Acceptable Pain Relief Research Articles

Acupuncture for low back pain and migraine

Acupuncture has been increasingly used as an integrative or complementary therapy for pain. It is well-tolerated with little risk of serious adverse effects. Traditional acupuncture and nontraditional techniques, such as electroacupuncture and dry needling, often result in reported pain improvement. Acupuncture is an ancient Chinese medical practice that involves inserting thin needles into specific points on the body. Acupuncture can be used to treat a wide range of health conditions, including migraines and low back pain. Acupuncture works by stimulating the nervous system, releasing endorphins and increasing blood flow to the affected area. Acupuncture may also help to reduce inflammation and improve circulation in the body. Controlled trials have been published on pain syndromes, such as acupuncture for acute and chronic low back pain, knee osteoarthritis, headache, myofascial pain, neck pain, and fibromyalgia. For some conditions, enough data are available for systematic evaluations or meta-analyses. Acupuncture may provide modest benefits in the treatment of chronic low back pain, tension headache and chronic headache, migraine headache prophylaxis, and myofascial pain.The benefits of acupuncture for people with back pain has been well researched compared to many other conditions, with more higher quality clinical trials. This systematic review will focus on the use of acupuncture and its role in the treatment of low back pain to help better guide physicians in their practice. To determine the effects of a policy of ‘use acupuncture’ on headache, health status and chronic pain. The results of this study will determine if acupuncture, alone or as an adjunct to pharmacotherapy provides effective, safe and acceptable pain relief for patients.

A threshold of lower preoperative mental health is associated with decreased achievement of comfort and capability benchmarks following rotator cuff repair: a retrospective cohort study

Preoperative biomedical patient characteristics are known to affect the time to achievement of clinically significant outcomes (CSOs) following arthroscopic rotator cuff repair (RCR). However, less is known about the association between preoperative mental status and the time to achievement of CSOs. We hypothesize that higher preoperative mental status is associated with faster achievement of CSOs following arthroscopic RCR. Patient-reported outcome measures (PROMs) were collected preoperatively and at postoperative intervals up to 2 years. PROMs included pain visual analog scale (VAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Single Assessment Numeric Evaluation (SANE), and Veterans RAND 12-Item Health Survey (VR-12) scores. Threshold values for CSOs were obtained from previous literature. Mean time to achievement of CSOs was calculated using a Kaplan-Meier analysis. A Cox proportional hazards regression analysis was performed to identify preoperative variables associated with earlier achievement of CSOs. Sixty-nine patients with an average age of 59±8 years were included. Patients with higher preoperative mental status, as measured by VR-12 mental component summary (MCS), experienced significantly earlier substantial pain improvement postoperatively (P=.0471). Patients with higher preoperative mental status also achieved CSOs for physical health at earlier time points (P=.0187). Preoperative VR-12 MCS scores ≥ 40 were associated with earlier achievement of CSOs for pain (P=.0005) and physical health (P=.0015). Ninety-eight percent of patients with preoperative MCS scores ≥40 achieved acceptable pain relief at 4.5 months vs. 56% of all other patients at 12.3 months (P=.0001). Patients with preoperative MCS scores ≥40 experienced significantly faster improvement in physical health compared to patients with preoperative MCS scores <40 (P=.0006). Higher preoperative mental status, especially a preoperative MCS score ≥40, is associated with significantly faster improvement in pain and physical function following arthroscopic RCR. Nearly all patients (98%) with preoperative MCS score ≥40 achieved an acceptable state of pain relief compared with only 56% of patients with preoperative MCS score <40. These findings indicate that a holistic approach with equal consideration of preoperative mental health and rotator cuff pathophysiology is vital to the successful management of rotator cuff tendinopathy.

Topical medications for the treatment of recurrent aphthous stomatitis: A network meta-analysis.

The present network meta-analysis aims to answer the question "what is the best topical intervention for the treatment of recurrent aphthous stomatitis that can provide an acceptable pain relief and promote wound healing?" From inception to October 2022, PubMed, Embase, Scopus, Cochrane Library, and China National Knowledge Infrastructure were searched to identify all potentially eligible randomized controlled trials. The primary outcomes were pain scores and/or healing time, while the secondary outcomes were the associated side effects. The Bayesian network meta-analysis accompanied by a random effect model and 95% credible intervals were calculated. Forty-three randomized controlled trials with a total of 3067 participants, comparing 20 different topical medications, were included. Concerning pain reduction, the network meta-analysis failed to show any statistically significant differences when different topical treatments were compared together or even with a placebo at different time intervals. Except for doxycycline, which showed a statistically significant difference in terms of accelerating healing time, other topical interventions showed no statistically significant differences when compared with placebo or with each other. Within the limitations of the current network meta-analysis, it seems that: A low to moderate quality of evidence showed no superiority of any topical treatment over others concerning pain reduction, although rank probability tests revealed sucralfate, doxycycline, hyaluronic acid, and chamomile as the most efficacious treatment options at different evaluation times. Hence, further well-designed clinical trials with larger sample sizes are warranted. Topical doxycycline was shown to be the most efficacious intervention in promoting healing of recurrent aphthous stomatitis.

Approach to Painful Diabetic Peripheral Neuropathy

Painful diabetic peripheral neuropathy (PDPN) is a commonly encountered problem by a physician and poses a major treatment challenge. Although poor glycemic control is considered to be a main cause for the development of peripheral neuropathy, the overall etiopathogenesis remains unclear and needs further research. There are various tools to assess the status of nerves, but PDPN being a subjective factor is often measured in terms of pain scores or pain scale looking at the intensity and the phenotype of pain. PDPN affects the individual's quality of life and daily living and often disturbs the sleep and mental health. The management of PDPN includes achieving good glycemic control, following foot care practices, including the use of appropriate footwear and treatment for pain relief. The treatment of choice varies from topical application to the pain relieving patches and use of drugs such as anticonvulsants, antidepressants, and opioids which have shown some beneficial effect. Interventional and regional anesthesia have also been tried for the treatment of PDPN. Surgical decompression has shown a favorable effect on pain relief. There are unmet needs in the therapeutic management of PDPN, as available drugs give acceptable pain relief in very few patients, and fear of side effects may limit full-dose treatment. Till date, no medicine is available to reverse neuropathy.

Evaluation and Outcome of IA Hyaluronic Inj. vs. Corticosteroid Therapy for OA Knee: Tertiary Level Hospital in Bangladesh

Background: There are many types of arthritis, but osteoarthritis (OA) is one of the most frequent. IA injections of corticosteroids into the knee joint may improve pain and impairment by relieving joint inflammation. Purpose: To evaluate the effectiveness and safety of hylastan, a novel viscosupplements, with a single intra-articular corticosteroid injection in the treatment of knee osteoarthritis pain (OA). Because of its large molecular weight, the sodium hyaluronate in Hylastan is more likely to stay in the joint for an extended period of time than other viscosupplements. Methods: Multicentered based randomized quasi-experimental comparative study was performed in Shah Mokhdum Medical College, Rajshahi, Bangladesh, from January 2019 to December 2021. Enrolled patients aged ≥40 years. Patients were randomized 1:1:1 to one of three arms: 2 X 4 mL hylastan (n = 129; arthrocentesis then IA hylastan Day 0, same treatment Week 2); 1 X 4 mL hylastan (n = 130; arthrocentesis then IA hylastan Day 0, arthrocentesis only Week 2); steroid (n = 132; arthrocentesis then IA methylprednisolone acetate 40 mg Day 0, arthrocentesis only Week 2). The primary clinical outcome measure was changed from baseline in WOMAC A pain score overall postbaseline visits to Week 26. Results: Statistically significant pain reduction was observed in all three arms, with similar mean (95 % CI) changes in WOMAC A: 2 X 4 mL hylastan -0.9 (-1.0, -0.7); 1 X 4 mL hylastan -0.8 (-0.9, -0.7); steroid -0.9 (-1.0, -0.8); all p &lt; 0.0001 versus baseline. Changes in secondary outcomes were similar in all three arms. Target knee adverse events were comparable for all treatments. Conclusions: An acceptable safety profile and effective pain relief were found with both IA hylastan injection regimens. The hypothesis of better pain relief with IA hylastan was not met compared to IA corticosteroid. The effectiveness and safety of hylastan compared to other viscosupplements require more investigation. Level of evidence Therapeutic study, Level I.

Rupture Rate, Functional Outcome and Patient Satisfaction after Primary Flexor Tendon Repair with the Modified 4-Strand Core Suture Technique by Tsuge and Using the Arthrex FiberLoop® with Early Motion Rehabilitation.

Purpose:Our hypothesis was that the rupture rate after primary flexor tendon repair in the modified 4-strand core suture technique using the FiberLoop® (Arthrex, Munich, Germany) is lower than in other suture materials and functional outcome and patient satisfaction are superior compared to the current literature. Patients and methods: A 2-stage retrospective, randomized follow-up study of 143 patients treated with the Arthrex FiberLoop® after flexor tendon injury in zones 2 or 3 from May 2013 to May 2017 was performed. In the 1st stage, the rupture rate of all patients was assessed after a follow-up of at least one year by interview to exclude revision surgery. In the 2nd stage, 20% of the patients could be randomly clinically examined. Functional parameters, such as finger and wrist range of motion measured by goniometer, grip strength measured by Jamar dynamometer (Saehan, South Korea), patient satisfaction measured by school grades (1–6), pain levels measured by visual rating scales (0–10) and functional outcome according to the DASH-score were assessed. The Buck-Gramcko and Strickland scores were calculated. The length of sick leave was recorded. Results: A rupture rate of 2.1% was recorded. 29 patients (20%) were followed up at a mean of 34 ± 7.5 months postoperatively. 10.3% of these patients had an incomplete fingertip palm distance. The mean postoperative grip strength was 24 ± 3.1 kg. 93% of the patients were very satisfied with the treatment. No patient complained of pain postoperatively. The mean postoperative DASH score was 6.7 ± 2.8 points. The mean Buck-Gramcko score was 14 ± 0.2 points. 93% of the patients had excellent and 7% good results according to the Strickland score. 67% of patients had a work accident and returned to work at a mean of 4 ± 0.2 months postoperatively. 31% of patients suffered a non-occupational injury and returned to work at a mean of 3 ± 0.4 months postoperatively. Conclusions: Primary flexor tendon repair in the modified 4-strand core suture technique using the Arthrex FiberLoop® has proven to be a viable treatment option in our series. The rupture rate was lower than in other suture materials. It leads to acceptable pain relief, grip strength and functional outcome. Level of Evidence: IV; therapeutic.

Spinal Cord Stimulation for Chronic Refractory Neuropathic Pain: A Technical Note Initial Experience of Two cases

AbstractSpinal cord stimulation is an established procedure for relieving chronic neuropathic pain conditions. Although it has been over five decades since the first spinal cord stimulation (SCS) was developed, it has only been used in a few cases in India. It is primarily based on the “Gate Theory” of pain. The mechanism of its action is not exactly clear, but reports have suggested that it plays the main role in selectively stimulating the large diameter pain fibers in the dorsal aspect of spinal cord. SCS procedure involves a very careful case selection, and current evidence suggests that only a few conditions of chronic refractory neuropathic pain are its established indications. In these patients too, the efficacy rate remains around 50 to 75%. The overall pain relief observed is around 50% decrease in visual analog scale (VAS) scores. It is a technically simple procedure involving placement of electrodes over the dorsal aspect of spinal cord in the epidural space. The procedure is a staged one in which trial lead electrodes are first implanted and stimulated with an external pulse generator (EPG). If the trial is successful and patient has acceptable pain relief over 1 week of stimulation at various settings, the patient undergoes the permanent implantation of electrodes at the same position. The permanent electrodes are then stimulated by an implantable pulse generator (IPG) in the subcutaneous pocket (abdominal or gluteal). Complications are rare and are more related to hardware like lead migration and breakage. Since it is does not damage the cord per se, its acceptance as a procedure for pain is known quite well in the Western world. Its availability and cost of implants is the major hurdle in its use in a developing nation like India. Here, we present a technical note and our experience of two cases of thoracic spinal cord stimulation for chronic neuropathic pain at our institution.

Interventional management for cancer pain

The WHO analgesic ladder (1986) has recommended certain oral analgesics vis-a-vis intensity of cancer pain for optimum relief as a practical doctrine, easy to implement, and taught extensively to healthcare professionals globally. However, the WHO approach despite been implemented appropriately and aggressively in the last three decades, 10%–20% of patients may not achieve acceptable pain relief. There is a refractory group of patients which is considered for interventional pain management; however, reserving this modality as a last resort is questioned by interventional protagonists. It is anticipated that the general understanding of interventional approach on cancer pain relief may not only expedite pain relief but should also consider all potential therapeutic options. Interventional physicians, mainly anesthesiologists, have a well-defined and beneficial role in the treatment of cancer pain, if patients are appropriately selected with various cancer pain syndromes. Pain physicians should successfully optimize outcomes depends on timely referral with adequate assessment and patient selection. Pain physicians have a complex role. Managing expectations of referring physicians, of patients, and family members, assuring adequacy of interventional care is not an easy task. An experienced, skilled interventionist who is well versed in not only techniques of procedure but side effects management, if any, will assume full responsibility for pre- and postintervention evaluation and follow-up care as indicated by the circumstances of each patient to be managed.

Evaluation of an Intrathecal Drug Delivery Protocol Leads to Rapid Reduction of Systemic Opioids in the Oncological Population.

Objective: The article that follows is purposed at demonstrating how IT opioid plus bupivacaine achieves sustained acceptable pain relief while simultaneously rapidly reducing oral morphine equivalents (OME). Background: Cancer patients represent a population with significant morbidity, pain, and limited life expectancy. It is, therefore, vital to achieve satisfactory analgesia quickly and safely. To date, there is limited data in the literature that discusses efficacy of combined intrathecal (IT) medication therapy in reducing systemic opioids in the oncological population. Methods: This was a retrospective analysis that reviewed cancer pain patients from day of IT pump implantation through the six-month postoperative time point. A cohort of 50 oncological patients who had intrathecal drug delivery systems (IDDSs) implanted at Memorial Sloan Kettering Cancer Center between 2017 and 2019 were studied. Median OMEs were the primary modality of analysis for this review. Mean visual analogue scale scores were secondarily reviewed. Results: Median OMEs decreased from 503 preoperative to 105 at six months postoperative time point. Median time to discharge was 6.5 days. Unfortunately, due to malignant mortality, 27 patients did not make it to the 6-month postoperative time point. Discussion: IDDSs with opioid plus bupivacaine represent a safe and efficient route toward expeditious pain relief and decreased OMEs in the cancer pain population.

Current Evidence for Acute Pain Management of Musculoskeletal Injuries and Postoperative Pain in Pediatric and Adolescent Athletes.

Sports-related injuries in young athletes are increasingly prevalent with an estimated 2.6 million children and adolescents sustaining a sports-related injury annually. Acute sports-related injuries and surgical correction of sports-related injuries cause physical pain and psychological burdens on pediatric athletes and their families. This article aims to evaluate current acute pain management options in pediatric athletes and acute pain management strategies for postoperative pain after sports-related injuries. This article will also elucidate which areas of pain management for pediatric athletes are lacking evidence and help direct future clinical trials. We conducted a literature search through PubMed and the Cochrane Central Register of Controlled Trials to provide an extensive review of initial and postoperative pain management strategies for pediatric sports-related musculoskeletal injuries. The current knowledge of acute pain management for initial sports-related injuries, postoperative pain management for orthopedic surgeries, as well as complementary and alternative medical therapies in pediatric sports-related injuries is presented. Studies evaluating conservative management, enteral and nonenteral medications, regional anesthesia, and complementary medical therapies are included. Adequate pain management is important for sports injuries in children and adolescents for emotional as well as physical healing, but a balance must be achieved to provide acceptable pain relief while minimizing opioid use and side effects from analgesic medications. More studies are needed to evaluate the efficacy of nonopioid analgesic medications and complementary therapies in pediatric patients with acute sports-related injuries.

Decreasing Narcotic Use for Nonsurgical Births

To reduce narcotic administration during birth. Many professional and government agencies, including the American College of Obstetricians and Gynecologists (ACOG) and AHWONN, are addressing a growing opioid crisis in America. At the same time, the American Academy of Pediatrics (AAP) issued a new statement regarding the safety concerns with opioid use by women who are breastfeeding. Two plan–do–check–act cycles. Plan: The call to action from our professional organizations prompted practice changes for both physicians and nurses. Do: A “warning order” was issued by the AAP and AGOC in April to July 2017. An informal action plan was developed during staff huddles and was rolled out as a single intervention in August 2017. Check: Initially, the New Family Center (NFC) did not receive expected results. After evaluation, we learned that not all nurses and physicians were changing practice to the new recommendations. Act: After reviewing results, additional education was provided in small in-services. Scripting tools were also provided to the nurses. Nurses were prompted to educate patients that over-the-counter medications are safer for both mothers and newborns and to review potential side effects for both. Nurses were encouraged to call the physician to request topical medications and nonnarcotic oral analgesics. Nurses were empowered to offer medications in the following order: (1) nonmedicinal, (2) topical, (3) over-the-counter analgesics, and (4) narcotic analgesic if previous interventions did not provide acceptable pain relief. Plan: After a second review of results in October 2017, NFC noted a vast increase in the administration of over-the-counter medications as well as an inconsistent decrease in narcotics dispensed per month. Signs in patient rooms were posted. Nurses were instructed to incorporate the signs with teaching moments. It was also noted that the nurses in the labor and delivery unit were encouraging and offering narcotic use prior to transfer. Do: Signs were placed in every patient room and service line education occurred (December 2017). Check: Opiate treatment has decreased 50%. Act: Continue data collection for another 6–12 months. Near 50% reduction in narcotic administration. Less opioid administration promotes faster recovery postbirth, decreases the risk of sedation in breastfeeding newborns, and decreases the risk for dependency and addiction after discharge.

Not Just Cutting It—A Successful Interprofessional Cooperation Between Palliative Care, Pain and Neurosurgery in the Treatment of Intractable Cancer Pain (TH337)

•List three neurosurgical procedures that selectively intervene along the pain processing pathways and to describe their role in the treatment of intractable cancer pain.•Perform case analysis of different clinical cases of patients with intractable cancer pain and to appropriately make an interdisciplinary based patient selection for different neurosurgical procedures. There is a great importance to deliver good pain management to cancer patients suffering from advanced metastatic disease. Unfortunately, there are selected patients for whom pharmacotherapy does not achieve acceptable pain relief or is limited by marked side effects. These patients, may benefit from neurosurgical procedures that selectively intervene along the pain processing pathways. Patients with localized pain can benefit from selective percutaneous cordotomy, while patients who suffer from diffuse pain due to widespread disease are candidates for stereotactic radiofrequency cingulotomy. Patients with intractable abdominal or pelvic visceral pain can benefit from midline myelotomy. A careful patient selection is critical for the success of these procedures. An integrative team consisting of palliative care specialists, pain specialists and a neurosurgeon focused on this task provides a platform to optimize patients' selection. We will present our experience from the interdisciplinary evaluation of cancer patients undergoing neurosurgical interventions for intractable pain. We will review the clinical considerations guiding the choice of the therapeutic approach through representative clinical cases. This concurrent session will provide a review of ablative neurosurgical interventions; the current evidence for their use, their benefits, and risks. Through comprehensive case presentations and analysis, we will discuss patient selection considerations, patient safety and personal preferences guiding the assignment of each procedure to a specific patient.

Hydromorphone for cancer pain.

Hydromorphone for cancer pain.

Knee Arthrodesis in Persistently Infected Total Knee Arthroplasty.

The reported incidence of infection in total knee arthroplasty (TKA) varies from 0.5 to 15%. The most common indication for knee arthrodesis is persistent infection after repeated staged knee replacement. The purpose of this study is to investigate the success of fusion with monoplanar fixators and eradication rates of infection, and to evaluate the satisfaction of patients who underwent a last-resort TKA due to infection.This is a retrospective review of infected knee arthroplasties that were treated with knee arthrodesis using unilateral external fixators at a single institution from 1999 through 2012. The patients' charts were analyzed for demographics, types of external fixators used, infection parameters, external fixator indexes, complications, positions of fusion, and leg length discrepancies (LLDs). Patients were called back to return for additional follow-up. A self-administered general health status questionnaire (SF-36) was assessed to evaluate life quality.There were 14 women and 3 men with an average age of 67 ± 16.6 years. Antibiotic-loaded acrylic cements were used as a spacer for an average of 3.4 ± 1.2 months in all patients. Monoplanar type of external fixator was used in all 17 patients. Fusions were achieved in all but one patient. The mean duration of fusion was 6.8 ± 2.2 months and external fixator duration was 7.6 ± 2.4 months. Average LLD was 2.9 ± 1.7 cm. The mean coronal alignment of fusion was 6.8 degrees (± 3.3 degrees, range 4-15 degrees) valgus and mean flexion was 11.3 degrees (± 6.5 degrees, range 3-30 degrees). Compared with the healthy controls, the SF-36 scores were significantly lower in patients with knee arthrodesis (physical component score [PCS]-arthrodesis: 39.3 vs. PCS- healthy controls: 47.9, p < 0.05; mental component score [MCS]-arthrodesis: 38.6 versus MCS-healthy controls: 47.7, p < 0.05).Use of monoplanar fixators for arthrodesis in infected TKA can achieve high fusion rates with the control of infection. If fusion can be achieved, the patient satisfaction is low with acceptable pain relief and functionality. We observed that monoplanar external fixators increased patients' comfort levels compared with circular external fixators. Further studies are needed to compare different arthrodesis modalities in patients with infected TKA.

Safety and effectiveness of minimally invasive sacroiliac joint fusion in women with persistent post-partum posterior pelvic girdle pain: 12-month outcomes from a prospective, multi-center trial.

Postpartum posterior pelvic girdle pain (PPGP) affects nearly 20 % of women who experience back pain in the peripartum period. The sacroiliac joint is a source of this pain in 75 % of women with persistent PPGP. A subset of women will fail to obtain acceptable pain relief from the current array of non-surgical treatment options. The purpose of this study is to assess the safety and effectiveness of minimally invasive sacroiliac (SI) joint fusion in women with chronic SI joint dysfunction whose pain began in the peri-partum period whose symptoms were recalcitrant to non-surgical management. A sub-group analysis of subjects with sacroiliac joint disruption and/or degenerative sacroiliitis enrolled in a prospective, multi-center trial of SI joint fusion was performed. Subjects with PPGP were identified and compared with women without PPGP and with men. Of 172 enrolled subjects, 52 were male, 100 were females without PPGP and 20 females had PPGP. PPGP subjects were significantly younger (43.3 years, vs. 52.8 for females without PPGP and 50.5 for men, p = 0.002). There were no differences in any other demographic or baseline clinical measure. Women with PPGP experienced a significant improvement in pain (−51 mm on VAS), function (−20.6 pts on ODI) and quality of life (SF-36 PCS +10.4, MCS +7.2, EQ-5D +0.31) at 12 months after surgery. These improvements were characteristic of the overall study results; no difference was detected between sub-groups. The sacroiliac joint can be a source of pain in women with persistent PPGP and should be investigated as a pain generator. In this study, women with carefully diagnosed chronic SI joint pain from PPGP recalcitrant to conservative therapies experienced clinically beneficially improvements in pain, disability and quality of life after minimally invasive SI joint fusion using a series of triangular porous plasma spray coated implants.

Trigeminal neuralgia pain relief after gamma knife stereotactic radiosurgery

ObjectivesTo report outcomes of patients with medical and/or surgical refractory trigeminal neuralgia (TN) treated with gamma knife stereotactic radiosurgery (GK SRS). MethodsOne hundred and forty-nine patients with 152 cases of TN treated with GK SRS were analyzed. All patients, except one, received a dose of 40Gy to the 50% isodose volume. The Barrow Neurological Institute (BNI) pain intensity score was used to grade pain. Actuarial rates of pain relief were calculated. Multiple factors were analyzed for association with pain relief. ResultsThe median follow up was 27 months (4–71 months). Overall 92% of cases achieved a BNI score I–III after GK SRS. Of those who had pain relief after GK SRS, 32% developed pain recurrence defined as a BNI score of IV or V. The actuarial rate of freedom from pain recurrence (BNI scores I–III) of all treated cases at 1, 2 and 3-years was 76%, 69% and 60%, respectively. On univariate analysis age ≥70 was predictive of better pain relief (p=0.046). Type of pain, prior surgery, multiple sclerosis, number of isocenters, treated nerve length, volume and thickness and distance from the root entry zone to the isocenter were not significant for maintaining a BNI score of I–III. Those who achieved a BNI score of I or II were more likely to maintain pain relief compared to those who only achieved a BNI score of III (93% vs 38% at three years, p<0.01). The rate of pain relief of twenty-seven patients who underwent repeat GK SRS was 70% and 62% at 1 and 2 years, respectively. Toxicity after first GK SRS was minimal with 25% of cases experiencing only new or worsening post-treatment numbness. ConclusionGK SRS provides acceptable pain relief with limited morbidity in patients with medical and/or surgical refractory TN.

An Exploratory Analysis of the Correlation of Pain Scores, Patient Satisfaction With Relief From Pain, and a New Measure of Pain Control on the Total Dose of Opioids in Pain Care

We explored the associations between opioid dose and multiple measures of pain. Thirty-two consecutive patients admitted solely for an acute exacerbation of cancer-related pain or for surgery were followed for their entire hospital stay (115 days of pain). For each hospital day, we collected pain scores, the number of pain scores, trends in pain scores, the percentage of time patients had 100% acceptable relief from pain, and the number of times patients were asked about acceptable pain relief. Finally, we asked those who had 100% relief of pain whether they could have used more pain medicine. Linear regression models were fit to estimate the amount of variation explained (R) in dose of medication, by each pain measurement variable. Nineteen patients with cancer (74 days of pain) and 13 patients undergoing surgery (41 days of pain) were evaluated. Pain scores, the number of pain scores, trends in pain scores, and 100% acceptable relief scores poorly correlated with the use of medication in the linear regression models (R for all models ≤0.2). A question about needing more pain medicine explained the greatest amount of variation in opioid dose. Pain and acceptable relief scores do not adequately reflect the use of medication. A prospective study is needed to further assess the value of additional measures of the adequacy of pain care.

Proximal Scaphoid Arthroplasty Using the Medial Femoral Trochlea Flap

Background The medial trochlea of the femur (medial femoral trochlea, MFT) provides a source of convex osteocartilaginous vascularized bone that has been demonstrated to have a similar contour to the proximal scaphoid. This provides a potential solution for difficult recalcitrant proximal pole scaphoid nonunions. Materials and Methods Sixteen consecutive patients who underwent MFT proximal scaphoid arthroplasty were reviewed. Follow-up data were recorded at a minimum of 6 months, with an average of 14 months. The results of this cohort were previously reported in detail but are summarized herein. Description of Technique The ability to reconstruct both bone and cartilage of the nonunion enables the surgeon to resect the nonunited proximal pole to prepare for scaphoid reconstruction. A segment of osteocartilaginous MFT is harvested in dimensions required by the scaphoid defect. The MFT segment is harvested on the transverse branch of the descending geniculate vessels. Fixation may be achieved with ease due to the size of the reconstructed segment. Results Computed tomography imaging demonstrated 15 of 16 reconstructed scaphoids achieving osseous union. Follow-up range of motion (ROM) of the wrist averaged 46.0° extension (range 28-80°) and 43.8° flexion (range 10-80°), which was similar to preoperative (average 45.7° extension and 43.0° flexion). Scapholunate angles remained unaffected (51.6° preoperatively and 48.6° postoperatively), indicating preservation of carpal relationships. Conclusions Vascularized MFT flaps provide a useful tool in the treatment of difficult proximal pole scaphoid nonunions. Early follow-up demonstrates high rate of achieving union with acceptable ROM and good pain relief.

Equianalgesic doses of opioids - their use in clinical practice.

Opioid rotation is an established means of managing the side-effects of strong opioids.1 From its origins in palliative care, the concept has moved into the fields of acute and chronic pain in cases where it is felt that changing a strong opioid may confer a benefit or if it becomes necessary in the context of co-morbidity. In an acute pain setting, for example, if a patient is undergoing an operation that may result in a reduction in their renal function then it may be necessary to change their opioid to one without metabolites that can cause problems with accumulation. In a pain clinic, it may be that a patient has developed tolerance over time to the analgesic effect of an opioid that was initially helpful, and the clinician believes that opioid rotation rather than dose escalation is an appropriate way to manage this. In a hospice, a patient may be receiving acceptable pain relief using a strong opioid, but may also be struggling with side-effects; therefore, a change to a different opioid, anticipated to have fewer side-effects, is planned. The question, therefore, clinicians often find themselves asking is, ‘If I am starting with “a” opioid at “b” dose, what dose of “x” opioid do I need to prescribe to have the same analgesic effect?’. This information can be derived from the equianalgesic dose, which is the dose of two opioids required to produce the same analgesic effect.2 There are a number of sources of information available to guide clinicians. The British National Formulary (BNF) publishes tables comparing a number of strong opioids with morphine as the ‘gold standard’.3 The Palliative Care Formulary provides more comprehensive information, and for some drugs information is given in the summary of product characteristics.4 In the wider literature there are summary tables,5,6 diagrams7,8 and now online resources including medically orientated smartphone applications. Importantly, however, the BNF and most publications display notices of caution alongside such tables. The BNF notes, ‘these equivalences are intended only as an approximate guide; patients should be carefully monitored after any change in medication and dose titration may be required’. There are a number of reasons why caution is raised alongside the publication of such tables, and these relate to patient factors and issues surrounding the information used to create the tables.

Acupuncture as analgesia for low back pain, ankle sprain and migraine in emergency departments: Study protocol for a randomized controlled trial

BackgroundPain is the most common reason that patients present to an emergency department (ED) and is often inadequately managed. Evidence suggests that acupuncture is effective for pain relief, yet it is rarely practiced in the ED. The current study aims to assess the efficacy of acupuncture for providing effective analgesia to patients presenting with acute low back pain, migraine and ankle sprain at the EDs of four hospitals in Melbourne, Australia.MethodThe study is a multi-site, randomized, assessor-blinded, controlled trial of acupuncture analgesia in patients who present to an ED with low back pain, migraine or ankle sprain. Patients will be block randomized to receive either acupuncture alone, acupuncture as an adjunct to pharmacotherapy or pharmacotherapy alone. Acupuncture will be applied according to Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA). Pain after one hour, measured using a visual analogue scale (VAS), is the primary outcome. Secondary outcomes measures include the following instruments; the Oswestry low back pain disability questionnaire, 24-hour Migraine Quality of Life questionnaire and Patient's Global Assessment of Ankle Injury Scale. These measures will be recorded at baseline, 1 hour after intervention, each hour until discharge and 48 ± 12 hours of ED discharge. Data will also be collected on the safety and acceptability of acupuncture and health resource utilization.DiscussionThe results of this study will determine if acupuncture, alone or as an adjunct to pharmacotherapy provides effective, safe and acceptable pain relief for patients presenting to EDs with acute back pain, migraine or ankle sprain. The results will also identify the impact that acupuncture treatment may have upon health resource utilisation in the ED setting.Trial registrationAustralia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000989246