Pain physician最新文献

Background: Effective postoperative analgesia enhances the patient's comfort and facilitates early mobilization and recovery.

Objective: This study compared the analgesic efficacy of the erector spinae plane block (ESPB), thoracic paravertebral block (TPVB), and quadratus lumborum block (QLB) for pelvi-ureteric surgeries. The primary outcome measure in the study was the total morphine consumption during the first 48 hours following the operation. The secondary outcomes included the levels of postoperative pain, the time of first rescue analgesia, and the satisfaction of patients.

Study design: Randomized double-blind noninferiority trial.

Setting: Kafr Elsheikh University Hospitals, Egypt.

Methods: This trial was performed on 90 patients between the ages of 21 and 65, men and women, who had an American Society of Anesthesiologists physical status of I or II and were undergoing elective pelvi-ureteric surgeries. Patients were assigned equally to the TPVB, QLB, and ESPB groups. Before the induction of general anesthesia, blocks were performed using 20 mL of 0.25% bupivacaine. The numeric rating scale (NRS) score was measured in the post-anesthesia care unit at one, 2, 4, 6, 8, 12, 24, 36, and 48 hours. If the NRS score was ≥ 4, the patient received 3 mg of intravenous morphine.

Results: The time of the performing block was shorter in the ESPB group than in the TPVB or QLB group (P < 0.001), but the TPVB and QLB groups were comparable. The intraoperative consumption of fentanyl and total consumption of morphine at 24 and then 48 hours postoperatively were comparable among the 3 groups, as were the satisfaction of the patient, NRS scores, time of first rescue analgesia, and complications (P > 0.05).

Limitations: A relatively small sample size, a single-center setting, and the absence of a control group.

Conclusions: In pelvi-ureteric surgeries, the ESPB, TPVB, and QLB provided comparable intraoperative and postoperative analgesia, patient satisfaction, and postoperative complications, but the ESPB was performed more quickly. Therefore, we recommend the ESPB as a routine regional anesthetic technique.

Background: Recent research underscores the potential of intradiscal biologics, such as mesenchymal stem cells (MSCs), platelet-rich plasma (PRP), and alpha-2-macroglobulin, in promoting chondrogenesis within lumbar intervertebral discs as a treatment for discogenic low back pain. Studies indicate significant improvements in pain relief, physical function, and overall quality of life following these interventions.

Objective: This study aims to evaluate the effectiveness of intradiscal injections of MSCs and PRP in managing low back and lower extremity pain. A systematic review and meta-analysis were conducted to assess the outcomes of these treatments.

Study design: A systematic review and meta-analysis evaluating the efficacy of PRP and MSC injections for discogenic low back and lower extremity pain.

Data sources: The review included literature from PubMed, Cochrane Library, the U.S. National Guideline Clearinghouse (NGC), prior systematic reviews, and reference lists, covering studies from 1966 to September 2024.

Study selection: Randomized controlled trials (RCTs), observational studies, and case reports focusing on biologic injections into the disc were included.

Data extraction and synthesis: Data were extracted and assessed for methodological quality. Evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria and summarized based on best evidence synthesis principles on a 1-to-5 scale.

Results: The analysis included 8 RCTs (4 evaluating PRP, 5 evaluating MSCs) and 8 observational studies (4 assessing PRP, 4 assessing MSCs) for managing chronic low back pain. Evidence quality was deemed fair (Level III) with limited certainty and moderate recommendation strength based on qualitative and quantitative analyses.

Limitations: Paucity of high-quality studies.

Conclusion: This systematic review and single-arm meta-analysis suggest that intradiscal injections of MSCs and PRP may be effective in managing discogenic low back pain, supported by Level III evidence.

Background: The use of facet joint interventions for spinal pain management experienced rapid growth between 2000 and 2010, with an annual increase of 14.2%. However, this trend slowed significantly from 2010 to 2019, with a reduced growth rate of just 2.9% annually. A more recent analysis highlighted a steep decline in facet joint interventions and sacroiliac joint injections, with an overall decrease of 33.2% and an annual decline rate of 12% per 100,000 Medicare beneficiaries between 2019 and 2022.

Objective: This study aims to update and analyze utilization patterns of facet joint interventions for chronic pain management in the U.S. Medicare population over three periods: 2000-2010, 2010-2019, and 2019-2022.

Study design: A retrospective cohort study analyzing utilization trends and influencing factors for facet joint interventions in the FFS Medicare population in the United States from 2000 to 2022.

Methods: Data were obtained from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary database (2000-2022). Utilization rates were calculated based on Medicare beneficiaries for each year and expressed as procedures per 100,000 beneficiaries. Episodes or procedural visits included only primary codes, while services encompassed all procedure levels, including add-on codes.

Results: Utilization patterns showed substantial fluctuations. From 2000 to 2010, facet joint intervention rates grew at 14.4% annually, slowing to 2.2% from 2010 to 2019. The COVID-19 pandemic led to a 19.3% decline in episodes. From 2019 to 2022, episodes of facet joint interventions decreased by 21.2% per 100,000 beneficiaries, while the rate of services dropped by 37%, with an annual decrease of 14.3%. Specific declines included lumbar and cervical facet joint injections (38.8% and 40.2%, respectively) and lumbosacral and cervicothoracic facet joint neurolysis (33.6% and 30.8%, respectively). The reduction in facet joint injections and nerve blocks was greater than that observed for neurolytic procedures.

Limitations: Data were limited to the FFS Medicare population and were available only through 2022, excluding patterns for Medicare Advantage Plans, which covered nearly half of Medicare enrollees in 2022. Additionally, this study shares the common limitations of retrospective claims-based reviews.

Conclusion: This retrospective analysis reveals a substantial decline in facet joint intervention episodes, with an overall decrease of 21.2% per 100,000 Medicare beneficiaries and an annual decline rate of 7.6% for episodes from 2019 to 2022.

Background: Post dural puncture headache (PDPH) is a major challenging complication and may be a cause of morbidity after spinal anesthesia. Currently there is no definitive management for PDPH, so the search for effective treatment continues.

Objectives: Our aim was to investigate the analgesic effectiveness of oral prednisolone vs oral pregabalin for managing PDPH subsequent to spinal anesthesia for lower limb surgeries.

Study design: A prospective controlled double-blind randomized study.

Setting: Academic University Hospitals.

Methods: A total of 63 patients who had lower limb surgeries and suffered PDPH after spinal anesthesia were randomly allocated into one of 3 groups. Group C patients received conservative treatment and to maintain blinding, a tablet of vitamins was given to them twice per day for 3 days; Group P patients received conservative treatment and oral prednisolone 20 mg once daily plus one tablet of vitamins (in order to ensure blinding) for 3 days; Group G patients received oral pregabalin 150 mg twice daily for 3 days in addition to conservative treatment. The primary outcomes we measured were the Visual Analog Scale (VAS) score and modified Lybecker score. The secondary outcomes we measured were the total dose of rescue analgesia, the need for an epidural blood patch (EBP), and adverse effects from the study drugs.

Results: When comparing the intensity of headaches assessed through both the VAS and the modified Lybecker score, no statistically significant disparities were observed in relation to baseline measurements. While after starting treatment by 12 hours and 24 hours, the headache intensity was statistically significantly lower in Group G compared to Group P and Group C, but there was no significant difference between Group C and Group P at 12 hours. The headache intensity was statistically significantly higher in Group C compared to Group P and Group G, but there was no significant difference between Group P and Group G at 48 hours and 72 hours. Ketorolac consumption was statistically significantly higher in group C than the other groups. However, it was statistically significantly lower in group G than group P. Only 2 patients in group C were indicated for EBP while no patients in either Groups P or G required an EBP.

Limitations: Our study's limitations include the paucity of literature studying prednisolone and pregabalin use in PDPH, our study's small sample size, and the lack of sufficient studies for comparing results may limit the generalization of our findings.

Conclusion: Both oral prednisolone and pregabalin were effective in reducing PDPH severity; oral pregabalin is superior to prednisolone.

Background: Chronotype defines an organism's biological preference for timing of activity and sleep. Being a morning chronotype (i.e., tending to wake up early and go to bed earlier at night) is associated with protection against chronic musculoskeletal pain and headaches, but the relationship between chronotype and neuropathic pain sensitivity remains unclear.

Objectives: The aim of this pilot study was to explore the relationship among chronotype, neuropathic pain sensitivity, and pain interference in patients with chronic neuropathic pain disorders.

Study design: This was a prospective, observational, single-center, cross-sectional study.

Setting: Patients were recruited from pain management clinics.

Methods: The Morningness-Eveningness Questionnaire (MEQ) was used to evaluate circadian typology. Linear mixed-effects models, principal component analysis, and principal component regression were used to determine the predictors of pain intensity and pain interference evaluated by the Numeric Rating Scale (NRS) and Patient-Reported Outcomes Measurement Information System Pain Interference (PROMIS-PI) scores, respectively.

Results: We analyzed 38 adults who had at least one documented chronic neuropathic pain diagnosis. Morning-chronotype patients reported higher NRS scores over time and lower PROMIS-PI t-scores than did intermediate chronotypes. MEQ, depression, risk of sleep apnea, sleep quality, and body mass index (BMI) were all significant independent predictors of average NRS scores and PROMIS-PI t-scores.

Limitations: The population was small and homogeneously white, with an average age of 57 years. However, this population was representative of our pain clinic.

Conclusions: Morning chronotypes are more sensitive to chronic neuropathic pain, reporting higher pain scores than do intermediate chronotypes. However, in this study, morning chronotypes were more resistant to neuropathic pain interference, suggesting that they may experience less disturbance of their physical, mental, and social activities than intermediate chronotypes. Further, larger studies are needed.

Background: Hip osteoarthritis is a joint disease that causes  worsening pain and inhibits activities of daily living. Due to poor pain control and the function of usual clinical treatment, joint infiltration with orthobiologics is a therapeutic alternative. Among these, bone marrow aspirate (BMA) represents a cellular therapy with promising clinical results.

Objective: Our study aimed to assess the clinical response of joint infiltration with BMA for hip osteoarthritis.

Study design: We conducted a systematic review and meta-analysis of the main outcomes in hip osteoarthritis after infiltration with BMA and bone marrow concentrate (BMC).

Methods: We systematically searched PubMed, Embase, Cochrane, and Science Direct for studies evaluating patients with hip osteoarthritis who received joint infiltration with BMA or BMC. In the absence of studies with a control group, we performed a pairwise meta-analysis comparing results of a single group at follow-up vs baseline.

Results: We included 4 studies with improvement in Numeric Rating Scale pain scores associated with BMA or BMC therapy at 3 months (mean difference [MD], -3.48 points; 95% CI, -5.81 to -1.15), 6 months (MD, -3.25 points; 95% CI, -4.07 to -2.42), and 12 months (MD, -2.79 points; 95% CI, -3.83 to -1.74). There was also  a significant improvement in measurable quality of life through validated questionnaires at 3 months (standardized mean difference [SMD], -0.91; 95%, CI -1.59 to -0.23), 6 months (SMD, -1.38; 95% CI, -1.79 to -0.98), and 12 months (SMD, -1.30; 95% CI, -2.44 to -0.16).

Limitations: Among our study's limitations is the lack of a randomized controlled trial in the meta-analysis.  Also, since there was no comparator, we could not conduct a pairwise meta-analysis. Finally, the small sample size  limits the generalization of the findings.

Conclusion: In this meta-analysis, joint infiltration with BMA or BMC was associated with an improvement in pain and quality of life in patients with hip osteoarthritis. Further randomized studies are needed to improve the quality of evidence.