Severe Neuropathic Pain Research Articles

Surgery as an Effective Therapy for Ulnar Nerve Neuropathic Pain Caused by Gunshot Wounds: A Retrospective Case Series

Peripheral nerve injuries remain a major medical problem worldwide and are associated with multiple causes, including gunshot wounds (GSWs), which are the second most common cause of brachial plexus injuries in peacetime and the main, or only, cause reported in wartime studies. The ulnar nerve (UN) is one of the most affected nerves. Peripheral nerve trauma may cause intense neuropathic pain, which is very difficult to control. Particularly UN gunshot injuries may impact individual daily life, as injuries to this nerve result in both sensory and motor deficits within the hand. We evaluated the improvement of neuropathic pain after surgical treatment in a consecutive series of 20 patients with UN injury due to GSWs. This single-center, retrospective, consecutive case series included 20 patients with UN injuries due to GSWs, who presented with excruciating neuropathic pain and underwent surgical treatment between 2005 and2017. Of injuries, 13 occurred in the right upper limb (65%); 12 patients had a high UN injury (60%). Regarding associated injuries, 8 patients had bone injuries (40%), and 4 patients had arterial injuries (20%). A neuroma in continuity was detected in 8 cases (40%), and 4 patients (20%) had shrapnel lodged within the UN. All patients had severe neuropathic pain and functional deficit, with a mean visual analog scale score of 8.45 ± 1.4 and a mean reduction of 6.95 points 12 months after surgery; 10 patients (50%) had a British Medical Research Council score ≥M3. Surgery is an effective treatment for neuropathic pain from GSWs. Early isolated external neurolysis is associated with better pain management and functional outcomes postoperatively.

A Novel Technique Restores Function while Eliminating Intractable Neuropathic Pain in a 71-Year-Old Diabetic Patient under Challenging Injury Conditions

Abstract Background The extent of functional recovery induced in healthy patients by sensory nerve grafts, the clinical “gold standard” technique for repairing peripheral nerves with a gap, is significantly limited by increasing gap length, time between trauma and repair, and patient age. When the values of any two, or all three, variables increase simultaneously, there is little to no recovery. For diabetic patients, even under the best of conditions and without any large variables, the extent of axon regeneration and functional recovery is significantly less, but generally none. Therefore, novel techniques are required that enhance recovery in diabetic patients. Methods A 12-cm long median nerve gap in the wrist/palm of a 71-year-old male long-term diabetic patient was bridged 1.3 years post nerve injury with a sural nerve graft within a platelet-rich plasma-filled collagen tube. Results By 2 months post-repair, the patient's level 6 chronic neuropathic pain was permanently eliminated. By 6.75 months, the palm had recovered good sensitivity to stimuli of all sensory modalities, including 4.56 g pressure and less than 15 mm two-point discrimination. Each finger had good motor function of M3–5, with partial to complete sensitivity to stimuli of all sensory modalities and an overall recovery of S3. Conclusion This technique permanently eliminates severe chronic neuropathic pain while simultaneously inducing good motor and sensory recovery in a long-term diabetic patient, under conditions where recovery is rarely, if ever, seen, even in non-diabetic patients. This technique holds great promise of restoring function to diabetic patients, for whom it is otherwise not possible.

Regenerative peripheral nerve interface prevents neuroma formation after peripheral nerve transection.

Neuroma formation after peripheral nerve transection often leads to severe neuropathic pain. Regenerative peripheral nerve interface has been shown to reduce painful neuroma in the clinic. However, no reports have investigated the underlying mechanisms, and no comparative animal studies on regenerative peripheral nerve interface and other means of neuroma prevention have been conducted to date. In this study, we established a rat model of left sciatic nerve transfection, and subsequently interfered with the model using the regenerative peripheral nerve interface or proximal nerve stump implantation inside a fully innervated muscle. Results showed that, compared with rats subjected to nerve stump implantation inside the muscle, rats subjected to regenerative peripheral nerve interface intervention showed greater inhibition of the proliferation of collagenous fibers and irregular regenerated axons, lower expressions of the fibrosis marker α-smooth muscle actin and the inflammatory marker sigma-1 receptor in the proximal nerve stump, lower autophagy behaviors, lower expressions of c-fos and substance P, higher expression of glial cell line-derived neurotrophic factor in the ipsilateral dorsal root ganglia. These findings suggested that regenerative peripheral nerve interface inhibits peripheral nerve injury-induced neuroma formation and neuropathic pain possibly via the upregulation of the expression of glial cell line-derived neurotrophic factor in the dorsal root ganglia and reducing neuroinflammation in the nerve stump.

Ultrasound-guided pulsed radiofrequency for neuromyelitis optica spectrum disorder-associated neuropathic pain: A case report.

Neuropathic pain (NP) is one of the most prevalent and troublesome symptoms of neuromyelitis optica spectrum disorder (NMOSD), seriously affecting the patient's life. At present, effective treatment for NP induced by NMOSD does not exist. Pulsed radiofrequency (PRF), an emerging microinvasive therapy, alleviates pain and is widely used to treat various types of NP. This is the first report describing a patient with NMOSD-associated NP treated with PRF on the left cervical 6 nerve root. A 49-year-old female with NMOSD-associated severe NP in the left upper limb and left shoulder tried several medications, but none were effective. She was diagnosed with NP caused by NMOSD.To alleviate severe pain, we performed PRF on the left cervical nerve root under the guidance of ultrasound. This treatment was repeated 3 times. The patient's pain was significantly relieved, with a visual analog scale score decreasing from 7-8/10 to 2-3/10, which was maintained during the 3-month follow-up period, without complications. PRF might be effective for the management of intractable neuropathic pain caused by NMOSD.

Data-Driven Path Analytic Modeling to Understand Underlying Mechanisms in COVID-19 Survivors Suffering from Long-Term Post-COVID Pain: A Spanish Cohort Study.

Pain can be present in up to 50% of people with post-COVID-19 condition. Understanding the complexity of post-COVID pain can help with better phenotyping of this post-COVID symptom. The aim of this study is to describe the complex associations between sensory-related, psychological, and cognitive variables in previously hospitalized COVID-19 survivors with post-COVID pain, recruited from three hospitals in Madrid (Spain) by using data-driven path analytic modeling. Demographic (i.e., age, height, and weight), sensory-related (intensity or duration of pain, central sensitization-associated symptoms, and neuropathic pain features), psychological (anxiety and depressive levels, and sleep quality), and cognitive (catastrophizing and kinesiophobia) variables were collected in a sample of 149 subjects with post-COVID pain. A Bayesian network was used for structural learning, and the structural model was fitted using structural equation modeling (SEM). The SEM model fit was excellent: RMSEA < 0.001, CFI = 1.000, SRMR = 0.063, and NNFI = 1.008. The only significant predictor of post-COVID pain was the level of depressive symptoms (β=0.241, p = 0.001). Higher levels of anxiety were associated with greater central sensitization-associated symptoms by a magnitude of β=0.406 (p = 0.008). Males reported less severe neuropathic pain symptoms (−1.50 SD S-LANSS score, p < 0.001) than females. A higher level of depressive symptoms was associated with worse sleep quality (β=0.406, p < 0.001), and greater levels of catastrophizing (β=0.345, p < 0.001). This study presents a model for post-COVID pain where psychological factors were related to central sensitization-associated symptoms and sleep quality. Further, maladaptive cognitions, such as catastrophizing, were also associated with depression. Finally, females reported more neuropathic pain features than males. Our data-driven model could be leveraged in clinical trials investigating treatment approaches in COVID-19 survivors with post-COVID pain and can represent a first step for the development of a theoretical/conceptual framework for post-COVID pain.

Effect of TGF-β1-Mediated Exercise Analgesia in Spared Nerve Injury Mice.

Peripheral nerve injury leads to severe neuropathic pain. Previous studies have highlighted the beneficial effects of physical exercise on alleviating neuropathic pain. Exercise regulating transforming growth factor-β1 (TGF-β1) can improve several diseases and relieve neuropathic pain induced by peripheral nerve injury. Here, we investigated whether exercise could alleviate neuropathic pain by modulating TGF-β1 expression. We assessed mechanical and cold pain behavior and conducted molecular evaluation of the spinal cord. We found that spared nerve injury (SNI) led to mechanical and cold allodynia in the hind paw, elevated the expression of latency-associated peptide- (LAP-) TGF-β1, and activated astroglial in the spinal cord. Exercise decreases allodynia, astroglial activation, and LAP-TGF-β1 in SNI mice. Intrathecal injection of a TGF-type I receptor inhibitor attenuated exercise analgesia and enhanced astroglial activation. These findings demonstrate that exercise induces analgesia by promoting TGF-β1 activation and inhibiting astrogliosis. Our study reveals a new underlying mechanism for exercise-attenuated neuropathic pain in the maintenance stage of neuropathic pain after nerve injury.

Drug Utilization and Evaluation of Antiepileptic Drugs in a Tertiary Care Hospital

Abstract: Aim: Drug utilization and evaluation (DUE) study of antiepileptic drugs in a tertiary care hospital. Methods: A total of 110 case records of patients were included in a prospective observational study which was conducted for duration of 6 months. The prescription pattern was analyzed based on age, gender, route of administration, indication, duration of therapy, type of seizures, generation of Anti-Epileptic Drugs (AEDs), and rationality. Results: AEDs were prescribed more for patients between the ages of 51-60 years. The majority of patients receiving AEDs were males and AEDs were mostly used in the neurology department followed by neurosurgery and general medicine. Levetiracetam was prescribed most commonly as monotherapy. Lorazepam and midazolam were the most common add-on drugs. Gabapentin was mostly prescribed for severe neuropathic pain. The oral route was the common route of administration of AEDs. AEDs were highly prescribed for prophylaxis of seizures. Second-generation AEDs were highly used compared to other drugs. Conclusion: Second-generation AEDs were used as monotherapy and were found to be effective in reducing seizures and economically affordable for patients. As monotherapy, levetiracetam was the drug of choice followed by lorazepam. Keywords: Drug Utilization Evaluation (DUE), Epilepsy, Antiepileptic drugs, Levetiracetam, Phenytoin, Seizures.

PO123 / #650 BURST SPINAL CORD STIMULATION TO TREAT BILATERAL LOWER LIMB NEUROPATHIC PAIN SECONDARY TO TRANSVERSE MYELITIS; A CASE STUDY: E-POSTER VIEWING

We describe the case of a 69-year-old female referred for Spinal Cord Stimulation (SCS) consideration, with a ten year history of severe bilateral lower limb neuropathic pain secondary to transverse myelitis diagnosed by neurologists at the time. Confirmatory MRI showed high signal from T2 to T7 and thinning of the spinal cord. The patient had some relief with gabapentin and TENS but otherwise anti-neuropathic agents had no clinically meaningful effect. Physiotherapy, acupuncture and T10 nerve root injections were also not beneficial.

P41 Spotting the needle amongst the haystack - when asthma isn’t asthma

Introduction/BackgroundEosinophilic granulomatosis with polyangiitis (EGPA), previously known as Churg-Strauss Syndrome, is a rare, small to medium vessel ANCA associated vasculitis. Hallmarks of EGPA include asthma, chronic rhinosinusitis, and peripheral neuropathy.EGPA is characterized by a prodrome of asthma and allergic rhinitis, followed by peripheral blood hyper-eosinophilia and accumulation of extravascular eosinophils, and finally systemic vasculitis. Extra-pulmonary involvement is common, sometimes with fatal outcomes. The onset of EPGA is typically between 25-50 years; however, EGPA also occurs during childhood and has a significant morbidity and mortality.Description/MethodOur patient presented to the emergency department with a 2-week history of lethargy, wheeze and left sided neck swelling.After testing COVID-19 positive eight months prior to this, she developed wheezy episodes and was subsequently diagnosed with asthma which was managed with bronchodilators as required. She was reviewed by an allergist who confirmed a dust mite allergy and prescribed Montelukast. She remained well during the summer months however during winter she had 3 distinctive episodes of wheeze and cough which were managed by antibiotics and prednisolone.In the emergency department, an echocardiogram was performed which showed a cardiac tamponade. She was transferred to CICU where she had a pericardial drain inserted. The fluid was abundant with inflammatory cells. Multiple investigations were performed as follows: Hb: 135g/L, wbc: 20.30 x 10 9/L, Eosinophils: 12.77 x 10 9/L, CRP: 51 mg/L, ESR: 75 mm/hr, LDH: 1188 IU/L, IgE: 8000 UI/ml, ANA, ANCA: negative. CT chest showed mediastinal lymphadenopathy and patchy bilateral infiltrate and cardiac MRI showed myopericarditis and LV fibrosis. BMA showed no malignant cells and sinusitis was confirmed by CT.On examination, she was underweight. Her nasal mucosa looked inflamed. Otherwise systemic examination was unremarkable.In the context of poor ejection fraction (20%) with LV fibrosis, urgent MDT was arranged and concluded that our working diagnosis was EGPA. The decision was made to start IV methylprednisolone 10mg/kg/day for 3 days and Ivermectin.That night our patient had a VF arrest which required a single shock conversion 4J/kg. There was 7-minute downtime.Treatment was escalated to include cyclophosphamide, rituximab and plasmapheresis. The patient made a remarkable recovery, extubated and transferred to a normal ward.Her eosinophils count and inflammatory markers improved dramatically following treatment. However, she developed severe neuropathic left leg pain and NCS confirmed peripheral neuropathy.Discussion/ResultsEGPA is a very rare disease and diagnosis can be challenging especially with the absence of histopathology diagnosis.Early empirical treatment especially in a very ill child in intensive care unit can save lives and divert the progress of the disease.This patient has fulfilled the American College of Rheumatology criteria to diagnose EGPA including asthma, eosinophil count > 10% of upper normal, peripheral neuropathy, pulmonary infiltrates on CT thorax and paranasal sinuses abnormalities. Cardiac biopsy of the fibrotic mass may be a useful tool for diagnosis; however, this invasive procedure may expose this patient with high risk of fatal arrhythmias. Since other causes of eosinophilia were ruled out including parasitic infections, lymphoproliferative disorders, and rare primary immunodeficiency syndromes (hyper-IgE syndrome due to STAT3 or DOCK8 deficiency and Omenn syndrome) and the patient responded well to treatment, the diagnosis of EGPA was supported.Key learning points/ConclusionAsthma not responding to bronchodilator could be another diagnosis Eosinophilia should be interpreted with caution.Defer the need for histopathology diagnosis in critically ill childrenCardiac involvement is a life-threatening markerEarly diagnosis prevents life threatening complications.

Trigeminal neuralgia and the merit of small clinical trials

Trigeminal neuralgia is a severe chronic neuropathic pain condition characterised by paroxysmal pain in a region of the face corresponding to one or more divisions of the trigeminal nerve. 1 Cruccu G Di Stefano G Truini A Trigeminal neuralgia. N Engl J Med. 2020; 383: 754-762 Crossref PubMed Scopus (90) Google Scholar Available treatments are not always effective and can be associated with intolerable side-effects. 2 Bendtsen L Zakrzewska JM Abbott J et al. European Academy of Neurology guideline on trigeminal neuralgia. Eur J Neurol. 2019; 26: 831-849 Crossref PubMed Scopus (171) Google Scholar In trigeminal neuralgia, and in neuropathic pain in general, available drugs have all been identified through empirical clinical observations, whereas investigational drugs identified through bottom-up translational approaches have not been efficacious in clinical trials. 3 Finnerup NB Attal N Haroutounian S et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015; 14: 162-173 Summary Full Text Full Text PDF PubMed Scopus (2042) Google Scholar This situation contrasts with migraine, for which several new drugs have been identified through translational approaches and approved for clinical use, from the triptans in the 1990s to more recent approvals of selective serotonin receptor agonists and drugs targeting calcitonin gene-related peptide (CGRP). Safety and efficacy of erenumab in patients with trigeminal neuralgia in Denmark: a double-blind, randomised, placebo-controlled, proof-of-concept studyErenumab did not reduce pain intensity compared with placebo in patients with trigeminal neuralgia and CGRP probably does not have an important role in paroxysmal pain. Well tolerated, effective treatments in trigeminal neuralgia are still needed. Full-Text PDF

Anti- and Pro-Nociceptive mechanisms in neuropathic pain after human spinal cord injury.

Deficient endogenous pain modulation and increased nociceptive excitability are key features of central sensitization and can be assessed in humans by conditioned pain modulation (CPM, anti-nociceptive) and temporal summation of pain (TSP, pro-nociceptive), respectively. This study aimed to investigate these measures as proxies for central sensitization in subjects with chronic neuropathic pain (NP) after spinal cord injury (SCI). In paraplegic subjects with NP (SCI-NP; n= 17) and healthy controls (HC; n= 17), parallel and sequential sham-controlled CPM paradigms were performed using pressure pain threshold at the hand, that is, above lesion level, as test stimulus. The conditioning stimulus was a noxious cold (verum) or lukewarm water bath (sham) applied contralaterally. Regarding pro-nociceptive mechanisms, a TSP protocol with individually-adjusted pressure pain stimuli at the thenar eminence was used. CPM and TSP magnitudes were related to intensity and spatial extent of spontaneous NP. Neither the parallel nor sequential sham-controlled CPM paradigm showed any significant inhibition of above-level pressure pain thresholds for SCI-NP or HC. Accordingly, no group difference in CPM capacity was found, however, subjects with more intense spontaneous NP showed lower inhibitory CPM capacity. TSP was observed for both groups but was not enhanced in SCI-NP. Our results do not support altered above-level anti- or pro-nociceptive mechanisms in SCI-NP compared with HC; however, they also highlight the relevance of spontaneous NP intensity with regards to the capacity of endogenous pain modulation in SCI subjects. Central sensitization encompasses deficient endogenous pain modulation and increased nociceptive excitability. These two mechanisms can be assessed in humans by conditioned pain modulation and temporal summation of pain, respectively. Our data demonstrates a lack of descending pain inhibition only in subjects with severe neuropathic pain which may hint towards central sensitization at spinal and/or supra-spinal levels. Disentangling the mechanisms of endogenous pain modulation and neuronal hyperexcitability might improve mechanism-based treatment of neuropathic pain in subjects with spinal cord injury.

727 Pulmonary Embolism Following Posterior Shoulder Dislocation and Traumatic Brachial Plexus Injury - a Case Report

Abstract Traumatic brachial plexus injuries are considered to be among the rarest but most debilitating complications of shoulder dislocation. In addition, posterior shoulder dislocations are also rare, accounting for only 2–4% of all shoulder dislocations. A 40-year-old female patient presented to the emergency department (ED) with a dislocated right shoulder secondary to a mechanical fall. Plain film X-rays demonstrated a posterior dislocation of the humeral head. The shoulder was reduced under procedural sedation. Clinical examination after relocation demonstrated dense flaccid paralysis affecting all dermatomes and myotomes throughout the right upper limb. Urgent magnetic resonance imaging (MRI) of the shoulder showed oedematous thickening and haematoma along the brachial plexus, a large ‘reverse’ Hill-Sachs lesion, greater tuberosity avulsion fracture and glenohumeral capsular tear. The patient was referred to the specialist peripheral nerve injury unit, who advised nerve conduction studies and a magnetic resonance angiogram (MRA) to rule out expanding haematoma. The MRA scan revealed brachial plexus findings consistent with the MRI scan, no active bleeding, however a thrombus in the brachial vein. Two days after the MRA scan, the patient presented to ED with ongoing flaccid paralysis, severe neuropathic pain, and right-sided chest pain. Blood tests revealed a d-dimer &amp;gt;1000. CT pulmonary angiography confirmed extensive bilateral pulmonary emboli and she was commenced on appropriate anticoagulation. Association between brachial plexus injury, flaccid paralysis and venous thromboembolism are rare sequelae resulting from posterior shoulder dislocation. Further studies are required to investigate its incidence and establish whether all patients should receive VTE prophylaxis as standard.

Is the left/right judgment task performance altered in unilateral carpal tunnel syndrome: And associated with symptom severity?

BackgroundLeft/right judgment task performance (LRJT) is impaired in severe neuropathic pain conditions. However, comparison of LRJT performance in patients with carpal tunnel syndrome (CTS) with a control group with similar cognitive functions has not been investigated. ObjectiveThe aim of the study was to compare the LRJT performance of CTS patients with healthy controls and the unaffected side. MethodsSeventy-five CTS patients with dominant, right-hand involvement and 75 control subjects were included in the study. The Recognize® tablet application was used for LRJT performance. Tactile acuity (Two-point discrimination) and handgrip strength; pain severity (Visual Analog Scale) and neuropathic component of pain (Pain Detect Questionnaire); symptom severity and functional impact of CTS (Boston CTS Assessment Test) were evaluated. Mixed-design ANOVAs and correlation analyses were used for data analysis. DesignCross-sectional study. ResultsAnalysis of variance showed that there was no significant effect of side (affected versus unaffected) or group (CTS versus control group) on recognition accuracy or time. Significant group*site interactions were found for the two-point discrimination F (1,148) = 6.388, p = 0.013; and for handgrip strength F (1,148) = 17.552, p < 0.01. A statistically significant negative correlation was found between recognition accuracy and symptom duration and a significant positive correlation was found between recognition accuracy and handgrip strength in CTS patients (r = −0.267, p = 0.020; r = 0.290, p = 0.012). ConclusionCTS patients recognize the affected side as accurately and quickly as the unaffected side and control group. Further research is needed to clarify the relationship between LRJT performance in the severely affected CTS group. ClinicalTrials.gov registration numberNCT04967144 ClinicalTrials.gov registration date19 July 2021

ID:16060 Dorsal Root Ganglion Stimulation to Treat Focal and Diffuse Pain After Minimally Invasive Spine Surgery

Dorsal root ganglion stimulation (DRG-S) is an accepted neuromodulatory technique for the treatment of focal and dermatomal pain syndromes, and emerging evidence is demonstrating its efficacy in non-dermatomal syndromes such as failed back surgery syndrome (FBSS). Chronic pain patients often present with more than one source of pain1 and patients that experience a surgical complication are more likely to experience a second complication2. Here we present a patient who lost efficacy with SCS, leading to an extreme lateral interbody fusion (XLIF), which was complicated by flank hernia and severe focal neuropathic pain post-surgical repair. A year after XLIF, she was diagnosed with FBSS. DRG-S was successfully used to treat both conditions.

091 CIDP mimic in a patient with HIV; An unusual presentation of POEMS syndrome

A 37-year old woman with HIV on antiretrovirals (undetectable viral load; CD4 count 520) presented with a painful length dependant sensorimotor polyneuropathy. Investigations showed mild neutropenia, IgA 5.2g/L without paraprotein. Nerve conduction studies indicated a demyelinating polyneuropathy. CSF was acellular with protein 1193mg/L. Despite multiple courses of IVIg and subsequently pulsed IV and oral steroids, her power deteriorated considerably. A nerve biopsy showed loss of myelinated fibres with inflammation. On reinvestigation an IgA lambda paraprotein (5.2g/L) with raised VEGF (1190ng/L) was identified. Bone marrow demonstrated 8% plasma cells; a CT-PET was normal. A diagnosis of POEMS syndrome was made and chemotherapy commenced. A full VEGF response and resolution of neuropathic pain was seen 6-months post treatment initiation; however, treatment was complicated by venous sinus thrombosis and hypocortisolaemia.POEMS syndrome is a rare plasma cell dyscrasia with protean clinical manifestations, though all develop a progressive peripheral neuropathy. There is no reported association with HIV and POEMS, though HIV in association with CIDP has been reported and is usually responsive to treatment. It is important to challenge a CIDP diagnosis when refractory to treatment with atypical features, particularly severe neuropathic pain, and to repeat investigations if clinical suspicion is high.liamcarroll@nhs.net

Peripheral Neurectomy With Customized Nerve Reconstruction for Periorbital Neuropathic Pain: Initial Experience and Clinical Outcomes.

To describe a novel, minimally invasive surgical technique to treat severe, intractable periorbital neuropathic pain. A retrospective analysis of patients with severe, treatment-refractory periorbital pain who underwent transection of affected sensory trigeminal branches with nerve repair was performed. Collected data included etiology and duration of neuropathic pain, comorbidities, prior treatment history, surgical technique including site of transected sensory nerves and type of nerve repair, preoperative and postoperative pain scores as well as follow-up duration. Differences between preoperative and postoperative values were analyzed by the Wilcoxon signed-rank test. A total of 5 patients with severe periorbital neuropathic pain underwent transection of affected supraorbital, supratrochlear, infratrochlear, infraorbital, zygomaticotemporal, and zygomaticofacial nerves with customized nerve reconstruction. All 5 had improvement of periorbital pain after surgery, with 3 (60%) noting complete resolution of pain and 2 (40%) experiencing partial pain relief over a median follow-up period of 9 months (interquartile range [IQR], 6-19 months). Of the 3 patients who had complete resolution of pain, all reported continued pain relief. Median McGill pain scores significantly decreased from 8.4 (IQR, 8.2-10.0) preoperatively to 0.0 (IQR, 0.0-4.8; p < 0.001) postoperatively. All patients reported satisfaction with the surgical procedure and stated that they would undergo the procedure again if given the option. One patient with history of postherpetic neuralgia (PHN) had reactivation of herpes zoster at postoperative month 3, which was self-limited, without worsening of her neuropathic pain. Another patient with PHN required a staged procedure to achieve complete pain relief. Peripheral neurectomy with customized reconstruction of involved sensory nerves can successfully reduce and even eradicate periorbital neuropathic pain that was previously recalcitrant to combination pharmacotherapy and prior neurolysis procedures.

Prevention and management of bortezomib-induced peripheral neuropathy in patients with multiple myeloma

Proteasome inhibitors and immunomodulators (IMiDs), primarily bortezomib and lenalidomide, are essential components of treatment for both newly diagnosed and relapsed/refractory multiple myeloma (MM), producing high response rates and resulting in improved overall survival. However, bortezomib often induces a dose-limiting toxicity in the form of peripheral neuropathy (PN). Neurotoxicity often affects patient’s quality of life and requires dose modification or withdrawal of therapy, with a possible effect on the overall response. A prompt recognition of predisposing factors (such as diabetes mellitus, vitamin B 12 deficiencies, or viral infections) and appearance of signs and symptoms, through a periodic neurological assessment with appropriate scales, is extremely important. Usually, bortezomib-induced PN is a sensory axonopathy characterized by numbness, tingling, and severe neuropathic pain in stocking and glove distribution while motor neuropathy is less frequently observed. Dose adjustment of bortezomib could be necessary during treatment. Anticonvulsants (pregabalin, gabapentin, carbamazepine, etc.) and tricyclic antidepressants (amitriptyline) are most often used to relieve neurological pain. In this review we focus on the clinical manifestations of bortezomibinduced PN, current understanding of the pathophysiological mechanisms as well as clinical and pharmacological aspects of prevention and management this complication. New proteasome inhibitors such as ixazomib and carfilzomib do not have the neurotoxicity of bortezomib. An early switch within the class of proteasome inhibitors from bortezomib to oral ixazomib appears to be an important approach to prevent severe PN. Our own clinical case of an early switch from bortezomib-based induction to IRd triplet (ixazomib, lenalidomide, dexamethasone) is cited as an illustration of the success of this approach.

A prospective, multicenter, open-label study of the clinical efficacy of tapentadol extended-release in the treatment of cancer-related pain and improvement in the quality of life of opioid-naïve or opioid-resistant patients

PurposeThis study aimed to investigate the clinical efficacy of tapentadol extended-release (ER) on pain control and the quality of life (QoL) of patients with moderate to severe chronic cancer pain in clinical practice in Korea.MethodsIn this prospective, open-label, multicenter trial, patients with sustained cancer pain as well as chronic pain, who were or were not using other analgesics were enrolled. Thirteen centers recorded a total of 752 patients during the 6-month observation period, based on the tapentadol ER dose and tolerability, prior and concomitant analgesic treatment, pain intensity, type of pain, adverse effects, and clinical global impression change (CGI-C). Of those 752 patients, 688 were enrolled, and 650 completed the study for efficacy and adverse drug reactions; among them, 349 were cancer patients.ResultsTapentadol ER significantly reduced the mean pain intensity including neuropathic pain during the observation period by 2.9 points (from a mean 7 ± 0.87 to 4.1 ± 2.02). Furthermore, QoL was observed to be significantly improved based on the CGI-C, an objective measure.ConclusionThis study showed that tapentadol ER was effective for treating patients with moderate to severe cancer pain and neuropathic pain, and therefore it significantly improved the patients’ QoL.

Zastosowanie pregabaliny u chorej z przewlekłym bólem neuropatycznym po zabiegu onkologicznym – opis przypadku

Chronic postsurgical pain is a frequent iatrogenic complication and the consequence of surgical treatment of neoplastic disease. The risk of developing chronic postsurgical pain depends on the type of surgery, its extent, but also on the patients’ factors. Neuropathic pain may occur in 50% of patients with chronic postsurgical pain and can only be treated symptomatically, both with pharmacotherapy and non-pharmacological methods. The recommended drugs are antiepileptic drugs, antidepressants, opioid analgesics and topical drugs. These drugs have proven their effectiveness in the population of patients with neuropathic pain unrelated to cancer treatment, but there are still no high-quality studies assessing their effectiveness in patients with chronic postsurgical pain resulting from oncological surgery. Studies in small groups of patients available in the literature confirm the effectiveness of antiepileptic and antidepressant drugs in this group of patients, what is observed in clinical practice as well. The article presents a case of a patient with severe neuropathic pain in the course of chronic postsurgical pain who was successfully treated with pregabalin in combination with tramadol and paracetamol.

Zastosowanie pregabaliny u chorej z bólem neuropatycznym w przebiegu neuropatii obwodowej indukowanej chemioterapią – opis przypadku

Chemotherapy-induced neuropathy (CIPN) is a frequent iatrogenic complication and a consequence of causal treatment of neoplastic disease. The risk of developing CIPN depends on the type of chemotherapy, the total dose, but also on the patients’ factors. There is currently no proven method that can prevent the occurrence of CIPN. Neuropathic pain may occur in 40% of patients with CIPN, decreases patients’ quality of life and can be treated symptomatically only, both with pharmacotherapy and non-pharmacological methods. Antiepileptics, antidepressants, opioid analgesics and topical drugs are recommended. These drugs have proven their effectiveness in the population of patients with neuropathic pain unrelated to cancer treatment, but there are still no high-quality studies assessing their effectiveness in patients with CIPN. Studies in small groups of patients available in the literature confirm the effectiveness of antiepileptic and antidepressant drugs in this group of patients, what is observed in clinical practice as well. The article presents a case of a patient with severe neuropathic pain in the course of CIPN who was successfully treated with pregabalin in combination with duloxetine.