Patients Achieved Pain Relief Research Articles

Surgical Management of Painful Digital Neuroma: A Systematic Review

Abstract Background Neuromas of the digits can be a mentally and physically disabling condition for patients in this systematic review, the authors discuss a variety of surgical techniques for digital neuroma management. Aim of the Work This systematic review aims to analyze and combine the results of relevant studies on surgical treatment for digital neuroma. It aims to determine the overall success of the surgical procedure and identify which techniques are more effective. Patients and Methods Four databases, including Embase, Scopus, PubMed, and Google Scholar, were searched for relevant studies. The search spans the years 1990 to 2022. Out of 1490 initial studies, 672 remained after removing duplicates. After screening the Abstracts, 647 were excluded for various reasons, leaving 12 eligible studies for inclusion in the systematic review, which included a total of 309 patients. Outcomes reporting included the visual analogue scale (VAS) to report pain, patient satisfaction, the Semmes-Weinstein Monofilament Test, The two-point discrimination test, a non-standard ordinal scale and the mean follow-up duration. Results The studies included neuroma excision, neuroma excision (and implantation into adjacent tissues), centro-central union, proximal relocation, interdigital direct neurorrhaphy, nerve allograft reconstruction, regenerative peripheral interface, dorsal transposition and epineural coaptation, collagen conduits, and muscle-in-vein conduits (MVCs).The results show that a majority of patients achieved pain relief after surgery, with high levels of satisfaction reported in some studies. The most successful surgical approach was not determined since there were no statistically significant differences between the various surgical techniques. However, neuroma excision followed by nerve repair/reconstruction (centro-central union, proximal relocation, direct neurorrhaphy, nerve allograft, regenerative peripheral interface, dorsal transposition and nerve conduit )show magnificent results compared to neuroma excision alone with or without implantation. Factors such as old age, smoking, and high PROMIS Depression scores were found to be independently associated with higher levels of pain interference. Conclusion The results suggest that surgical treatment is effective in reducing pain levels, with most patients reporting complete pain relief or improvement. Neuroma excision followed by nerve repair/reconstruction was found to result in better outcomes compared to neuroma excision alone with or without implantation.

Treatment of Persistent Idiopathic Dentoalveolar Pain with Venlafaxine: A Multicentric Retrospective Study on Its Effectiveness and Safety.

To determine the effectiveness and safety of venlafaxine in treating persistent idiopathic dentoalveolar pain (PIDP). A retrospective analysis was conducted on a cohort comprising 129 patients with a definite diagnosis of PIDP, who were treated with venlafaxine between May 2020 and December 2022 at three different institutions. Baseline characteristics were statistically described, and visual analog scale (VAS) scores before and during treatment were collected. The percentage of pain relief was calculated. Differences in baseline characteristics between responsive and unresponsive patients were evaluated. Additionally, side effects experienced during treatment were also summarized. Among the included patients, 4 suffered immediate side effects following the initial dose of venlafaxine and the treatment was discontinued. 104 (80.6%) patients achieved pain relief. VAS scores of responsive patients at weeks 2, and months 1, 2, and 3 were significantly lower than baseline (p<0.001). Duration of pain was the only factor related to responsiveness (Wilcoxon rank sum test p<0.001, logistic regression p=0.001). 64 patients (49.6%) suffered from mild side effects. No serious side effects were observed during the study. Venlafaxine is potentially effective and safe in the management of PIDP. Early application of venlafaxine following the diagnoses of PIDP can result in a higher possibility of pain relief.

Does Leuprolide Acetate Predict Successful Pain Relief after Hysterectomy and BSO in Endometriosis Patients?

<h3>Study Objective</h3> Evaluate whether patients with endometriosis-associated pelvic pain who achieve pain relief with leuprolide acetate are more likely to achieve pain relief after hysterectomy and oophorectomy (BSO). <h3>Design</h3> Retrospective chart review. <h3>Setting</h3> Academic teaching hospital. <h3>Patients or Participants</h3> Patients who underwent trial of leuprolide acetate prior to hysterectomy and BSO for endometriosis. <h3>Interventions</h3> We performed a retrospective chart review of patients from 2015-2021 who had a diagnosis of endometriosis and underwent a trial of leuprolide acetate prior to hysterectomy with BSO for pelvic pain (n=31). We reviewed pre-operative records, operative notes, and postoperative records to assess whether patients achieved pain relief following ovarian suppression with leuprolide acetate or definitive surgical management with hysterectomy and oophorectomy. Patients who achieved complete pain relief with leuprolide acetate or hysterectomy with oophorectomy were considered having achieved "complete pain relief". <h3>Measurements and Main Results</h3> 31 patients underwent a trial of leuprolide acetate prior to hysterectomy and BSO for endometriosis. Fifteen patients reported "complete pain relief" with leuprolide acetate therapy and 16 did not. The groups were similar in age, ethnicity, race, BMI, parity, number of past treatments for pelvic pain, mode of hysterectomy, blood loss during surgery, presence of adhesions, and surgical complications. There was a significant difference between the two groups as to whether they achieved complete pain relief after hysterectomy with BSO. Among patients with complete pain relief after leuprolide acetate therapy, 73.7% reported complete pain relief after surgery. In patients who did not experience complete pain relief with leuprolide acetate therapy, only 37.5% reported complete pain relief after surgery (p=.045). <h3>Conclusion</h3> Patients who had complete preoperative pain relief using leuprolide acetate were more likely to achieve pain relief with hysterectomy and BSO. A trial of leuprolide acetate prior to surgery may be helpful to predict which patients will benefit from hysterectomy and BSO for endometriosis-related pelvic pain.

Radiation Therapy for Malignant Lumbosacral Plexopathy: A Case Series.

BackgroundMalignant lumbosacral plexopathy is caused by a direct extension of an intrapelvic malignancy to involve the plexus nerves. In this report, we describe the effect of radiotherapy on patients with malignant lumbosacral plexopathy.Patients and methodsWe performed a retrospective review of the medical records of patients who underwent radiation therapy for pain caused by malignant lumbosacral plexopathy between 2017 and 2020 at our institution. The pain was measured using a numeric rating scale (0-10) at initiation and completion of radiotherapy or at the time when the maximum response was observed.ResultsA total of 12 tumor sites in 11 patients were included. Eight of the tumors invaded the iliopsoas muscle, and the remaining four invaded or abutted the piriformis muscle. The mean duration of follow-up was 215 days (31-675 days). All patients achieved pain relief at the end of radiotherapy, with complete resolution of pain in nine patients. The maximum effect was seen at a mean of three weeks (1-12 weeks) after the initiation of radiotherapy. Toxicities related to radiotherapy included grade 1 diarrhea in four patients and grade 1 frequent urination in one patient. Two patients experienced a relapse of pain at one and two months, respectively, after achieving their maximal response.ConclusionRadiotherapy provides significant pain relief for patients with the malignant lumbosacral syndrome. The recognition and diagnosis of this syndrome, and the use of radiation therapy as a therapeutic option, are important. Patients should be offered all possible therapies, regardless of curative or palliative intent.

Posterior-only debridement, internal fixation, and interbody fusion using titanium mesh in the surgical treatment of thoracolumbar tuberculosis with spinal epidural abscess: a minimum 5-year follow-up

ObjectiveTo investigate the clinical efficacy and feasibility of posterior-only debridement, internal fixation, and interbody fusion using titanium mesh in the surgical treatment of thoracolumbar tuberculosis (TB) with spinal epidural abscess.MethodsFrom January 2008 to January 2014, a total of 45 patients (27 male and 18 female) were reviewed. The patients were diagnosed with thoracolumbar TB with spinal epidural abscess. The patients underwent posterior-only debridement, internal fixation, and interbody fusion using titanium mesh. Hence, we assessed the intraoperative and postoperative complications, disease recurrences, kyphosis deformity correction, and neurological improvement following the American Spinal Injury Association (ASIA). We used SPSS 22.0 for the statistical analyses. An independent Student’s t-test was used for the analysis of preoperative and postoperative continuous variables. The value of P (P < 0.05) was considered statistically significant.ResultsThe mean age of patients was 37.76 ± 10.94 years (17–59 years). The mean follow-up time was 82.76 ± 12.56 months (60–128 months). The mean kyphosis Cobb angle preoperative was 29.36 ± 13.29° (5–55°) and postoperative was 3.58 ± 5.44° (− 6–13°), given the value of P (P < 0.001). According to the neurological score by the ASIA scale, there were 3 cases of grade B, 11 cases of grade C, 16 cases of grade D, and 15 cases of grade E preoperatively. The neurological score improved by 1 ~ 2 grades. All patients achieved pain relief and the VAS score significantly reduced at the last follow-up (P<0.05). While 1 patient had cerebrospinal fluid leakage, 1 had a neurological complication, 1 had delayed surgical wound healing, and 1 had a disease recurrence. No pseudoarthrosis or implant failure occurred in our patients. All patients achieved solid bone graft fusion.ConclusionFor thoracolumbar TB patients with spinal epidural abscess, posterior-only debridement, internal fixation, and interbody fusion using titanium mesh are safe and effective surgical treatments.

Is Osteoporotic Thoracolumbar Burst Fracture a Contraindication to Percutaneous Kyphoplasty? A Systematic Review

The management of pain after osteoporotic thoracolumbar burst fracture has not reached a treatment consensus. Percutaneous kyphoplasty has been shown to be efficient in reducing acute pain after burst fracture, although the topic remains highly controversial in this field. This study aimed to conduct a systematic review of the current literature to evaluate the effectiveness and safety of percutaneous kyphoplasty on the treatment of osteoporotic thoracolumbar burst fracture. A systematic review. University hospital. A comprehensive literature search was performed through PubMed, EMBASE, Web of Science, and Cochrane library without time restriction. Among the studies meeting the eligible criteria, any study in which percutaneous kyphoplasty was utilized alone in the treatment of osteoporotic thoracolumbar burst fracture was included in the current review. For radiographic outcome evaluation, vertebral height and kyphotic angle were analyzed. VAS (Visual Analog Scale) and ODI (Oswestry Disability Index) were utilized for clinical outcome evaluation. Complications such as cement leakage and adjacent vertebral fracture or relapse were also analyzed. In total, 289 patients (338 vertebral bodies) were included in the 8 studies. Clinical outcomes indicated that patients achieved pain relief (VAS) from 6.8 preoperatively to 1.1 postoperatively, and improvement of quality of life (ODI) ranged from 87.0 ± 6.0% to 23.9 ± 4.4%. The radiological outcome indicated that anterior vertebral height restoration ranged from 20.1 ± 2.3 to 85.3 ± 10.6, and posterior vertebral height restoration ranged from 27.3 ± 1.7 to 83.3 ± 7.4. Kyphotic angle achieved correction ranged from 21.7 ± 7.8° preoperatively to 3.17° postoperatively. The main complications after PKP were cement leakage and adjacent vertebral fracture or relapse, which had an incidence of 7.7% -45.4% and 4.3% -74.1%, respectively. Due to the good quality of the English publications, only English-language research searches were conducted, but they do not unduly affect our aggregate results impact. More prospective randomized controlled trials are needed to provide higher evidence for clinical practice. To osteoporotic thoracolumbar burst fracture is absolutely not a contraindication to percutaneous kyphoplasty. Percutaneous kyphoplasty can obtain satisfactory effectiveness for the treatment of osteoporotic thoracolumbar burst fractures. Complications can be effectively decreased by meticulous evaluation, careful manipulation, and appropriate precautionary measures.

Abstract No. 547 Interventional outcomes in the management of fibroadipose vascular anomaly at a tertiary care pediatric hospital

Fibro-adipose vascular anomaly (FAVA) is a pediatric vascular malformation resulting in debilitating pain and reduced mobility in otherwise healthy children. Multidisciplinary assessment and treatment is vital for management, though there is minimal literature assessing postoperative outcomes or follow-up among FAVA patients. 22 patients with biopsy-proven FAVA between June 2013 to February 2020 were referred to our institution for evaluation. Lesions were classified by a typical (calf, arm) or atypical (foot, knee, thigh, gluteal, hand, thoracic, abdominal) location. Documentation of pre- and postprocedural pain at first follow-up visit, length of follow-up after intervention, number of repeat interventions, and development of an additional lesion was obtained. 16 patients (ages 3–15; mean, 10.3 years) with 20 separate lesions (8 typical location; 12 atypical location) pursued invasive treatment for FAVA to ameliorate their pain. Primary interventions performed included sclerotherapy (n = 15), cryoablation (n = 1), sclerotherapy and cryoablation (n = 1), or surgery (n = 3). Technical success for each intervention was 100%, and there were no major complications. Median initial follow-up time was 30 days. 2 patients were lost to follow-up. 10/14 (71%) of patients reported a decrease or absence of pain. 4/14 (28%) sclerotherapy patients required repeat intervention for pain and underwent repeat sclerotherapy (n = 2), cryoablation (n = 3), surgery (n = 1), or sirolimus therapy (n = 1). The two patients who were treated with repeat sclerotherapy required additional intervention and achieved pain relief after cryoablation and surgery, respectively. Median interval between repeat interventions was 484 days. 2/14 patients (14%) developed additional FAVA lesions that required treatment. Median interval for recurrent disease was 408 days. Virtually all patients achieved pain relief after initial intervention. A fraction of patients required reintervention within 18 months. Though a limited sample, cryoablation demonstrated 100% pain relief among the five patients who received cryoablation as either a primary or secondary treatment.

Long-Term Efficacy of Intensive Zoledronate Therapy and Predictors of Retreatment in Paget\u2019s Disease of Bone

Despite the current debate on the best therapeutic approach, i.e. symptomatic vs intensive strategy, one zoledronate (Zol) infusion is effective in most patients with Paget’s disease of bone (PDB), whereas few need retreatment, whose predictors are not well established. We aimed to evaluate long-term efficacy of intensive Zol therapy and predictors of retreatment in PDB. Pagetic complications, clinical and biochemical response to Zol together with frequency of retreatment were retrospectively assessed in forty-seven PDB patients (age, mean ± SD: 72.5 ± 8.9 years, M/F: 24/23; symptomatic/asymptomatic: 16/31). Statistical analysis for retreatment prediction were based on Mann–Whitney U test, Pearson’s Χ2 and ROC curve analysis. During seven-year follow-up, all patients achieved pain relief and only one underwent arthroplasty. Bone alkaline phosphatase (BAP) detected three non-responder (6%) and six relapsing (13%) patients needing retreatment. Retreated patients had less old age (66.1 ± 11.2 vs 74.0 ± 7.7 years), higher frequency of polyostotic disease (78% vs 40%) and higher baseline (96.5 ± 24.8 vs 44.9 ± 27.7 mcg/l) and post-Zol nadir BAP levels (24.7 ± 24.1 vs 8.1 ± 4.1 mcg/l) than patients treated once (p < 0.05 for all comparisons). In multivariate analysis both serum baseline and post-Zol nadir BAP significantly predicted retreatment (OR 1.09, 95%CI 1.01–1.17 and 1.29, 1.03–1.62, respectively), with ROC curve analysis showing the greatest accuracies for threshold values of 75.6 and 9.9 mcg/l (sensitivity 88 and 90%, specificity 94 and 86%, AUC 0.92 and 0.93, respectively). Our data in mostly asymptomatic, metabolically active PDB patients treated with intensive Zol therapy show a negligible incidence of pagetic complications and long-term optimal disease control, with BAP being the best predictor of retreatment.

Occipital Neuralgia following Acoustic Neuroma Resection.

Background While postoperative outcomes of acoustic neuroma (AN) resection commonly consider hearing preservation and facial function, headache is a critical quality of life factor. Postoperative headache is described in the literature; however, there is limited discussion specific to occipital neuralgia (ON) following AN resection. Objective The aim of this study is to investigate the effectiveness of conservative management and surgery. Methods We conducted a retrospective review of 872 AN patients who underwent resection at our institution between 1988 and 2017 and identified 15 patients (1.9%) that met International Classification of Headache Disorders criteria for ON. Results Of the 15 ON patients, surgical approaches included 13 (87%) retrosigmoid (RS), one (7%) translabyrinthine (TL), and one (7%) combined RS + TL. Mean clinical follow-up was 119 months (11-263). Six (40%) patients obtained pain relief through conservative management, while the remaining nine (60%) underwent surgery or ablative procedure. Three (38%) patients received an external neurolysis, four (50%) received a neurectomy, one (13%) had both procedures, and one (13%) received two C2 to 3 radio frequency ablations. Of the nine patients who underwent procedural ON treatment, seven (78%) patients achieved pain relief, one patient (11%) continued to have pain, and one patient (11%) was lost to follow-up. Of the six patients whose pain was controlled with conservative management and nerve blocks, five (83%) found relief by using neuropathic pain medication and one (17%) found relief on nonsteroidal anti-inflammatory drug. Conclusion Our series demonstrates success with conservative management in some, but overall a minority (40%) of patients, reserving decompression only for refractory cases.

Association between clinical characteristics and pain relief in patients with axial spondyloarthritis treated with non-steroidal anti-inflammatory drugs.

Objectives The aim of this study was to evaluate pain relief in axial spondyloarthritis (axSpA) patients treated with non-steroidal anti-inflammatory drugs (NSAIDs) and to investigate the relation of the demographic, clinical, and psychological characteristics with pain relief.Patients and methods Between February 2017 and December 2019, a total of 94 patients (61 males, 33 females; mean age: 28.3±8.1 years; range, 14 to 54 years) who were diagnosed with axSpA and treated with NSAIDs were included. The patients were assessed at baseline and at three months. A reduction of 30% in the Numeric Rating Scale (NRS) indicates a clinically meaningful improvement. The patients were divided into the relief group (≥30% improvement in NRS) and non-relief group (<30% improvement). Potential influential factors for pain relief such as neuropathic pain (NP), disease activity, function, pain catastrophizing, and pain self-efficacy were assessed. The relationship between patients’ characteristics and pain relief was analyzed.Results Seventy-two (76.6%) patients achieved pain relief. These patients had significantly higher baseline erythrocyte sedimentation rate, C-reactive protein, and lower percentage of NP. There was no significant difference between the two groups in function, pain catastrophizing, and pain self-efficacy. Multiple logistic regression analysis revealed that patients with NP were less likely to achieve pain relief (odds ratio [OR]: 3.531, 95% confidence interval [CI]: 1.155-10.789; p=0.027).Conclusion Pain relief is still insufficient in some axSpA patients, despite the administration of NSAIDs. The presence of NP is significantly associated with poor pain relief. Alternative medications instead of NSAIDs are needed to achieve optimal pain relief, when NP is diagnosed.

Nitrous oxide/oxygen plus acetaminophen versus morphine in ST elevation myocardial infarction: open-label, cluster-randomized, non-inferiority study

BackgroundStudies have shown disparate results on the consequences of morphine use in ST-segment elevation myocardial infarction (STEMI). No study has evaluated alternative treatments that could be at least non-inferior to morphine without its potentially damaging consequences for myocardial function and platelet reactivity. The aim of this study was to evaluate whether nitrous oxide/oxygen plus intravenous acetaminophen (NOO-A) is non-inferior to morphine to control chest pain in STEMI patients.MethodsThis multicenter, open-label, cluster-randomized, controlled, non-inferiority study compared NOO-A with morphine in 684 prehospital patients with ongoing suspected STEMI of < 12 h duration and a pain rating score ≥ 4. The primary endpoint was the proportion of patients achieving pain relief (numeric rating score ≤ 3) after 30 min. Secondary safety endpoints included serious adverse events and death at 30 days.ResultsThe median baseline pain score was 7.0 in both groups. The primary endpoint occurred in 51.7% of the NOO-A group and 73.6% of the morphine group (absolute risk difference − 21.7%; 95% confidence interval − 29.6 to − 13.8). At 30 days, the rate of serious adverse events was 16.0 and 18.8% in the NOO-A and morphine groups respectively (p = NS). The rate of death was 1.8% (NOO-A group) and 3.8% (morphine group) (p = NS).ConclusionAnalgesia provided by NOO-A was inferior to morphine at 30 min in patients with acute STEMI in the prehospital setting. Rates of serious adverse events did not differ between groups.Trial registrationClinicalTrials.gov: NCT02198378.

Dosimetry, efficacy, and safety of three-dimensional printing noncoplanar template-assisted and CT-guided 125I seed implantation for recurrent retroperitoneal lymphatic metastasis after external beam radiotherapy

ObjectivesTo evaluate the dosimetry, efficacy, and safety of radioactive 125I seed implantation (RISI) assisted by three-dimensional printing noncoplanar template (3D-PNCT) and CT for recurrent retroperitoneal lymphatic metastasis (RRLM) after previous external beam radiotherapy. Methods and MaterialsFrom June 2016 to August 2018, 32 patients with RRLM successfully underwent 3D-PNCT–assisted and CT-guided RISI. The dosimetry, pain relief rate, performance improvement rate, overall response rate, disease control rate, local control time (LCT), overall survival (OS), and safety profiles were evaluated. ResultsDosimetric results showed that the D90, D100, V100, V150, V200, and homogeneity index were consistent in preoperation and postoperation (p > 0.05), except for the external index and conformal index (p = 0.048, p = 0.034). After RISI, 81.3% of the patients achieved pain relief, and 71.9% achieved an improvement of performance. The overall response rate and disease control rate were 85.3% and 94.1%, respectively. The LCT rates reached 66.2% and 43.2% in 1 year and two years, respectively, with a median LCT of 15.8 months. The OS rates were 74.1% and 28.1% in 1 year and two year, respectively, with a median OS reaching 17.6 months. Univariate analysis showed that when D90 > 130 Gy or D100 > 63 Gy or tumor size ≤49.8 cm3, LCT was extended significantly, but not for OS. Except for two patients developing Grade 1 retroperitoneal hematomas, no other severe adverse events were observed. Conclusions3D-PNCT and CT guidance provide excellent accuracy for RISI, which can be an effective and safe alternative for RRLM after external beam radiotherapy. Radiation dose and tumor size seem to significantly influence the local control.

Trigeminal root massage in microsurgical treatment of trigeminal neuralgia patients without arterial compression: When, how and why

BackgroundDuring the microsurgical exploration of trigeminal root in the pontocerebellar angle in patients with primary trigeminal neuralgia (TN) without an evident arterial compression, the surgeon is in an engaged situation because there are not well-established surgical strategies. The aim of this study is to describe in these cases the surgical maneuver we call “trigeminal root massage” (TRM). Methods52 consecutive patients with primary trigeminal neuralgia who had undergone a microsurgical suboccipital retrosigmoid exploration of trigeminal root were reviewed. Among them we found 10 patients without an evident arterial compression after a thorough microsurgical exploration. In the great majority of these 10 cases, we noticed a venous contact to the trigeminal root along this cisternal trajectory, in most cases we have had to coagulate the compressive vein/s and then cut. All underwent a simple trigeminal root massage, without interposition of any material implant. ResultsAll 10 patients experienced immediate pain disappearance and the postoperative course was uneventful except one case with a severe complication: cerebellar swelling, meningitis and hydrocephaly. The recurrence rate was 40%. Six patients achieved pain relief without specific medication with an average follow-up period of 5 years. There have been no mortalities nor any postoperative anesthesia dolorosa. ConclusionsThe described maneuver provides an easy and simple alternative way in cases where during a microsurgical exploration of trigeminal root, where we don’t find a clear arterial compression, with similar results than other possibilities such as partial sensory rhizotomy or more complicated and time consuming surgery as “nerve combing”. Nevertheless, a 40% of pain recurrence after an average follow-up of 5 years means that is a good alternative, but not a definitive technique at the moment for permanent cure of trigeminal neuralgia without arterial compression.

Trigeminal root massage in microsurgical treatment of trigeminal neuralgia patients without arterial compression: When, how and why.

During the microsurgical exploration of trigeminal root in the pontocerebellar angle in patients with primary trigeminal neuralgia (TN) without an evident arterial compression, the surgeon is in an engaged situation because there are not well-established surgical strategies. The aim of this study is to describe in these cases the surgical maneuver we call "trigeminal root massage" (TRM). 52 consecutive patients with primary trigeminal neuralgia who had undergone a microsurgical suboccipital retrosigmoid exploration of trigeminal root were reviewed. Among them we found 10 patients without an evident arterial compression after a thorough microsurgical exploration. In the great majority of these 10 cases, we noticed a venous contact to the trigeminal root along this cisternal trajectory, in most cases we have had to coagulate the compressive vein/s and then cut. All underwent a simple trigeminal root massage, without interposition of any material implant. All 10 patients experienced immediate pain disappearance and the postoperative course was uneventful except one case with a severe complication: cerebellar swelling, meningitis and hydrocephaly. The recurrence rate was 40%. Six patients achieved pain relief without specific medication with an average follow-up period of 5 years. There have been no mortalities nor any postoperative anesthesia dolorosa. The described maneuver provides an easy and simple alternative way in cases where during a microsurgical exploration of trigeminal root, where we don't find a clear arterial compression, with similar results than other possibilities such as partial sensory rhizotomy or more complicated and time consuming surgery as "nerve combing". Nevertheless, a 40% of pain recurrence after an average follow-up of 5 years means that is a good alternative, but not a definitive technique at the moment for permanent cure of trigeminal neuralgia without arterial compression.

Ultrasound-guided glossopharyngeal nerve block via the styloid process for glossopharyngeal neuralgia: a retrospective study.

ObjectiveTo examine the effectiveness and safety of ultrasound-guided glossopharyngeal nerve block via the styloid process for primary glossopharyngeal neuralgia.MethodsThis retrospective study included all patients receiving glossopharyngeal nerve block via the styloid process under ultrasound guidance for primary glossopharyngeal neuralgia between January 2015 and May 2018 at our hospital. The primary outcome of the study was pain relief as assessed using the visual analog scale (VAS). Treatment was considered effective if the VAS score decreased by more than 2 points.ResultsTwelve patients were included in the analysis. The baseline VAS scores ranged from 5 to 9. All patients received previous pharmacotherapy. Other previous treatments included pulsed mode radiofrequency (n=4), microvascular decompression (n=2), and glossopharyngeal nerve block (not under ultrasound guidance; n=2). The patients completed a total of 48 injections for glossopharyngeal nerve block. At discharge from the hospital, and at 6, 12, and 18 months thereafter, 10/12, 10/12, 7/12, and 4/12 patients achieved pain relief and the effective rate was 83.3% at discharge, 83.3% at 6 months, 58.3% at 1 year, and 33.3% at 18 months, respectively.ConclusionUltrasound-guided glossopharyngeal nerve block via the styloid process is a safe, radiation-free, repeatable, convenient, and effective treatment. It can provide a treatment option for patients with glossopharyngeal neuralgia.

Effect of the types of pretreatment imaging modalities on the treatment response to palliative radiation for painful bone metastases from solid cancer: a single-center retrospective analysis

BackgroundDetermining the appropriate gross tumor volume is important for irradiation planning in addition to palliative radiation for bone metastases. While irradiation planning is commonly performed using simulation computed tomography (CT), magnetic resonance imaging (MRI), bone scintigraphy, and 18fluorodeoxyglucose-positron emission tomography-CT (18FDG-PET-CT) are more sensitive for detecting bone metastasis and invasion areas. Therefore, this study evaluated whether pretreatment imaging modalities influenced the response to palliative radiation therapy (i.e., the irradiation effect) for painful bone metastases from solid malignant carcinomas.MethodsConsecutive patients with painful bone metastases treated with palliative radiation between January 2013 and December 2017 at our institution were included. We retrospectively investigated the pretreatment images from the different imaging modalities (CT, MRI, bone scintigraphy, and 18FDG-PET-CT) obtained between 1 month before and the initiation of palliative radiation and determined the primary site of carcinoma, histological type, metastatic lesion type (osteolytic, osteoblastic, or mixed), pathological fracture, and metastatic site (vertebral or not). We then evaluated the relationship between these factors and treatment response. We defined “response” as the condition in which patients achieved pain relief or reduced the use of painkiller medicines.ResultsIn total, 131 patients (78 men and 53 women) were included; the median age was 66 years (range, 24–89 years). Prescribed doses were 8–50 Gy/1–25 fractions with 2–8 Gy/fraction. Among the 131 patients, 105 were responders (response rate, 80%). The imaging modalities performed before irradiation were CT in 131 patients, MRI in 54, bone scintigraphy in 56, and 18FDG-PET-CT in 14. The Welch t-test and chi-square test showed no significant association between treatment response and each factor. Multiple logistic regression analysis including the imaging modality, metastatic site, and pathological fracture also showed no significant association with each factor.ConclusionsThere was no significant relationship between the type of pretreatment imaging and treatment response for painful bone metastases. Thus, setting the appropriate radiation field according to CT images and clinical findings could help avoiding further image inspection before palliative radiation for painful bone metastases.

Impact of Integral Dose on the Maintenance of Pain Relief in Patients with Idiopathic Trigeminal Neuralgia Treated with Upfront Gamma Knife Radiosurgery

Integral dose (ID) defined as the product of mean dose and target volume, is a measure of the absorbed radiation energy. To evaluate the effect of ID on the duration of pain relief after primary Gamma knife stereotactic radiosurgery (GKSRS) in trigeminal neuralgia. A total of 78 patients who achieved initial pain response of I-III on the Barrow Neurological Institute Pain Scale (BNI-PS) following primary GKSRS for idiopathic trigeminal neuralgia were included in this study. A Cox regression model was used to compute the prognostic factor with respect to the ID within the 50% isodose line. Facial pain relief maintenance interval was defined as time interval between the day of improved BNI-PS grade and pain level back to the BNI-PS IV or V. The median duration of follow-up was 42 months (range 6-108 months). After the initial GKSRS, patients achieved pain relief at a median of 0.5 months (range, 7 days to 6 months); 28 patients developed recurrence of pain. There was a positive correlation between the pain relief maintenance and increasing ID within 50% isodose line (hazard ratio 1.85, P= 0.04) on multivariable Cox-regression analysis. Using logistic regression analysis, we found that ID was not predictive of developing post-stereotactic radiosurgery hypoesthesia (P= 0.64, hazard ratio 1.057). Stereotactic radiosurgery can be individualized based on trigeminal nerve morphology to achieve durable pain relief in patients with trigeminal neuralgia. ID calculation aids in planning an optimal radiation dose based on the nerve morphology to provide durable pain relief of idiopathic trigeminal neuralgia.

Brain Dynamics and Temporal Summation of Pain Predicts Neuropathic Pain Relief from Ketamine Infusion.

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Ketamine is an N-methyl-D-aspartate receptor antagonist that reduces temporal summation of pain and modulates antinociception. Ketamine infusions can produce significant relief of neuropathic pain, but the treatment is resource intensive and can be associated with adverse effects. Thus, it is crucial to select patients who might benefit from this treatment. The authors tested the hypothesis that patients with enhanced temporal summation of pain and the capacity to modulate pain via the descending antinociceptive brain pathway are predisposed to obtain pain relief from ketamine. Patients with refractory neuropathic pain (n = 30) and healthy controls underwent quantitative sensory testing and resting-state functional magnetic resonance imaging and then completed validated questionnaires. Patients then received outpatient intravenous ketamine (0.5 to 2 mg · kg · h; mean dose 1.1 mg · kg · h) for 6 h/day for 5 consecutive days. Pain was assessed 1 month later. Treatment response was defined as greater than or equal to 30% pain relief (i.e., reduction in pain scores). We determined the relationship between our primary outcome measure of pain relief with pretreatment temporal summation of pain and with brain imaging measures of dynamic functional connectivity between the default mode network and the descending antinociceptive brain pathway. Approximately 50% of patients achieved pain relief (mean ± SD; Responders, 61 ± 35%; Nonresponders, 7 ± 14%). Pretreatment temporal summation was associated with the effect of ketamine (ρ = -0.52, P = 0.003) and was significantly higher in Responders (median [25th, 75th] = 200 [100, 345]) compared with Nonresponders (44 [9, 92]; P = 0.001). Pretreatment dynamic connectivity was also associated with the clinical effect of ketamine (ρ = 0.51, P = 0.004) and was significantly higher in Responders (mean ± SD, 0.55 ± 0.05) compared with Nonresponders (0.51 ± 0.03; P = 0.006). Finally, the dynamic engagement of the descending antinociceptive system significantly mediated the relationship between pretreatment pain facilitation and pain relief (95% CI, 0.005 to 0.065). These findings suggest that brain and behavioral measures have the potential to prognosticate and develop ketamine-based personalized pain therapy.

Short-term effectiveness of joint distraction by Ilizarov combined with arthroscopic debridement in treatment of knee osteoarthritis

To investigate the short-term effectiveness of joint distraction by Ilizarov combined with arthroscopic debridement in the treatment of knee osteoarthritis (KOA). Between January 2014 and January 2015, 15 patients (15 knees) with KOA were treated using arthroscopic debridement assisting with the Ilizarov distraction technology. There were 7 males and 8 females, aged from 45 to 64 years (mean, 55 years). The left knee and the right knee were involved in 6 and 9 cases respectively. The disease duration was 2.0-9.5 years (median, 6 years). They all had received conservative treatment for 6 months and got poor clinical improvement. The preoperative visual analogue scale (VAS) score, the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) score, the knee injury and osteoarthritis outcome score (KOOS), the range of motion (ROM) for knee, and the radiographic joint space width were 76.2±8.8, 59.3±5.7, 44.3±7.2, (75±21)°, and (2.5±0.4) mm respectively. According to Kellgren-Lawrence grade system, 11 cases were rated as grade III and 4 cases as grade IV. There was no poor incision healing, infection, and deep vein thrombosis. All the 15 patients were followed up 12-18 months (mean, 15.5 months). Patients achieved pain relief. The knee activity was obviously improved. The postoperative VAS score, WOMAC score, KOOS score, and ROM at 12 months were 20.9±7.8, 38.2±5.5, 92.1±6.9, and (118±14)° respectively, showing significant difference when compared with preoperative ones ( t=18.213, P=0.000; t=10.317, P=0.000; t=18.564, P=0.000; t=6.599, P=0.000). Postoperative X-ray film showed that joint space width at 12 months was (3.8±0.3) mm, showing significant difference when compared with preoperative one ( t=10.070, P=0.000). Joint distraction by Ilizarov combined with arthroscopic debridement can effectively relieve pain, improve the function and quality of life. It was beneficial to cartilaginous tissue repair and delaying the degenerative process of KOA. The short-term effectiveness is satisfactory.

Management of post-traumatic neglected cervical facet dislocation.

Post-traumatic unilateral or bilateral sub-axial cervical spine dislocations with locked facets are quite common. In developing countries like India, many patients with cervical injuries report late due to many reasons like rural backgrounds, lack of infrastructures and skilled surgeons, unawareness, poor socioeconomic status, lack of transportation to the specialized center with proper facility, etc. Early management is essential to maximize better neurological outcome. Delayed or neglected presentation makes treatment more challenging. Very few literatures are currently available regarding management of neglected cervical facet dislocation but no one offers clear cut management. Purpose of our study is to evaluate treatment outcome of 15 patients with post-traumatic neglected cervical facet dislocation. Here we have reviewed 15 patients with post-traumatic neglected presentation of cervical facet dislocations and evaluated their treatment outcome. This is a retrospective type of study done in spine care unit of VMMC and Safdarjung Hospital, New Delhi from July 2013 to June 2016. Record of 15 patients with neglected cervical dislocation who were undergone anterior cervical discectomy and fusion along with posterior lateral mass screw fixation depending upon close reduction and integrity of disco-ligamentous complex. 15 patients were included in this study. 4 patients underwent only anterior cervical discectomy and fusion (ACDF) after complete close reduction with intact disco-ligamentous complex. Remaining 11 patients who failed to achieve complete reduction or had posterior disco-ligamentous injuries underwent posterior partial facetectomy and lateral mass screw fixation with anterior discectomy and fusion concomitantly. Mean follow up period was 14 months. All patients achieved pain relief and sufficient neck movements. 1 patient with only nerve root injuries recovered completely. 6 out of 11 patients with incomplete spinal cord injuries, improved by one Frankel grade and remaining 5 patients by two grades. 3 patients with complete quadriplegia showed no clinical and neurological improvement. Proper decompression, reduction and fixation should be done in neglected cervical dislocation as it provides mechanical stability and alignment, facilitates rehabilitation, prevent kyphotic deformity as well as offers a fair chance of neurological recovery.