Regional Anesthesia and Pain Medicine最新文献

Background: Chronic spinal pain with widespread symptoms often responds poorly to peripherally focused treatments. Cognitive-behavioral therapy (CBT) can help but typically yields modest effects. This trial evaluated whether adding resilience-enhancing activities to medical assistant-coached CBT (PRISM-CBT) improves outcomes.

Methods: Adults with spinal pain and fibromyalgia symptoms were randomized to PRISM-CBT (n=119), standard CBT (n=120), or usual care (UC; n=60). The primary outcome was the Fibromyalgia Impact Questionnaire-Revised (FIQR) global impact score at 8 weeks (0-100; higher=worse). Secondary outcomes were pain interference and pain severity measured with the Brief Pain Inventory (BPI) (0-10; higher=worse).

Results: The primary outcome showed no difference between PRISM-CBT and usual care at 8 weeks, with an adjusted between-group difference of 0.20 points (95% CI -4.81 to 5.20, p=0.939). Yet, by 12 months, PRISM-CBT demonstrated a 7.4-point greater improvement compared with usual care (95% CI 0.15 to 14.64, p=0.045) and a 4.8-point greater improvement versus CBT at 8 weeks (95% CI 0.00 to 9.57, p=0.050). PRISM-CBT produced the most consistent benefit in BPI pain interference. Compared with usual care, interference was lower by 0.88 points at both 8 weeks (95% CI 0.25 to 1.50, p=0.006) and 6 months (95% CI 0.23 to 1.54, p=0.009) and by 1.42 points at 12 months (95% CI 0.53 to 2.32, p=0.002). Compared with standard CBT, interference was lower at 8 weeks (0.98 points, 95% CI 0.38 to 1.57, p=0.001), 6 months (0.63 points, 95% CI 0.01 to 1.25, p=0.045), and 12 months (1.92 points, 95% CI 1.09 to 2.76, p<0.001). BPI pain severity also favored PRISM-CBT, with greater improvements of 0.56 points vs usual care at 6 months (95% CI 0.03 to 1.08, p=0.039) and 0.86 points vs CBT at 12 months (95% CI 0.19 to 1.53, p=0.011).

Conclusions: This scalable, medical assistant-coached digital program shows promising benefits, including greater reductions in pain interference and a long-term improvement in global symptom burden, despite no difference at the primary endpoint.

Background: There is paucity of data from randomized controlled trials supporting the use of peripheral nerve stimulation, a well-established therapy for the treatment of chronic pain. This study was undertaken, in part, to provide randomized controlled trial data in support of patient access to appropriate peripheral nerve stimulation therapy. The COMFORT study is the first large, postmarket, multicenter randomized controlled trials investigating the use of a Food and Drug Administration-cleared micro-implantable pulse generator (IPG) for treating chronic pain via peripheral nerve stimulation therapy.

Methods: Consented, eligible subjects were randomized to either the active arm, which received peripheral nerve stimulation and conventional medical management, or the control arm, which received conventional medical management alone and were allowed to cross over to the active arm, after 3 months. Pain and patient-reported outcomes were captured. Therapy responders were subjects who achieved at least a 50% reduction in pain scores compared with baseline. We are reporting the 12-month results of this 36-month study.

Results: At 12 months, the responder rate was 87% with a 69% average reduction in pain compared with baseline (7.5±1.2 to 2.3±1.7; p<0.001). Statistical significance was achieved for all patient-reported outcomes. There was an excellent safety profile with no serious adverse device effects or reports of pocket pain. A majority of subjects used unique programming options and found this device easy to use and comfortable to wear.

Conclusions: These 12-month results are consistent with previously reported 6-month outcomes from this study, showing durability of peripheral nerve stimulation treatment with the micro-IPG system; subjects realized sustained large reduction in pain and improvement in patient-reported outcomes following treatment with this micro-IPG system.

Trial registration number: NCT05287373.

'Less is More' reflects the idea of Ludwig Mies van der Rohe, who only retained the essentials in his designs. This principle is also applicable in different areas of pain medicine.Several pioneers have worked hard to introduce the multidisciplinary approach to obtain the most appropriate treatment for the patient. Most of those pioneers received the Bonica Award before me, and I am happy that those persons mentored me and stimulated me in understanding pain management and developing my career. Pain management has known a great evolution, from accepting pain because of an underlying disease to recognizing pain as the fifth vital sign. The rise in interest in (interventional) pain management evolved parallel to the introduction of evidence-based medicine. Most physicians welcome reviews summarizing the available literature. There are many pitfalls of systematic reviews and meta-analyses, such as the interpretation of the information, which is predominantly done by epidemiologists, who have little clinical background to make a distinction between the effect of the treatment in different diagnoses. Guidelines are based on correct diagnosis, weighing the potential for complications against the anticipated benefits, are progressively introduced and should guide physicians in establishing a treatment plan. A group of physicians normally prepares these guidelines.The golden rule in the treatment selection is 'Less is More'.

Background: Neuropathic pain presents a significant clinical challenge, with spinal cord epigenetic mechanisms playing a critical role in its development. This study investigated the impact of nerve injury on the Barrier-to-Autointegration Factor (BAF) in the rat spinal dorsal horn.

Methods: Adult Sprague-Dawley rats underwent spinal nerve ligation (SNL) to model neuropathic pain. Pain behaviors were assessed using von Frey and burrow tests. Biochemical analyses measured mRNA and protein expression in the dorsal horn.

Results: SNL elevated BAF levels, which interacts with LEM domain-containing protein 2 (LEMD2), activating the histone-modifying enzyme EZH2. This enzyme adds a gene-silencing mark, H3K27me3, to the promoter region of the Oprm1 gene, which encodes the mu-opioid receptor. Consequently, the expression of the mu-opioid receptor is decreased, potentially contributing to neuropathic pain. Using gene knockdown techniques to reduce BAF expression, we reversed the changes in LEMD2, EZH2, and mu-opioid receptor expressions induced by SNL and attenuated mechanical allodynia. Additionally, knocking down LEMD2 disrupted the binding of BAF to the Oprm1 promoter, without affecting BAF levels. Inhibiting EZH2 also reversed the signaling without altering BAF and LEMD2 levels. Glutamate activated BAF pathways via pNR2B receptors, and NR2B receptor blockade reversed this effect.

Conclusion: These findings suggest that spinal pNR2B receptors may activate BAF, which interacts with LEMD2 to enhance EZH2-mediated H3K27me3 at the mu-opioid receptor promoter after nerve injury. Targeting this pathway may offer novel strategies to inhibit neuropathic pain.

Introduction: Previous studies suggest that new persistent opioid use (NPOU) after surgery was associated with larger perioperative opioid prescriptions, but the association between NPOU and postoperative opioid consumption is unknown.

Methods: This retrospective study included opioid naïve individuals aged 18-64 who underwent surgical procedures across 70 Michigan hospitals between July 1, 2018 and November 15, 2021 and were prescribed opioids at discharge. We used clinical and patient-reported opioid consumption data from the Michigan Surgical Quality Collaborative, a statewide surgical registry, linked with the state Prescription Drug Monitoring Program. Multivariable logistic regression modeling was used to assess the association between patient-reported opioid consumption during the 30 days after discharge and NPOU, defined as having an opioid fill during both 31-120 days and 121-210 days after discharge.

Results: Among 36,271 patients included, 482 (1.3%) developed NPOU. These patients consumed more opioid pills in the first 30 days postoperatively than those without NPOU (mean (SD): 7.3 (8.4) 5 mg oxycodone equivalent pills vs 4.1 (5.5), SMD=-0.41). In adjusted analyses, each additional opioid pill consumed in the 30-day postoperative period was associated with a 0.05 percentage-point increase in the predicted probability of NPOU (95% CI 0.04 to 0.07 percentage points). Thus, holding all other variables constant, a 10-pill increase in consumption would be associated with a 0.5 percentage-point increase in the probability of NPOU, or a 38.4% increase relative to the baseline rate of 1.3%.

Conclusion: Demonstrating that opioid consumption in the first 30 days after surgery was independently associated with NPOU underscores the importance of perioperative opioid prescribing on long-term outcomes.

Background/importance: Driving under the influence of drugs (DUID) refers to operating a vehicle after consuming drugs or medications other than alcohol that impair the ability to drive safely. There is no consensus on legal limits for drug intoxication while driving in the USA. Balancing the benefits of prescription medications, such as opioids, with traffic safety remains an ongoing public health challenge.

Objective: This article examines DUID policy and provides recommendations for policy improvement and unification grounded in scientific evidence on opioid-related impairment and driving risks.

Evidence review: A literature review of epidemiologic data, psychomotor effects, and public policy related to opioid use and driving was conducted. A total of 38 epidemiological studies, 21 studies on psychomotor effects, and pertinent laws and policies were reviewed.

Findings: Epidemiological data reveal an increasing prevalence of opioid-positive drivers and an association between opioid use and elevated risk of motor vehicle collisions. Psychomotor studies show mixed results, with some indicating impairment in opioid users and others suggesting minimal effects on driving ability. State laws regarding DUID remain heterogeneous, with trends toward expanded testing powers, lower impairment thresholds, and limitations on prescription-based defenses. The lack of standardized opioid testing limits and inconsistent policy approaches across states hinder effective management of opioid-related impaired driving.

Conclusions: A balanced public health approach can reduce opioid-involved crashes through education, prevention, enhanced enforcement tools, and rehabilitation. In drafting future DUID laws, policymakers must analyze evolving opioid research when balancing the pain relief of opioids with public roadway safety.

Introduction: Whether a popliteal plexus block improves postoperative pain following total knee arthroplasty remains debated. This randomized trial tested if adding a popliteal plexus block to a continuous femoral nerve block decreases postoperative opioid requirement.

Methods: We included 66 patients undergoing total knee arthroplasty. 32 received continuous femoral nerve block and popliteal plexus block (intervention), and 34 received continuous femoral nerve block alone (control). The primary endpoint was the 12-hour postoperative morphine-equivalent consumption (mg). Secondary outcomes included opioid consumption, Visual Analog Pain Score (0-10), and sensorimotor extension of the block in postanesthesia care unit, at 12 hours, 24 hours and 48 hours postoperatively.

Results: 66 patients with a median body mass index of 28.7 (IQR 26.3-33.8) were included in the study. In an intention-to-treat analysis, the median 12-hour morphine-equivalent consumption was lower in the intervention group (6.1 mg (0.5-14.5) vs 10 mg (5.0-17.3); one-sided Wilcoxon test (p=0.04)). The average pain intensity experienced in postanesthesia care unit was lower in the intervention group (median: 3.0 (3.0-5.0) vs 2.0 (1.0-4.0), two-sided Wilcoxon p=0.01) and fewer patients reported lateroposterior pain of the knee (11 (34.4%) vs 21 (61.8%) p=0.03). These benefits disappeared after 24 hours. The median duration of the popliteal plexus block procedure was 5.0 min (2.0-5.0).

Conclusions: Adding a popliteal plexus block to a continuous femoral nerve block decreases 12-hour opioid utilization, but the effect size is small, calling into question its clinical relevance.

Trial registration number: NCT04048889.