Long-term Pain Relief Research Articles

Long-term pain relief following percutaneous steroid treatment of spinal synovial cysts: a population-based cohort study

BackgroundSpinal synovial cysts are fluid-filled sacs that develop after facet joint degeneration and can give rise to radicular pain. If resistant to conservative management, surgical decompression or percutaneous steroid treatment...

Chronic Abdominal Pain After Previous Bariatric Surgery: Consider the Abdominal Wall.

Up to 30% of patients who undergo bariatric surgery experience recurrent abdominal pain within 3years after the operation. Although some causes for persisting discomfort are well known, a small portion of patients may suffer from an abdominal wall pain associated with Anterior Cutaneous Nerve Entrapment Syndrome (ACNES). Aim of the present study is to discuss incidence, clinical presentation, and treatment outcome in patients with ACNES after bariatric surgery. This retrospective observational cohort study analyzed electronically stored data of patients with ACNES having a history of bariatric surgery. All were treated for ACNES between 2011 and 2017 in a Dutch center of excellence for abdominal wall and groin pain. Success after treatment was defined as a minimal 50% drop in pain level using a Numeric Rating Scale. A total of 49 patients (female n = 44, median age 45 (25-63) years) were identified. Four (8%) experienced long-term pain relief after just one abdominal wall infiltration with lidocaine. Ten additional patients reported success after 2-5 injections. A total of 35 unresponsive patients chose to undergo a neurectomy that was successful in 27. Therefore, this step-up approach conferred an 84% success rate. Occurrence of ACNES after bariatric surgery was estimated at 1 in 100 patients. ACNES should be considered in the differential diagnosis of ongoing pain following previous bariatric surgery. A treatment regimen including abdominal wall infiltrations using an anesthetic agent or a neurectomy is successful in a vast majority of these patients.

Effectiveness of Platelet-Rich Plasma Injection in Rotator Cuff Tendinopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background: To investigate the effectiveness of platelet-rich plasma (PRP) injection among patients with rotator cuff tendinopathy in comparison with sham injection, no injection, or physiotherapy alone. Methods: From the earliest records to November 1, 2018, all published or unpublished randomized controlled trial (RCTs) comparing PRP injection with a control group (sham injection, no injection, or physiotherapy alone) in patients with rotator cuff tendinopathy were included. Eligible trials were included from the search results of electronic databases including PubMed, EMBASE, Scopus, The Cochrane Library, as well as the bibliographies of relevant trials. Five RCTs were enrolled in our meta-analysis. Two authors independently assessed the quality of RCTs with the Cochrane risk of bias tool. We designated pain reduction as the primary outcome and functional improvement as the secondary outcome. Standardized mean difference (SMD) was applied for random-effect meta-analysis. Results: In the short term (3–6 weeks) and medium term (12 weeks), the effectiveness of PRP injection and control group was indistinguishable in terms of both outcomes (pain reduction and functional improvement). Nevertheless, PRP injection led to significant long-term (>24 weeks) pain relief (SMD: 0.42, 95% confidence interval (CI): 0.12–0.72, without heterogeneity). For functional improvement in the long term, PRP injection was not more effective than the control group (SMD: 1.20, 95% CI: −0.20–2.59, with heterogeneity). Conclusions: PRP injection may provide benefit over the control group (sham injection, no injection, or physiotherapy alone) in reducing pain at long-term follow-up for patients with rotator cuff tendinopathy.

Sacral Insufficiency Fractures: a Review of Risk Factors, Clinical Presentation, and Management.

Sacral insufficiency fractures (SIF) are a common and often underdiagnosed source of low back pain. In patients with SIF, there is both a compromised sacroiliac joint and weakened sacrum, resulting in decreased resistance to torsional stress, leading to fracture. While conservative medical management is a safe option, minimally invasive intervention may provide improved short and long-term relief of low back pain in patients presenting with SIF. This comprehensive review is undertaken to provide an update to the current understanding of SIF with description of risk factors, clinical presentation, and management. Sacroplasty is a minimally invasive procedure in which polymethylmethacrylate (PMMA) cement is inserted into bone to improve its structural integrity and alleviate symptoms. Balloon sacroplasty (BSP) has also been successful in alleviating pain with minimal cement leakage in SIF patients. Various other interventional techniques, including navigation-assisted screw fixation have been used to address SIF and have shown improvement in pain with minimal side effects. This review included various modalities of treatments available to manage SIF. This review shows that in comparison with nonsurgical management, sacroplasty has been shown to have greater pain reduction and improved mobility.

On the Origin of Pain – the ‘Pain Channel’ Hypothesis

Theories of pain have traditionally attributed the sensory experience of pain to the brain. We present here a new hypothesis on the origin of pain which is based on a novel approach to the management of persistent pain. We call it the ‘pain channel’ hypothesis of the origin of pain. There are key components to the development of our hypothesis: [1] Our clinical outcome of a persistently pain-free state, representing a maintained pain score of 0/10 has been achieved in a growing cohort of various presentations of persistent pain now exceeding 130 patients over the course of the last five years. With complete control of pain, the patients rapidly return to their premorbid state and level of function. This result requires careful consideration and explanation. [2] Regional anaesthesia has been used as a diagnostic tool to confirm the clinically suspected source of the persistent pain. The pharmacodynamics of local anaesthetics identify the sodium channel of the primary nociceptive sensory neuron as the critical subcellular structure generating pain. [3] Sodium channel function has been recognised as a bioelectromagnetic phenomenon. [4] Neuromodulation has been used to provide our long-term pain relief result. We understand the neuromodulation unit as producing an electromagnetic field within the super low wavelength range of the electromagnetic spectrum and we have devised a strategy which we believe delivers maximal electromagnetic field effect to the intended sodium channels to create a long-term conduction block.We believe that our clinical outcome challenges the current understanding of the role of the brain in pain. We hypothesise that pain is a peripheral phenomenon rather than being a construct of the brain, as our strategy is peripherally based and completely reverses the presenting clinical profile of persistent pain. More specifically we hypothesise that the sensory phenomenon of pain is a function of specific sodium channels which are coded for pain and which are part of the subcellular structure of peripheral nociceptive sensory nerves.We believe that these hypotheses can lead to a change in focus in the diagnosis and management of pain and drive improvement in current technology and medications to facilitate effective treatment of persistent pain.

High-frequency spinal cord stimulation at 10\u2009kHz for the treatment of painful diabetic neuropathy: design of a multicenter, randomized controlled trial (SENZA-PDN)

BackgroundPainful diabetic neuropathy (PDN), a debilitating and progressive chronic pain condition that significantly impacts quality of life, is one of the common complications seen with long-standing diabetes mellitus. Neither pharmacological treatments nor low-frequency spinal cord stimulation (SCS) has provided significant and long-term pain relief for patients with PDN. This study aims to document the value of 10-kHz SCS in addition to conventional medical management (CMM) compared with CMM alone in patients with refractory PDN.MethodsIn a prospective, multicenter, randomized controlled trial (SENZA-PDN), 216 subjects with PDN will be assigned 1:1 to receive 10-kHz SCS combined with CMM or CMM alone after appropriate institutional review board approvals and followed for 24 months. Key inclusion criteria include (1) symptoms of PDN for at least 12 months, (2) average pain intensity of at least 5 cm—on a 0- to 10-cm visual analog scale (VAS)—in the lower limbs, and (3) an appropriate candidate for SCS. Key exclusion criteria include (1) large or gangrenous ulcers or (2) average pain intensity of at least 3 cm on VAS in the upper limbs or both. Along with pain VAS, neurological assessments, health-related quality of life, sleep quality, and patient satisfaction will be captured. The primary endpoint comparing responder rates (≥50% pain relief) and safety rates between the treatment groups will be assessed at 3 months. Several secondary endpoints will also be reported on.DiscussionEnrollment commenced in 2017 and was completed in 2019. This study will help to determine whether 10-kHz SCS improves clinical outcomes and health-related quality of life and is a cost-effective treatment for PDN that is refractory to CMM.Trial registrationClincalTrials.gov identifier: NCT03228420 (registered 24 July 2017).

Drainage procedure for pancreatolithiasis: re-examination of the pancreatic duct diameter standard.

PurposePancreatic duct decompression relieves pancreatic duct stone (PDS)-associated abdominal pain, though a consensus indication for the drainage procedure of the main pancreatic duct (MPD) is lacking. Moreover, major prognostic factors for postsurgical long-term pain relief and recurrence are largely unknown.MethodsThe clinical outcomes of 65 consecutive PDS patients undergoing surgery from 2008–2012 with 3+ years of follow-up were assessed.ResultsAt postsurgical follow-up (median, 4.5 years; range, 3–7 years; procedure: Partington, n = 32; Frey, n = 27; pancreatoduodenectomy, n = 3; distal pancreatectomy, n = 3), the early complication and complete stone clearance rates were 29.2% and 97%, respectively. Long-term, complete and partial pain relief were 93.9%, 83.1%, and 10.8%, respectively. The risk of pancreatic fistula was higher in the <8 mm group than in the >8 mm group (P < 0.05), and 80% of the pancreatic fistula cases occurred in the <8 mm group. A shorter pain duration (P = 0.007), smaller MPD diameter (P = 0.04), and lower Izbicki pain score (P < 0.001) predicted long-term pain relief. Pain recurrence after initial remission occurred in 5 patients and was only related to pain duration (P = 0.02). Stone recurrence and pancreatic exocrine functional and endocrine functional deterioration occurred in 2, 5, and 11 patients, respectively.ConclusionSurgery provides excellent stone clearance, long-term pain relief, and acceptable postoperative morbidity. Using 8 mm as the criterion for drainage surgery can minimize the postoperative pancreatic fistula risk. Individualized and timely surgical treatment may improve the effect of surgery.

A Randomized Longitudinal Double-Blind Clinical Trial on Long-Term Neuropathic Symptomatology Relief &amp;amp; Pain Analgesia

Diabetic neuropathic pain is one of the most difficult to treat with high levels of reoccurrence and a substantial increase with aging. It involves expensive hospitalizations, often resulting in an amputated lower limb. We explored a variety of methods treating neuropathic pain such as low-level laser, monochromatic near-infrared treatment, TENS, acupuncture and pulsed electromagnetic fields that demonstrated inconclusive, limited or temporary pain relief with minor or short-term improvements in mobility. Research conducted by ultra-low energy technologies reports pain relief and reduction of inflammation as a result of anti-oxidant electron donation transforming free radicals into stable molecules. We report the results of a randomized double blind one-year-long longitudinal clinical study on 10 diabetic mellitus (DM) subjects with chronic neuropathy, treated with ultra-low energy nanotechnology who experienced substantial long-term neuropathic pain relief. Importantly, pain analgesia and improvement in neuropathic symptomatology were not age-contingent. This contradicts past research postulating that age-accumulated inflammation and endothelial dysfunction can further exacerbate diabetic neuropathy. Importantly, a method offering age-independent, cost-effective, long-term neuropathic pain relief and increased mobility has major implications in reducing hospitalization time and overall expenses by offering a solution that enhances quality of life.

Role of local infiltration of methylene blue as an analgesic in stapled hemorrhoidopexy: A prospective study

Background: Stapled hemorrhoidopexy gained popularity due to low postoperative pain. Few patients still complain of postoperative anal pain. Methylene blue (MB) in caudal and epidural anesthesia gives long-term pain relief and has also been used to treat intractable pruritus ani. Objective: Evaluate the role of local infiltration of the MB as an analgesic in the procedure for prolapse and hemorrhoids (PPH) surgery. Design: Prospective observational study. Setting: Tertiary health care center. Patients and Methods: Patients with grade-III hemorrhoids were included and were divided into two groups: A and B. Group A received a perianal injection of 2 mL of 1% MB with 10 mL of 25% bupivacaine. Group B received a perianal injection of 2 mL of normal saline with 10 mL of 25% bupivacaine. Main Outcome Measures: Patients were followed up prospectively for pain, hospital stay, and complications. Results were noted and compared between the two groups. Sample Size: 50 patients. Results: Group A had significantly lower pain scores on day 3 (mean ± SD 2.08 ± 1.08) and day 7 (mean ± SD 0.64 ± 0.95) as compared to the pain scores on day 3 (mean ± SD 3.92 ± 1.35) (P-value = 0.000) and day 7 (mean ± SD 2.40 ± 1.0) (P-value = 0.000) in group B. Pain scores within first 24 h and day 21 post-surgery were not statistically significant between groups A and B (P-value = 0.286 and 0.19, respectively). Group B required a significantly higher number of both injectable and oral analgesics (mean + SD 4.03 + 0.94) as compared to group A patients (mean + SD 1.97 + 0.81) (P-value = 0.001). 4% of the patients in group B had prolonged hospital stay due to severe pain. Patients in group A also had a significant reduction in their requirement of analgesics. None of the patients who received MB had any local or systemic allergic reactions. Conclusion: Local infiltration of MB may be used as an effective analgesic in PPH patients without any increase in morbidity. Limitations: Single-center study with a small sample size. Conflict of Interest: None.

Duodenal-preserving pancreatic head resection with limited distal pancreatectomy: A novel, tailored approach for chronic pancreatitis

Presenter: Thomas Maatman MD | Indiana University Background: Operative management of chronic pancreatitis (CP) must be tailored to individual patient’s anatomy to achieve durable symptom relief. Incomplete drainage of an atrophic pancreatic tail is a common cause of symptom recurrence in patients undergoing drainage procedures. We have selectively applied limited distal pancreatectomy (DP) with duodenal-preserving pancreatic head resection (DPPHR) to patients with appropriate anatomy and hypothesized that this novel procedure provides durable therapy. Methods: Ten patients underwent DPPHR combined with limited DP between 2013-2018. Patient demographics, comorbidities, perioperative outcomes, and long-term CP-specific outcomes were recorded. Measurements of the pathology specimen determined pancreas tail volume. Chronic pancreatitis specific outcomes included endocrine/exocrine insufficiency, pain relief, and nutritional status. The amount of opioid pain medication was reported as daily morphine equivalents. Body mass index (BMI) and albumin were reported as surrogates for nutritional status. Descriptive statistics were applied. Continuous data are reported as means ± standard error of the mean. Results: Ten patients (8 females; age 49 ± 3 years) had etiology of idiopathic (n = 4), alcohol (n = 2), sequelae of severe acute pancreatitis (n = 1), hereditary (n = 1), autoimmune (n = 1), and pancreas divisum (n = 1). Operation was 57 ± 14 months after CP diagnosis. Patients had 6 ± 1 endoscopic procedures prior to operation. Mean operative time was 215 ± 11 minutes; estimated blood loss was 110 ± 28 mL. On average, 6 ± 1 cm of pancreatic tail was resected. Splenic preservation was possible in 7 patients. Postoperative LOS was 13 ± 2 days. Postoperative morbidity occurred in two patients; one grade B postoperative pancreatic fistula and one perforated duodenal ulcer. Readmission occurred in 5/10 patients at median time of 36 days (range, 16-78 days) postoperatively. Causes included abdominal pain (n = 2), small bowel obstruction (n = 1), intraabdominal abscess requiring antibiotic therapy (n = 1), and failure to thrive (n = 1). No perioperative mortality occurred. Overall, analgesic requirements and nutrition (measured by albumin) improved substantially (Figure 1). In addition, improvement in BMI (preoperative, 23.5 ± 1 kg/m2) was sustained at one- (23.7 ± 1 kg/m2), three- (25.6 ± 1 kg/m2), and five-years postoperatively (24.2 ± 1 kg/m2). At operation, 20% of patients required insulin; at five-year follow up this number was 25%. Eighty percent of patients were prescribed exocrine replacement preoperatively; all patients were on exocrine replacement at five-year follow up. During follow up (mean, 38 ± 7 months), one patient with hereditary CP underwent salvage total pancreatectomy with islet cell auto-transplantation 13 months postoperatively. Conclusion: In select chronic pancreatitis patients, including limited distal pancreatectomy with duodenal-preserving pancreatic head resection provides durable, long-term pain relief and improves nutritional parameters with minimal effect on pancreatic endocrine and exocrine function. This operation should be considered in select patients with appropriate anatomy.

10 kHz spinal cord stimulation for the treatment of chronic back and/or leg pain: Summary of clinical studies.

Chronic pain has a major impact on sufferers and their families. The associated health care costs are substantial. In the context of increasing prevalence, effective treatment options are ever more important. 10 kHz spinal cord stimulation has been shown to effectively provide pain relief, aid in opioid reduction, and improve quality of life in patients with chronic intractable pain. The present review aims to summarize the clinical evidence related to the use of 10 kHz SCS in chronic back and/or leg pain. We searched the PubMed database between 2009 and 2 June 2020 for articles reporting clinical studies that included at least 10 human subjects permanently treated with a 10 kHz SCS system (Senza® system) for chronic back and/or leg pain for a minimum of 3 months. A randomized controlled trial (SENZA-RCT), as well as several prospective and retrospective studies, reported clinical outcomes in subjects with chronic back and leg pain treated with 10 kHz SCS. A high proportion of subjects (60%–80%) reported long-term response to therapy. Pain relief was provided without paresthesia. Other studies showed promising pain relief outcomes in subjects with back pain ineligible for spinal surgery, neuropathic limb pain, and in those with previously failed traditional low-frequency SCS. Most studies reported improved quality of life metrics and/or reduced opioid intake. Level 1 evidence has already been established for the use of 10 kHz SCS in treating chronic back and leg pain, corroborated by real-world, clinical experience. Exploratory studies also show the potential of the therapy in other refractory pain syndromes, although larger studies are desired to validate their findings. Overall, the literature suggests that 10 kHz SCS provides long-term pain relief in a high proportion of patients, along with improved quality of life and reduced opioid consumption.

Pain-free survival after vagoglossopharyngeal complex sectioning with or without microvascular decompression in glossopharyngeal neuralgia.

Glossopharyngeal neuralgia (GN) is a rare pain condition in which patients experience paroxysmal, lancinating throat pain. Multiple surgical approaches have been used to treat this condition, including microvascular decompression (MVD), and sectioning of cranial nerve (CN) IX and the upper rootlets of CN X, or a combination of the two. The aim of this study was to examine the long-term quality of life and pain-free survival after MVD and sectioning of the CN X/IX complex. A combined retrospective chart review and a quality-of-life telephone survey were performed to collect demographic and long-term outcome data. Quality of life was assessed by means of a questionnaire based on a combination of the Barrow Neurological Institute pain intensity scoring criteria and the Brief Pain Inventory-Facial. Kaplan-Meier analysis was performed to determine pain-free survival. Of 18 patients with GN, 17 underwent sectioning of the CN IX/X complex alone or sectioning and MVD depending on the presence of a compressing vessel. Eleven of 17 patients had compression of CN IX/X by the posterior inferior cerebellar artery, 1 had compression by a vertebral artery, and 5 had no compression. One patient (6%) experienced no immediate pain relief. Fifteen (88%) of 17 patients were pain free at the last follow-up (mean 9.33 years, range 5.16-13 years). One patient (6%) experienced throat pain relapse at 3 months. The median pain-free survival was 7.5 years ± 10.6 months. Nine of 18 patients were contacted by telephone. Of the 17 patients who underwent sectioning of the CN IX/X complex, 13 (77%) patients had short-term complaints: dysphagia (n = 4), hoarseness (n = 4), ipsilateral hearing loss (n = 4), ipsilateral taste loss (n = 2), and dizziness (n = 2) at 2 weeks. Nine patients had persistent side effects at latest follow-up. Eight of 9 telephone respondents reported that they would have the surgery over again. Sectioning of the CN IX/X complex with or without MVD of the glossopharyngeal nerve is a safe and effective surgical therapy for GN with initial pain freedom in 94% of patients and an excellent long-term pain relief (mean 7.5 years).

Low-intensity, Kilohertz Frequency Spinal Cord Stimulation Differently Affects Excitatory and Inhibitory Neurons in the Rodent Superficial Dorsal Horn

Since 1967, spinal cord stimulation (SCS) has been used to manage chronic intractable pain of the trunk and limbs. Compared to traditional high-intensity, low-frequency (<100 Hz) SCS that is thought to produce paresthesia and pain relief by stimulating large myelinated fibers in the dorsal column (DC), low-intensity, high-frequency (10 kHz) SCS has demonstrated long-term pain relief without generation of paresthesia. To understand this paresthesia-free analgesic mechanism of 10 kHz SCS, we examined whether 10 kHz SCS at intensities below sensory thresholds would modulate spinal dorsal horn (DH) neuronal function in a neuron type-dependent manner. By using in vivo and ex vivo electrophysiological approaches, we found that low-intensity (sub-sensory threshold) 10 kHz SCS, but not 1 kHz or 5 kHz SCS, selectively activates inhibitory interneurons in the spinal DH. This study suggests that low-intensity 10 kHz SCS may inhibit pain sensory processing in the spinal DH by activating inhibitory interneurons without activating DC fibers, resulting in paresthesia-free pain relief.

Treatment of Supraorbital Neuralgia Using Ultrasound-Guided Radiofrequency Thermocoagulation of the Supraorbital Nerve: A Retrospective Study.

PurposeThere is no standard clinical treatment protocol for supraorbital neuralgia patients who respond poorly to conservative treatment. Radiofrequency thermocoagulation, a neurologically damaging procedure, is a treatment for supraorbital neuralgia. However, assessments of its long-term efficacy are lacking. Thus, this study aimed to evaluate the long-term efficacy and safety of ultrasound-guided radiofrequency thermocoagulation for treating supraorbital neuralgia.Patients and MethodsWe retrospectively reviewed our clinical database for supraorbital neuralgia patients who underwent an ultrasound-guided radiofrequency thermocoagulation procedure. Demographic data and baseline characteristics, time of onset, postoperative pain intensity, time of recurrence, subsequent treatment, complications and side effects were collected and analysed. The Kaplan-Meier estimator was used to determine recurrence-free survival.ResultsA total of 53 supraorbital neuralgia patients were included in this study. All patients experienced complete pain relief within one month. The median follow-up time of the 53 patients was 36.0 months (IQR, 12.0–72.0 months). A total of 13 patients experienced pain recurrence, with a median recurrence-free time of 97 months according to the Kaplan-Meier estimator. The cumulative proportion of recurrence-free survival was 96.2% at 12 months, 88.4% at 24 months, 82.7% at 36 months, 70.0% at 48 months, 66.3% at 60 months, and 49.7% at 97 months. All but one patient with recurrent pain underwent a second or third radiofrequency thermocoagulation procedure and achieved complete pain relief. Numbness of supraorbital nerve innervation occurred in all patients. However, the numbness scores gradually decreased over time.ConclusionUltrasound-guided radiofrequency thermocoagulation is a safe, effective treatment for supraorbital neuralgia patients who respond poorly to conservative treatments. These patients attained excellent long-term pain relief with a gradual reduction in numbness.

Multi-arm Avidin nano-construct for intra-cartilage delivery of small molecule drugs

Targeted drug delivery to joint tissues like cartilage remains a challenge that has prevented clinical translation of promising osteoarthritis (OA) drugs. Local intra-articular (IA) injections of drugs suffer from rapid clearance from the joint space and slow diffusive transport through the dense, avascular cartilage matrix comprised of negatively charged glycosaminoglycans (GAGs). Here we apply drug carriers that leverage electrostatic interactions with the tissue's high negative fixed charge density (FCD) for delivering small molecule drugs to cartilage cell and matrix sites. We demonstrate that a multi-arm cationic nano-construct of Avidin (mAv) with 28 sites for covalent drug conjugation can rapidly penetrate through the full thickness of cartilage in high concentration and have long intra-cartilage residence time in both healthy and arthritic cartilage via weak-reversible binding with negatively charged aggrecans. mAv's intra-cartilage mean uptake was found to be 112× and 33× the equilibration bath concentration in healthy and arthritic (50% GAG depleted) cartilage, respectively. mAv was conjugated with Dexamethasone (mAv-Dex), a broad-spectrum glucocorticoid, using a combination of hydrolysable ester linkers derived from succinic anhydride (SA), 3,3-dimethylglutaric anhydride (GA) and phthalic anhydride (PA) in 2:1:1 M ratio that enabled 50% drug release within 38.5 h followed by sustained release in therapeutic doses over 2 weeks. A single 10 μM low dose of controlled release mAv-Dex (2:1:1) effectively suppressed IL-1α-induced GAG loss, cell death and inflammatory response significantly better than unmodified Dex over 2 weeks in cartilage explant culture models of OA. With this multi-arm design, <1 μM Avidin was needed – a concentration which has been shown to be safe, preventing further GAG loss and cytotoxicity. A charge-based cartilage homing drug delivery platform like this can elicit disease modifying effects as well as facilitate long-term symptomatic pain and inflammation relief by enhancing tissue specificity and prolonging intra-cartilage residence time of OA drugs. This nano-construct thus has high translational potential for enabling intra-cartilage delivery of a broad array of small molecule OA drugs and their combinations to chondrocytes, enabling OA treatment with a single injection of low drug doses and eliminating toxicity issues associated with multiple high dose injections.

Amniotic Umbilical Cord Particulate for Discogenic Pain.

Discogenic low back pain is the most common type of low back pain and is a major cause of morbidity worldwide. Current nonoperative treatment options are limited in efficacy and lack evidence of long-term pain relief; thus, there is an unmet clinical need for an effective treatment for patients with discogenic pain. Amniotic membrane and umbilical cord (AMUC) particulate may be useful in relieving pain and inhibiting the degenerative cascade in patients with discogenic pain by reducing inflammation. To evaluate the effectiveness of AMUC particulate for discogenic pain. Six months of conservative therapy failed in patients who had discogenic pain confirmed by magnetic resonance imaging and provocative discography. They subsequently received intradiskal injection of 50 to 100 mg of AMUC particulate for cervical, lumbar, and lumbosacral disks. A total of 11 patients with 20 disks were included. Before treatment, all patients reported severe pain, and 10 patients took opioids daily. After treatment, the median reported pain relief was 40%, 50%, and 75% at 1-month (n=6), 3 months (n=8), and 6 months (n=5), respectively. Complete pain relief was noted in 1 patient; however, 2 patients (18%) reported no pain relief at 1 and 3 months. No adverse events, repeated procedures, or complications occurred. This preliminary evidence suggests that a single intradiskal injection of AMUC particulate is safe and may provide symptomatic pain relief in some patients with discogenic pain.

The Liverpool duodenum-and spleen-preserving near-total pancreatectomy can provide long-term pain relief in patients with end-stage chronic pancreatitis.

Total pancreatectomy may improve symptoms in patients with severe end-stage chronic pancreatitis. This might be achieved whilst preserving both the duodenum- and spleen-(DPSPTP). Mature clinical outcomes of this approach are presented. Single-centre prospective cohort study performed between September 1996 and May 2016. Demographic, clinical details, pain scores and employment status were prospectively recorded during clinic attendance. Fifty-one patients (33 men, 18 women) with a median (interquartile range) age of 40.8 (35.3-49.4) years, a median weight of 69.8 (61.0-81.5) Kg and a median body mass index of 23.8 (21.5-27.8), underwent intended duodenum-and spleen-preserving near-total pancreatectomy for end-stage chronic pancreatitis. Aetiology was excess alcohol in 25, idiopathic (no mutation) in 15, idiopathic (SPINK-1/CFTR mutations) in two, hereditary (PRSS1 mutation) in seven and one each post-necrotising pancreatitis and obstructive pancreatic duct divisum in 1. The main indication for surgery was severe pain. Findings included parenchymal calcification in 79% and ductal calculi in 24%, a dilated main pancreatic duct in 57% and a dilated main bile duct in 17%, major vascular involvement in 27% and pancreato-peritoneal fistula in 2%. Postoperative complications occurred in 20 patients with two deaths. Median pain scores were 8 (7-8) preoperatively and 3 (0.25-5.75) at 5years (p = 0.013). Opiate analgesic use was significantly reduced postoperatively (p = 0.048). Following surgery, 22 (63%) of 38 patients of working age re-entered employment compared with 12 (33%) working preoperatively (p = 0.016). Duodenum-and spleen-preserving near-total pancreatectomy provided long-term relief in adult patients with intractable chronic pancreatitis pain, with improved employment prospects.

Transforaminal Epidural Injection of Local Anesthetic and Dorsal Root Ganglion Pulsed Radiofrequency Treatment in LumbarRadicular Pain: A Randomized, Triple-Blind, Active-Control Trial.

Lumbar radicular pain (LRP) results from inflammation and irritation of lumbar spinal nerves and the dorsal root ganglion (DRG). Our study is a prospective, triple-blind, randomized, activecontrol trial (CTRI/2016/02/006666) comparing transforaminal epidural local anesthetic (LA) injection and pulsed radiofrequency treatment of DRG in patients with chronic LRP. Patients with LRP after failed conservative management for >3months received selective diagnostic nerve root block with 1mL 2% lidocaine. Fifty patients showing positive responses were divided into groups of 25 each. The LA group received transforaminal epidural injection of 1mL 0.5% bupivacaine. The lumbar pulsed radiofrequency (LPRF) group received transforaminal epidural injection of 1mL 0.5% bupivacaine with 3 cycles of pulsed radiofrequency of the DRG for 180seconds RESULTS: Both groups were compared by observing pain intensity on a 0- to 100-point VAS and improvement in functional status by the Oswestry Disability Index (ODI version 2.0) at 2 weeks and 1, 2, 3, and 6 months. All baseline variables were comparable between the 2 groups. Statistically significant reduction in both outcomes was seen in the LPRF group compared to the LA group from 2weeks to 6months. One hundred percent of patients in the LPRF group had a ≥20- point decrease in VAS and significant percentage reduction in ODI at all time intervals up to 6 months, whereas it was seen in 80% and 28% of patients in the LA group at 3 and 6months, respectively. No complications were seen in any patients CONCLUSION: Pulsed radiofrequency of the DRG applied for longer duration results in long-term pain relief and improvement in the functional quality of life in patients with chronic LRP.

Long-Term Outcomes and Alignment following Isolated Fibular Sesamoidectomy

Category:Bunion, Midfoot/Forefoot, SesamoidIntroduction/Purpose:Potential etiologies of sesamoid related pain include repetitive stresses, fracture, cartilage lesions, arthrosis, and/or osteonecrosis. When patients fail to respond to conservative treatment, surgical intervention may be indicated in the form of sesamoid bone grafting, shaving/debridement, and/or sesamoid excision. Minimal published literature exists regarding the long-term safety and efficacy of fibular sesamoidectomy. The purpose of this study was to evaluate patients following isolated, complete fibular sesamoidectomy for long-term pain relief, functional outcome, and changes in hallux alignment.Methods:A query of a tertiary referral center administrative database was performed using the CPT code 28135 for sesamoidectomy between 10/1/2005 and 9/1/2016. Patients who underwent an isolated fibular sesamoidectomy were identified and contacted by their treating physicians with a recruitment letter, phone call, or e-mail to return for an office visit. The primary outcome measure was preoperative to final postoperative change in ten-point visual analog scale pain score. Secondary measures included satisfaction, hallux flexion strength, change in hallux alignment, and final post-operative functional outcome scores.Patients who met the 2-year clinical or radiographic follow-up minimum were included. Patients who underwent concomitant joint realignment procedures or had a medical history of either diabetes or peripheral neuropathy were excluded.Results:Ninety-three fibular sesamoidectomies were identified. Thirty-six sesamoidectomies (35 patients) met inclusion criteria (median follow-up 60 months). The average patient was 36-years-old with a BMI of 24.7 kg/m2 and underwent sesamoidectomy a mean 1.1 years after initial diagnosis. Median VAS scores improved 5 (6 to 1) points at final follow-up (p<0.0001). Final post- operative hallux valgus angle (HVA) did not differ from pre-operative values (10.5°/8.5°, p=0.12); similarly, intermetatarsal angle (IMA) did not differ (8.0°/7.9°, p=0.53). 88% of patients would have surgery again and 70% were “very satisfied” with their result. Hallux flexion strength (mean 14.7 pounds) did not differ following sesamoidectomy relative to the contralateral foot (mean 16.1 pounds) (p=0.23). Among the full 93 case cohort, 3 patients underwent 4 known reoperations.Conclusion:Fibular sesamoidectomy effectively provides long-term pain relief for patients with sesamoiditis, fracture, nonunion, osteonecrosis, and arthritis at long-term follow-up (median 5 years). Potential long-term sequelae, including hallux flexion weakness, change in hallux alignment, and deterioration of patient satisfaction/function were not encountered.

Optimal Management of Endometriosis and Pain.

The pathophysiology of endometriosis-associated pain involves inflammatory and hormonal alterations and changes in brain signaling pathways. Although medical treatment can provide temporary relief, most patients can achieve long-term sustained pain relief when it is combined with surgical intervention. Owing to its complexity, there is an ongoing debate about how to optimally manage endometriosis-associated pain. We believe optimal management for this condition requires: 1) possible egg preservation in affected young patients with and without endometriomas; 2) preoperative medical suppression to inhibit ovulation and to avoid removal of functional cysts that might look like endometriomas; and 3) postoperative hormonal suppression to decrease recurrence, but this treatment should be modified according to disease severity, symptoms, and fertility goals.