Conventional Analgesic Treatment Research Articles

Efficacy and Safety of Celiac Plexus Neurolysis in the Treatment of Chronic Pain Secondary to Oncological Pathology of the Upper Hemiabdomen: A Systematic Review and Meta-Analysis.

The management of chronic pain among patients with abdominal cancer is complex; against that, the neurolysis of the celiac plexus (CPN) is the best technique at the moment to determine the efficacy and safety in the treatment of chronic pain secondary to oncological pathology of the upper abdomen. This was a systematic review of controlled clinical trials between 2000 and 2021, in the sources MEDLINE/PubMed, Cochrane, Scopus, Web of Science, and Google Scholar. Three independent evaluators analysed the results of the bibliographical research. The quality of the studies was assessed with the Jadad scale and the mean difference (95% confidence interval) and heterogeneity of the studies (I2) were calculated with Review Manager 5.3. Seven hundred and forty-four publications were identified, including 13 studies in the qualitative synthesis and three studies in the quantitative synthesis. No difference was found in the decrease in pain intensity between 1 and 12 weeks after the intervention, comparing the experimental group with the control (P > 0.05). The adverse effects related to neurolysis were not serious and transitory, mentioning the most frequent adverse effects and reporting a percentage between 21% and 67% (with 17% for echoendoscopic neurolysis and 49% for percutaneous neurolysis). Celiac plexus neurolysis for the treatment of severe chronic pain secondary to oncological pathology in the upper hemiabdomen produces similar pain relief as conventional pharmacological analgesic treatment. It is a safe analgesic technique since the complications are mild and transitory.

Differences in efficacy and safety between intrathecal infusion devices in cancer pain.

Intrathecal infusion therapy is widely accepted for cancer pain patients when conventional analgesic treatments are not sufficient. There are different types of devices for carrying out this therapy: partially externalized devices (PED), used when life expectancy is under 3 months, and totally implanted devices (TID), when it is larger. Our objective is to compare the efficacy, functionality, and complication rate in both types. We included 132 patients with mild-severe cancer pain, treated with intrathecal infusion therapy by fixed flow devices, PED, or TID, during the study time. Demographic, physical oncologic, and pain control data of the patients were recorded prior to starting therapy and at months 1, 3, and 6. Functionality status and complications were also collected from the patient's medical records and clinical files. Pain control improved after starting therapy, with an overall reduction of 4.75 points in VAS score at 1 month in the both groups, without significant differences between them, keeping it at 3 months and 6. 33.3% of the patients developed complications and were more frequent in the PED group, being catheter dislocation the most common. Patients with TID required more often hospital admission to solve the complication. Intrathecal infusion therapy has been shown to be a very effective and safe therapy for the treatment of moderate to severe oncologic pain. There are no significant differences between PED and TID in terms of degree of pain control, therapeutic success, efficacy on episodic or nocturnal pain, or the presence of serious complications.

Low-dose ketamine infusions for chronic pain management: Does this qualify as evidence-based practice?

Chronic pain is becoming increasingly prevalent and burdensome both worldwide and in the United Kingdom. Due to the complexity of chronic pain and the therapeutic challenge associated, management is often difficult and requires multidisciplinary care encompassing a combination of pharmacological and non-pharmacological strategies. Conventional analgesic treatments, such as opioids and anticonvulsants, are effective in less than half of chronic pain sufferers and are typically limited to short-term use to prevent complications associated with long-term use such as tolerance and dependence. Consequently, research and clinical interest in alternative management options for chronic pain have increased in recent years, with ketamine being one example under investigation. However, since ketamine has been licensed as an anaesthetic for decades, it has bypassed the traditional scrutinous drug development sequence that is typically seen for therapeutics marketed for pain. As such, data supporting the unlicensed administration of ketamine for chronic pain management is lacking and is being outpaced by the rates of off-label use in pain clinics. Recent limited evidence suggests that ketamine, when given as an intravenous infusion in subanaesthetic doses for refractory pain patients, may provide modest analgesic effects in nearly all aetiologies of chronic pain, with side effects common but typically mild. However, there are concerns over the safety of this practice due to the paucity of robust supportive evidence and the accompanying lack of clinical guidelines or standardised protocols. This review shall summarise the literature examining the use of subanaesthetic-dose ketamine infusions for chronic pain to comment on the current level of evidence, with limitations of existing research and future recommendations discussed.

At-home Topical Sevoflurane Added to the Conventional Analgesic Treatment for Painful leg Ulcers Greatly Improved the Analgesic Effectiveness and Reduced Opioid Consumption in a Single-Center Retrospective Comparative Study with one-Year Follow-up.

The general anesthetic sevoflurane is being repurposed as a topical analgesic for painful chronic wounds. This study was aimed to compare the analgesic effectiveness and safety of systemic analgesics alone or plus at-home topical sevoflurane for the management of patients with painful nonrevascularizable leg ulcers who were referred to a Pain Clinic by their attending vascular surgeons. We reviewed charts of patients treated in a single Pain Clinic with analgesic Standard of Care either alone (group SoC) or plus at-home topical sevoflurane (group SoC + Sevo), according to safety criteria. The area under the curve of pain over a year (AUC-Pain) was the primary outcome for analgesic effectiveness. Opioids were converted into Oral Morphine Milligram Equivalents. Groups SoC (n = 26) and SoC + Sevo (n = 38) were similar in baseline characteristics. Compared to SoC, median values [interquartile range] of area under the curve of pain for one-year follow-up were markedly lower for SoC + Sevo (54 [35-65] vs. 15 [11-23]; p < 0.000001, U Mann-Whitney test). Oral Morphine Milligram Equivalents were similar at baseline (SoC: 78.5 [22.5-135] vs. SoC + Sevo: 101.3 [30-160]; p = 0.753), but significantly lower for SoC + Sevo at three (120 [22.5-202.5] vs. 30 [0-80]; p = 0.005), six (120 [11.3-160] vs. 20 [0-67.5]; p = 0.004), nine (114.4 [0-154] vs. 0 [0-37]; p = 0.018), and 12 months (114.4 [0-154] vs. 0 [0-20]; p = 0.001). Multiple linear regression analysis revealed the addition of sevoflurane to be the most likely variable to explain this difference in outcome (ß:-33.408; p < 0.000001). Nine patients (24%) in SoC + Sevo had adverse effects attributed to sevoflurane, but only one patient needed to stop using sevoflurane due severe dermatitis. In conclusion, the addition of topical sevoflurane to the analgesic standard of care in patients with painful nonrevascularizable leg ulcers was a well-tolerated therapy that significantly improved pain control and allowed for a significant reduction in opioid consumption.

Mandibular tori interfering with the mobility of the lingual frenulum: a short case report

Introduction: Tori are benign hamartoma-like bone excrescences, usually asymptomatic. Their removal should not be systematic. Observation: A 62-year-old patient showed bilateral tori only leaving a 1.5 mm space for the lingual frenulum path between them. The direct functional consequence was a frequent blockage of the salivary caruncles below the tori. Tori resection was performed under local anaesthesia. Surgical outcome was simple with conventional analgesic treatment and oral care. Comfort and function were immediately restored. Discussion: The originality of this case does not lie in the nature of the lesions but in the uncommon size of their hypertrophy, which caused a lingual functional impairment. We have not found a similar case described in the literature.

Pain relief in a patient with massive sino-nasal tumor

Maxillofacial neoplasms, though relatively rare, are potentially devastating tumors, that may require medical or surgical intervention. Among all the head and neck tumors, sino-nasal tumors make up 3%. Such tumors can be very vascular as well as extremely painful. Conventional analgesic treatment in a cascading manner usually proves to be inadequate and unsatisfactory

Neurolisis del plexo celíaco: una revisión sistemática

Introducción: La mayoría de los pacientes con cáncer desarrollarán dolor crónico. El tratamiento tradicional sigue la escalera de tres pasos de la OMS para el alivio del dolor por cáncer. Sin embargo, este tratamiento tiende a ser ineficaz con el tiempo. A medida que la enfermedad progresa, se necesitan dosis más altas de opioides para lograr un control óptimo del dolor, aumentar los efectos adversos relacionados con ellos y afectar la calidad de vida. La neurólisis del plexo celíaco (CPN) es um método alternativo de analgesia que puede ser extremadamente útil para esos pacientes. Objetivo: El objetivo de este trabajo es evaluar la efectividad de la CPN en el control del dolor crónico y revisar su técnica. Métodos: Las bases de datos PUBMED, MEDLINE y LILACS se utilizaron para realizar una revisión sistemática, utilizando el impacto como criterio de selección. Los veintiún artículos que seleccionamos se organizaron en una tabla para el análisis estadístico. Resultados: La mayoría de los estudios concluyeron que la CPN es un método efectivo para el control del dolor crónico en la parte superior del abdomen y disminuye el consumo de opioides, aunque su efectividad depende del tiempo de administración y la progresión de la enfermedad. Discusión: la CPN es un procedimiento quirúrgico que destruye las fibras neurales del plexo celíaco, responsable de la inervación sensible de las vísceras abdominales superiores. Como resultado, las vías aferentes del dolor visceral se bloquean, disminuyendo el dolor. Los pacientes que sufren de dolor crónico originado en la parte superior del abdomen debido a cáncer pancreático, pancreatitis crónica, cáncer gástrico, cáncer hepático metastásico, cáncer biliar, cáncer es-ofágico u otras patologías que involucran las vísceras abdominales superiores pueden beneficiarse del procedimiento. Múltiples enfoques están disponibles; los posteriores están asociados con menos daño de los órganos viscerales y complicaciones neurológicas. Los enfoques guiados por imágenes que utilizan tomografía computarizada están relacionados con mejores resultados. Las complicaciones son raras, se pueden encontrar complicaciones graves en menos del 2% de los pacientes. Conclusión: Los médicos deben considerar la CPN como un posible método de control del dolor para pacientes con dolor crónico originado em las vísceras abdominales superiores. Aunque el impacto en las escalas de mortalidad y dolor puede ser comparable al tratamiento analgésico convencional, este procedimiento es preferible a los pacientes debido a la menor cantidad de efectos secundarios y la disminución en el consumo de opioides.

The role of multimodal postoperative analgesia after primary hip arthroplasty

Introduction: Due to the increasing number of arthroplasties, the number of post-operative hospital days was reduced and the rate of rehabilitation accelerated. For this, proper postoperative analgesia is essential and the multimodal pain relief is an excellent tool. Aim: The aim of our study was to compare postoperative functional results, postoperative pain levels, and opioid analgesic needs of patients who received conventional and novel analgesic treatments. Method: In our prospective study, 81 patients were enrolled who underwent primary hip prosthesis surgery in our institution between February 2017 and January 2018. Of the randomized patients, 38 were in the control group and 43 in the multimodal pain group. We have tested their analgesic needs and the subjective pain levels of patients with the help of the visual analog scale (VAS). Results: Patients receiving multimodal pain relief had significantly lower opioid analgesic requirements and significantly lower VAS values assessed at 6 hours, and 3 and 4 days postoperatively. In addition, the patients in this group stayed in the hospital for a significantly shorter time after surgery. Conclusions: Based on our experience, multimodal pain relief in one-sided primary hip joint arthroplasty significantly reduced the patients' postoperative subjective pain sensation and pain killer consumptions. Orv Hetil. 2019; 160(52): 2054-2060.

Efficacy of CT Guided Pulsed Radiofrequency Treatment for Trigeminal Postherpetic Neuralgia.

ObjectivesTrigeminal postherpetic neuralgia (TPHN) often presents with moderate to severe pain, hyperalgesia, and allodynia. Conventional analgesic treatments are poorly effective, which seriously affects the quality of life. This retrospective study aimed to evaluate the efficacy of pulsed radiofrequency (PRF) for the treatment of TPHN.MethodsA total of 90 TPHN patients were selected between January 2014 and December 2016 in the Department of Pain Management, Shengjing Hospital, China Medical University. Patients were randomly divided into two groups according to the order of enrollment (n = 45 per group): group A, peripheral nerve (supraorbital nerve, infraorbital nerve and mental nerve) PRF; group B, gasserian ganglion PRF. Follow-up assessments of visual analogue scale (VAS) pain assessment, SF-36 health status questionnaire, total efficiency rate, and drug dosage of anticonvulsants and opioid analgesics were performed at time points of 1 week, 1 month, 3 months, 6 months, and 1 year after surgery.ResultsAt each postsurgery time point, the VAS decreased, SF-36 (physical and mental components) increased, and drug dosage of anticonvulsants and opioids analgesics decreased in both treatment groups; values at each time point were significantly different from presurgery values (P < 0.05). Compared with group A, VAS decreased, SF-36 increased, and dosage of anticonvulsants and opioids analgesics decreased significantly in group B (P < 0.05). The total efficiency rates one year after surgery in group A and group B were 68.9 and 86.7%, respectively. The total efficiency rate of group B was statistically higher than that of group A (P < 0.05).ConclusionPRF relieved TPHN, and gasserian ganglion PRF was more effective than peripheral nerve PRF. The method was effective and improved the quality of life of the patients. PRF is recommended as a treatment for TPHN.

Esmolol, Antinociception, and Its Potential Opioid-Sparing Role in Routine Anesthesia Care.

β-Adrenergic blockade is an important mechanism for reducing morbidity and mortality in patients with hypertension and heart failure. Esmolol has been used widely for its chronotropic and antihypertensive effects. However, there has been recent inquiry regarding perioperative esmolol use and nociceptive modulation. Conventional postoperative analgesic treatment has relied primarily on opioids, which present their own adverse effects and pharmacoepidemiologic repercussions. Esmolol, to date, has not shown any direct analgesic or anesthetic properties; however, recent studies suggest that esmolol may have antinociceptive and postoperative opioid-sparing effects. In this Daring Discourse narrative, we describe the role of esmolol in current perioperative β-blockade guidelines (related to noncardiac surgery), briefly describe studies supporting the antinociceptive effects of esmolol, propose mechanisms for esmolol antinociception, and forecast potential routine esmolol use intraoperatively (as part of a multimodal total intravenous anesthetic) and its effects on opioid sparing. The reading audience of regional anesthesiologists and acute pain medicine physicians is uniquely positioned to take a lead role in promulgating this care advance amid (i) the unwanted effects of the opioid epidemic and (ii) the uncertain notion of whether routine general anesthesia care (with fentanyl) may indirectly be contributing to the epidemic.

Pain and analgesic drugs in chronic venous ulcers with topical sevoflurane use

ObjectivePain in chronic venous ulcers (CVUs) notably increases with the usual cleaning of the wound. Chronic pain is usually poorly controlled even with the multiple analgesic treatments available. Analgesics can have different serious adverse effects and medical interactions in old patients with several comorbidities. This study reports the efficacy and safety of topical sevoflurane for treatment of pain in CVUs. MethodsWe report a descriptive and retrospective study of 30 patients older than 65 years with painful CVUs refractory to conventional analgesic treatments. Patients received topical sevoflurane treatment before the usual cleaning of the ulcer. Cleaning visits with sevoflurane every 2 days for a period of 1 month were scheduled. We compared the visual analog scale results and analgesic drugs for cleaning with and without topical sevoflurane. The systemic pharmacokinetics of sevoflurane after topical application has not been determined. ResultsPain related to CVUs decreased with topical sevoflurane. Sevoflurane had an analgesic effect with latency time between 2 and 7 minutes. The duration of analgesia ranged between 8 and 18 hours. The time needed to take an analgesic treatment increased after application of sevoflurane. The use of other conventional analgesic drugs, including paracetamol, metamizole, nonsteroidal anti-inflammatory drugs, tramadol, and major opioids, was progressively reduced. The main local adverse effects were mild and transient, including heat, pruritus, and erythema. There were no systemic adverse effects. ConclusionsTopical sevoflurane has an intense, fast, and long-lasting local analgesic effect with an adequate safety profile. It also diminishes the taking of other conventional analgesic drugs. Topical sevoflurane is an efficient and safe therapeutic alternative for refractory painful CVUs.

Acupuncture for posttonsillectomy pain in children: a randomized, controlled study.

Surgeons have searched for the technique or medication that will produce a 'painless tonsillectomy'; however, this seems to be an impossible goal. Previous studies have shown that perioperative acupuncture may be a useful adjunct for acute postoperative pain and that acupuncture, in addition to nonsteroidal anti-inflammatory drugs, is effective in adults for the treatment of postoperative swallowing pain after tonsillectomy. Acupuncture has been shown to be safe in children. A retrospective review of acupuncture for posttonsillectomy pain in juvenile patients showed a significantly reduced pain score immediately after treatment. To examine whether acupuncture, in addition to conventional analgesic treatment, will be effective in the treatment of posttonsillectomy pain in children. We conducted a randomized, controlled, single-blinded study comparing conventional postoperative analgesic treatment with the same regime plus acupuncture to assess whether postoperative treatment of children aged 3-12years undergoing tonsillectomy with acupuncture will reduce pain and to examine possible unwanted effects of this treatment. Sixty children were recruited and randomly divided into a study group and a control group. The results indicate that in the study group, there was less pain, less analgesic drug consumption, and higher patient/parent satisfaction with analgesic treatment scores. No adverse effects were recorded. Acupuncture, in addition to conventional analgesic treatment, is an effective treatment for posttonsillectomy pain. Acupuncture is safe and well received by children and their parents.

From “mechanical” to “neuropathic” back pain concept in FBSS patients. A systematic review based on factors leading to the chronification of pain (part C)

IntroductionBeyond initial lesions, any form of spinal (re)operation can cause direct potential aggression to the nervous system by contact with neural tissue or by imprinting a morphological change on the neural tissue. The potential consequences of nerve root injury affect both peripheral and axial dermatomal distribution. The hypothesis of a possible neuropathic aspect associated with the back pain component of failed back surgery syndrome (FBSS) therefore appears to be reasonable. Its pathophysiology remains unclear due to the permanent interplay between nociceptive and neuropathic pain components, resulting in the coexistence of physiological and pathological pain at the same anatomical site. This paper is designed to extensively review the fundamental mechanisms leading to chronification of pain and to suggest considering the emerging concept of “neuropathic back pain”. MethodsLiterature searches included an exhaustive review of 643 references and 74 book chapters updated by searching the major electronic databases from 1930 to August 2013. ResultsInflammatory and neuropathic back pain could be distinguished from pure nociceptive pain as a result of an increased activity and responsiveness of sensitized receptors at the peripheral nervous system and also as a consequence of increased afferent inflow to the central nervous system, moving to a new, more excitable “wind-up” state. This can be clinically translated to an amplified response to a moderate/intense stimulus (primary hyperalgesia) or an aversive sensation provoked by the activation of low-threshold mechanoreceptors through non-noxious stimuli, which defines allodynia. Activated non-neuronal cells including microglia have been found to be cellular intermediaries in mechanical allodynia. Major changes in the spinal cord are the loss of inhibitory mechanisms, resulting in an increased activity of interneurons or projection neurons and a structural reorganization of the central projection pattern. This abnormal excitability of sensory neurons is coupled to changes in the neurotransmitter phenotype, which could induce a resistance to conventional analgesic treatments. ConclusionA clear understanding of the factors leading to the chronification of back pain should help us to move to the choice of mechanism related pain treatments to improve outcomes in FBSS chronic condition.

Infiltration of impar and caudal ganglia in the management of traumatic coccydynia refractory to conventional analgesic treatment

Introduction Coccydynia is a term that refers to pain in the region of the coccyx. Most cases are associated with abnormal mobility of the coccyx which may trigger a chronic inflammatory process leading to degeneration of this structure. Non-surgical management remains the gold standard treatment for coccydynia, consisting of decreased sitting, seat cushioning, coccygeal massage, stretching, manipulation, local injection of steroids or anaesthetics, and postural adjustments. Materials and methods A retrospective study of 23 patients who underwent treatment for coccydynia and failed to respond to conservative management. They were treated by radiologically guided infiltration of the ganglion blockade impar and/or caudal blockade with 1% lidocaine 60–80 mg triamcinolone. Of these 23 patients, 21 were available for clinical review and completed a questionnaire giving their assessment of the effect of the infiltration of the ganglion impar block and/or caudal block. Results Good results were obtained in 16 of the 21 patients with coccydynia due to trauma. In five patients the results were moderate or poor, although none described worse pain after the operation. They are no complications after the infiltration. Conclusion Ganglion impar block and/or caudal block offered satisfactory relief of pain in the majority of patients regardless of the cause of their symptoms.

Intrathecal neurolytic block in a patient with refractory cancer pain

We report the successful treatment of refractory cancer pain by bilateral intrathecal neurolysis using phenol-glycerol. A 60-year-old man had recurrent sigmoid cancer and metastases to the lumbar (L4-5) and sacral bones. He complained of refractory pain in the lower back and lower extremities despite high-dose opioid treatment based on the WHO ladder. On admission to our hospital, he received continuous intravenous infusion of morphine (7,000mg/day) with ketamine (300mg/day) and lidocaine (700mg/day). Intravenous midazolam was required to treat extreme anxiety. Because of inadequate pain relief and severe drowsiness, intrathecal phenol-glycerol neurolytic block was performed twice at the L2/3 intervertebral space. His analgesia was greatly improved and high-dose intravenous opioid was retitrated and ceased. He remained comfortable and lucid at home for 2months, until 2days before his death at hospital. Intrathecal neurolytic block may be appropriate for some patients suffering from refractory pain that is resistant to conventional opioid analgesic treatment.

Treatment-resistant sensory motor symptoms in persons with SCI may be signs of restless legs syndrome

Case report on the successful treatment with pramipexole in four men with chronic spinal cord injury (SCI) suffering from refractory symptoms that were previously considered to be manifestations of a post-traumatic spastic syndrome or neuropathic pain. To raise awareness among health professionals regarding the diagnostic and therapeutic possibility of restless legs syndrome (RLS) and periodic limb movements (PLMs) in some patients with SCI responding poorly to conventional treatment for spasticity or neuropathic pain. Neurorehabilitation department of the Rehabilitation Medicine Center of Northern University Hospital, Umeå, Sweden. Medical records and clinical data were retrospectively reviewed. All cases obtained treatment with pramipexole, initially 0.09-0.72 mg day(-1). Two of the cases had RLS and PLMs, one RLS only and one PLMs only. All four reported symptoms in the lower extremities and one also in the upper extremities. Three patients with residual gait function reported RLS score with/without treatment as follows: 32/11, 37/12 and 33/12. One patient with complete paraplegia (with incomplete RLS score) reported 22/10. After a follow-up period of 16, 20, 43 and 49 months, respectively, all four still reported excellent outcomes. Two remained on initial dosage; one had increased dosage from 0.09 to 0.18 mg day(-1) and one from 0.27 to 0.80 mg day(-1) during the follow-up period. In persons with SCI suffering from infralesional involuntary movements and/or dysesthesia and with poor response to conventional antispastic or analgesic treatment, the possibility of RLS or PLMs should be considered, as these conditions seem eminently treatable.

An expert opinion on postoperative pain management, with special reference to new developments

Importance of the field: Recently, much attention has been directed towards the effect of opioid-sparing strategies on postoperative morbidity and hospitalization, and on different nociceptive mechanisms involved in various postoperative pain states and surgical procedures. This has resulted in an increased interest in secondary, or adjunct, analgesics and procedure-specific analgesic methods.Areas covered in this review: The present paper aims to review and discuss recent developments within the field of various adjunct, systemic analgesics and local/regional anesthetic methods for management of postoperative pain, based on evidence from randomized, clinical trials published within the last 5 years.What the reader will gain: The reader will gain insight into the current role of pregabalin, glucocorticoids and systemic lidocaine for the management of postoperative pain. In addition, the current status of local infiltration analgesia for hip and knee arthroplasty, transversus abdominis plane block for abdominal operations, and the analgesic effect of wound instillation of capsaicin are reviewed.Take home message: The evidence of a substantial analgesic effect of pregabalin on acute postoperative pain is questionable, and more convincing evidence of the role of glucocorticoids and systemic lidocaine is needed before they should be recommended as analgesics in daily clinical practice. Local infiltration analgesia after hip and knee arthroplasty, transversus abdominis plane block after abdominal operations and local application of capsaicin lend some promise, but there is still a lack of well-performed RCTs to draw any firm conclusions. Procedure-specific analgesic combinations within well-defined rehabilitation paradigms should be explored further to reduce adverse effects associated with the use of conventional analgesic treatment protocols, and to improve postoperative outcome.

Femoroacetabular impingement caused by an osteochondroma of the pubic ramus

Introduction Hip pain in young adults may be caused by multiple factors. One of these may be femoroacetabular impingement. Case report We present the case of a 28-year-old amateur cyclist male with pain in the right hip refractory to conventional analgesic treatment. Initial radiological study was normal and MRi showed diffuse edema in the periacetabular region, suggestive of a sarcomatous lesion. A 3D CT-scan demonstrated the existence of an osteochondroma in the anterior wall of the cup, which led to femoroacetabular impingement. Conclusion Alter resection of the tumor the patient remains asymptomatic 6 years from surgery.

Atrapamiento femoroacetabular por osteocondroma de rama iliopubiana

Introduction Hip pain in young adults may be caused by multiple factors. One of these may be femoroacetabular impingement. Case report We present the case of a 28-year-old amateur cyclist male with pain in the right hip refractory to conventional analgesic treatment. Initial radiological study was normal and MRi showed diffuse edema in the periacetabular region, suggestive of a sarcomatous lesion. A 3D CT-scan demonstrated the existence of an osteochondroma in the anterior wall of the cup, which led to femoroacetabular impingement. Conclusion Alter resection of the tumor the patient remains asymptomatic 6 years from surgery.

Reversal of pathological pain through specific spinal GABAA receptor subtypes

Inflammatory diseases and neuropathic insults are frequently accompanied by severe and debilitating pain, which can become chronic and often unresponsive to conventional analgesic treatment. A loss of synaptic inhibition in the spinal dorsal horn is considered to contribute significantly to this pain pathology. Facilitation of spinal gamma-aminobutyric acid (GABA)ergic neurotransmission through modulation of GABA(A) receptors should be able to compensate for this loss. With the use of GABA(A)-receptor point-mutated knock-in mice in which specific GABA(A) receptor subtypes have been selectively rendered insensitive to benzodiazepine-site ligands, we show here that pronounced analgesia can be achieved by specifically targeting spinal GABA(A) receptors containing the alpha2 and/or alpha3 subunits. We show that their selective activation by the non-sedative ('alpha1-sparing') benzodiazepine-site ligand L-838,417 (ref. 13) is highly effective against inflammatory and neuropathic pain yet devoid of unwanted sedation, motor impairment and tolerance development. L-838,417 not only diminished the nociceptive input to the brain but also reduced the activity of brain areas related to the associative-emotional components of pain, as shown by functional magnetic resonance imaging in rats. These results provide a rational basis for the development of subtype-selective GABAergic drugs for the treatment of chronic pain, which is often refractory to classical analgesics.