Regional Anesthesia and Pain Medicine最新文献

Background: Neuropathic pain is a maladaptive and chronic condition with limited effective treatments. Although recent studies have suggested that certain lipid metabolites, like lysophosphatidylcholine (LPC), may contribute to chronic pain, their specific roles and mechanisms remain unclear.

Objective: This study investigated the role and mechanism of LPC(18:1), a lipid subtype, in neuropathic pain caused by nerve injury.

Methods: Using a mouse model of spinal nerve ligation, LPC(18:1) levels were measured in serum, dorsal root ganglion (DRG), spinal cord (SC) and cerebrospinal fluid (CSF). Nociception was assessed using von Frey and Hargreaves' methods, while molecular analyses explored inflammatory pathways and oxidative stress.

Results: LPC(18:1) levels significantly increased in the serum, DRG and CSF after nerve injury. Administration of LPC(18:1) induced heightened pain responses and activated inflammatory pathways, including protein kinase C (PKC) and extracellular regulated protein kinase (ERK) in the DRG, as well as glial cells in the SC. The findings suggested that oxidative stress played a role in LPC(18:1) production, and its effects were mediated by G protein-coupled receptor 132 (GPR132).

Conclusion: LPC(18:1) may serve as a potential biomarker and therapeutic target for managing neuropathic pain.

Introduction: This exploratory study investigates the potential of perineuromal hydrodissection as an adjunct to opioid therapy for postamputation pain, specifically focusing on residual limb and phantom limb pain (PLP). Given the correlations between acute pain and the development of chronic pain, the primary aims were to estimate the effect size of early hydrodissection of scar tissue around residual limb neuroma(s) and to identify the best time frame for treatment.

Methods: Seventy-four patients with war-related limb amputations and painful neuromas were included in this observational analysis. Thirty-eight Ukrainian patients with war-related limb amputation and a painful neuroma(s) who underwent hydrodissection and opioid therapy within 6 months of amputation were compared with 36 patients who received opioids alone. Co-primary outcome measures were median reduction from baseline in average residual limb and PLP at 12 weeks. The composite positive outcome was designated as a ≥2-point decrease or 30% reduction in average residual limb and PLP, satisfaction with treatment, and not requiring an increase in analgesics.

Results: Hydrodissection as an add-on to opioids resulted in a greater reduction in average residual limb pain at 12 weeks (-2.00±1.00 vs -1.00±1.00; p<0.001) and earlier time periods, but PLP only through 4 weeks. At 12 weeks, Hospital Anxiety and Depression Scale anxiety (10.00±2.00 vs 11.00±1.00; p<0.001) but not depression score was lower in the hydrodissection group. Opioid use in the hydrodissection group significantly declined from 41.32±9.63 to 33.42±8.78 morphine equivalents per day (p=0.001) over the study, but not in the opioid-only group (p=0.20). Differences in 12-week satisfaction rates were not significant.

Conclusions: This exploratory study suggests perineuromal hydrodissection may improve residual limb pain and to a lesser degree phantom limb pain, particularly when implemented early in the course of postamputation pain. The study provides preliminary effect size estimates and identifies acute pain as a potential characteristic of patients who may respond more favorably to this intervention. Randomized controlled trials are needed to confirm these findings and control for the confounding variables identified.

The infrapatellar branch of the saphenous nerve (IPBSN) is implicated in nerve injury from different knee surgeries because of its intimate course relative to the knee joint capsule. Pain physicians encounter patients in their practice for the management of neuralgia of this nerve or in the context of advanced management of knee osteoarthritis. This article aims to provide a comprehensive review of the anatomy, sonoanatomy, and the intervention of the IPBSN in pain management of infrapatellar neuralgia and chronic knee pain.

Background: Intra-articular corticosteroid (IACS) injection and peri-articular corticosteroid injection are commonly used to treat musculoskeletal conditions. Results vary by musculoskeletal region, but most studies report short-term benefit with mixed results on long-term relief. Publications showed adverse events from single corticosteroid injections. Recommended effective doses were lower than those currently used by clinicians.

Methods: Development of the practice guideline for joint injections was approved by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine and the participating societies. A Corticosteroid Safety Work Group coordinated the development of three guidelines: peripheral nerve blocks and trigger points; joints; and neuraxial, facet, and sacroiliac joint injections. The topics included safety of the technique in relation to landmark-guided, ultrasound-guided, or radiology-aided injections; effect of the addition of the corticosteroid on the efficacy of the injectate; and adverse events related to the injection. Experts on the topics were assigned to extensively review the literature and initially develop consensus statements and recommendations. A modified version of the US Preventive Services Task Force grading of evidence and strength of recommendation was followed. A modified Delphi process was adhered to in arriving at a consensus.

Results: This guideline focuses on the safety and efficacy of corticosteroid joint injections for managing joint chronic pain in adults. The joints that were addressed included the shoulder, elbow, hand, wrist, hip, knee, and small joints of the hands and feet. All the statements and recommendations were approved by all participants and the Board of Directors of the participating societies after four rounds of discussion. There is little evidence to guide the selection of one corticosteroid over another. Ultrasound guidance increases the accuracy of injections and reduces procedural pain. A dose of 20 mg triamcinolone is as effective as 40 mg for both shoulder IACS and subacromial subdeltoid bursa corticosteroid injections. The commonly used dose for hip IACS is 40 mg triamcinolone or methylprednisolone. Triamcinolone 40 mg is as effective as 80 mg for knee IACS. Overall, IACS injections result in short-term pain relief from a few weeks to a few months. The adverse events include an increase in blood glucose, adrenal suppression, detrimental effect on cartilage lining the joint, reduction of bone mineral density, and postoperative joint infection.

Conclusions: In this practice guideline, we provided specific recommendations on the role of corticosteroids in joint, bursa, and peritendon injections for musculoskeletal pain.

Objective: To identify factors associated with poor postoperative pain experience by examining patient-related and procedural variables.

Methods: An exploratory secondary analysis was conducted on data from 971 adult patients undergoing elective surgery under general anesthesia across five French teaching hospitals. Preoperative anxiety was assessed using the Amsterdam Preoperative Anxiety and Information Scale (APAIS). Pain, sleep quality and well-being were measured preoperatively and postoperatively using visual analog scales (VAS). The primary endpoint was the patient experience measured by the Evaluation du Vécu de l'Anesthésie Generale (EVAN-G) questionnaire on postoperative day 1, with poor pain experience defined as a score below the 25th percentile on the EVAN-G pain dimension. Univariate and multivariate logistic regression analyses were performed to identify factors associated with poor pain experience.

Results: Poor pain experience was reported by 271 patients (27.9%). Multivariate analysis identified intraoperative use of remifentanil and sufentanil as an independent predictor of poor pain experience with an OR of 26.96 (95% CI 2.17 to 334.23, p=0.01). Additionally, age (OR 0.97, p=0.003), absence of premedication (OR 0.49, p=0.035) and orthopedic surgery (OR 0.29, p=0.005) were associated with a lower likelihood of poor pain experience. Conversely, American Society of Anesthesiologists (ASA) 3 status (OR 5.09, p=0.028), postoperative anxiolytic use (OR 8.20, p<0.001), amnesia (OR 1.58, p=0.001), higher VAS pain (p<0.001) and lower well-being scores (p=0.007) on day 1 were predictors of poor pain experience.

Conclusion: The intraoperative use of remifentanil and sufentanil is independently associated with poorer postoperative pain experience. These findings highlight the need to reassess intraoperative analgesic strategies to enhance patient outcomes and reduce postoperative complications.

Objective: Buprenorphine is an atypical opioid with analgesic efficacy and a more favorable safety profile than conventional opioids or tramadol. In 2019, access to on-label buprenorphine formulations was limited in comparison to conventional opioids, despite evidence supporting buprenorphine's first-line analgesic use. Considering recent policy changes increasing buprenorphine accessibility, we determined differences in unrestricted insurance coverage between buprenorphine, conventional opioids, and other atypical opioids.

Methods: We used data from Managed Market Insights and Technology's Coverage Search and Kaiser Family Foundation to generate estimates on percentages of US-covered lives with unrestricted access to oxycodone, morphine, tramadol, tapentadol, generic and on-label transdermal buprenorphine, on-label buccal buprenorphine, and on-label sublingual buprenorphine/naloxone in 2024.

Results: 79.7% of commercial and 99.1% of Medicare lives had unrestricted oxycodone access. Morphine access was unrestricted for 45.7% of commercial and 62.8% of Medicare lives. Unrestricted access to tramadol was available for 88.2% of commercial and 96.3% of Medicare lives. 37.3% of commercial and 10.1% of Medicare lives had unrestricted tapentadol access. Unrestricted access to on-label transdermal buprenorphine was available for 21.0% of commercial and 2.59% of Medicare lives. Generic transdermal buprenorphine was available for 52.1% of commercial and 30.0% of Medicare lives. Buccal buprenorphine was available without restriction for 52.7% of commercial and 19.8% of Medicare lives. Sublingual buprenorphine/naloxone had unrestricted coverage for 34.6% of commercial and 32.7% of Medicare lives.

Conclusions: Access to buprenorphine formulations was limited in comparison to other opioids. This study emphasizes a need for commercial and Medicare health insurance plans to broaden buprenorphine coverage.

Background: Clinical understanding of the obturator nerve's cutaneous and motor branches is crucial for performing effective obturator nerve blocks, particularly for procedures involving the thigh and hip. Literature and anatomical references report highly variable patterns of the frequency and cutaneous distribution of obturator nerve innervation.This study examines the frequency and distribution of the cutaneous branch of the anterior ramus of the obturator nerve (cb-ar-ON) and assesses the most effective anatomical sites for nerve blockade.

Methods: Dissections were conducted on 14 sides from eight cadavers to identify the presence, branching pattern and innervation areas of the cb-ar-ON. Ultrasound-guided injections of low-volume dye were performed proximally between the adductor longus and gracilis muscles and distally near the great saphenous vein to assess optimal targeting.

Results: cb-ar-ON were found in 43% of cadaveric sides, branching off the anterior ramus of the obturator nerve 6-10 cm distal to the inguinal ligament. When present, the cb-ar-ON innervated a 4-9 cm² area in the posteromedial popliteal fossa. Proximal ultrasound-guided blocks targeting the area between the adductor longus and gracilis muscles effectively stained the cb-ar-ON in 100% of cases where the branch was present.

Conclusion: The cb-ar-ON provides variable and limited cutaneous innervation, appearing in 43% of cases, primarily in the posteromedial popliteal fossa. Effective blockade can be achieved with a proximal approach between the adductor longus and gracilis muscles.These findings suggest that clinical evaluation of obturator nerve block based on cutaneous anesthesia is unreliable.