Pain physician最新文献

Background: Spinal muscular atrophy ( SMA ) is a rare genetic neuromuscular disorder characterized by progressive muscle atrophy and weakness. Nusinersen, the only US Food and Drug Administration-approved antisense oligonucleotide specifically for SMA management, is administered intrathecally. However, a substantial proportion of adult patients with SMA develop severe scoliosis, posing significant technical challenges for traditional lumbar puncture procedures. Real-time ultrasound guidance offers a potential solution for intrathecal nusinersen administration in these challenging cases.

Objectives: We sought to evaluate the technical feasibility and safety profile of real-time, ultrasound-guided intrathecal delivery of nusinersen in adult patients with SMA and complex spinal anatomy, including those with scoliosis or vertebral hardware.

Study design: Retrospective chart review.

Setting: This study was conducted at a single medical center.

Methods: The data were retrospectively collected from the medical records Of 26 adult patients with SMA who had challenging intrathecal access (scoliosis or vertebral hardware) and who underwent real-time ultrasound-guided intrathecal nusinersen administration. Real-time ultrasound-guided lumbar puncture was performed using either the paramedian sagittal oblique view translaminar approach or the coronal view transforaminal approach. Procedure time, technical success, and adverse events were noted.

Results: A total of 151 real-time, ultrasound-guided lumbar punctures were performed. All procedures were technically successful and well-tolerated. The mean procedure time for the paramedian sagittal oblique view translaminar approach was 10.5 ± 1.7 minutes for moderate scoliosis and 20.7 ± 9.3 minutes for severe scoliosis. The mean procedure time for the transforaminal approach, used when the paramedian sagittal oblique view translaminar approach was not feasible, was 22.5 ± 6.1 minutes. No severe adverse events were observed.

Limitations: This was a retrospective, single-center study with a relatively small sample size. Generalizability may be limited.

Conclusions: Real-time ultrasound-guided intrathecal administration of nusinersen is feasible and appears safe in adult patients with SMA and complex spinal anatomies. Further prospective, multi-center clinical trials are warranted to validate these findings and evaluate long-term safety and efficacy in a larger patient cohort.

Background: Pulsed radiofrequency (PRF) is a neuromodulatory technique that has been widely used for pain management and has recently gained attention as a nondestructive alternative to conventional radiofrequency ablation (RFA), particularly for peripheral neuropathic pain. Over the past decade, PRF has been increasingly investigated for its potential benefits in various chronic pain conditions.

Objective: This review aims to summarize the fundamental principles, mechanisms of action, available evidence, and clinical applications of PRF in chronic pain management.

Study design: Narrative review.

Methods: A comprehensive literature search was conducted using PubMed, Scopus, and Google Scholar for studies on PRF published up to 2024. Key words included "pulsed radiofrequency," "pulse radiofrequency," "pulsed RF," and "pulse RF." Relevant case reports, case series, observational studies, randomized controlled trials (RCTs), meta-analyses, systematic reviews, and review articles were included.

Results: PRF has shown promising results in managing various neuropathic pain conditions, particularly radicular pain and postherpetic neuralgia. Clinical evidence also supports its effectiveness in trigeminal neuralgia, occipital neuralgia, cervicogenic headache, chronic migraine, meralgia paresthetica, pudendal neuralgia, and coccygodynia, as well as musculoskeletal conditions such as knee osteoarthritis and shoulder pain. Emerging applications, including intraarticular and transcutaneous PRF, have demonstrated potential benefits. Adjusting PRF settings, such as high-voltage PRF, extended-duration PRF, and pulsed dose radiofrequency, may further enhance treatment effectiveness, though additional validation is needed.

Limitations: This review is narrative in nature and not a systematic analysis. The included studies vary in quality, ranging from case reports to systematic reviews, depending on the availability of research for each condition. Additionally, significant heterogeneity exists in PRF methodologies, treatment parameters, and outcome measures, with a lack of standardized protocols contributing to variability in clinical outcomes.

Conclusion: PRF is a safe, non-ablative technique that modulates pain through electrical fields. It has demonstrated effectiveness in neuropathic pain, particularly radicular pain and postherpetic neuralgia. PRF offers long-term pain relief with minimal risks, though further research is needed to optimize its parameters and expand its applications in chronic pain management.

Background: Observational studies have reported relationships among physical activity (PA), leisure sedentary behaviors (LSBs), lifestyle habits, and chronic pain (CP). However, these findings may be unreliable due to confounding biases.

Objectives: To evaluate the causal effects of PA, LSB, and lifestyle habits on CP.

Study design: This study performed a 2-sample Mendelian randomization to assess the causal effects of the 3 exposures of interest on MCP and evaluated the robustness of the results through a series of sensitivity analyses.

Setting: The genetic instruments were obtained from UK Biobank, which provides publicly accessible genome-wide association studies (GWAS) summary statistics based on individuals of European ancestry.

Methods: We used GWAS summary statistics of multisite chronic pain (MCP) in 387,649 individuals from the UK Biobank to identify genetically predicted MCP. Data on PA, LSBs, and lifestyle habits were derived from large GWAS datasets (n > 300,000). Causal effects were assessed by inverse variance weighted (IVW), MR-Egger, weighted median, maximum likelihood, and penalized weighted median. Sensitivity analyses, including MR-PRESSO, Cochran's Q test, MR-Egger intercept, and leave-one-out analysis, were performed to evaluate the robustness of the MR results.

Results: The results of univariable MR analyses indicated that genetically predicted computer use (OR = 0.905 [0.832, 0.984]) and strenuous sports or other exercises (SSOEs) (OR = 0.490 [0.361, 0.664]) reduced the risk of MCP. Watching television (OR = 1.320 [1.262, 1.380]) and smoking initiation (OR =1.164 [1.122, 1.207]) increased the risk of MCP. Reverse inference results showed that watching television (beta = 0.256 [0.170, 0.341]) and smoking initiation (OR = 1.475 [1.257, 1.732) were risk factors for MCP, while SSOEs (OR = 0.900 [0.871, 0.931) and VPA (OR = 0.945 [0.900, 0.993]) reduced the likelihood of MCP.

Limitations: This study was unable to use non-overlapping samples to assess the causal association in every 2-sample MR analysis due to the restriction of GWAS datasets, resulting in inevitable bias.

Conclusion: This study revealed that television-watching and smoking initiation increased the risk of CP, while computer use and vigorous PA served as protective factors.

Background: Low dose ketamine infusions (LDKI) may provide adequate adjuvant analgesia while reducing postoperative opioid consumption in specific populations, such as patients with opioid tolerance or high intensity postoperative pain. However, there is currently limited data on the incidence of central nervous system adverse effects such as delirium, hallucinations, agitation, sedation, or nightmares using LDKI in treating postoperative pain.

Objectives: We aimed to compare the incidence of central nervous system adverse effects in patients receiving an LDKI compared with patients not receiving an LDKI for the first postoperative 48 hours.

Study design: Unicentric prospective cohort comparative study.

Setting: An academic university hospital.

Methods: Patients older than 18 who underwent major orthopedic, abdominal, or thoracic surgery were grouped into those who received an LDKI (LDKI group, n = 101), and patients who did not receive ketamine (non-K group, n = 138) based on the responsible anesthesiologist decision. The LDKI group received a 0.1 mg/kg/h ketamine infusion as part of a multimodal analgesic plan. The primary outcome was a composite of postoperative LDKI-related central nervous system adverse effects (delirium, hallucinations, or nightmares) within the first 48 hours after exposure compared with the non-K group. The secondary outcomes were pain intensity and cardiovascular variables (blood pressure and heart rate).

Results: There were no differences in cognitive dysfunction (delirium), agitation or sedation between groups (P > 0.05). The primary composite objective of central nervous system symptoms occurred in 12.9% of the LDKI group compared with 2.2% in the non-K group. The adjusted risk of psychomimetic symptoms using propensity score matching was an odds ratio of 4.84 (95% CI, 1.33 - 17.76) with a P value < 0.016. The cumulative incidence of nightmares (8.9% vs 0.72%, P = 0.001) and hallucinations (6.8% vs 2.2%, P = 0.071) were both higher in the LDKI group.Hemodynamic variables were not statistically different between groups. Pain level was significantly lower in the LDKI group (P = 0.03), however, both groups presented a mean Visual Analog Scale score below 4 mm.

Limitations: Our study is limited by its observational method, since no intervention was assigned by the investigator.

Conclusions: An LDKI (0.1 mg/kg/h) for postoperative pain is associated with a low incidence of minor central nervous system effects, i.e., nightmares and hallucinations. There is no significant association with major central nervous system adverse effects, such as delirium, sedation, or agitation, supporting its safety as an adjuvant in multimodal analgesia.

Background: Chronic post-herniorrhaphy inguinal pain (CPIP) is a significant complication following inguinal hernia repair, affecting 2-5% of patients with severe pain. The condition is characterized by persistent pain lasting more than 3 months and often involves neuropathic mechanisms caused by nerve damage or inflammatory responses. CPIP exerts a substantial impact on patients' quality of life, and the management of the condition remains controversial and challenging.

Objectives: To evaluate recent literature on various interventions for treating chronic inguinal pain after inguinal hernia repair, including the outcomes thereof, and to suggest an evidence-based algorithmic approach to managing post-herniorrhaphy chronic pain.

Study design: Systematic literature review with qualitative data synthesis.

Setting: Published studies from January 2012 to February 2023 of patients with chronic post-herniorrhaphy inguinal pain.

Methods: A systematic review was conducted under PRISMA guidelines, analyzing studies published throughout a period of 11 years and 2 months from the MEDLINE/PubMed and EMBASE databases. The review included randomized controlled trials, prospective and retrospective studies, case series, and case reports focusing on CPIP treatments. We collected the demographic data (gender, age), main etiologies, and specific treatments applied in each study. Based on the reviewed evidence, we propose an algorithmic approach to managing patients with CPIP.

Results: The review incorporated 10 studies involving 152 patients, who were predominantly male (88.2%) with an average age of 49.7 years. Treatment approaches were classified into 3 main categories: nerve blocks or pulsed radio frequency, neurectomy, and neurostimulation/ablation techniques. Nerve blocks demonstrated the highest efficacy (up to 98.1% pain relief), followed by neurostimulation and ablation (approximately 92.8%). Neurectomy, though reported widely, showed variable success and higher invasiveness.

Limitations: A publication bias might have been present due to the inclusion of studies published only in English. The included studies also had heterogeneous methodologies. Additionally, we excluded gray literature, which could have caused publication limitation.

Conclusions: Despite significant advances in the understanding of CPIP, there remains no universally accepted treatment algorithm. Minimally invasive techniques, including nerve blocks, pulsed radio frequency, and neurostimulation, show promising results and should be prioritized before clinicians resort to such surgical interventions as neurectomy. This review highlights the need for multidisciplinary evaluation and proposes an evidence-based treatment algorithm to optimize CPIP management.