Permanent Pain Research Articles

Reassuring patients about low back pain.

Lowbackpain is oneof themost commonlyencountered conditions in clinical practice. Despite trends showing increasing use of advanced imaging tests, opioids, and invasive surgical and interventional procedures,with attendant increases in costs, theprevalence andburdens associatedwith lowback pain appear to be on the rise.1 Most acute low back pain improves substantially within the first 4weeks.However, a small proportionofpatientswith acute lowback pain go on to develop chronic disabling symptoms. Suchpatients often are refractory to treatments and account for the majority of the costs associated with low back pain. Preventing the transition fromacute to chronic lowback pain is therefore an important goal of current evaluation and management strategies. Back pain is best understood as a complex biopsychosocial condition. For example, the presence of common degenerative findings on spinal imaging poorly correlates with the presence of and severity of low back pain or the likelihood of developing chronic disabling symptoms. Rather, predictors of chronicity are primarilypsychosocial.2Clinical practice guidelines recommend an approach to low back painmanagement that includes an emphasis on self-care and the identification andmanagement of psychosocial contributors to chronicity,withearly interventions to address such factors when present.3 Reassurance is frequently recommended in patientswith pain conditions but has beendescribed as being supported by “a surprisingly thin evidence base.”4 Reassurance is a complex process involving the dynamic interplay between a caregiver and thepatient. Thegoal of reassurance is to alleviatepatientworriesandfears regarding lowbackpainandtopositively change associated behaviors. Common concerns in patients with back pain are that it signifies a serious underlying problem such as cancer, that the back pain will prevent the ability towork or participate in activities they enjoy, or that the back pain signifies the onset of progressive or permanent damage. Suchworriesmay leadpatients to avoidnormal activities that cause discomfort because of concerns that they will further damage the back (fear avoidance behavior) or to believe that the worst possible outcome (eg, permanent pain and disability) is inevitable (catastrophizing). These types of behaviors, referred to as maladaptive coping strategies, are an important predictor of chronicity.2 Psychological symptoms such as anxiety, which may be associated in part with illness concerns, also predict chronicity. A number of therapies for low back pain—such as advice to remain active, exercise therapy, and cognitive-behavioral therapy—aim in part to address and correct maladaptive coping beliefs and behaviors. Asystematic review in this issueof JAMAInternalMedicine byTraegerandcolleagues5evaluatedtheeffectsofprimarycare– based education on reassurance in patients with acute or subacute lowbackpain.The reviewwasgenerallywell conducted, meetingstandardsfor identificationofstudies,selectionofstudies for inclusion, risk of bias assessment, and data synthesis. It included12 randomizedtrials inwhicheducationwasdelivered through a self-care booklet or verbally. The education content varied but commonly included concepts consistent with evidence-basedclinical practiceguidelines, suchas thebenign nature and generally favorable prognosis of low back pain, advice to stayactivewithgraded return tousual activity, andpromotion of self-management. The review found primary care– based education to be associated with improved measures of reassurance vs usual care or a control intervention through 12 months.Themagnitudeofeffectwas relatively small, basedon pooledstandardizedmeandifferences (−0.15 to−0.21), andwas mainlypresent in trials inwhicheducationwasgivenbyaphysician rather than anurse or physiotherapist.However, educationwasalso associatedwith fewer subsequent lowbackpain– relatedprimarycarevisits(equivalenttoanumberneededtotreat witheducationof17toavoid1lowbackpain–relatedprimarycare visit).Although the reviewestimatedacostof $1700 toprevent 1 furthervisit, this calculationmaybeanoverestimatebecause it appeared to be based on the entire cost of the clinic visit in which education occurred. Patient education is likely to occur in the context of a visit for low back pain that is already taking place; thus, the additional costs with the interventionmay actually bemuch lower. Achallenge in interpreting the findingsof the review is that there is no standardizedmeasure for reassurance. Rather, the review combined results for different constructs conceptually related to reassurance, such asmeasures of fear, catastrophizing,worry, or anxiety.Theuseofdifferentmeasuresmight explainsomeof theobservedstatisticalheterogeneity inpooled analyses because the effectswere largest formeasures of fear, with no clear effects on the other outcome types. Another issue in interpreting the findings is that effective blindingof patients and caregivers is difficult in studies of patient education. Observed effects could therefore be related in part to Related article page 733 Reassurance in Patients With Acute Low Back Pain Original Investigation Research

Novel Minimal Invasive Surgical Techniques for the Treatment of Segmental-Lateral Pathologic Lesions of the Spine

Introduction Laminectomy, commonly used dorsal approach for the surgical removal of most of the pathologic lesions, situated in the spinal canal and the neuroforamen destroying the dorsal stabilizing structures of the spinal column. Retraction and detachment of the longitudinal muscles, removal of the vertebral arches (laminectomy), and injury of the joint capsules and ligaments are responsible most of short and late-time complications. Among these complications, spinal deformities, segmental instability, and permanent spinal pain are most often mentioned in the literature. The main objective of the authors was to develop and evaluate the novel minimally invasive techniques suitable for exploring and treating different segmental-lateral pathologies, expanding to the neuroforamen or even paravertebrally, with preservation of the stability of the spine. One of the key issues of this article was to summarize these procedures, with evaluating the safety and efficacy in the routine spine surgery. Patients and Methods A total of 167 patients were operated and followed up during 2000 to 2011 in our Institute with segmental lateral spinal pathologies. For the surgical treatment, we used “Over-the-top” decompression, hemi–semi laminectomy, supraforaminal burr-hole, open-tunnel, and paravertebral approaches alone or in combination. These surgical techniques are mostly our developments, or modifications of previously used surgical techniques. Results The new surgical procedures developed or modified by our team are effective techniques for treating the spinal pathologies located in the spinal canal, neuroforamen, or even the paravertebral space. The posterior stabilizing structures of the spine, as the vertebral laminae and the longitudinal musculature are mostly preserved. Leaving the longitudinal paraspinal musculature innervations intact, and with the preservation of the bone–muscle attachments and ligaments, the dynamic stability of the spine remains unchanged. Retaining the bony structures (vertebral arches) and the vertebral joints the static stability of the spinal column remain intact, the chance of developing the long-term spinal deformation is minimal. During the follow-up, we performed static and dynamic X-ray, MR, and CT scans, completed with neurological examinations to evaluate the progression of the illness, the neurological deficit, and the actual state of the spinal column. With clinical use and evaluation of the various surgical approaches, we determined the main indications and contraindications of the surgical procedures, highlighting the pit-falls and limitations. Conclusion The aforementioned minimally invasive surgical approaches are suitable for treating segmental–lateral spinal pathologies. For the routine clinical use, we organized the surgical techniques into a complete framework based on the location of the pathologic lesions.

Treatment of Chronic Facial Pain Including Cluster Headache by Repetitive Transcranial Magnetic Stimulation of the Motor Cortex With Maintenance Sessions: A Naturalistic Study.

To assess the long-term maintenance of analgesia induced by high-frequency repetitive transcranial magnetic stimulation (rTMS) of the motor cortex contralateral to pain in a naturalistic study of patients with chronic refractory facial pain. 55 patients were included (cluster headache, n=19; trigeminal neuropathic pain, n=21; atypical facial pain, n=15). The rTMS protocol consisted of an "induction phase" of one daily rTMS session for five days per week during two consecutive weeks, followed by a "maintenance phase" of two sessions during one week, then one session in weeks 4 and 6, and a monthly session for the next five months. In a subset of patients, navigated targeting was performed and session duration was shortened from 20-min to 10-min (with the same number of 2000 pulses per session). The analgesic effect of rTMS was assessed on a 0-10 visual numerical scale from 15 to 180 days after treatment initiation. All pain measures significantly decreased from baseline to D15: the intensity of permanent pain (5.2±1.6 to 3.2±1.9) and paroxysmal pain (8.6±1.5 to 4.5±3.4), as well as the daily number of painful attacks (5.6±3.1 to 2.3±3.1). The percentage of responders (defined as pain score decrease ≥30%) was 73% at D15 and dropped to 40% at D180. The analgesic effect was similar regardless of the type of pain and was significantly lower when session duration was shortened, irrespective of the number of pulses. This long-term maintenance rTMS protocol can be a therapeutic option in the clinical management of patients with chronic refractory facial pain, including cluster headache. However, only part of the patients respond to this technique and session duration should not be reduced.

Percutaneous Vertebroplasty for Pathological Vertebral Compression Fractures Secondary to Multiple Myeloma--Medium-Term and Long-Term Assessment of Pain Relief and Quality of Life.

In patients with multiple myeloma (MM) there is ahigh risk of compression fractures of the spine. In the majority of cases, the method of treatment is percutaneous vertebroplasty (PV) or kyphoplasty (PK). The number of studies verifying their efficacy in MM is still relatively small. The aim of this study has been to assess medium- and long-term pain relief as well as improvement in the quality of life (QL) after PV in MM cases. There was aprospective group of 34 MM cases in which atotal of 131 vertebral bodies were augmented by means of PV. It was possible to follow up 22patients who agreed to take part in the assessment. Their level of daily activity and the level of pain were assessed using the Oswestry Back Pain scale and avisual analogue scale (VAS) before PV and at alater date (medium-term follow up was amean of 10months after the last operation). Five out of eight cases in which 4.5-5years had elapsed since the first PV were tested again (long-term follow-up). Relief of pain and improvement of QL, assessed amean of 10months after PV, proved to be statistically significant. On the average, pain decreased by 4.7 points as measured on the VAS scale and the average improvement in the QL measured on the Oswestry scale was 27.7%. There were no neurological or general complications. After 4.5-5years, there has not been any significant change in the level of pain relief or the improvement in the QL in the 5cases in which long-term assessment was possible. In MM cases, PV is asimple, effective and safe method for the treatment of vertebral infiltration and compression fractures, giving permanent long-term pain relief and concomitant improvement in the QL.

Regulation of gene expression and pain states by epigenetic mechanisms.

The induction of inflammatory or neuropathic pain states is known to involve molecular activity in the spinal superficial dorsal horn and dorsal root ganglia, including intracellular signaling events which lead to changes in gene expression. These changes ultimately cause alterations in macromolecular synthesis, synaptic transmission, and structural architecture which support central sensitization, a process required for the establishment of long-term pain states. Epigenetic mechanisms are essential for long-term synaptic plasticity and modulation of gene expression. This is because epigenetic modifications are known to regulate gene transcription by aiding the physical relaxation or condensation of chromatin. These processes are therefore potential regulators of the molecular changes underlying permanent pain states. A handful of studies have emerged in the field of pain epigenetics; however, the field is still very much in its infancy. This chapter draws upon other specialities which have extensively investigated epigenetic mechanisms, such as learning and memory and oncology. After defining epigenetics as well as the recent field of "neuroepigenetics" and the main molecular mechanisms involved, this chapter describes the role of these mechanisms in the synaptic plasticity seen in learning and memory, and address those epigenetic mechanisms that have been linked with the development of acute and prolonged pain states. Finally, the idea that long-lasting epigenetic modifications could contribute to the transition from acute to chronic pain states by supporting maladaptive molecular changes is discussed.

Use of Thoracoscopic Splanchnicectomy for the Relief of Chronic Pancreatic Pain: a Case Series

Chronic pancreatitis may cause disabling pain not responding to oral analgesics and/or drainage procedures. Although pancreatectomy is a definitive treatment, it carries a significant morbidity and mortality. Celiac plexus ablation is beneficial, although it is a temporary method for pain relief. While bilateral splanchnicectomy provides a more permanent pain relief, it is a difficult procedure requiring thoracotomy and results in significant morbidity. Thoracoscopy is an attractive alternative to perform splanchnicectomy. The results of a case series on video assisted thoracoscopic sympathectomies performed at the university surgical unit, Peradeniya, Sri Lanka from January 2011 to June 2013 was analyzed to evaluate the surgical technique and to quantify the efficacy of pain relief. Operating time, blood loss, intraoperative complications, conversion to open surgery, pre-operative and post-operative pain assessment using visual analogue scale score (VAS) were recorded. Seven patients who underwent video assisted thoracoscopic splachnicectomy were analyzed. All had an acceptable operating time (6omin), no measurable blood loss, no conversions to open surgery, no intercostal drainage, early mobilization and feeding. All had an average VAS of 8-10 pre-operatively. This reduced to a VAS of 1 or no pain in all, on post-operative day one, at one and six months. The few who experienced mild pain needed occasional use of paracetamol or diclofenac sodium. Non required narcotic analgesics. Bilateral thoracoscopic splanchnicectomy is a safe, effective and more attractive alternative as it carries a minimum morbidity, mortality and provides an excellent relief of chronic agonizing pancreatic pain.

Osteoid osteoma of the proximal femur: Treatment by percutaneous bone resection and drilling (PBRD). A report of 44 cases

IntroductionOsteoid osteoma is a benign osteogenic tumor that is mainly located in the lower limbs. According to Campanacci the proximal femur is involved in 25% of cases. We present a series of 44 cases of osteoid osteoma located in the neck of the femur or the lesser trochanter treated by the minimally invasive method, CT-guided percutaneous bone resection and drilling (PBRD). Materials and methodsThis series included 44 patients, 20 girls and 24 boys, treated between 1987 and 2012. The average age at surgery was 12.7 years old (range 4–34). The diagnosis was based on the “association” of scintigraphy (hyperfixation) – CT scan (nidus located on the femoral neck or near the lesser trochanter). These patients underwent CT-guided PBRD under general anesthesia. Specific ancillary material was used to reach and remove the nidus and a cylinder of bone was sent to the pathologist for assessment. A lateral or anterior approach was used in all cases except one in which a posterior incision was made. Histological confirmation was obtained in 23 cases (the bone fragment was damaged in 21 cases). ResultsForty-two patients were reviewed after a minimum follow-up of one year (12–56 months). Two patients were lost to follow-up. Results were evaluated clinically and on CT scan 1 year after surgery: there were 35 cures with complete and permanent pain relief. There were 5 failures and 1 case of recurrence requiring a second CT-guided PBRD procedure as well 2 complications involving femoral fracture (one associated with failure). DiscussionThe proximal femur is a common location of osteoid osteoma. Treatment requires careful preoperative planning to determine the surgical approach for safe removal. PBRD is a minimally invasive technique, allowing complete resection with suitable ancillary equipment. This method should be compared with thermoablation, which is a similar technique. ConclusionCT-guided PBRD is a therapeutic option in case of osteoid osteoma of the proximal femur. Level of evidenceLevel IV.

Assessment of the Effect of Pain on Daily Functioning of Patients with the Diagnosed Back Pain Syndrome

Introduction. The back pain syndrome is one of the most common health problem of the contemporary society. Acute pain syndromes of the lower section of the spine affect 28 people per 1000 inhabitants. The disease more often affects men aged 25–64. In the population of one hundred thousand inhabitants 107 men and 64 women suffer from acute pain syndrome of the cervical spine. Most often the pain occurs between 50 and 54 years of age. Also, back pain syndromes constitute a serious economic problem for the contemporary society as they are statistically the most frequent in the case of men and the second in the case of women reason for absence from work, and in 20% of cases they indicate the necessity of granting disability pension due to permanent inability to work.Aim. Assessment of pain intensity effect on daily functioning of patients diagnosed with the back pain syndrome.Material and Methods. The research included 187 patients diagnosed with back pain syndrome aged from 20 to 83 years and it was carried out in April and May 2013. The diagnostic survey method and statistical analysis were applied.Results. The most difficult issue for the respondents in their daily functioning was to accept permanent pain stimuli (100%), permanent stiffness in the back or neck, (96.33%), copying with the pain when the performance of everyday duties required prolonged sitting or standing (99.47%) as well as the performance of daily household activities (100%). Back pain to greater or lesser extent resulted in the loss of control over major spheres of everyday life in the respondents, on average from 3.34 to 6.37 on the scale from 1 to 10 points. All respondents admitted having problems with remaining in the sitting position for a long time. The average loss of fitness in the group of respondents ranged 39.30±18.09 points (Me=37; range from 7 to 88 points). Based on the average value ± 1 SD it was stated that 16.58% (n=31) of respondents had light malfunction, whereas 65.78% (n=123) had moderate and 17.64% (n=33) serious.Conclusions. 1. Chronic back pain has a devastating impact on the daily functioning of patients with diagnosed spinal pain syndrome 2. The most difficult issue for the respondents in their daily functioning was to accept permanent pain stimuli 3. The average strength of the negative impact of the back pain on daily functioning ranged from 6.25 to 6.49 in the scale from 1 to 10 points. 4. All respondents admitted that back pain to greater or lesser extent resulted in a loss of control over major spheres of everyday life. 5. Just over a quarter of respondents (25.13%) did not have major problems, resulting from the pain, with the performance of daily duties at work. 6. For more than three quarters of the respondents (77.01%) pain while sitting in the chair for a few hours was a significant problem in everyday functioning. 7. The statistical analysis carried out, showed a significant correlation between the intensity of the back pain and lowering of physical fitness. (JNNN 2014;3(4):157–168)

Osteoarthritis in morbidly obese children and adolescents, an age-matched controlled study.

Main objective of this study was to investigate the association of pain and early cartilage lesions in morbidly obese children and adolescents. A total of 57 subjects were included in the study. Morbidly obese patients (n=39) were subdivided into two groups: Group A: (11 males and 9 females, 14.2±2.7years) with permanent knee pain; and Group B: (10 males and 9 females, 14.4±2.2years) without permanent or without any knee pain. Group C (8 males and 10 females, 15.0±2.9years) included age-matched children and adolescents of normal weight. MRI examinations were performed in all subjects, and an extensive analysis of the images was conducted according to the condition of the cartilage surface and the meniscus. Patients' subjective health was assessed by means of four well-known knee scores (IKDC, KOOS, Tegner/Lysholm, and VAS). Nonparametric Jonckheere-Terpstra test was used to test the trend of the natural order between the three groups. In 38 of 39 morbidly obese children and adolescents, in at least one region of the knee, a marked cartilage lesion could be shown by MRI. Group A showed significantly (p<0.001) more cartilage lesions (mean 3.7) compared to Group B (mean 2.8) and Group C (mean 0.8). IKDC, and all the KOOS subunits, showed significantly (p<0.001, p Bonferroni<0.001) increasing scores from Group A to B to C, in addition to KOOS symptoms. Morbid obesity causes early lesions of the knee cartilage, even in young patients. Significantly, more patients with reported pain show more severe damages.

Management of bone metastases

The skeleton is the most common site to be affected by advanced breast, prostatic, lung, kidney, thyroid and other solid tumors (in addition to myeloma multiplex). Bone metastases cause significant morbidity with nearly always fatal outcome. Over 600 000 new patients diagnosed in the developed countries yearly. On average every 4-6 months patients suffer from series of severe skeletal complications such as pathologic fractures, spinal cord compression, hypercalcemic events, etc., besides the permanent pain. Local external beam radiotherapy, systemic radioisotope-, endocrine-, and chemotherapy, oral and i.v. bisphosphonates and recently s.c. denosumab are the mainstays of treatment, in addition to pain-killers and other usual "classical" interventions. The modern treatments singificantly reduce the probability of skeletal complications and improve the patients' quality of life and, sometimes, they extend the survival as well. The authors briefly summarize the available treatment options.

Frequency, severity and predictors of playing-related musculoskeletal pain in professional orchestral musicians in Germany

Playing-related musculoskeletal disorders (PRMD) in professional musicians are common. Existing literature demonstrates that up to 86 % of musicians are affected. The aim of the study was to evaluate the frequency of musculoskeletal pain in professional orchestral musicians with regard to their instrument affiliation. Of special interest were pain intensity and its association with predictors such as gender, instrument group, age or stage fright. Professional orchestra players completed a self-report questionnaire to assess playing-related musculoskeletal pain and its frequency and intensity in various body regions on a numeric rating scale (NRS). Relative frequencies and prevalence ratios for different instrument groups were estimated. Out of 720 approached musicians, 408 were included in the sample (response rate 57 %); overall, 89.5 % had been affected by current or past playing-related musculoskeletal pain, 62.7 % reported pain in the previous 3 months, and 8.6 % reported current pain. Pain distribution and frequency varied between instrument groups. For all instrument groups, the neck was the most common pain region. About 43 % of musicians presented more than five pain regions, in particular violin players. Approximately 40 % of musicians indicated frequent or permanent pain. Average pain intensities increased from NRS 3.8 up to a range of 5.9 and 7.4 for frequent and permanent pain, respectively. Female gender and stage fright were proven to be predictors for musculoskeletal pain. Professional orchestral musicians are greatly affected by PRMD, often experiencing frequent or permanent pain, high pain levels and pain in various body regions. As PRMD might contribute considerably to performance disability, sick leave and the possibility of premature termination of a musicians' career, this study highlights the necessity for tailored therapeutic and preventive strategies in performing arts medicine.

Differences between patients with chronic widespread pain and local chronic low back pain in primary care - a comparative cross-sectional analysis

BackgroundChronic pain is a common reason for consultation in general practice. Current research distinguishes between chronic localized pain (CLP) and chronic widespread pain (CWP). The aim of this study was to identify differences between CWP and chronic low back pain (CLBP), a common type of CLP, in primary care settings.MethodsFifty-eight German general practitioners (GPs) consecutively recruited all eligible patients who consulted for chronic low back pain during a 5-month period. All patients received a questionnaire on sociodemographic data, pain characteristics, comorbidities, psychosomatic symptoms, and previous therapies.ResultsGPs recruited 647 eligible patients where of a quarter (n = 163, 25.2%) met the CWP criteria according to the American College of Rheumatology. CWP patients had significantly more comorbidities and psychosomatic symptoms, showed longer pain duration, and suffered predominantly from permanent pain instead of distinguishable pain attacks. CWP patients were more often females, are less working and reported a current pension application or a state-approved grade of disability more frequently. We found no other differences in demographic parameters such as age, nationality, marital status, number of persons in household, education, health insurance status, or in health care utilization data.ConclusionsThis project is the largest study performed to date which analyzes differences between CLBP and CWP in primary care settings. Our results showed that CWP is a frequent and particularly severe pain syndrome.Trial registrationGerman Clinical Trial Register, DRKS00003123.

Is the Whipple Procedure Harmful for Long-term Outcome in Treatment of Chronic Pancreatitis? 15-Years Follow-up Comparing the Outcome after Pylorus-Preserving Pancreatoduodenectomy and Frey Procedure in Chronic Pancreatitis

The aim of this study was to report on 15-year long-term results of a randomized controlled trial comparing extended drainage procedure (Frey) and classical resectional procedure [pylorus-preserving pancreatoduodenectomy (PD)] in patients with chronic pancreatitis. Chronic pancreatitis is a common inflammatory disease with a prevalence of 10 to 30 cases per 100,000 inhabitants. It is characterized by the progressive conversion of pancreatic parenchyma to fibrous tissue. Different surgical procedures are used in treatment of persistent pain. Sixty-four patients suffering from chronic pancreatitis with inflammatory mass in the pancreatic head were randomly assigned in 2 treatment groups (PD, n = 32) and (Frey, n = 32). The perioperative course of the randomized controlled trial and the 7 years follow-up have been previously published. All participating patients were contacted with a standardized, validated questionnaire (EORTC QLQ C30) to evaluate the long-term survival, quality-of-life pain, and exocrine and endocrine function. In the 15-year long-term follow-up, the pain control was good and comparable between both groups, but the quality of life was better after Frey procedure in regard of the physical status [PD: 100 (0-100) vs PD: 60 (0-100) (P = 0.011)]. No significant differences in terms of the Pain Score were detected between both groups [PD: 7 (0-100) vs Frey 4 (0-100) P = 0.258]. Seven patients after Frey OP and 6 patients after PD were free of pain. Analyzing the postoperative overall survival, a higher long-term mortality was found after PD (53%) than that found after Frey procedure (30%) resulting in a longer mean survival (14.5 ± 0.8 vs 11.3 ± 0.8 years; P = 0.037). No correlation between endocrine or exocrine pancreatic function and pain was found, whereas continuous alcohol consumption was associated with poorer outcome regarding quality of life (P < 0.001) and pain score (P < 0.001). PD and Frey procedure provide good and permanent pain relief and improvement of the quality of life in long-term follow-up. In addition, a longer survival was found after the organ sparing resection. Together with better short-term results, the organ-sparing procedure seems to be favorable in treatment of chronic pancreatitis.

Oral surgery: part 4. Minimising and managing nerve injuries and other complications

Many post-operative complications can be avoided with good patient selection, training and surgical planning. Obtaining explicit patient consent is also an essential component of treatment. The most significant complications from oral surgical interventions are iatrogenic trigeminal nerve injuries, which can result in permanent altered sensation and pain, causing considerable functional and psychological disability. This paper provides some useful suggestions on minimising the risks of these injuries. By understanding the risk factors and modifying the resulting intervention, more of these injuries may be prevented.

Editorial: Management of Neck Pain

Editorial: Management of Neck Pain

Platelet-Rich Plasma and the Elimination of Neuropathic Pain

Peripheral neuropathic pain typically results from trauma-induced nociceptive neuron hyperexcitability and their spontaneous ectopic activity. This pain persists until the trauma-induced cascade of events runs its full course, which results in complete tissue repair, including the nociceptive neurons recovering their normal biophysical properties, ceasing to be hyperexcitable, and stopping having spontaneous electrical activity. However, if a wound undergoes no, insufficient, or too much inflammation, or if a wound becomes stuck in an inflammatory state, chronic neuropathic pain persists. Although various drugs and techniques provide temporary relief from chronic neuropathic pain, many have serious side effects, are not effective, none promotes the completion of the wound healing process, and none provides permanent pain relief. This paper examines the hypothesis that chronic neuropathic pain can be permanently eliminated by applying platelet-rich plasma to the site at which the pain originates, thereby triggering the complete cascade of events involved in normal wound repair. Many published papers claim that the clinical application of platelet-rich plasma to painful sites, such as muscle injuries and joints, or to the ends of nerves evoking chronic neuropathic pain, a process often referred to as prolotherapy, eliminates pain initiated at such sites. However, there is no published explanation of a possible mechanism/s by which platelet-rich plasma may accomplish this effect. This paper discusses the normal physiological cascade of trauma-induced events that lead to chronic neuropathic pain and its eventual elimination, techniques being studied to reduce or eliminate neuropathic pain, and how the application of platelet-rich plasma may lead to the permanent elimination of neuropathic pain. It concludes that platelet-rich plasma eliminates neuropathic pain primarily by platelet- and stem cell-released factors initiating the complex cascade of wound healing events, starting with the induction of enhanced inflammation and its complete resolution, followed by all the subsequent steps of tissue remodeling, wound repair and axon regeneration that result in the elimination of neuropathic pain, and also by some of these same factors acting directly on neurons to promote axon regeneration thereby eliminating neuropathic pain.

THU0558 Role of Physical Exercise in Patients with Hip Osteoarthritis

BackgroundHip osteoarthritis evolution is slow, but progressive, with increasing degradation of the joint, worsening instability, with permanent pain and reduced walk perimeter.ObjectivesThe purpose of this study was to examine the...

Novel minimal invasive surgical techniques for the treatment of segmental-lateral pathologic lesions of the spine, preserving the dorsal stabilizing structures

Objective: Laminectomy, the commonly used dorsal approach for the surgical removal of most of the pathologic lesions, situated in the spinal canal and the neuroforamen destroying the dorsal stabilizing structures of the spinal column. Retraction and detachment of the longitudinal muscles, removal of the vertebral arches (laminectomy), and injury of the joint capsules and ligaments are responsible most of short and late-time complications. Among of these complications spinal deformities, segmental instability and permanent spinal pain are most often mentioned in the literature. The main objective of the authors was to develop and evaluate the novel minimally invasive techniques suitable for exploring and treating different segmental-lateral pathologies, expanding to the neuroforamen or even paravertebraly, with preservation of the stability of the spine. One of the key issues of this article was to summarize these procedures, with evaluating the safety and efficacy in the routine spine surgery. Methods: 153 patients were operated and followed up during 2000 to 2010 in our Institute with segmental lateral spinal pathologies. For the surgical treatment we used “Over-the-top” decompression, hemi-semi laminectomy, supraforaminal burr-hole, open-tunnel and paravertebral approaches alone or combined with each-other. The above mentioned surgical techniques are mostly our developments, or modifications of previously used surgical techniques. Results: The new surgical procedures developed or modified by our team, are effective techniques for treating the spinal pathologies located in the spinal canal, neuroforamen or even the paravertebral space. The posterior stabilizing structures of the spine, as the vertebral laminae and the longitudinal musculature are mostly preserved. Leaving the longitudinal paraspinal musculature innervations intact, and with the preservation of the bone-muscle attachments and ligaments, the dynamic stability of the spine remains unchanged. Retaining the bony structures (vertebral arches) and the vertebral joints the static stability of the spinal column remain intact, the chance of developing the long-term spinal deformation is minimal. During the follow up we performed static and dynamic X-ray, MR and CT scans, completed with neurological examinations to evaluate the progression of the illness, the neurological deficit and the actual state of the spinal column. With clinical use and evaluation of the various surgical approaches we determined the main indications and contraindications of the surgical procedures, highlighting the pit-falls and limitations. Conclusion: The above mentioned minimally invasive surgical approaches are suitable for treating segmental – lateral spinal pathologies. . For the routine clinical use we organized the surgical techniques into a complete framework based on the location of the pathologic lesions. DOI: 10.17489/biohun/2013/1/24

Ist eine Höhenrekonstruktion mit vergleichsweise wenig Zement für die Radiofrequenz-Kyphoplastie über einen monopedikulären Zugang möglich?

Percutaneous cement augmentation systems have been proven to be an effective treatment for vertebral compression fractures in the last 10 years. A special form available since 2009 is the radiofrequency kyphoplasty (RF) in which the applied energy raises the viscosity of the cement. The aim of this study is to find out if a smaller cement amount in radiofrequency kyphoplasty can also restore vertebral body height in osteoporotic vertebral compression fractures. The treatment was minimally invasive using the StabiliT® vertebral augmentation system by DFine. In a retrospective study from 2011 to January 2012, 35 patients underwent RF kyphoplasty for 49 fresh osteoporotic vertebral compression fractures. From the clinical side the parameters, demographics and pain relief using a visual analogue scale (VAS: 0 to 100 mm) were collected. For the radiological outcome the vertebral body height (anterior, mean and posterior vertebral body height with kyphosis angle) after surgery and after three months was measured and compared to the cement volume. All patients still had permanent pain on the fractured level after conservative treatment. The time from initial painful fracture to treatment was 3.0 weeks ± 1.3. Average visual analogue scale results decreased significantly from 71 ± 9.2 preoperatively to 35 ± 6.2 postoperatively (p < 0.001) and to 30 ± 5.7 (p < 0.001) after three months. With a mean cement volume in the thoracic spine of 2.9 ± 0.7 ml (1.8-4.1) and lumbar spine of 3.0 ± 0.7 ml (2.0-5.0) we had a significant vertebral body height restoration. Anterior and mean vertebral body heights significantly increased by an average of 2.3 and 3.1 mm, kyphosis angle significantly decreased with an average of 2.1° at three-month follow-up (p < 0.05). In two vertebrae (4.1 %) a minimal asymptomatic cement leakage occurred into the upper disc. In two patients (5.7 %) we had new fractures in the directly adjacent segment that were also successfully treated with radiofrequency kyphoplasty. With a mean cement volume of 3.0 ml radiofrequency kyphoplasty achieves rapid and short-term improvements of clinical symptoms with a significant restoration of vertebral body height. There was no correlation between restoration of vertebral body height and pain relief. With a cement leakage of 4.1 % RF kyphoplasty is a safe and effective minimally invasive percutaneous cement augmentation procedure. Our data confirm the higher safety described in literature for kyphoplasty in contrast to vertebroplasty.

Limited Range of Indications for Cannabis

In my job as a neurologist and psychiatrist specializing in the relatively new discipline of pain medicine, a focus of my work has for many years been harm prevention—of nephropathy due to analgesics, gastrointestinal complications of NSAIDs such as hemorrhage of perforation, toxic hepatopathy, and drug-induced chronic headache with complications (1). Long-term treatment with opioid analgesics—after checking responsiveness and tolerability by means of regular and systematic follow-up—had far better results in this setting than did non-opioids (2). NSAIDs are effective in acute treatment and are the reasonable option in that setting, but they are associated with complications in the longer term. For cannabinoids, important risks include triggering of psychosis, schizophrenia, and cognitive impairments (3), which the authors mentioned in their article (4). It should also be pointed out that cannabis and cannabinoids are effective in only a proportion of patients in possible indications such as permanent pain in multiple sclerosis or other neuropathic pain conditions or severe spasms. This contingency (that which is not necessary, but which may be, or not be, possible), which runs as theme throughout pain medicine, can therefore not offer conclusions that follow a set pattern, such as “There is now clear evidence that cannabinoids are useful for the treatment of various medical conditions,” but only conclusions along the lines that cannabinoids may be useful. Furthermore, the authors state: “The use of such preparations may therefore be reasonable for patients in whom conventional treatment does not achieve adequate relief of symptoms such as spasticity, pain, nausea, vomiting, or loss of appetite.” This is correct in principle, but it does not include a definition of “conventional treatment.” The rational range of indications for cannabis/cannabinoids is therefore limited.