Pain Medicine最新文献

Introduction: Spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS) are used to treat refractory pain, but even well-selected patients can fail to have analgesic benefit following implantation. The analgesia afforded by SCS/PNS may be enhanced or attenuated by the ongoing use of analgesic medications that are often consumed by patients who receive SCS and PNS implants. We undertook a scoping review to scan and summarize the evidence for impact of adjuvant pharmacotherapy on SCS and PNS therapy in animal and human settings.

Materials and methods: A comprehensive medical literature review was performed on major medical databases including MEDLINE, EMBASE, CINAHL, CENTRAL, and Google Scholar from inception until July 31, 2024, for both human and animal studies. Data on the effect of pharmacotherapy on SCS analgesic efficacy and adverse effects were extracted and summarized using the Arksey and O'Malley population, concept, context model for scoping reviews.

Results: Twenty-seven studies, 9 on animals and 18 on humans were identified. In human studies, SCS non-responders with neuropathic pain had analgesia restored by addition of intrathecal baclofen and clonidine. Patients who eliminated opioid use, or who were opioid naive, had superior clinical outcomes with SCS compared to those continuing opioids. Cannabinoids were associated with enhanced SCS analgesia. Patients on benzodiazepines had higher likelihood of SCS explantation. Animal studies showed intrathecal ketamine restored SCS analgesic benefits, while baclofen, clonidine, cannabinoid receptor agonists, tricyclic antidepressants, serotonin, and norepinephrine reuptake inhibitors, augmented SCS responses while benzodiazepines were found to inhibit analgesic effects of PNS.

Conclusions: This review indicates that adjunctive analgesic therapy may play a significant role in either enhancing or attenuating analgesic benefits from SCS and PNS. By optimizing the use of analgesic medications, it may be possible to restore or enhance pain relief from both SCS and PNS.

Objective: To estimate the prevalence of serious spinal pathologies and nonspinal conditions in people seeking care for low back pain.

Methods: Literature searches were conducted in 6 electronic databases. Observational studies investigating the prevalence of serious spinal pathologies and nonspinal conditions in adults seeking health care for a complaint of low back pain were considered eligible. Risk of bias was assessed with a tool for prevalence studies. Meta-analyses using random effect models were conducted to obtain pooled prevalence estimates.

Results: Eleven studies were included in this review; most (64%) were at low risk of bias. With moderate certainty of evidence, the pooled prevalence of serious spinal pathologies was 2.9% (95% confidence interval: 1.6% to 5.2%) in people with a complaint of low back pain at presentation. The prevalence, however, varied by setting: primary care, 0.8%; emergency department, 2.1%; secondary care, 4.6%; and tertiary care, 6.9%. With moderate certainty of evidence, the prevalence of individual serious spinal pathologies ranged from 0.3% for cauda equina syndrome to 2.4% for spinal fracture. The prevalence of nonspinal conditions from Australian emergency department studies varied greatly, ranging from 21.5% to 58.3%.

Conclusion: The prevalence of serious spinal pathologies and nonspinal conditions varied greatly. Differential diagnostic strategies with clear care pathways need to be available to ensure a prompt diagnosis of serious spinal pathologies and nonspinal conditions.

Study registration: PROSPERO CRD42022352568.

Importance: Knee osteoarthritis (OA) is a prevalent and disabling condition, especially in older adults. For patients who are not candidates for total knee arthroplasty (TKA) due to comorbidities or limited access to care, minimally invasive pain-relief options are critically needed.

Objective: To assess the efficacy and safety of ultrasound-guided chemical neurolysis using 95% ethanol targeting four genicular nerves in patients with symptomatic knee OA who have not responded to conservative management.

Design: Double-blind, randomized, sham-controlled clinical trial.

Participants: A total of 100 adults with symptomatic knee OA, confirmed radiographically and unresponsive to conservative treatment, were enrolled and randomized.

Interventions: Patients were randomized to receive ultrasound-guided chemical neurolysis of the superomedial, superolateral, recurrent tibial, and inferomedial genicular nerves with 95% ethanol (treatment group) or a sham procedure (control group).

Main outcomes and measures: The primary outcome was pain intensity measured by the Numerical Rating Scale (NRS) at 7 days, 30 days, 3 months, and 6 months post-procedure. Secondary outcomes included opioid consumption and health-related quality of life measured by the EQ-5D-5L questionnaire. Safety outcomes focused on the occurrence of neurological complications. Analyses were conducted using an intention-to-treat approach with appropriate handling of missing data.

Results: Patients in the ethanol neurolysis group experienced significantly greater reductions in NRS scores at all follow-up points compared to the sham group (P < .0001). Opioid consumption was also significantly reduced in the neurolysis group throughout the 6-month period (P < .0001). Quality of life, as assessed by EQ-5D-5L, improved significantly in the treatment group (P < .0001). No neurological deficits or serious adverse events were reported in either group.

Conclusions and relevance: Ultrasound-guided chemical neurolysis of the SMGN, SLGN, RTGN, and IMGN with 95% ethanol is a safe and effective minimally invasive treatment for patients with refractory knee OA pain. It significantly reduces pain and opioid use while improving quality of life, making it a valuable therapeutic option for individuals ineligible for surgical intervention.

Importance: The CDC recommends initiating opioids for pain treatment at the lowest effective dose and duration; however, how dose, duration, and drug type jointly influence opioid use disorder risk remains a critical gap not addressed by current guidelines.

Objective: We examine how interactions between dose, duration, and other medication factors (eg, drug type) influence opioid use disorder (OUD) risk.

Design, setting, participants, interventions: Using Medicaid claims data (2016-2019) from 25 states, we analyzed opioid-naïve adults, newly diagnosed with musculoskeletal pain who initiated opioids within 3 months of diagnosis. A 6-month washout confirmed no prior opioid exposure or musculoskeletal diagnosis. Initial opioids were categorized by "dose-days supplied" (low [>0-20 mg MME] to very high [>90 mg MME] dose, and short [1-7 days] to moderate [>7-30 days] supply) and by opioid type; physical therapy (PT) sessions were also recorded. Using Poisson regression models, we estimated the OUD risk associated with dose-days categories, adjusting for baseline demographics, clinical characteristics, and medications. We separately examined opioid dose-days and PT, and assessed PT's moderating effect on dose-days' impact.

Results: Among 30 536 patients, half initiated opioids at 20-50 MME for 1-7 days, and 20% received PT. OUD risk was 2-3 times higher for opioids initiated for >7-30 days compared to 1-7 days across doses, and 5.5 times higher for opioids initiated for >7-30 days at >90 MME versus 1-7 days at <20 MME. PT alone, neither affected OUD risk nor mitigated the increased risk from longer or higher dose opioids.

Conclusions: Our findings support the need for careful opioid prescribing and alternative pain management strategies, as the observed associations between initial prescription characteristics and OUD were not mitigated by adjunctive PT.

Relevance: This study demonstrated that initial opioid prescriptions of 7-30 days, especially above 90 MME/day, increased OUD risk in opioid-naïve patients with musculoskeletal pain; physical therapy did not mitigate the risk. Different opioids posed varied risks, even at the same dose and duration. Careful prescribing and alternative pain management are essential.

Purpose: Lesions of the vertebral endplates (Modic changes) are associated with low back pain (LBP), and different pathological processes, including inflammation, have been proposed as causative. This study aimed to explore the relationship between [18F]FDG uptake (inflammation) and [18F]NaF uptake (bone remodeling) and patient-reported back pain as well as conventional MRI detected endplate changes.

Methods: Participants were selected from an IRB-approved study, creating 2 arms: [18F]NaF (n = 11) and [18F]FDG (n = 11). Scans were performed on a 3.0 T PET-MRI scanner. An MSK radiologist rated endplates changes using Modic classification and a relative scale: None; only edema; edema > fat; edema=fat; edema< fat; only fat. Radiotracer uptake (SUVmax) in endplate-adjacent bone was measured using ROIs. VAS scores (0-10) for back pain were recorded before imaging. Generalized estimating equations assessed associations between pain and radiotracer uptake as outcomes and radiologic findings as predictors, adjusted for age, sex, and body mass index (BMI).

Results: The study included 220 endplates from 22 patients (110 per arm). Overall, pain was positively associated with edematous lesions (beta 0.21, P = .024) but not with fatty changes (beta 0.10, P = .567). In the [18F]NaF arm, tracer uptake was associated with edematous lesions (beta 1.79, P = .001) and with pain (beta 0.18, P = .007). In the [18F]FDG arm, tracer uptake was negatively associated with edematous lesions (beta -0.11, P = .013) and showed no significant association with pain (beta -1.50, P = .064).

Conclusion: Our study shows that [18F]NaF-PET-MRI detected bone-remodeling is more closely linked to painful vertebral end-plate degeneration than inflammatory [18F]FDG signal.

Importance: Endometriosis is a disease often associated with chronic pelvic pain. It affects around 190 million females of reproductive age globally.

Objective: To investigate the effect of physiotherapy techniques (PTs) in relieving endometriosis-associated pain.

Design: This systematic review and meta-analysis followed the PRISMA 2020 and Cochrane Handbook guidelines. The study protocol was followed and registered on PROSPERO (CRD42023474231).

Setting: A systematic search was conducted in 3 databases: PubMed, Embase, and Cochrane.

Participants: We used the following PICO strategy: population, women with endometriosis-associated pelvic pain; intervention, PTs; comparator, non-PTs; outcome, pelvic pain changes. The article selection was conducted by 2 independent reviewers.

Main outcome(s) and measure(s): Two authors extracted data independently from the eligible articles. For continuous outcomes, the mean difference (MD) in change scores between intervention and control groups was used as an effect size with a 95% confidence interval (CI). Within-group correlation of before- and after-treatment was assumed to be equal across groups and studies.

Results: Out of 8 eligible studies identified in our selection, 7 were included in the quantitative analysis. PTs were effective in reducing pain compared to non-PTs (MD -1.97, CI -2.99 to -0.95), and physiotherapy modalities (electrotherapy and laser devices) had the greatest reduction in pain levels (MD -2.03, CI -3.9 to -0.14) among all studies. Additionally, locally applied techniques resulted in greater pain reduction than the generally applied techniques.

Conclusion and relevance: Physiotherapy techniques are effective in reducing pain in women with endometriosis, especially when applied locally.

Objective: This study identifies distinct biobehavioral phenotypes among patients with chronic low back pain (cLBP) using Latent Profile Analysis (LPA).

Methods: These phenotypes were derived from baseline data from two cohorts within the NIH HEAL BACPAC consortium: BACKHOME, a large nationwide e-cohort (N = 3025) utilized for model training, and COMEBACK as external test set, a deep phenotyping cohort (N = 450) utilized for generalization. The analysis incorporated variables including pain characteristics, psychosocial factors, lifestyle habits, and social determinants of health. Model fit was optimized via 10-fold cross-validation with 100 bootstraps and evaluated using Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), and Entropy(uncertainty).

Results: Four classes were identified: Class 1 ("High Distress and Maladaptive Behaviors") displayed high levels of anxiety, depression, and fear avoidance. Class 2 ("Resilient and Adaptive Coping") exhibited low maladaptive behaviors and high pain self-efficacy. Class 3 ("Intermediate Maladaptive Patterns") represented moderate levels of psychological and behavioral challenges, while Class 4 ("Emotionally Regulated with High Pain Burden") demonstrated strong emotional regulation despite significant pain burden. Class sizes were 701, 413, 893, and 947 for the train set, and 127, 108, 95, and 68 for the test set, respectively. Fit metrics supported the model's performance and generalizability (BACKHOME (train set): AIC = 77 792, BIC = 78 338, Entropy = 0.82; COMEBACK(test set): AIC = 72 437, BIC = 73 880, Entropy = 0.81). Statistical analysis revealed significant differences between classes (P < .05) in key variables such as pain self-efficacy, fear avoidance, and emotional awareness, and changes in pain severity and health-related quality of life over time (P ≤ .001), indicating clinical utility.

Conclusions: Our findings highlight the heterogeneity of cLBP and suggest that tailored treatments targeting these distinct subgroups could improve clinical outcomes. This work advances our understanding of cLBP by providing a robust framework for identifying patient subgroups based on biobehavioral characteristics. Results underscore the value of LPA in uncovering clinically meaningful patterns in complex conditions like cLBP, paving the way for more personalized treatment approaches.