Pain physician最新文献

Background: Post-mastectomy pain syndrome (PMPS) is a chronic neuropathic condition thought to be mediated mainly by the sympathetic nervous system. Effective treatment options for PMPS include T2 and T3 sympathectomy, performed through either thermal radiofrequency (TRF) or chemical neurolysis.

Objectives: This trial compares the efficacy of pulsed radiofrequency (RF) to that of neurolysis for post-mastectomy pain relief.

Setting: This double-blinded, randomized trial was conducted in the National Cancer Institute of Cairo, Egypt.

Methods: Fifty-four female patients with PMPS that did not respond to stellate ganglion blocks were included in the trial. Patients were assigned to receive either TRF (80° C for 120 seconds) or chemical neurolysis (phenol 8%) under fluoroscopic guidance. Primary outcomes included reduced scores on the Visual Analog Scale (VAS). Secondary outcomes included PI changes, skin temperature, opioid and pregabalin consumption, incidence of breakthrough pain, complications, and quality-of-life scores on the 36-Item Short-Form Survey (SF-36).

Results: Both TRF and chemical neurolysis resulted in significant pain reduction, with improvements >= 50% in VAS scores (77.8% [TRF] vs. 85.2% [neurolysis], P = 0.484). Perfusion index (PI) scores increased more rapidly in the neurolysis group at 5 minutes (5.9 ± 0.9 vs. 5.3 ± 0.7, P = 0.008) but were comparable at 20 minutes. Opioid consumption and breakthrough pain episodes significantly decreased in both groups after the procedures. The TRF group had fewer complications but required a longer procedural duration (22 ± 2 min vs. 16 ± 2 min, P < 0.001).

Limitations: This trial took place as a single center study and used a limited sample size.

Conclusion: Both TRF and chemical neurolysis are effective for T2 and T3 sympathectomy in the management of PMPS. Although neurolysis provides faster PI changes, TRF can offer a potentially safer profile. PI can serve as a reliable tool for the assessment of T2 and T3 sympathetic blocks.

Background: The etiology of bone cancer pain (BCP) is multifaceted, and effective therapeutic strategies for treating the condition remain elusive. Prior research has implicated sirtuin 1 (SIRT1) in the pathogenesis of BCP, suggesting the protein's potential to modulate autophagy and mitigate nociceptive sensitization; however, the underlying mechanisms of BCP are not fully understood.

Objectives: This study aimed to elucidate the role of SIRT1 in activating autophagy and its impact on the development of nociceptive hypersensitivity in a rat model of BCP.

Study design: Controlled animal study.

Setting: Female Sprague Dawley® rats weighing 180-220 g were used.

Methods: The BCP model was established by a single injection of Walker 256 breast cancer cells (10 µL, 107cells/mL) into the tibia. Mechanical pain sensitivity was assessed behaviorally using an Electronic von Frey Anesthesiometer.

Results: Western blot (WB) analysis revealed reduced SIRT1 levels and elevated beclin-1 expression, an increased LC3II/LC3I ratio, and enhanced P62 expression in the dorsal horns of spinal cord tissues from rats with BCP. Immunofluorescence assays demonstrated co-localization of SIRT1 with neuronal cells and beclin-1. Subsequent experiments indicated that intrathecal administration of a SIRT1 agonist in rats with BCP postponed the downregulation of SIRT1, decreased the acetylation of beclin-1, and facilitated beclin-1 nuclear translocation. This treatment also led to a reduction in the LC3II/LC3I ratio and P62 expression levels. Collectively, these findings suggest that SIRT1 may ameliorate nociceptive hypersensitivity in rats with BCP through the promotion of beclin-1 nuclear translocation, thereby restoring autophagic flux.

Limitations: This study focused on peripheral/spinal mechanisms but not supraspinal/cortical contributions. Pharmacological tests were limited to a single time point, potentially missing dynamic pain changes during tumor progression. Nevertheless, the findings of this study offer valuable preliminary insights.

Conclusion: This research uncovers a novel mechanism of SIRT1 in the genesis of nociceptive hypersensitivity in BCP and offers potential avenues for therapeutic intervention.

Background: Patients undergoing thoracoscopic surgery often suffer from acute and chronic pain that severely affects their quality of life. To mitigate this, continuous intercostal nerve block (CINB) and patient-controlled intravenous analgesia (PCIA) can be used. However, no studies have compared the analgesic effects of CINB vs. PCIA among patients following video-assisted thoracoscopic surgery (VATS).

Objectives: To compare the analgesic efficacy of CINB with that of PCIA after VATS.

Study design: A prospective, randomized, controlled clinical trial.

Setting: Department of Anesthesiology, Affiliated Hospital of Qingdao University.

Methods: A total of 130 patients undergoing VATS were randomly assigned to the CINB or PCIA groups after the operation. The primary outcome was pain intensity assessed during rest and following coughing. This was measured using the visual analog scale (VAS) at 12, 24, 48, and 72 h, 2 months, and 3 months post-surgery. Secondary outcomes were adverse effects, location of pain, analgesic rescue, and patient satisfaction.

Results: Pain scores on rest and coughing 72 h after operation, as well as the VAS at 2 months post-VATS, were significantly lower in the CINB group than those in the PCIA group. The rates of surgical incision pain at 72 h and 2 months after surgery were significantly decreased in the CINB group compared with those in the PCIA group. Patients in the CINB group had a significantly lower incidence of adverse reactions, needed less analgesic rescue, and had higher satisfaction than those in the PCIA group.

Limitations: The limitations of this study include its short follow-up period and the single-center design.

Conclusions: CINB for patients undergoing VATS was superior to PCIA according to pain score, adverse effects, analgesic rescue, and patient satisfaction. CINB may be a viable alternative pain management for patients after VATS.

Background: Celiac plexus block (CPB) and celiac plexus neurolysis (CPN) are interventions used to treat chronic abdominal pain, particularly in cancer patients with pancreatic malignancy and patients who have chronic pancreatitis. Both CPB and CPN have been shown to significantly improve pain in patients with abdominal cancers while decreasing opioid consumption and side effects. Existing data on the technical variations and complications associated with both CPB and CPN are limited.

Objectives: We sought to examine the technical factors, patient demographic data, and intra- and post-operative complications and side effects of CBP and CPN.

Study design: We conducted a retrospective analysis of all patients at our institution who underwent CPB and/or CPN between September 2017 and February 2023. The study primarily included a chart review of patient data followed by statistical analysis.

Methods: Computed tomography-guided imaging was used for all patients' CPB and/or CPN procedures, which included injections of either lidocaine or ethanol, respectively. Data were collected on patient demographics and baseline disease status, procedural indications, procedural technique, and intra- and post-procedural complications. Patients were stratified based on malignant and nonmalignant pain indications.

Results: Of the 141 patients included in the study, 70.2% of were found to have undergone treatment for malignancy-related pain. When assessing needle position, there were no significant differences in technical data between groups. Rates of side effects, including hypotension, diarrhea, and localized pain, were overall low and similar to those reported in meta-analyses. There was a subjective improvement in pain in 67.4% of all patients.

Limitations: This study is limited by its retrospective observational nature and the inability to perform standardized pain scoring pre- and post-procedurally. Data on opioid use and consumption was inferred from prescribing data, which might not have accurately reflected real-world use. Despite these issues, this study provides insight into key patient data around CPB and/or CPN.

Conclusions: This study bridges a gap in the literature to address both technical variables and procedural complications of the CPB for patients with malignant and nonmalignant pain.

Background: Patients on regimens of a single calcitonin gene-related peptide (CGRP) may show a delayed response to migraine symptoms. Individuals on such regimens may not even exhibit a reduction of migraine symptoms within a reasonable time frame. Some clinicians have elected to combine small-molecule antagonists (SMAs) and ligand monoclonal antibodies (L-mAbs) to target CGRP molecules and receptors for the purpose of potentially providing increased synergistic relief.

Objectives: This study aimed to compare the safety and effectiveness of dual-CGRP therapy for patients receiving combined synergistic SMA and L-mAb to the safety and effectiveness of mono-CGRP treatment.

Study design: A retrospective matched cohort study.

Setting: This study was conducted at a single neurological center in the United States.

Methods: A retrospective matched cohort study at a neurological care center analyzed 90 chronic migraine patients who were aged >= 18 years and treated with CGRP inhibitors (L-mAbs: fremanezumab, galcanezumab, eptinezumab; SMAs: ubrogepant, rimegepant, atogepant; or a combination) between May 2018 and February 2024. The study compared 27 patients receiving dual L-mAb and SMA CGRP treatments with 63 patients receiving mono-L-mAb or mono-SMA CGRP treatments, matched by age and gender. Variables included current age, age at diagnosis, gender, onabotulinumtoxinA use, headache frequency, duration, severity, and associated symptoms before the treatment and 3 months after it. Adverse events were recorded for both treatment groups. All hypothesis tests were two-tailed and considered significant at a P-value < 0.05.

Results: Dual-CGRP therapy reduced headache severity by 20%, in contrast to the 10% reduction seen with mono-CGRP therapy (P = 0.039). Patients receiving dual-CGRP therapy also experienced an average reduction of 4 headache days, with some patients experiencing up to 14 fewer days, while mono-CGRP patients showed no change; however, this finding was not statistically significant (P = 0.112). No significant differences in other migraine-associated symptoms were found between the groups. Adverse events in the mono- and dual-CGRP groups were mild, with no serious adverse events or discontinuations reported.

Limitations: Limitations of our study include a relatively small sample size, the study's retrospective design, the absence of newer CGRP agents, an inability to control confounders, and the predominant use of a few CGRP inhibitors among patients.

Conclusion: Dual-CGRP regimens may enhance migraine symptom control by reducing headache severity without causing significant adverse events. However, these findings need confirmation through randomized, placebo-controlled clinical trials that use larger sample sizes.

Background: The main symptom of herpes zoster (HZ) is pain. While numerous antiviral agents, administered either orally or intravenously, have been recommended for treating this symptom in clinical practice, the optimal strategy for preventing HZ-associated pain remains uncertain.

Objective: This study aimed to evaluate the efficiency and safety of a novel analgesic mixture containing parecoxib for treating thoracic HZ neuralgia through ultrasound (US)-guided paravertebral blockades.

Study design: An open-label, prospective, randomized clinical trial.

Setting: A university hospital.

Methods: Sixty patients with thoracic HZ neuralgia receiving appropriate antiviral therapy and pregabalin treatment were randomly divided into 2 equally sized groups. Group C (the control group) received a conventional mixture (0.25% lidocaine + 1/4 betamethasone + 0.1% ropivacaine + saline, 15 mL volume). Group N received the experimental mixture (the above components + 1000 µg of methylcobalamin + 20 mg of parecoxib, 15 mL in volume). Under US-guidance, 15 mL of the assigned mixture was injected below the costotransverse ligament at the affected thoracic segment. The scores on the numeric rating scale (NRS) and Pittsburgh Sleep Quality Index (PSQI) were assessed at baseline and at 12 hours and then 7 days after treatment. Safety parameters (nausea, vomiting, constipation, injection site reactions, pneumothorax, local anesthetic toxicity, and respiratory depression) were monitored.

Results: Both groups showed significant reductions in their NRS scores and improvements to their sleep (P < 0.001). Compared to the control mixture, the novel drug combination was associated with superior NRS scores (P < 0.001) and significantly improved PSQI scores (P < 0.001) at 7 days after treatment. Side effects and complications (nausea, vomiting, constipation, injection site reactions, pneumothorax, local anesthetic toxicity, and respiratory depression) were not observed in either group of patients.

Limitations: The sample size of this study was relatively small. Study section and publication bias might have affected the general findings.

Conclusions: Compared to conventional treatment, US-guided paravertebral blocks that used the novel drug combination provided more sustained analgesia and greater sleep quality enhancement without additional safety concerns. This optimized formulation represents a promising therapeutic approach for treating thoracic HZ-associated neuralgia.