Average leg pain one and three months after the injection on a 0-10 numerical rating scale. A positive outcome was defined as a ≥2 point decrease in leg pain coupled with a positive global perceived effect. All patients had one month follow-up visits; patients whose condition improved remained blinded for their three mo...
To determine the incidence of neuropathic pain after cooled radiofrequency ablation (RFA) of the ... more To determine the incidence of neuropathic pain after cooled radiofrequency ablation (RFA) of the sacral lateral branches for the treatment of chronic posterior sacroiliac joint complex pain. Retrospective chart review of all patients with chronic posterior sacroiliac joint complex pain who underwent cooled RFA of the sacral lateral branches in our practice between July 2011 and February 2014. Single academic pain practice at a tertiary care medical center. Thirty-six patients with chronic posterior sacroiliac joint complex pain. All charts were reviewed to determine the procedure date, unilateral or bilateral, number of levels treated, and number of individual lesions. Side effects were assessed for their presence or absence, character, intensity, duration, and whether treatment was initiated or symptoms resolved spontaneously. Forty-eight separate procedures were performed, with a total of 193 levels and 430 lesions. Three patients had transient postprocedure neuropathic pain yield...
Gadolinium-induced encephalopathy is a well documented complication due to the inadvertent entran... more Gadolinium-induced encephalopathy is a well documented complication due to the inadvertent entrance of a high dose of gadolinium into the intrathecal compartment. In lab animals, injecting gadolinium into the intrathecal compartment resulted in neurotoxicity and seizures. It is also well recognized that the presence of autologous blood in the intrathecal compartment can cause a broad range of neurological changes that can include seizures and mental status changes. At the time of writing this report, there were no references in the literature of simultaneous injection of gadolinium and blood into the subarachnoid space. We present a case of a patient who received a high dose of gadolinium in the epidural space for needle placement confirmation during a fluoroscopically-guided epidural steroid injection for the treatment of lumbar radiculopathy. The injection was complicated by a wet tap necessitating an epidural blood patch for post-dural puncture headache. Shortly after the injecti...
The education of physicians is a fundamental obligation within medicine that must remain closely ... more The education of physicians is a fundamental obligation within medicine that must remain closely aligned with clinical care. And although medical education in pain care is essential, the current state of medical education does not meet the needs of physicians, patients, or society. To address this, we convened a committee of pain specialist medical student educators. Tasked with creating systematically developed and valid recommendations for clinical education, we conducted a survey of pain medicine leadership within the American Academy of Pain Medicine (AAPM). The survey was conducted in two waves. We asked AAPM board members to rate 194 previously published pain medicine learning objectives for medical students; 79% of those eligible for participation responded. The "Top 5" list included the awareness of acute and chronic pain, skillfulness in clinical appraisal, promotion of compassionate practices, displaying empathy toward the patient, and knowledge of terms and definitions for substance abuse. The "Top 10" list included the major pharmacological classes as well as skills in examination, communication, prescribing, and interviewing. The "Top 20" list included the pain care of cognitively impaired populations, those with comorbid illness, and older adults. With the survey results in consideration, the committee produced a new recommended topic list for curricula in pain medicine. We strongly recommend that adequate resources are devoted to fully integrated medical curricula in pain so that students will learn not only the necessary clinical knowledge but also be prepared to address the professional, personal, and ethical challenges that arise in caring for those with pain. We conclude that improved medical education in pain is essential to prepare providers who manifest both competence and compassion toward their patients.
Clonidine is a partial alpha 2 adrenergic agonist that has a variety of different actions includi... more Clonidine is a partial alpha 2 adrenergic agonist that has a variety of different actions including antihypertensive effects as well as the ability to potentiate the effects of local anesthetics. It can provide pain relief by an opioid-independent mechanism. It has been shown to result in the prolongation of the sensory blockade and a reduction in the amount or concentration of local anesthetic required to produce perioperative analgesia. Different routes for the administration of regional anesthesia, including intravenous, intrathecal and epidural ones, as well as the addition of clonidine for peripheral neural blockade, have been described. It has been also used for intra-articular administration. The latest articles describing the use of clonidine in regional anesthesia are discussed. Most authors agree that the use of clonidine for regional neural blockade in combination with a local anesthetic results in increased duration of sensory blockade with no difference in onset time. The addition of clonidine to the local anesthetic opioid mixtures seems to produce analgesia of longer duration, more rapid onset and higher quality. The higher doses of clonidine were associated with a more cephalad spread of the spinal blockade and increased sedation and hypertension. When clonidine is added to a fentanyl-bupivacaine mixture for epidural labor analgesia, it seems to provide satisfactory analgesia of a longer duration than that produced by the fentanyl-bupivacaine combination alone. Similar results were found when epidural analgesia using levobupivacaine with clonidine was used in patients undergoing total hip arthroplasty. Less clear results were seen when clonidine was used for caudal anesthesia in a pediatric patient population. The addition of clonidine to intravenous regional anesthesia resulted in prolongation of the tourniquet time and improvement of postoperative analgesia. However, the latter was found to be short-lived. In another study, the effects of clonidine used for intra-articular administration in combination with morphine were investigated. These authors found a significantly higher rate of satisfaction in the group of patients receiving clonidine plus morphine. Although several recent studies have shown certain benefits from the use of clonidine for regional anesthesia, further investigations are necessary to clarify its role.
To evaluate whether an epidural steroid injection or gabapentin is a better treatment for lumbosa... more To evaluate whether an epidural steroid injection or gabapentin is a better treatment for lumbosacral radiculopathy. A multicenter randomized study conducted between 2011 and 2014. Computer generated randomization was stratified by site. Patients and evaluating physicians were blinded to treatment outcomes. Eight military, Veterans Administration, and civilian hospitals. 145 people with lumbosacral radicular pain secondary to herniated disc or spinal stenosis for less than four years in duration and in whom leg pain is as severe or more severe than back pain. Participants received either epidural steroid injection plus placebo pills or sham injection plus gabapentin. Average leg pain one and three months after the injection on a 0-10 numerical rating scale. A positive outcome was defined as a ≥2 point decrease in leg pain coupled with a positive global perceived effect. All patients had one month follow-up visits; patients whose condition improved remained blinded for their three mo...
To determine the incidence of neuropathic pain after cooled radiofrequency ablation (RFA) of the ... more To determine the incidence of neuropathic pain after cooled radiofrequency ablation (RFA) of the sacral lateral branches for the treatment of chronic posterior sacroiliac joint complex pain. Retrospective chart review of all patients with chronic posterior sacroiliac joint complex pain who underwent cooled RFA of the sacral lateral branches in our practice between July 2011 and February 2014. Single academic pain practice at a tertiary care medical center. Thirty-six patients with chronic posterior sacroiliac joint complex pain. All charts were reviewed to determine the procedure date, unilateral or bilateral, number of levels treated, and number of individual lesions. Side effects were assessed for their presence or absence, character, intensity, duration, and whether treatment was initiated or symptoms resolved spontaneously. Forty-eight separate procedures were performed, with a total of 193 levels and 430 lesions. Three patients had transient postprocedure neuropathic pain yield...
Gadolinium-induced encephalopathy is a well documented complication due to the inadvertent entran... more Gadolinium-induced encephalopathy is a well documented complication due to the inadvertent entrance of a high dose of gadolinium into the intrathecal compartment. In lab animals, injecting gadolinium into the intrathecal compartment resulted in neurotoxicity and seizures. It is also well recognized that the presence of autologous blood in the intrathecal compartment can cause a broad range of neurological changes that can include seizures and mental status changes. At the time of writing this report, there were no references in the literature of simultaneous injection of gadolinium and blood into the subarachnoid space. We present a case of a patient who received a high dose of gadolinium in the epidural space for needle placement confirmation during a fluoroscopically-guided epidural steroid injection for the treatment of lumbar radiculopathy. The injection was complicated by a wet tap necessitating an epidural blood patch for post-dural puncture headache. Shortly after the injecti...
The education of physicians is a fundamental obligation within medicine that must remain closely ... more The education of physicians is a fundamental obligation within medicine that must remain closely aligned with clinical care. And although medical education in pain care is essential, the current state of medical education does not meet the needs of physicians, patients, or society. To address this, we convened a committee of pain specialist medical student educators. Tasked with creating systematically developed and valid recommendations for clinical education, we conducted a survey of pain medicine leadership within the American Academy of Pain Medicine (AAPM). The survey was conducted in two waves. We asked AAPM board members to rate 194 previously published pain medicine learning objectives for medical students; 79% of those eligible for participation responded. The "Top 5" list included the awareness of acute and chronic pain, skillfulness in clinical appraisal, promotion of compassionate practices, displaying empathy toward the patient, and knowledge of terms and definitions for substance abuse. The "Top 10" list included the major pharmacological classes as well as skills in examination, communication, prescribing, and interviewing. The "Top 20" list included the pain care of cognitively impaired populations, those with comorbid illness, and older adults. With the survey results in consideration, the committee produced a new recommended topic list for curricula in pain medicine. We strongly recommend that adequate resources are devoted to fully integrated medical curricula in pain so that students will learn not only the necessary clinical knowledge but also be prepared to address the professional, personal, and ethical challenges that arise in caring for those with pain. We conclude that improved medical education in pain is essential to prepare providers who manifest both competence and compassion toward their patients.
Clonidine is a partial alpha 2 adrenergic agonist that has a variety of different actions includi... more Clonidine is a partial alpha 2 adrenergic agonist that has a variety of different actions including antihypertensive effects as well as the ability to potentiate the effects of local anesthetics. It can provide pain relief by an opioid-independent mechanism. It has been shown to result in the prolongation of the sensory blockade and a reduction in the amount or concentration of local anesthetic required to produce perioperative analgesia. Different routes for the administration of regional anesthesia, including intravenous, intrathecal and epidural ones, as well as the addition of clonidine for peripheral neural blockade, have been described. It has been also used for intra-articular administration. The latest articles describing the use of clonidine in regional anesthesia are discussed. Most authors agree that the use of clonidine for regional neural blockade in combination with a local anesthetic results in increased duration of sensory blockade with no difference in onset time. The addition of clonidine to the local anesthetic opioid mixtures seems to produce analgesia of longer duration, more rapid onset and higher quality. The higher doses of clonidine were associated with a more cephalad spread of the spinal blockade and increased sedation and hypertension. When clonidine is added to a fentanyl-bupivacaine mixture for epidural labor analgesia, it seems to provide satisfactory analgesia of a longer duration than that produced by the fentanyl-bupivacaine combination alone. Similar results were found when epidural analgesia using levobupivacaine with clonidine was used in patients undergoing total hip arthroplasty. Less clear results were seen when clonidine was used for caudal anesthesia in a pediatric patient population. The addition of clonidine to intravenous regional anesthesia resulted in prolongation of the tourniquet time and improvement of postoperative analgesia. However, the latter was found to be short-lived. In another study, the effects of clonidine used for intra-articular administration in combination with morphine were investigated. These authors found a significantly higher rate of satisfaction in the group of patients receiving clonidine plus morphine. Although several recent studies have shown certain benefits from the use of clonidine for regional anesthesia, further investigations are necessary to clarify its role.
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Papers by Vitaly Gordin