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Papers by Allen Burton

Pain Medicine, 2010

Objective. In response to the Accreditation Council for Graduate Medical Education's (ACGME) new... more Objective. In response to the Accreditation Council for Graduate Medical Education's (ACGME) new pain medicine fellowship requirement, which emphasizes multidisciplinary training strategies aimed at providing improved clinical care for pain patients, we developed a multidisciplinary team training education model for trainees in our institution's Fellowship Program in Pain Medicine. Although the biopsychosocial model guides the delivery of care by multidisciplinary pain teams, there is a gap on how to improve team attitudes and functioning within an already extensive pain medicine curriculum. The current study aimed to fill that gap by developing and incorporating an educational model that focuses on interpersonal relationships among team members and strategies for improving team performance over time.Design, Setting, Participants, Intervention, and Outcome Measures. Here, we provide a brief overview of our institution's pain medicine fellowship training program highlighting how we have included a team training component into lectures, interdisciplinary case conferences, and journal club articles that focus on topics in the ACGME pain medicine curriculum. We present data from a team attitude and functioning assessment battery administered to 11 pain medicine fellows at the outset and end of their fellowship.Results and Conclusions. Mean assessment scores increased from the beginning of the fellowship to the end of the fellowship on interdisciplinary pain team knowledge, current team skills, and attitude toward health care teams. The current study demonstrated effective ways for assessing team attitudes and functioning and including this educational component into a 1-year pain medicine curriculum. Based on our results, we will continue to teach and model effective teamwork in an effort to enhance our trainees' attitudes toward working on an interdisciplinary pain team.

Current Pain and Headache Reports, 2008

Percutaneous vertebroplasty is the injection of a vertebral compression fracture (VCF) with bone ... more Percutaneous vertebroplasty is the injection of a vertebral compression fracture (VCF) with bone cement, generally polymethylmethacrylate. Percutaneous kyphoplasty is the placement of balloons into the vertebral body with an inflation/deflation sequence to create a cavity before the cement injection. These procedures are most often performed in a percutaneous fashion on an outpatient (or short stay) basis. The procedure is indicated for painful VCFs due to osteoporosis or malignancy, and painful hemangiomas. The procedure may have efficacy in painful vertebral metastasis and traumatic compression fractures. Much evidence favors the use of this procedure for pain associated with these disorders. The overall risks of the procedure are low, but serious complications (including spinal cord compression) can occur. With good patient selection and careful technique, these complications are avoidable, making the risk-to-benefit ratio highly favorable.

Expert Review of Anticancer Therapy, 2007

Pain Medicine, 2009

Background. The incidence of spinal epidural abscess has increased in the past decades. Traditio... more Background. The incidence of spinal epidural abscess has increased in the past decades. Traditionally, management was based on surgical decompression. More recent studies have shown conservative management has successful outcomes in selected patients.Case Report. We present a case, in which an elderly woman presented with new onset radicular pain and mild leukocytosis more than a week after a complicated revision of an intrathecal catheter in place for management of chronic axial low back pain. Magentic resonance imaging (MRI) revealed a posterior epidural abscess from T12 to L2. Two Touhy needles were placed in the epidural space with fluoroscopic guidance for drainage of the abscess. A catheter was then advanced into the epidural space for irrigation with saline and an antibiotic solution. Intravenous antibiotics were continued for a total of 6 weeks. Radicular pain resolved immediately post-procedure. Serial MRIs also showed decreasing size of the abscess.Conclusion. Posterior spinal epidural abscesses may be successfully treated by way of the two Touhy needle and catheter technique for drainage and irrigation. This procedure should be reserved for patients that present with no neurological deficits or deemed nonsurgical candidates. Patients should continue on prolonged intravenous antibiotics and be monitored closely for clinical deterioration and undergo serial follow-up MRIs.

Pain Practice, 2011

Pain in patients with cancer can be refractory to pharmacological treatment or intolerable side e... more Pain in patients with cancer can be refractory to pharmacological treatment or intolerable side effects of pharmacological treatment may seriously disturb patients' quality of life. Specific interventional pain management techniques can be an effective alternative for those patients. The appropriate application of these interventional techniques provides better pain control, allows the reduction of analgesics and hence improves quality of life. Until recently, the majority of these techniques are considered to be a fourth consecutive step following the World Health Organization's pain treatment ladder. However, in cancer patients, earlier application of interventional pain management techniques can be recommended even before considering the use of strong opioids. Epidural and intrathecal medication administration allow the reduction of the daily oral or transdermal opioid dose, while maintaining or even improving the pain relief and reducing the side effects. Cervical cordotomy may be considered for patients suffering with unilateral pain at the level below the dermatome C5. This technique should only be applied in patients with a life expectancy of less than 1 year. Plexus coeliacus block or nervus splanchnicus block are recommended for the management of upper abdominal pain due to cancer. Pelvic pain due to cancer can be managed with plexus hypogastricus block and the saddle or lower end block may be a last resort for patients suffering with perineal pain. Back pain due to vertebral compression fractures with or without pathological tumor invasion may be managed with percutaneous vertebroplasty or kyphoplasty. All these interventional techniques should be a part of multidisciplinary patient program.

Pain Practice, 2011

Pain in patients with cancer can be refractory to pharmacological treatment or intolerable side e... more Pain in patients with cancer can be refractory to pharmacological treatment or intolerable side effects of pharmacological treatment may seriously disturb patients' quality of life. Specific interventional pain management techniques can be an effective alternative for those patients. The appropriate application of these interventional techniques provides better pain control, allows the reduction of analgesics and hence improves quality of life. Until recently, the majority of these techniques are considered to be a fourth consecutive step following the World Health Organization's pain treatment ladder. However, in cancer patients, earlier application of interventional pain management techniques can be recommended even before considering the use of strong opioids. Epidural and intrathecal medication administration allow the reduction of the daily oral or transdermal opioid dose, while maintaining or even improving the pain relief and reducing the side effects. Cervical cordotomy may be considered for patients suffering with unilateral pain at the level below the dermatome C5. This technique should only be applied in patients with a life expectancy of less than 1 year. Plexus coeliacus block or nervus splanchnicus block are recommended for the management of upper abdominal pain due to cancer. Pelvic pain due to cancer can be managed with plexus hypogastricus block and the saddle or lower end block may be a last resort for patients suffering with perineal pain. Back pain due to vertebral compression fractures with or without pathological tumor invasion may be managed with percutaneous vertebroplasty or kyphoplasty. All these interventional techniques should be a part of multidisciplinary patient program.

Pain physician

Chronic persistent pain as a result of terminal illness, either as a consequence of the disease o... more Chronic persistent pain as a result of terminal illness, either as a consequence of the disease or the necessary treatment, is common in patients with cancer. For these patients with moderate-to-severe intractable pain, intrathecal (IT) drug delivery systems may represent an effective option for pain management. Thus, IT drug delivery is a viable treatment strategy for both neuropathy and nociceptive pain in the cancer population. However, there is a scarcity of comprehensive guidelines in implanting IT drug delivery systems in the treatment of pain caused by cancer. This article outlines consensus guidelines for the implementation of intrathecal therapy in patients with cancer-related pain and other end of life states causing pain. We highlight the multidisciplinary criteria that warrant careful consideration to ensure meaningful analgesia. Evidence was compiled, ranked, and strength considered by an invited panel of well-published and innovative clinician research leaders in pain ...

Neuromodulation : journal of the International Neuromodulation Society, 2014

The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulati... more The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society (INS) evaluated evidence regarding the safety and efficacy of neurostimulation to treat chronic pain, chronic critical limb ischemia, and refractory angina and recommended appropriate clinical applications. The NACC used literature reviews, expert opinion, clinical experience, and individual research. Authors consulted the Practice Parameters for the Use of Spinal Cord Stimulation in the Treatment of Neuropathic Pain (2006), systematic reviews (1984 to 2013), and prospective and randomized controlled trials (2005 to 2013) identified through PubMed, EMBASE, and Google Scholar. Neurostimulation is relatively safe because of its minimally invasive and reversible characteristics. Comparison with medical management is difficult, as patients considered for neurostimulation have failed conservative management. Unlike alternative therapies, neurostimulation is not associated with medi...

Pain physician, 2005

The lifetime prevalence of spinal pain has been reported as 54% to 80%, with as many as 60% of pa... more The lifetime prevalence of spinal pain has been reported as 54% to 80%, with as many as 60% of patients continuing to have chronic pain five years or longer after the initial episode. Spinal pain is associated with significant economic, societal, and health impact. Available evidence documents a wide degree of variance in the definition and the practice of interventional pain management. To develop evidence-based clinical practice guidelines for interventional techniques in the management of chronic spinal pain, with utilization of all types of evidence, applying an evidence-based approach, with broad representation of specialists from academic and clinical practices. A systematic review of diagnostic and therapeutic interventions applied in managing chronic spinal pain by a policy committee. Design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions, and statements about relationships between clinical interventio...

Anesthesiology, Jan 27, 2015

Current treatments for chronic pain have limited effectiveness and commonly known side effects. G... more Current treatments for chronic pain have limited effectiveness and commonly known side effects. Given the prevalence and burden of intractable pain, additional therapeutic approaches are desired. Spinal cord stimulation (SCS) delivered at 10 kHz (as in HF10 therapy) may provide pain relief without the paresthesias typical of traditional low-frequency SCS. The objective of this randomized, parallel-arm, noninferiority study was to compare long-term safety and efficacy of SCS therapies in patients with back and leg pain. A total of 198 subjects with both back and leg pain were randomized in a 1:1 ratio to a treatment group across 10 comprehensive pain treatment centers. Of these, 171 passed a temporary trial and were implanted with an SCS system. Responders (the primary outcome) were defined as having 50% or greater back pain reduction with no stimulation-related neurological deficit. At 3 months, 84.5% of implanted HF10 therapy subjects were responders for back pain and 83.1% for leg...

Pain Medicine, 2011

Painful vertebral compression fractures (VCFs), whether pathologic or osteoporotic, are a sourc... more Painful vertebral compression fractures (VCFs), whether pathologic or osteoporotic, are a source of morbidity in cancer patients. At our tertiary cancer center, over the past decade we have used vertebroplasty (VP) and kyphoplasty (KP) to treat painful VCFs. More data are needed on the treatment of VCFs in cancer patients with these techniques. We retrospectively reviewed the medical records of cancer patients with painful VCFs that had been treated at our institution between January 1, 2001 and May 31, 2008. Information was collected on demographic and clinical characteristics, features of the fractures, procedural details, and complications. Pre- and post-procedural pain and related symptoms were assessed using a subset of patients who had responded to the Brief Pain Inventory and the Edmonton Symptom Assessment Scale. A total of 407 cancer patients had 1,156 fractures that had been treated with VP or KP during 536 surgical procedures. Patients had an average of 2.8 fractures (range, 1-10). The majority of patients had pathologic fractures due to multiple myeloma (43%) or osteoporotic fractures (35%). Most fractures occurred in the thoracolumbar region. Adjacent-level fractures occurred in 18% of patients. Surgery provided significant relief from pain and several related symptoms. Symptomatic, serious complications requiring open surgery occurred in two cases (<0.01%) in our series. Our single-center experience revealed that a large number of cancer patients suffer from painful VCFs. The use of VP or KP in treating painful VCFs in cancer patients has good efficacy and an acceptably low complication rate.

Neurosurgery, 2015

most recent follow-up. Fifty percent improvement in headache was the only predictor of outcome va... more most recent follow-up. Fifty percent improvement in headache was the only predictor of outcome variables combined (total MIDAS, MIDAS-B, and BDI) (P ¼ .021). Of note, this improvement in functional outcome was only significant during the perioperative period and not throughout the length of follow-up. No other predictive factors were significantly correlated with the functional outcomes. Among the predictor variables, a strong correlation was found for disability status being inversely related to reporting 50% improvement in headache (r ¼ 20.582).

Neuromodulation: Technology at the Neural Interface, 2014

The International Neuromodulation Society (INS) has determined that there is a need for guidance ... more The International Neuromodulation Society (INS) has determined that there is a need for guidance regarding safety and risk reduction for implantable neurostimulation devices. The INS convened an international committee of experts in the field to explore the evidence and clinical experience regarding safety, risks, and steps to risk reduction to improve outcomes.

Neuromodulation: Technology at the Neural Interface, 2014

Pain Medicine, 2010

Objective. In response to the Accreditation Council for Graduate Medical Education's (ACGME) new... more Objective. In response to the Accreditation Council for Graduate Medical Education's (ACGME) new pain medicine fellowship requirement, which emphasizes multidisciplinary training strategies aimed at providing improved clinical care for pain patients, we developed a multidisciplinary team training education model for trainees in our institution's Fellowship Program in Pain Medicine. Although the biopsychosocial model guides the delivery of care by multidisciplinary pain teams, there is a gap on how to improve team attitudes and functioning within an already extensive pain medicine curriculum. The current study aimed to fill that gap by developing and incorporating an educational model that focuses on interpersonal relationships among team members and strategies for improving team performance over time.Design, Setting, Participants, Intervention, and Outcome Measures. Here, we provide a brief overview of our institution's pain medicine fellowship training program highlighting how we have included a team training component into lectures, interdisciplinary case conferences, and journal club articles that focus on topics in the ACGME pain medicine curriculum. We present data from a team attitude and functioning assessment battery administered to 11 pain medicine fellows at the outset and end of their fellowship.Results and Conclusions. Mean assessment scores increased from the beginning of the fellowship to the end of the fellowship on interdisciplinary pain team knowledge, current team skills, and attitude toward health care teams. The current study demonstrated effective ways for assessing team attitudes and functioning and including this educational component into a 1-year pain medicine curriculum. Based on our results, we will continue to teach and model effective teamwork in an effort to enhance our trainees' attitudes toward working on an interdisciplinary pain team.

Current Pain and Headache Reports, 2008

Percutaneous vertebroplasty is the injection of a vertebral compression fracture (VCF) with bone ... more Percutaneous vertebroplasty is the injection of a vertebral compression fracture (VCF) with bone cement, generally polymethylmethacrylate. Percutaneous kyphoplasty is the placement of balloons into the vertebral body with an inflation/deflation sequence to create a cavity before the cement injection. These procedures are most often performed in a percutaneous fashion on an outpatient (or short stay) basis. The procedure is indicated for painful VCFs due to osteoporosis or malignancy, and painful hemangiomas. The procedure may have efficacy in painful vertebral metastasis and traumatic compression fractures. Much evidence favors the use of this procedure for pain associated with these disorders. The overall risks of the procedure are low, but serious complications (including spinal cord compression) can occur. With good patient selection and careful technique, these complications are avoidable, making the risk-to-benefit ratio highly favorable.

Expert Review of Anticancer Therapy, 2007

Pain Medicine, 2009

Background. The incidence of spinal epidural abscess has increased in the past decades. Traditio... more Background. The incidence of spinal epidural abscess has increased in the past decades. Traditionally, management was based on surgical decompression. More recent studies have shown conservative management has successful outcomes in selected patients.Case Report. We present a case, in which an elderly woman presented with new onset radicular pain and mild leukocytosis more than a week after a complicated revision of an intrathecal catheter in place for management of chronic axial low back pain. Magentic resonance imaging (MRI) revealed a posterior epidural abscess from T12 to L2. Two Touhy needles were placed in the epidural space with fluoroscopic guidance for drainage of the abscess. A catheter was then advanced into the epidural space for irrigation with saline and an antibiotic solution. Intravenous antibiotics were continued for a total of 6 weeks. Radicular pain resolved immediately post-procedure. Serial MRIs also showed decreasing size of the abscess.Conclusion. Posterior spinal epidural abscesses may be successfully treated by way of the two Touhy needle and catheter technique for drainage and irrigation. This procedure should be reserved for patients that present with no neurological deficits or deemed nonsurgical candidates. Patients should continue on prolonged intravenous antibiotics and be monitored closely for clinical deterioration and undergo serial follow-up MRIs.

Pain Practice, 2011

Pain in patients with cancer can be refractory to pharmacological treatment or intolerable side e... more Pain in patients with cancer can be refractory to pharmacological treatment or intolerable side effects of pharmacological treatment may seriously disturb patients' quality of life. Specific interventional pain management techniques can be an effective alternative for those patients. The appropriate application of these interventional techniques provides better pain control, allows the reduction of analgesics and hence improves quality of life. Until recently, the majority of these techniques are considered to be a fourth consecutive step following the World Health Organization's pain treatment ladder. However, in cancer patients, earlier application of interventional pain management techniques can be recommended even before considering the use of strong opioids. Epidural and intrathecal medication administration allow the reduction of the daily oral or transdermal opioid dose, while maintaining or even improving the pain relief and reducing the side effects. Cervical cordotomy may be considered for patients suffering with unilateral pain at the level below the dermatome C5. This technique should only be applied in patients with a life expectancy of less than 1 year. Plexus coeliacus block or nervus splanchnicus block are recommended for the management of upper abdominal pain due to cancer. Pelvic pain due to cancer can be managed with plexus hypogastricus block and the saddle or lower end block may be a last resort for patients suffering with perineal pain. Back pain due to vertebral compression fractures with or without pathological tumor invasion may be managed with percutaneous vertebroplasty or kyphoplasty. All these interventional techniques should be a part of multidisciplinary patient program.

Pain Practice, 2011

Pain in patients with cancer can be refractory to pharmacological treatment or intolerable side e... more Pain in patients with cancer can be refractory to pharmacological treatment or intolerable side effects of pharmacological treatment may seriously disturb patients' quality of life. Specific interventional pain management techniques can be an effective alternative for those patients. The appropriate application of these interventional techniques provides better pain control, allows the reduction of analgesics and hence improves quality of life. Until recently, the majority of these techniques are considered to be a fourth consecutive step following the World Health Organization's pain treatment ladder. However, in cancer patients, earlier application of interventional pain management techniques can be recommended even before considering the use of strong opioids. Epidural and intrathecal medication administration allow the reduction of the daily oral or transdermal opioid dose, while maintaining or even improving the pain relief and reducing the side effects. Cervical cordotomy may be considered for patients suffering with unilateral pain at the level below the dermatome C5. This technique should only be applied in patients with a life expectancy of less than 1 year. Plexus coeliacus block or nervus splanchnicus block are recommended for the management of upper abdominal pain due to cancer. Pelvic pain due to cancer can be managed with plexus hypogastricus block and the saddle or lower end block may be a last resort for patients suffering with perineal pain. Back pain due to vertebral compression fractures with or without pathological tumor invasion may be managed with percutaneous vertebroplasty or kyphoplasty. All these interventional techniques should be a part of multidisciplinary patient program.

Pain physician

Chronic persistent pain as a result of terminal illness, either as a consequence of the disease o... more Chronic persistent pain as a result of terminal illness, either as a consequence of the disease or the necessary treatment, is common in patients with cancer. For these patients with moderate-to-severe intractable pain, intrathecal (IT) drug delivery systems may represent an effective option for pain management. Thus, IT drug delivery is a viable treatment strategy for both neuropathy and nociceptive pain in the cancer population. However, there is a scarcity of comprehensive guidelines in implanting IT drug delivery systems in the treatment of pain caused by cancer. This article outlines consensus guidelines for the implementation of intrathecal therapy in patients with cancer-related pain and other end of life states causing pain. We highlight the multidisciplinary criteria that warrant careful consideration to ensure meaningful analgesia. Evidence was compiled, ranked, and strength considered by an invited panel of well-published and innovative clinician research leaders in pain ...

Neuromodulation : journal of the International Neuromodulation Society, 2014

The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulati... more The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society (INS) evaluated evidence regarding the safety and efficacy of neurostimulation to treat chronic pain, chronic critical limb ischemia, and refractory angina and recommended appropriate clinical applications. The NACC used literature reviews, expert opinion, clinical experience, and individual research. Authors consulted the Practice Parameters for the Use of Spinal Cord Stimulation in the Treatment of Neuropathic Pain (2006), systematic reviews (1984 to 2013), and prospective and randomized controlled trials (2005 to 2013) identified through PubMed, EMBASE, and Google Scholar. Neurostimulation is relatively safe because of its minimally invasive and reversible characteristics. Comparison with medical management is difficult, as patients considered for neurostimulation have failed conservative management. Unlike alternative therapies, neurostimulation is not associated with medi...

Pain physician, 2005

The lifetime prevalence of spinal pain has been reported as 54% to 80%, with as many as 60% of pa... more The lifetime prevalence of spinal pain has been reported as 54% to 80%, with as many as 60% of patients continuing to have chronic pain five years or longer after the initial episode. Spinal pain is associated with significant economic, societal, and health impact. Available evidence documents a wide degree of variance in the definition and the practice of interventional pain management. To develop evidence-based clinical practice guidelines for interventional techniques in the management of chronic spinal pain, with utilization of all types of evidence, applying an evidence-based approach, with broad representation of specialists from academic and clinical practices. A systematic review of diagnostic and therapeutic interventions applied in managing chronic spinal pain by a policy committee. Design consisted of formulation of essentials of guidelines and a series of potential evidence linkages representing conclusions, and statements about relationships between clinical interventio...

Anesthesiology, Jan 27, 2015

Current treatments for chronic pain have limited effectiveness and commonly known side effects. G... more Current treatments for chronic pain have limited effectiveness and commonly known side effects. Given the prevalence and burden of intractable pain, additional therapeutic approaches are desired. Spinal cord stimulation (SCS) delivered at 10 kHz (as in HF10 therapy) may provide pain relief without the paresthesias typical of traditional low-frequency SCS. The objective of this randomized, parallel-arm, noninferiority study was to compare long-term safety and efficacy of SCS therapies in patients with back and leg pain. A total of 198 subjects with both back and leg pain were randomized in a 1:1 ratio to a treatment group across 10 comprehensive pain treatment centers. Of these, 171 passed a temporary trial and were implanted with an SCS system. Responders (the primary outcome) were defined as having 50% or greater back pain reduction with no stimulation-related neurological deficit. At 3 months, 84.5% of implanted HF10 therapy subjects were responders for back pain and 83.1% for leg...

Pain Medicine, 2011

Painful vertebral compression fractures (VCFs), whether pathologic or osteoporotic, are a sourc... more Painful vertebral compression fractures (VCFs), whether pathologic or osteoporotic, are a source of morbidity in cancer patients. At our tertiary cancer center, over the past decade we have used vertebroplasty (VP) and kyphoplasty (KP) to treat painful VCFs. More data are needed on the treatment of VCFs in cancer patients with these techniques. We retrospectively reviewed the medical records of cancer patients with painful VCFs that had been treated at our institution between January 1, 2001 and May 31, 2008. Information was collected on demographic and clinical characteristics, features of the fractures, procedural details, and complications. Pre- and post-procedural pain and related symptoms were assessed using a subset of patients who had responded to the Brief Pain Inventory and the Edmonton Symptom Assessment Scale. A total of 407 cancer patients had 1,156 fractures that had been treated with VP or KP during 536 surgical procedures. Patients had an average of 2.8 fractures (range, 1-10). The majority of patients had pathologic fractures due to multiple myeloma (43%) or osteoporotic fractures (35%). Most fractures occurred in the thoracolumbar region. Adjacent-level fractures occurred in 18% of patients. Surgery provided significant relief from pain and several related symptoms. Symptomatic, serious complications requiring open surgery occurred in two cases (<0.01%) in our series. Our single-center experience revealed that a large number of cancer patients suffer from painful VCFs. The use of VP or KP in treating painful VCFs in cancer patients has good efficacy and an acceptably low complication rate.

Neurosurgery, 2015

most recent follow-up. Fifty percent improvement in headache was the only predictor of outcome va... more most recent follow-up. Fifty percent improvement in headache was the only predictor of outcome variables combined (total MIDAS, MIDAS-B, and BDI) (P ¼ .021). Of note, this improvement in functional outcome was only significant during the perioperative period and not throughout the length of follow-up. No other predictive factors were significantly correlated with the functional outcomes. Among the predictor variables, a strong correlation was found for disability status being inversely related to reporting 50% improvement in headache (r ¼ 20.582).

Neuromodulation: Technology at the Neural Interface, 2014

The International Neuromodulation Society (INS) has determined that there is a need for guidance ... more The International Neuromodulation Society (INS) has determined that there is a need for guidance regarding safety and risk reduction for implantable neurostimulation devices. The INS convened an international committee of experts in the field to explore the evidence and clinical experience regarding safety, risks, and steps to risk reduction to improve outcomes.

Neuromodulation: Technology at the Neural Interface, 2014