Long-term Pain Relief Research Articles

Pulsed radiofrequency of the C2 dorsal root ganglion and epidural steroid injections for cervicogenic headache.

Cervicogenic headache (CEH) is characterized by unilateral headache symptoms referred to the head from the cervical spine. Few methods have addressed long-term pain relief for CEH. This study was undertaken to evaluate pain control and quality of life after pulsed radiofrequency (PRF) for the C2 dorsal root ganglion and epidural steroid injections (ESI) for CEH. This was a case-control study. One hundred thirty-nine patients suffering from CEH were enrolled in this study. Of these patients, 87 CEH patients underwent PRF for the C2 dorsal root ganglion and ESI therapy, and 52 CEH patients only underwent ESI therapy. Quality of life and pain control were measured with the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life Questionnaire (QLQ-C30) and Izbicki pain scores. Kaplan-Meier curve was used to evaluate the efficacy of the treatment in the groups. Before therapy, the median of Izbicki pain score in PRF+ESI group and ESI group was 78.5 and 72.5, respectively (p = 0.574). After 2year follow-up, significant reduction was found in the two groups (11.25 versus 40.00, p < 0.001). The two groups demonstrated an equal distribution of age and gender (p > 0.05). SF (68.52 ± 21.50 versus 50.63 ± 15.42), PF (70.61 ± 29.47 versus 47.87 ± 21.53), RF (52.04 ± 17.92 versus 38.13 ± 24.07), EF (61.17 ± 28.41 versus 43.52 ± 25.48), CF (55.36 ± 19.82 versus 46.82 ± 23.54), and QL (59.31 ± 27.44 versus 50.73 ± 21.90) were significantly higher in PRF+ESI group than in ESI group. Kaplan-Meier curve showed that the probability of treatment success in PRF+ESI group was higher than that in ESI group (median pain relief: ESI group, 4months; PRF+ESI group, 8months) (Log-Rank test, p < 0. 001). There was no serious side effect in this study. The combination of PRF for the C2 dorsal root ganglion and ESI is a relatively safe therapy for CEH. This technique not only provides the sustained relief of pain symptom but improves the quality of life in patients with CEH.

Efficacy of Care for Blind Painful Eyes.

Pain relief for a blind painful eye often follows an escalating paradigm of interventions. This study compares the efficacy of common interventions. A retrospective chart review of blind painful eye cases was conducted at a single tertiary institution from April 2012 to December 2016. Demographics, etiology, treatment, and pain level were assessed. Among 99 blind painful eyes, 96 eyes initially received medical therapy (topical steroids, cycloplegics, and/or hypotensives), with pain relief in 39% of eyes. Minimally invasive interventions (laser cyclophotocoagulation, retrobulbar injection, or corneal electrocautery) were performed 41 times in 36 eyes, 34 of which had failed medical therapy, and led to pain relief in 75% of eyes. Evisceration or enucleation was performed in 28 eyes, and long-term pain relief was achieved in 100% of eyes. Surgery allowed discontinuation of oral analgesics in 100% of cases versus 20% for minimally invasive therapy (p = 0.005) and 14% for medical therapy (p = 0.0001). Compared with medical therapy, minimally invasive therapy was 2.5 times more likely to achieve lasting pain relief (p = 0.003) and surgical therapy 35.6 times more likely to achieve lasting pain relief (p = 0.011). High initial pain score was associated with nonsurgical treatment failure. Medical therapy provides pain relief in a moderate number of patients with a blind painful eye. When medical therapy fails, minimally invasive therapy and surgical interventions are successively more effective in relieving ocular pain. High initial pain score is a risk factor for nonsurgical therapy failure and may merit an earlier discussion of surgical intervention.

Abstract P4-11-01: A simple intervention for long-term relief of chronic post mastectomy pain

Abstract Background: Post-mastectomy pain syndrome (PMPS) is a common and often debilitating condition. One common cause likely results from injury to the T4 and T5 sensory nerves during breast surgery, with resulting neuroma formation. It manifests as a pain syndrome diagnosed by “trigger points” that reproduce exquisite pain upon palpation. Pain specialists have found a combination of corticosteroids and local anaesthetic given through perineural infiltration, at other sites, effective in alleviating these neuromas or trigger points. Utilizing this principle, we initiated a quality improvement project to treat PMPS. This perineural injection led to remarkable, long-lasting relief of the first few patients, we therefore continued treating patients with clinical symptoms suggestive of a neuroma. We report on long-term pain relief after trigger point injections (TPI) for women with PMPS. Methods: An observational cohort study of women with PMPS and clinical evidence of neuroma was undertaken. Patients were examined by breast surgeons at a single institution. We injected a 2mL mixture of equal parts 0.5% bupivacaine and 4 mg/mL dexamethasone into each trigger point. Demographics, type of breast and axillary surgery, duration of pain, history of surgical complications, adjuvant radiotherapy, number of injections required, location of trigger points and dates of injection were obtained from the electronic medical record. Patients were surveyed via telephone interview for long-term resolution of pain. Descriptive statistics are reported, univariate and bivariate analyses were conducted using Stata 12 (College Station, TX). Results: We identified 89 trigger points on 61 breasts in 53 patients with PMPS. Patient age ranged from 30-92 years. Mean number of surgeries prior to injection was 2.2 (range 1-8). In this cohort, we found mastectomy was the most frequent surgical procedure preceding the development of a neuroma (41 breasts), followed by reduction mammoplasty with or without concurrent partial mastectomy (16 breasts), and least frequently lumpectomy alone (4 breasts). The time from the onset of neuropathic pain to the first trigger point injection varied from as early as 1 week post-operatively to 132 months (mean 22.2 months). Effectiveness of the TPI was assessed by physical examination immediately (1-3 minutes) after the injection, then with telephone interview (at &amp;gt;/=3 months post TPI). All 53 patients had long-term follow-up data (≥3 months). Long-term relief was achieved in 84 of 89 trigger points (94.4%) or 54 of 61 breasts (88.5%). Trigger point injections were well tolerated by all patients and no complications were reported. Discussion: Perineural infiltration with bupivacaine and dexamethasone is a safe, simple, and effective treatment option for PMPS with an associated trigger point. Our data suggest this significant problem can easily be resolved in an outpatient setting. All breast specialists should inquire about the presence of symptoms consistent with PMPS and understand the value of intervention to eliminate neuropathic pain. This technique should be added to the armamentarium of all surgeons who perform breast surgery. Citation Format: Keane HJ, Khoury AL, Hosseini A, Varghese FP, Mukhtar R, Eder SE, Wong J, Esserman LJ. A simple intervention for long-term relief of chronic post mastectomy pain [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-11-01.

Chronic localized back pain due to entrapment of cutaneous branches of posterior rami of the thoracic nerves (POCNES): a case series on diagnosis and management.

Introduction and aimChronic back pain (CBP) may be caused by a variety of conditions including dysfunctional muscles, ligaments or intervertebral discs, improper movement of vertebral column joints, or nerve root compression. Recently, CBP was treated successfully in a patient having an entrapment of cutaneous branches of the posterior rami of the thoracic nerves, termed posterior cutaneous nerve entrapment syndrome (POCNES). Our aim is to describe clinical presentation, differential diagnosis, and management of patients with such a neuropathic pain syndrome.MethodsThis study analyzed prospectively obtained data from consecutive patients suspected of having POCNES, presenting to two Dutch hospitals between January 2013 and September 2016. Patients received a diagnostic 2–5 mL 1% lidocaine injection just below the thoracolumbar fascia. Pain was scored using a numerical rating scale (0 = no pain to 10 = worst possible pain). A >50% pain reduction was defined as success. A neurectomy was proposed if pain reduction was temporary or insufficient after one to three injections. Long-term treatment effect was determined using a verbal rating scale (VRS; 1 = very satisfied, no pain, to 5 = pain worse).ResultsFourteen patients (12 women, median age 26, age range 18–73) were diagnosed with POCNES. Eighty-one percent (n=11) reported a >50% pain drop after injection (NRS pain scores of median 8.0 [IQR 7.0–8.0] to median 3.0 [IQR 1.5–3.5], P<0.001). In one patient, repeated injections were successful long-term (VRS score of 2). Two patients declined surgery, whereas the remaining eleven underwent a neurectomy that was successful in seven (64%). A 57% long-term efficacy (median 29 months follow-up, range 5–48, VRS score 1–2) was attained in the entire study population.ConclusionPOCNES should be considered in the differential diagnosis of chronic localized back pain. A treatment regimen including injections and neurectomy of the specific cutaneous branch results in long-term pain relief in more than half of these patients.

Early Outcomes of Cemented versus Cementless Total Knee Arthroplasty

Introduction. Total knee arthroplasty (TKA) has been provento be very effective for long-term pain relief in the degenerativeknee. Few studies have investigated short-term clinicaland functional outcomes between the cemented and cementlessTKA. The specific aim of this study was to assess the potentialdifference of functional outcomes in the early postoperativeperiod between these two surgical options usingthe Knee Society Score (KSS) and range of motion (ROM).&#x0D; Methods. A total of 164 knees that had undergone TKA by a singlesurgeon at a single institution between 2007 and 2010 were reviewed.Three different TKA prosthetic designs (cruciate retaining(CR), posterior stabilized (PS) and cruciate substituting (CS))were included. Data collection included patient demographics,pre- and post-operative ROM, and pre- and post-operative KSSat each visit (1.5 months, 3 months, and 12 months). Two separateKSS scores were assigned: functional score and clinical score.&#x0D; Results. Sixty-seven knees underwent cemented TKA and 97knees underwent cementless TKA. No significant differencewas recognized in either age or body mass index for thesetwo TKA groups. The cementless group showed a significantearly ROM improvement after 1.5 months post-operative (p &lt;0.05), while the cemented group showed ROM improvementonly after three months post-operative. No significant differencewas detected in terms of KSS between the cemented andcementless TKA groups at each measured time period. Bothgroups showed marked KSS improvement (cemented: 135%,cementless: 125%) after 1.5 months post-operative and theKSS seemed to be stabilized after three months post-operativefor both groups (cemented: p = 0.36; cementless: p = 0.07).&#x0D; Conclusions. There was a significant early ROM improvementfor the cementless TKA group compared to the cementedTKA group, but no statistical significant difference was notedin KSS in the early post-operative period when comparing cementedand cementless TKA groups. The findings provide evidencethat cementless TKA patients can undergo an identicalpost-operative protocol to cemented TKA, without concernsabout implant stability or function. KS J Med 2016;9(4):93-98.

Sphenopalatine Ganglion Block and Radiofrequency Ablation: Technical Notes and Efficacy.

Background: Sphenopalatine ganglion (SPG) blockade or lesioning can offer significant pain relief for cluster headaches (CHs) and a variety of other pain syndromes involving the head and face. Methods: We reviewed the literature on the efficacy of SPG block and radiofrequency ablation (RFA) using PubMed and Google Scholar. Results: The infrazygomatic technique can be used to directly access the SPG for injection of local anesthetic or lesioning using RFA. Important technical points to achieve these procedures are described. SPG blockade efficacy is supported by randomized controlled studies but SPG RFA is not. Conclusion: Targeting the SPG is a promising treatment option for refractory CHs. RFA and neuromodulation have the potential to offer long-term significant pain relief, but more randomized studies are needed to demonstrate their efficacy.

Long-term efficacy of 1–1.2 kHz subthreshold spinal cord stimulation following failed traditional spinal cord stimulation: a retrospective case series

Background and objectiveWe investigated whether an effective long-term pain relief could be achieved using subthreshold 1–1.2 kHz spinal cord stimulation (SCS) among patients who were initially implanted with traditional paresthesia-based...

Ultrasound guided cryoanalgesia of peripheral nerve lesions

ObjectiveTo describe our experience performing cryoablative procedures for patients with painful peripheral nerve lesions, excluding patients with chronic regional pain syndrome.SummaryThe real-time nature of ultrasound makes it ideally suited to provide guidance for a variety of musculoskeletal interventional procedures involving peripheral nerves. Continuous observation of the needle ensures proper placement and allows continuous monitoring when performing localized ablative therapy and therefore, more accurate positioning of a cryoprobe, use of smaller needles, as well as access to small structures. In the current talk, we describe our experience performing cryoablative procedures for a variety of painful peripheral nerve lesions. In our experience, patients undergoing cryoneurolysis have reported varying degrees of long-term pain relief and improvement in function; no serious complications have yet been identified. Ultrasound guided cryoneurolysis can provide a useful, safe alternative to other ablative techniques to achieve long-term analgesia. In as much as there is only limited patient outcome data available to date, we present descriptive information as to our current technique with limited patient follow-up. For purposes of the current discussion, we will not include examples of patients with chronic regional pain syndrome as they form a complex group of patients not easily addressed through simple targeted ablative techniques. To describe our experience performing cryoablative procedures for patients with painful peripheral nerve lesions, excluding patients with chronic regional pain syndrome. The real-time nature of ultrasound makes it ideally suited to provide guidance for a variety of musculoskeletal interventional procedures involving peripheral nerves. Continuous observation of the needle ensures proper placement and allows continuous monitoring when performing localized ablative therapy and therefore, more accurate positioning of a cryoprobe, use of smaller needles, as well as access to small structures. In the current talk, we describe our experience performing cryoablative procedures for a variety of painful peripheral nerve lesions. In our experience, patients undergoing cryoneurolysis have reported varying degrees of long-term pain relief and improvement in function; no serious complications have yet been identified. Ultrasound guided cryoneurolysis can provide a useful, safe alternative to other ablative techniques to achieve long-term analgesia. In as much as there is only limited patient outcome data available to date, we present descriptive information as to our current technique with limited patient follow-up. For purposes of the current discussion, we will not include examples of patients with chronic regional pain syndrome as they form a complex group of patients not easily addressed through simple targeted ablative techniques.

Intravesical injections of platelet-rich plasma is effective and safe in treatment of interstitial cystitis refractory to conventional treatment-A prospective clinical trial.

Current treatments for interstitial cystitis/bladder pain syndrome (IC/BPS) are usually unsuccessful in achieving long-term bladder pain relief and irritable symptom improvement. This study investigated the clinical efficacy of platelet-rich plasma (PRP) intravesical injections on IC/BPS patients refractory to conventional therapies. Forty patients received four monthly intravesical injections of 10 mL PRP extracted from 50 mL of whole blood. The primary end-point was Global Response Assessment (GRA) at 3 months after the 4th PRP injection. Secondary endpoints included changes in O'Leary-Sant symptom score (OSS), visual analog scale (VAS) of pain, daily frequency, nocturia, functional bladder capacity (FBC), maximum flow rate, voided volume, post-void residual volume (PVR) from baseline to 3 months after the 4th PRP injection. All 40 patients (37 women and 3 men, aged 55.5 ± 11.1 years) completed the four injections and follow-up visits. GRA improved after the 1st PRP injection and the satisfaction persists till the primary end-point. The success rate was 45%, 52%, 70%, 70%, and 67.5% after the 1st, 2nd, 3rd, 4th, and 3 months after the 4th PRP injection, respectively. OSS and VAS also significantly decreased. The PVR did not change after repeated PRP injections, FBC increased, frequency, and nocturia were decreased after PRP injections. All patients were free of urinary tract infection or difficulty urinating. The study demonstrated that repeated intravesical injections of autologous PRP can increase bladder capacity and provide IC symptom improvement in patients with IC/BPS refractory to conventional therapy. Autologous PRP injection is safe and effective in selected patients.

The incidental finding of elevated anti GQ1B antibodies in a patient with selective small fiber neuropathy

Small fiber neuropathy occurs in several autoimmune diseases and autoantibodies against neuronal proteins may play a role in SFN pathophysiology.1−2 Antigangliosides antibodies anti-GQ1b have not previously associated to SFN. We describe a 45-year-old woman complaining of a two-year history of tingling and/or burning pain sensation in the arms and legs, with nocturnal exacerbation. The anamnesis revealed a ten-year history of an autoimmune disorder including HLA-B27 negative psoriatic arthritis, complement C3 deficiency membrano-proliferative glomerulonephritis and sicca syndrome. Neurological examination did not disclose ophthalmoplegia, signs of central nervous dysfunctions or peripheral large nerve fiber abnormalities. Laboratory screening disclosed IgM antiganglioside antibodies anti-GQ1b (high titer) and anti-GD1b (low titer). Skin biopsies from distal leg and thigh revealed decreased epidermal nerve fiber density, whereas autonomic innervation of dermal annexes was preserved. Motor and sensory nerve conduction studies were normal excluding a large nerve fiber involvement. SFN likely explained the sensory dysfunctions complained of by the patient. A trial with adalizumab resulted in long-term pain relief. This is the first report of SFN associated with antigangliosides antibodies anti-GQ1b. Further studies will clarify a possible pathogenetic role of these antibodies in SFN. Moreover, their recognition of in SFN may be an indicator of patients who would potentially benefit from immunotherapy.

Variables affecting the potential efficacy of PRP in providing chronic pain relief.

Although chronic pain affects about 1% of the US population, it remains largely resistant to treatment. Despite great variability in pain outcomes, the application of autologous platelet-rich plasma (PRP) has become increasingly popular in attempts to reduce chronic pain. The variability in PRP efficacy raises the question of whether PRP actually has an analgesic capacity, and if so, can that capacity be made consistent and maximized. The best explanation for the variability in PRP analgesic efficacy is the failure during PRP preparation and application to take into account variables that can increase or eliminate its analgesic capabilities. This suggests that if the variables are reduced and controlled, a PRP preparation and application protocol can be developed leading to PRP inducing reliable, complete, and long-term pain relief. The goal of this study was to examine some of the variables that influence platelets and see how they might be controlled to increase the analgesic potential of PRP. Among the variables examined are the physiological status of the patient, methods used to prepare PRP, and methods of PRP application. The goal of modifying these variables is to minimize platelet serotonin content, maximize platelet content of factors that reduce inflammation and pain, while maintaining their bioactivity, maximize platelet capacity to aggregate at injury sites, induce rapid and simultaneous release of their contents, and optimize PRP application protocols. It is concluded that controlling some or many of these variables will lead to PRP that induces reliable, maximum, and long-term relief of chronic pain.

Long-term pain relief at five years after medical, repeat surgical procedures or no management for recurrence of trigeminal neuralgia after microvascular decompression: analysis of a historical cohort

Background: Management strategies for the recurrence of trigeminal neuralgia after microvascular decompression include repeat procedures, medical management or no further therapy. No consensus exists as to which strategy is best for pain relief. The aim of this study was to determine the characteristics of patients with recurrences after microvascular decompression in the cohort, and to compare long-term pain relief between different management strategies.Materials and methods: A historical cohort of patients who underwent microvascular decompression at a neurosurgical institution between 1982–2002, followed up by postal survey at five years, was included. Characteristics of patients who experienced a recurrence were compared to those who were recurrence free, and pain relief was compared between each management strategy.Results: From 169 responders who were included in the study, 28 (16.6%) experienced a recurrence after MVD. No characteristics were significantly different between patients who experienced a recurrence and those who did not. Repeat procedures, including repeat microvascular decompression, partial sensory rhizotomy or radiofrequency thermocoagulation, yielded the highest proportion of pain relief after recurrence (p = 0.031), with 63.6% of patients pain-free at five-years. There was no evidence to suggest that the choice of repeat procedure influenced the likelihood of pain relief after recurrence. No further treatment yielded 57.1% pain-free, whereas medical therapy had the lowest proportion of pain-free patients, at 10.0%.Conclusion: A variety of options are available to patients for recurrence of TN after microvascular decompression with repeat procedures yielding the greatest likelihood of long-term pain relief in this historical cohort. The choice of management should consider the mechanism of recurrence, the benefits and risks of each option and the severity of the pain. Regardless of the management strategy selected, careful phenotyping of patients before and after surgery is paramount.

Dedicated Linear Accelerator Radiosurgery for Classic Trigeminal Neuralgia: A Single-Center Experience with Long-Term Follow-Up

During the past decades, stereotactic radiosurgery, and Gamma Knife in particular, has proved its safety and efficacy for drug-resistant classic trigeminal neuralgia. However, few large series exist using linear accelerator (LINAC) reporting long-term follow-up. Between 2006 and 2015, 301 patients were treated by LINAC at our institution. The prescribed radiation dose was 90 Gy at the far anterior target. Clinical response was defined using the Barrow Neurological Institute scale. We considered grades I and IIIa as a successful response. Mean duration of follow-up was 54.6 months (range, 12-132 months). Two hundred and seventy-three patients (90.7%) were initially pain free, and 28 patients (9.3%) were unchanged. The actuarial probabilities of maintaining pain relief with or without medication (Barrow Neurological Institute grade I and IIIa) at 0.5, 1, 2, 4, 5, and 10 years were 88.7%, 85.0%, 76.1%, 68.8%, 65.8%, and 48.1%, respectively. Hypesthesia was present in only 26.2% of patients (very bothersome, 0.3%). No anesthesia dolorosa was reported. The actuarial probabilities of maintaining pain relief without further surgery at 0.5, 1, 2, 4, and 5 years were 99.3%, 98.3%, 95.8%, 91.0%, and 89.7%, respectively. Among all treated patients, 86.5% were satisfied by the procedure and would undergo stereotactic radiosurgery again. Stereotactic radiosurgery with dedicated LINAC is associated with high rates of long-term pain relief, with minimal invasiveness and rare complications. LINAC is a possible therapeutic alternative for drug-resistant trigeminal neuralgia and could be proposed to selected patients as the first intention therapy, among other surgical solutions.

Phantom limb pain: peripheral neuromodulatory and neuroprosthetic approaches to treatment

Post-amputation phantom limb pain (PLP) is a widespread phenomenon that can have physical, psychological, and functional impacts on amputees who experience the condition. The varying presentations and mechanisms of PLP make it difficult to effectively provide long-term pain relief. Multiple neuromodulatory approaches to treating PLP have focused on electrical stimulation of the peripheral nervous system, with varying degrees of success. More recently, research has been done to study the effects of neuroprosthetic approaches on PLP. Neuroprosthetics combine the use of a functional prosthetic with stimulation to the peripheral nerves in the residual limb. Although many of the neuroprosthetic studies focus on improving function, several have shown preliminary evidence for the reduction of severity of PLP. In this review we provide an overview of the current understanding of the neurological mechanisms that initiate and sustain PLP, as well as the neuromodulatory and neuroprosthetic approaches under development for treatment of the condition. Muscle Nerve 59:154-167, 2019.

Factors predicting outcome after anterior neurectomy in patients with chronic abdominal pain due to anterior cutaneous nerve entrapment syndrome (ACNES)

BackgroundChronic abdominal pain due to anterior cutaneous nerve entrapment syndrome may require surgery to provide long-term pain relief in up to 70% of patients. Factors predicting outcome after an anterior neurectomy are unknown. The aim of the study is to identify factors associated with treatment failure to possibly allow for optimizing patient counselling and selection. MethodsCharacteristics of anterior cutaneous nerve entrapment syndrome patients who were unresponsive to nonsurgical therapies and underwent an anterior neurectomy in a tertiary referral center from 2011 to 2016 were analyzed. Treatment failure was defined as <50% pain reduction using a numeric pain rating scale (numeric pain rating score 0–10) approximately 2 months postoperatively. A prediction model based on a multivariate regression analysis was tested for its discriminative value. ResultsA total of 495 patients (78% female, median age 40 years, range 8–83) undergoing an anterior neurectomy were eligible for analysis. Pain medication use (odds ratio 1.84, P = .027, confidence interval 1.07–3.17), abdominal surgery in the past (odds ratio 1.85, P = .026, confidence interval 1.08–3.18), the presence of paravertebral tender points at exit points of intercostal nerves (odds ratio 2.58, P = .003, confidence interval 1.39–4.80), and failure to favorably respond to a diagnostic rectus sheath block (odds ratio 3.74, P = .000, confidence interval 3.74 – 7.10) were identified as factors predicting surgical failure. However, a prediction model including these 4 factors had poor accuracy with an area under the curve of 0.64 (confidence interval 0.58–0.70). ConclusionThe present study identified risk factors associated with treatment failure that are useful in counseling anterior cutaneous nerve entrapment syndrome patients prior to a surgical intervention.

Comparison of Efficacy of Lateral Branch Pulsed Radiofrequency Denervation and Intraarticular Depot Methylprednisolone Injection for Sacroiliac Joint Pain

Sacroiliac joint dysfunctional pain has always been an enigma to the pain physician, whether it be the diagnosis or the treatment. Diagnostic blocks are the gold standard way to diagnose this condition. Radiofrequency neurotomy of the nerves supplying the sacroiliac joint has shown equivocal results due to anatomical variation. Intraarticular depo-steroid injection is a traditional approach to treating sacroiliac joint pain. For long-term pain relief, however, lesioning the sacral lateral branches may be a better approach. This study compared the efficacy of intraarticular depo-methylprednisolone injection to that of pulsed radiofrequency ablation for sacroiliac joint pain. This study used a randomized, prospective design. Thirty patients with diagnostic block-confirmed sacroiliac joint dysfunctional pain were randomly assigned to 2 groups. One group received intraarticular methylprednisolone and another group underwent pulsed radiofrequency of the L4 medial branch, the L5 dorsal rami, and the lateral sacral branches. Reduction in Numeric Rating Scale (NRS) for pain at 1 month post-procedure remained similar in Group A, while in Group B few patients reported a further decrease in the NRS score (3.333 ± 0.4880 and 2.933 ± 0.5936, respectively). At 3 months post-procedure, the NRS score began to rise in most patients in group A, while in Group B, the NRS score remained the same since the last visit (4.400 ± 0.9856 and 3.067 ± 0.8837, respectively). At 6 months post-procedure, the NRS score began to rise further in most patients in group A. In Group B, the NRS score remained the same in most of the patients since the last visit (5.400 ± 1.549 and 3.200 ± 1.207). There was a marked difference between the 2 groups in Oswestry Disability Index (ODI) scores at 3 months post-procedure (Group A, 12.133 ± 4.486 vs Group B, 9.133 ± 3.523) and at 6 months post-procedure there was a significant (P = 0.0017) difference in ODI scores between Group A and Group B (13.067 ± 4.284 and 8.000 ± 3.703, respectively). Global Perceived Effect (GPE) was assessed in both groups at 3 months post-procedure Only 33.3% (Confidence Interval (CI) of 11.8- 61.6 ) of patients in Group A had positive GPE responses whereas in Group B, 86.67% (CI of 59.5- 98.3 ) of patients had positive GPE responses. At 6 months post-procedure, the proportion of patients with positive GPE declined further in Group A, while in Group B, positive GPE responses remained the same (20% with a CI of 4.30- 48.10 and 86.67% with a CI of 59.5- 98.3, respectively ). Small sample size. This comparative study shows that pulsed radiofrequency denervation of the L4 and L5 primary dorsal rami and S1-3 lateral branches provide significant pain relief and functional improvement in patients with sacroiliac joint pain. Low back pain, sacroiliac joint dysfunctional pain, radiofrequency, intraarticular injection.

The impact of physical activity level on the short- and long-term pain relief from supervised exercise therapy and education: a study of 12,796 Danish patients with knee osteoarthritis

It is unknown if people with knee osteoarthritis (OA) who are already physically active benefit from exercise therapy. To study the impact of physical activity level on pain relief, post-intervention and 12 months following exercise therapy and education. The analyses included 12,796 patients with knee OA from the Good Life with osteoArthritis in Denmark (GLA:D®) program. GLA:D® consists of 12 sessions of supervised neuromuscular exercise and two sessions of education delivered by trained physical therapists. The impact of physical activity level on change in knee pain intensity (0-100) immediately post-intervention and at 12 months was estimated using a mixed-effects model adjusted for age, sex, body mass index (BMI), educational level and comorbidity. Physical activity level was assessed using the University of California, Los Angeles (UCLA) activity scale. Physically inactive patients had worse baseline pain compared to patients with low to very high physical activity level (6-15 points worse; P<0.001). Pain decreased by 13.4 points (95% CI; 9.7 to 17.1) following the treatment program and by 12.8 points (7.7-18.0) at 12 months in the inactive patients, with similar improvements in patients with higher levels of physical activity (P=0.278 to 0.851). In patients with knee OA, similar and persistent long-term pain relief was found from supervised exercise therapy and education regardless of the initial physical activity level. Patients with high to very high levels of physical activity can expect pain relief from supervised exercise therapy and education similar to that of more physically inactive patients.

Long-term pain relief in canine osteoarthritis by a single intra-articular injection of resiniferatoxin, a potent TRPV1 agonist.

The translational potential of analgesic approaches emerging from basic research can be augmented by client-owned dog trials. We report on a peripheral interventional approach that uses intra-articular injection of the ultrapotent TRPV1 agonist resiniferatoxin (RTX) to produce a selective long-term chemoinactivation of nociceptive primary afferent nerve endings for pain control in naturally occurring canine osteoarthritis. A single injection of 10 µg of RTX, produced suppression of pain, improvement in gait, weight bearing, and improvement in the dog's activities of daily living lasting 4 months or longer. Two to 3 years after the injection, there are no alterations to suggest that removal of inflammatory pain caused accelerated joint degeneration (Charcot joint) in any of the dogs. To amplify the effective use of canine subjects in translational analgesia research, we report a high-quality canine dorsal root ganglion transcriptome. Some targets for analgesia are highly conserved both in protein sequence and level of expression within a target tissue while others diverge substantially from the human. This knowledge is especially important for development of analgesics aimed at peripheral molecular targets and provides a template for informed translational research. The peripheral site of action, long duration of analgesia, apparent safety, and retention of coordination, all resulting from a single dose suggest that intra-articular RTX may be an effective intervention for osteoarthritis pain with few or no side effects and lead to an improved quality of life.

A Shared Decision Approach to Chronic Abdominal Pain Based on Cine-MRI: A Prospective Cohort Study

Chronic abdominal pain develops in 11-20% of patients undergoing abdominal surgery, partly owing to post-operative adhesions. In this study we evaluate results of a novel diagnostic and therapeutic approach for pain associated with adhesions. Prospective cohort study including patients with a history of abdominal surgery referred to the outpatient clinic of a tertiary referral center for the evaluation of chronic abdominal pain. Subgroups were made based on outcome of adhesion mapping with cine-MRI and shared decision making. In operatively managed cases, anti-adhesion barriers were applied after adhesiolysis. Long-term results for pain were evaluated by a questionnaire. A total of 106 patients were recruited. Seventy-nine patients had adhesions on cine-MRI, 45 of whom underwent an operation. Response rate to follow-up questionnaire was 86.8%. In the operative group (Group 1), the number of negative laparoscopies was 3 (6%). After a median of 19 (range 6-47) months follow-up, 80.0% of patients in group 1 reported improvement of pain, compared with 42.9% in patients with adhesions on cine-MRI who declined surgery (group 2), and 26.3% in patients with no adhesions on cine-MRI (group 3), P = 0.002. Consultation of medical specialists was significantly lower in group 1 compared with groups 2 and 3 (35.7 vs. 65.2 vs. 58.8%; P = 0.023). We demonstrate long-term pain relief in two-thirds of patients with chronic pain likely caused by adhesions, using cine-MRI and a shared decision-making process. Long-term improvement of pain was achieved in 80% of patients who underwent surgery with concurrent application of an anti-adhesion barrier.

Reliability of MRI for predicting characteristics of neurovascular conflicts in trigeminal neuralgia: implications for surgical decision making.

The choice of microvascular decompression (MVD), among the several other surgical options, for treating refractory classical trigeminal neuralgia (TN) relies mostly on preoperative imaging, but the degree of reliability of MRI remains a matter of debate. The authors approached the question of predictability of neurovascular conflict (NVC) in a series of 100 protocolized MRI studies from patients with TN who underwent MVD, by reexamination of MR images, blinded to the clinical data and surgical findings, including the side of the neuralgia. Patients included in the study were those who underwent MVD after surgical indication had been determined based on a protocolized imagery workup (3D high-resolution T2-weighted cisternography centered on the trigeminal nerve, 3D time-of-flight angiography, and 3D gadolinium-enhanced T1-weighted imaging) performed at our institution. All MR images were blindly reexamined, and neurovascular relationships were described on both sides, noting the existence of compression, vessels involved, situation along the root, and degree of compression. The results of MRI evaluation were then compared with actual surgical findings. The extent of agreement and quality of the prediction were expressed with Cohen's kappa coefficient (κ) and receiver operating characteristic (ROC) statistics. A conflict had actually been found during surgery in 94 of 100 patients. The sensitivity of MRI to detect a conflict was 97% and the specificity was 50%. Vessel type was identified with high reliability (κ = 0.80), while the grade of the conflict and its situation along the root showed poor to average reliability (κ = 0.38 and κ = 0.40, respectively). The area under the ROC curve for predicting the presence of a conflict according to the grades of conflict seen on MRI was 0.93, which is considered very good. The positive predictive value was differentiated according to the grade of conflict, with a very high value for high grades of vascular conflict. This study shows an overall good reliability of MRI to predict the existence of an NVC. The prediction value is excellent for high grades of compression. Some apparent low-grade compressions on MRI may be revealed as false positives in surgical exploration. This raises the question of what other imaging methods might be used to determine not only the existence of a conflict but also its degree of compression. The degree of compression is of paramount importance to predict the probability of long-term pain relief, and therefore in the decision to propose MVD as the first choice of surgical treatment.