Current Pain and Headache Reports最新文献

Purpose of review: Occipital neuralgia, cervicogenic headache, and migraine are disorders that are commonly accompanied by neck pain. Although these disorders may present with similar features, coexist in the same patient, and have variable degrees of involvement of the C2 and C3 nerve roots, it is important to distinguish between these three entities, as the presumed diagnosis can lead to different diagnostic and therapeutic modalities.

Recent findings: Occipital neuralgia in particular is underdiagnosed, occipital nerve blocks are underutilized, and technical aspects that can influence the efficacy of occipital nerve blocks are not taught in most clinical training programs. There are often significant delays in referring refractory cases for interventional and surgical management. In patients presenting with headache and neck pain, making an accurate diagnosis is critical in order to optimize management. Without addressing comorbid diagnoses, patients tend to have suboptimal responses to both acute and preventative headache pharmacological therapies.

Purpose of review: This narrative review evaluates the efficacy and clinical applications of the rhomboid intercostal nerve block (RINB) for postoperative pain management. With growing interest in ultrasound-guided regional anesthetic techniques, RINB has emerged as a promising approach for thoracic, abdominal, and breast surgeries. We aim to synthesize current evidence on its analgesic effectiveness, opioid-sparing potential, and comparative advantages.

Recent findings: An ultrasound guided rhomboid intercostal nerve block (RINB), delivers anesthetic into the intercostal muscles to relieve chest wall pain, including thoracoscopic, abdominal, and mastectomy surgeries. Anesthetic delivered between the rhomboid major and intercostal muscle demonstrated clinical efficacy resulting in improved patient recovery, post-operative analgesia, and reduced opioid consumption. Clinical studies have demonstrated that RINB has comparable and even more effective analgesic efficacy of previously utilized ultrasound guided nerve blocks with an excellent safety profile in patients receiving thoracoscopic, abdominal, and mastectomy surgeries.

Purpose of review: Chronic discogenic low back pain (LBP) is a common cause of disability worldwide. Current management options include conservative, surgical, and minimally invasive interventional injections. Intradiscal orthobiological injections of platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC), and mesenchymal stem cells (MSCs) have been introduced as regenerative treatment options.

Recent findings: Many studies have demonstrated improvements in patients' reported outcomes (PROMs) measuring the areas of pain, disability, function, and satisfaction. The results are promising with statistical improvements shown throughout various studies. Adverse events such as increased pain and infection have been reported with these injections; however, the complication rate has yet to be delineated. Numerous studies report no adverse events in their sample size. The present investigation summarizes recent evidence for the efficacy and risks of PRP, BMAC, and MSC injections.

Purpose of review: Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), are widely prescribed for mental health disorders. These medications, however, are linked to increased bleeding risks related to inhibition of serotonin reuptake, which impairs platelet aggregation. The present investigation explores the pharmacodynamics of antidepressants, clinical evidence of bleeding complications, and strategies to manage these risks.

Recent findings: While SSRIs and SNRIs pose the highest risk, tricyclic and atypical antidepressants show comparatively lower bleeding incidences. The concomitant use of anticoagulants, NSAIDs, or antiplatelet agents significantly amplifies bleeding risk. Current guidelines stress individualized risk assessment, alternative drug selection, and preventive measures, such as gastroprotective agents. Future research may offer novel approaches to mitigate bleeding while maintaining therapeutic efficacy, ensuring the safety of antidepressants in clinical practices.

Purpose of review: Lumbar radiofrequency ablation (LRFA) is an interventional procedure that utilizes thermal energy to selectively ablate the lumbar medial branch nerves (LMBN) to provide relief from facet-mediated chronic axial low back pain. While LRFA is widely performed, considerable variability exists in its technical execution. This review aims to synthesize the current literature on key device- and procedure-related factors that influence radiofrequency lesioning and to clarify common misconceptions regarding LRFA.

Recent findings: Emerging evidence suggests that several device-related parameters-including cannula and needle size, active tip length, temperature settings, lesioning duration, and needle angulation-affect lesion size and clinical outcomes. However, the impact of adjunctive steroid administration on lesion characteristics and therapeutic efficacy remains inconclusive. Furthermore, while some concerns have been raised regarding the potential for LRFA to accelerate spinal degeneration, definitive evidence is lacking. There is, however, a plausible association between LRFA and multifidus atrophy. The use of motor testing prior to ablation is warranted. Current data support the safety of LRFA in patients with posterior spinal instrumentation and implantable devices. Device- and procedure-specific variables may significantly influence LRFA lesion characteristics and clinical outcomes. While the safety profile of LRFA is generally favorable, potential complications exist, underscoring the need for a nuanced understanding of optimal procedural techniques. Despite its widespread adoption, misconceptions persist regarding optimal approaches, safety considerations, and determinants of efficacy. This review critically evaluates the existing literature to address these controversies and provide an evidence-based perspective on LRFA.

Purpose of review: Gabapentin, introduced in the 1990s as an anticonvulsant and anti-epileptic drug, has become a cornerstone treatment for various neurological and pain-related conditions. Its approved uses include seizure disorders, postherpetic neuralgia, and restless leg syndrome, while off-label applications commonly include diabetic neuropathy, fibromyalgia, post-traumatic stress disorder, and insomnia. The efficacy of gabapentin stems from its ability to modulate voltage-gated calcium channels, reducing excitatory neurotransmitter release in the central nervous system. However, its pharmacological versatility is accompanied by significant risks, including weight gain and combination additive and/or synergistic opioid-related respiratory depression.

Recent findings: Weight gain, affecting up to 25% of patients, is primarily attributed to secondary effects such as altered gastrointestinal function and peripheral edema. This adverse effect can negatively impact treatment adherence, especially in patients with chronic conditions requiring long-term therapy. Patients with preexisting metabolic disorders face heightened risks, necessitating strategies like dietary counseling and tailored treatment adjustments to mitigate weight gain. In multimodal pain management, gabapentin mediated additive and/or synergistic effects with opioids enable reduced opioid doses but increase the risk of respiratory depression and overdose. These dose-dependent interactions amplify sedative effects, particularly in vulnerable populations such as the elderly. To optimize therapeutic benefits while minimizing risks, healthcare providers must adopt individualized treatment plans, carefully adjust dosages, and educate patients. Further research is essential to better understand mechanisms of action, improve safety profiles, and develop prescribing practices that balance efficacy with reduced adverse outcomes.

Objective: Chronic pain conditions are among the leading causes of years lost to disability. Low Dose Naltrexone (LDN) has anti-inflammatory and immunomodulatory properties. LDN, by blocking Toll-Like Receptors (TLR), prevents central sensitization and conversion of acute pain state to a state of chronic pain. This meta-analysis compared LDN's effectiveness in chronic pain syndromes based on published randomized trials.

Method: Seven studies were included after a systematic search and screening from PubMed, Embase, Scopus, Cochrane, and clinical trial registries. The efficacy outcome analyzed was the standardized mean difference (SMD), the Cohen's d, of change in pain scores between LDN and the comparator drugs using the random-effect model. Subgroup analyses by condition type and comparator were performed to analyze the effect of LDN. Adverse events were evaluated using incidence rate ratio(IRR), publication bias by funnel plot, risk of bias by Cochrane Risk of Bias tool version 2.0, and certainty of evidence by GRADE evaluation.

Results: LDN did not show a significant difference in pain response compared to control groups [d = -0.11 (95%CI -0.96 to 0.74); P = 0.31]. In fibromyalgia, LDN had improvement compared to placebo [d = -0.34 (95%CI -0.62 to -0.06); P = 0.0186]. Against active comparators, LDN had no difference [d = 0.67 (95% CI -4.69 to 6.02); P = 0.35]. Adverse events were increased with LDN compared to placebo [IRR = 1.4 (95% CI 1.12 to 1.75); P = 0.0026] but comparable to active comparators [IRR = 0.55 (95% CI 0.04 to 7.31); P = 0.65].

Conclusion: LDN is better than placebo in fibromyalgia pain management, and LDN is similar to active controls in chronic pain management.

Prospero registration number: CRD42024511451.

Purpose of review: As higher doses of ketamine are being used in numerous medical conditions such as Complex Regional Pain Syndrome (CRPS), it is critical to examine common adverse effects (AEs) explicitly associated with high doses of ketamine (HDK).

Recent findings: HDK is often associated with psychiatric symptoms such as agitation, anxiety, and sleep disturbances. Psychiatric effects have been documented in various methods of administration of HDK, including oral, intravenous, and intranasal formulations. Emesis is a common AE of HDK and is more prevalent at higher ketamine doses. Hepatotoxicity is common after HDK, is dose-dependent, and is usually transient. HDK-induced uropathy is another potential AE. When monitored appropriately, HDK administered in a hospital setting appears safe; practitioners should be mindful that certain AEs of HDK are likely dose-dependent.

Purpose of review: Cancer-related pain poses a significant clinical challenge, especially in advanced stages where systemic analgesic therapies become insufficient or intolerable. Intrathecal drug delivery systems (IDDS) offer targeted pain control while minimizing systemic exposure. However, the optimal trialing approach before permanent IDDS implantation remains contentious. This narrative review examines literature on IDDS trialing strategies in cancer pain management. A comprehensive search was conducted of PubMed, MEDLINE, and Embase databases and identified studies published up to January 2025. The review included prospective and retrospective studies, randomized controlled trials, cohort studies, and case series on trialing techniques, clinical outcomes, safety, tolerability, and efficacy. Key strateghies assessed include single-shot intrathecal bolus, multiple intrathecal boluses, continuous epidural infusion, and continuous intrathecal infusion. The review found significant variability in trialing practices, with limited high-quality comparative data to support standardized protocols. Trial success criteria varied widely, encompassing pain reduction, side effects, and patient-reported outcomes.

Recent findings: The studies described a range of trialing strategies with varying durations, opioid dosages, and criteria for success. However, due to the lack of direct comparisons between these approaches, it is difficult to draw clear conclusions about the relative effectiveness of continuous intrathecal, continuous epidural, and bolus-based trials. Some institutions bypassed trialing, prioritizing symptom relief over procedural risks.

Conclusion: This review highlights the need for individualized trialing strategies based on patient status, institutional preferences, and clinician expertise. Given the variability in current practices, further research is needed to establish evidence-based guidelines and optimize clinical decision-making.