Current Pain and Headache Reports最新文献

Purpose of review: This narrative review addresses the growing public health concern of persistent opioid use following major orthopedic surgery. It aims to identify and analyze the critical factors that contribute to the transition from acute to persistent opioid consumption in this context.

Recent findings: Patient-related characteristics, including pre-existing conditions and prior substance use, are critical predictors of prolonged opioid use. Additionally, surgery-related factors such as the type and duration of procedures complicate postoperative pain management. The prevalence of persistent opioid use after surgery remains high despite the emergence of effective Enhanced Recovery After Surgery protocols and patient education initiatives. Multimodal analgesia is highlighted as a vital strategy for reducing the risk of long-term opioid dependency. Persistent opioid use after orthopedic surgery poses significant challenges, including increased risks of physical and mental health complications, the development of opioid use disorder, and a substantial economic burden on healthcare systems. Targeted interventions and continuous research are essential to mitigate these risks, reduce long-term opioid dependency, and improve overall patient outcomes.

Purpose of review: This review aims to summarize the current understanding of cluster headaches (CH) in children, focusing on epidemiology, pathophysiology, clinical characteristics, diagnostic challenges, treatment strategies, and future research directions.

Recent findings: Cluster headaches in children are infrequent, with an incidence that appears to be significantly lower than that observed in adults, highlighting the need for more comprehensive studies. Pediatric patients often present with atypical symptoms, such as shorter pain duration and less pronounced autonomic features, leading to frequent misdiagnosis or delayed diagnosis. The hypothalamus plays a central role in the pathophysiology of CH, involving circadian rhythm disturbances, trigeminal nerve-vascular activation, and autonomic dysfunction. High-flow oxygen and triptan medications are effective for acute treatment in adults, but their safety and efficacy in children require further validation. Preventive treatments, such as verapamil, are used cautiously in pediatric patients, with close monitoring for side effects. Non-pharmacological interventions, including lifestyle adjustments and psychological support, are critical for long-term management. Cluster headaches in children are a rare but debilitating condition that poses significant diagnostic and therapeutic challenges. Current diagnostic criteria, primarily based on adult data, may not fully capture the unique clinical features of pediatric patients, leading to misdiagnosis or missed diagnosis. Treatment strategies are largely extrapolated from adult studies, with limited evidence-based data for children. Future research should focus on improving diagnostic criteria, exploring pediatric-specific pathophysiological mechanisms, and validating safe and effective treatment options. Early identification and intervention are essential to improving the quality of life and long-term outcomes for pediatric patients.

Background: Refractory chronic migraine (rCM) is characterized by debilitating headaches that do not respond adequately to conventional medical treatments, leaving patients severely disabled. In these rare cases, central cervical spinal cord stimulation or occipital nerve stimulation (ONS) may offer a potential therapeutic option. However, these techniques are not without risks, lack clear scientific evidence, and impose a significant economic burden. Therefore, it is crucial to identify parameters that can assist physicians in selecting appropriate candidates for implantation. This study aimed to investigate the role of psychological profiles in predicting outcomes for ONS in rCM patients.

Methods: We conducted a retrospective analysis on rCM patients treated with ONS at a second-level neuromodulation university facility. These patients were refractory to conventional medical treatments, including onabotulinumtoxin-A injections (monoclonal antibodies targeting CGRP were not yet available). The NRS for migraine intensity, the number of monthly migraine attacks, and drug consumption were assessed at 6-month and 12-month follow-ups post-implant. Psychological profiles were evaluated prior to OCN using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). A multivariable logistic regression model was developed to predict ONS outcomes, incorporating MMPI-2 as a covariate. The model's accuracy and performance were assessed through non-parametric bootstrap, calibration, and discrimination analyses.

Results: Twenty-three rCM patients were analysed. ONS was able to significantly reduce the pain intensity, the number of headache attacks per month, and drug consumption compared to pre-treatment levels at both 6- and 12-month follow-ups. The final multivariable logistic model at 12 months showed that the MMPI-2 Depression score was independently and negatively associated with favourable outcomes following ONS (optimism-adjusted OR 0.52, 95% CI 0.21-0.77, p = 0.03). The ROC curve indicated high model sensitivity (AUC: 0.96, 95% CI: 0.88-0.98), and the calibration plot revealed a good fit, with some improvement needed in mid-range predicted probabilities.

Conclusion: ONS significantly reduced pain intensity, headache frequency, and drug use at the 12-month follow-up compared to pre-treatment levels. The MMPI-2 Depression score was an independent predictor of ONS failure, highlighting the importance of comprehensive psychological assessments in patient selection for ONS.

Purpose of review: This article assesses the current evidence and guidelines on peripheral nerve stimulation (PNS) and provides recommendations for its use in managing moderate to severe chronic pain.

Recent findings: PNS has been utilized for over 50 years in the treatment of chronic pain. However, since 2015, the Food and Drug Administration (FDA) has approved percutaneously implanted PNS leads and neurostimulators, providing a minimally invasive, non-opioid alternative for managing persistent and refractory chronic pain. The American Society of Interventional Pain Physicians (ASIPP) has established evidence-based consensus guidelines for the clinical use of PNS systems in addressing chronic pain. ASIPP guidelines performed extensive evidence synthesis, including systematic reviews, randomized controlled trials (RCTs), and observational studies using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria or certainty of evidence, and qualitative synthesis based on the best available evidence. The evidence level and recommendations showed fair evidence with moderate strength of recommendation for implantable PNS systems following a trial or selective lumbar medial branch stimulation without a trial and for temporary PNS for 60 days. This review offers a comprehensive analysis of peripheral neuropathic pain as a cause of chronic, intractable, function-limiting, and high-impact pain. It discusses the diagnosis of peripheral nerve and neuropathic pain, evidence evaluation and synthesis, medical necessity criteria, patient education, and clinical recommendations. The goal is to enhance patient outcomes by integrating PNS technology into clinical practice.

Purpose of review: Patients frequently report inadequate pain management following surgical procedures. Physicians must often prescribe analgesics, notably opioids, as a means of providing pain relief. Due to the addictive nature of this class of medications, improper post-surgical pain management propagates the United States opioid crisis. The administration of multimodal analgesia is a strategy implemented to decrease long-term outpatient prescription opioid use. Magnesium sulfate has recently attracted interest for its potential use as an adjunct in multimodal analgesia in addition to its other diverse uses in medicine. This review aims to highlight the most recent data validating the use of magnesium sulfate in perioperative multimodal analgesia.

Recent findings: A narrative review was conducted using PubMed and Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations. Articles that examined the effects of intravenous magnesium sulfate on perioperative pain and/or recovery from 1946 to present were considered. 15 articles met the inclusion criteria and discussed the use of magnesium sulfate as an adjunct in multimodal analgesia across the following surgical specialties: cardiac surgery, general surgery, gynecologic surgery, orthopedic surgery, urologic surgery, neurosurgery, and otolaryngology surgery. The results of the cited studies indicate that magnesium sulfate is a well-tolerated multimodal analgesic agent that reduces postoperative pain, reduces opioid consumption, and increases patient satisfaction.

Purpose of review: Notalgia paresthetica (NP) is a chronic sensory neuropathy characterized by localized pruritus and dysesthesia, most commonly affecting the upper back. Despite being a relatively common condition, it remains underdiagnosed and frequently mismanaged. This review covers the pathophysiology, clinical presentation, diagnostic evaluation, and treatment approaches for NP.

Recent findings: Recent studies support a multifactorial pathogenesis for NP, with compression or irritation of the dorsal rami of thoracic spinal nerves playing a central role. Imaging and electromyography have shown variable utility in diagnosis, while histological findings often lack specificity. Although there is no universally effective treatment, advances in topical medications, systemic oral medications, and interventional therapies may be considered. Physical therapy and postural correction remain important non-pharmacologic strategies. NP is a neuropathic condition with evolving diagnostic and therapeutic approaches. Early recognition, multidisciplinary evaluation, and individualized treatment plans are essential for improving patient outcomes. Further research is needed to establish standardized diagnostic criteria and long-term treatment efficacy.

Purpose of review: Chronic pain significantly impacts quality of life for millions globally, with spinal cord stimulation (SCS) as an established treatment for refractory chronic pain. However, traditional SCS therapies face limitations including inconsistent patient outcomes, challenges in patient selection, and difficulties in sustaining therapeutic efficacy. This review examines how artificial intelligence (AI) can enhance the efficacy and personalization of SCS therapy by optimizing patient selection, refining stimulation parameters, and enabling real-time adaptive adjustments.

Recent findings: Recent advances demonstrate that integrating AI with SCS significantly improves patient outcomes through predictive modeling for patient selection and real-time adaptive stimulation. Predictive analytics utilizing machine learning algorithms have successfully identified patient cohorts most likely to benefit from SCS therapy, enhancing response rates and reducing suboptimal outcomes. Closed-loop AI systems incorporating physiological feedback, such as evoked compound action potentials (ECAPs), dynamically optimize stimulation parameters, resulting in sustained pain relief, decreased programming burden, and improved device longevity. Despite these promising results, critical challenges persist, particularly related to data standardization, ethical considerations, and regulatory compliance. AI holds transformative potential for spinal cord stimulation, offering increased precision, personalization, and therapeutic efficiency in managing chronic pain. Although early results are encouraging, comprehensive clinical validation and multidisciplinary collaboration remain essential. Addressing ethical, regulatory, and data management challenges will be critical for widespread adoption of AI-enhanced SCS therapies in routine clinical practice.

Purpose of review: Chronic pain management presents significant emotional challenges for clinicians due to the complex and prolonged nature of the conditions they treat. This editorial aims to explore how emotional stressors, such as compassion fatigue, emotional labor, and ethical dilemmas, impact both clinician well-being and patient outcomes. It also emphasizes the need for effective strategies to address clinician stress and enhance overall care quality.

Recent findings: Healthcare professionals working in chronic pain management are particularly susceptible to emotional stress, which can lead to burnout, job dissatisfaction, and poor mental health. Research highlights the prevalence of stressors such as compassion fatigue, emotional labor, heavy workloads, and time pressures. These stressors contribute to a decline in clinician well-being, which in turn negatively impacts patient care quality. Many studies also point to the interconnection between clinician burnout and compromised patient outcomes, emphasizing the importance of addressing these issues. Addressing the emotional stress faced by clinicians in chronic pain care is crucial for improving both clinician satisfaction and patient outcomes. Effective strategies, including mindfulness practices, self-compassion, wellness programs, and flexible work schedules, have been identified as potential solutions to mitigate burnout and enhance clinician resilience. By implementing these strategies, healthcare systems can improve clinician well-being and ultimately provide higher-quality care to patients.

Purpose of review: Cardiac surgery is associated with significant postoperative pain. Compared to traditional analgesics, regional nerve blocks target specific anatomical areas to improve analgesia and to reduce postoperative opioid consumption.

Recent findings: Pecto-intercostal fascial plane block (PIFB) is a novel analgesic technique that involves ultrasound-guided injection of anesthetic between pectoralis major and external intercostal muscles. Since PIFB is a relatively underexplored method of analgesia, to date, few manuscripts have reviewed and synthesized current literature related to PIFB.

Conclusion: The present investigation focuses on relevant anatomy and physiology behind the PIFB, compares this novel technique with other traditional and novel methods of analgesia, and describes indications and contraindications for PIFB in cardiac surgery and other surgeries.

Purpose of review: The purpose of this educational review is to describe the contrast spread patterns that indicate accurate needle placement in the epidural space and spread patterns associated with erroneous needle insertion.

Recent findings: Epidural injections are minimally invasive and commonly used for patients with acute and chronic back pain that does not respond to conservative management. Imaging with contrast is frequently used during this procedure to improve accuracy and reduce adverse events. Contrast spread patterns are an important tool that can help identify where the needle is placed and whether the placement is accurate. Despite this, there may be discrepancies in the interpretation of spread patterns which ultimately reduce the utility of contrast. Inaccurate needle placement may result in intrathecal/subarachnoid, subdural, fascial, or retrodural space of Okada injections. The correct interpretation of contrast spread patterns on imaging is crucial for confirming accurate epidural needle placement. Furthermore, understanding contrast patterns of improper needle placement can prevent adverse events that result from injection outside of the epidural space.