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Thoracic surgery is associated with one of the highest rates of chronic postsurgical pain (CPSP) among all surgical subtypes. Chronic postsurgical pain carries significant medical, psychological, and economic consequences, and further interventions are needed to prevent its development. This study aimed to determine the prevalence, characteristics, and risk factors associated with CPSP after thoracic surgery. A prospective cohort study. Single-center tertiary care hospital. This study included 285 adult patients who underwent thoracic surgery at Toronto General Hospital in Toronto, Canada, between 2012 and 2020. Demographic, psychological, and clinical data were collected perioperatively, and follow-up evaluations were administered at 3, 6, and 12 months after surgery to assess CPSP. Chronic postsurgical pain was reported in 32.4%, 25.4%, and 18.2% of patients at 3, 6, and 12 months postoperatively, respectively. Average CPSP pain intensity was rated to be 3.37 (SD 1.82) at 3 months. Features of neuropathic pain were present in 48.7% of patients with CPSP at 3 months and 71% at 1 year. Multivariate logistic regression models indicated that independent predictors for CPSP at 3 months were scores on the Hospital Anxiety and Depression Scale (adjusted odds ratio [aOR] of 1.07, 95% CI of 1.02 to 1.14, p = 0.012) and acute postoperative pain (aOR of 2.75, 95% CI of 1.19 to 6.36, p = 0.018). None. Approximately 1 in 3 patients will continue to have pain at 3 months after surgery, with a large proportion reporting neuropathic features. Risk factors for pain at 3 months may include preoperative anxiety and depression and acute postoperative pain. [ABSTRACT FROM AUTHOR]

Background: Somatic nerve pain is one of the most common complications following surgery of the foot and ankle but may also arise following traumatic injury or chronic nerve compression. The sural nerve is a commonly affected nerve in the foot and ankle; it is at risk given the proximity to frequently used surgical approaches, exposure to crush injuries, and traction from severe ankle inversion injuries. The purpose of this study is to investigate the outcomes of sural nerve neurectomy with proximal implantation for sural neuromas (SN) and chronic sural neuritis (CSN). Methods: Patients that underwent neurectomy with proximal implantation (20 muscle, 1 adipose tissue) by 2 foot and ankle specialists for isolated SN- and CSN-related pain at a single tertiary institution were included. Demographic data, baseline outcomes including 36-Item Short Form Health Survey (SF-36), Foot and Ankle Ability Measure (FAAM), and visual analog scale (VAS) were recorded. Final follow-up questionnaires using Patient Reported Outcomes Measurement Information System (PROMIS) lower extremity function, pain interference (PI), and neuropathic pain quality, FAAM, and VAS were administered using REDCap. Perioperative factors including neuropathic medications, diagnostic injections, the use of collagen wraps, and perioperative ketamine were collected from the medical record. Descriptive statistics were performed and potential changes in patient-reported outcome measure scores were evaluated using Wilcoxon signed-rank tests. Results: The 21 patients meeting inclusion criteria for this study had a median age of 47 years (interquartile range [IQR], 43-49) and had median follow-up duration of 33.7 months (IQR, 4.5-47.6). Median FAAM activities of daily living score improved from 40.6 (38.7-50.7) preoperatively to 66.1 (53.6-83.3) postoperatively, P =.032. FAAM sports scores improved from 14.1 (7.8-21.9) to 41.1 (25.0-60.9) postoperatively, P =.002. VAS scores improved from a median of 9.0 (8.0-9.0) to 3.0 (3.0-6.0), P <.001. At final follow-up, patients reported PROMIS lower extremity function score median of 43.8 (35.6-54.9), PROMIS neuropathic pain quality score of 54.1 (43.6-61.6), and PROMIS PI of 57.7 (41.1-63.8). Patients with both anxiety and depression reported less improvement in pain and physical. Other perioperative factors lacked sufficient numbers for statistical analysis. Conclusion: Sural nerve neurectomy and proximal implantation (20 muscle, 1 adipose) provided significant improvement in pain and function for patients with sural neuromas and chronic sural neuritis at median follow-up of 33.7 months. Anxiety and depression were associated with significantly poorer outcomes following surgery. Patients with CRPS as well as recent nicotine use tended to report less improvement in pain and worse function after surgery, although this sample size was too limited for statistical analysis of these variables. Further research is needed to identify the ideal surgical candidates and perioperative factors to optimize patient outcomes. Level of Evidence: Level IV, retrospective case series. [ABSTRACT FROM AUTHOR]

To give an overview of central aspects of pain medicine-specific clinical reasoning when assessing a pain patient. Clinical reasoning is the thinking and decision-making processes associated with clinical practice. Three core pain assessment areas that are crucial for clinical reasoning in the field of pain medicine are discussed, each of them consisting of three points. First, it is important to distinguish acute, chronic non-cancer, and cancer-related pain conditions. This classical and very simple trichotomy still has important implications treatment-wise, e.g., concerning the use of opioids. Second, the pain mechanism needs to be assessed. Is the pain nociceptive, neuropathic, or nociplastic? Simply put, nociceptive pain has to do with injury of non-neural tissue, neuropathic pain is caused by a disease or lesion of the somatosensory nervous system, and nociplastic pain is believed to be related to a sensitized nervous system (c.f. the concept of "central sensitization"). This also has implications concerning treatment. Some chronic pain conditions are nowadays viewed more as diseases rather than the pain being merely a symptom. In the new ICD-11 pain classification, this is conceptualized by the characterization of some chronic pains as "primary". Third, in addition to a conventional biomedical evaluation, psychosocial and behavioral aspects must also be assessed, the pain patient being viewed as an active agent and not merely as the passive recipient of an intervention. Hence, the importance of a dynamic bio-psycho-social perspective. The dynamic interplay of biological, psychological, and social aspects must be taken into account, putative behavioral "vicious circles" thereby being identified. Some core psycho-social concepts in pain medicine are mentioned. The clinical applicability and clinical reasoning power of the 3 × 3 framework is illustrated by three short (albeit fictional) case descriptions. [ABSTRACT FROM AUTHOR]

The management of patients with chronic pain is one of the most important issues In medicine and public health. Chronic pain conditions cause substantial suffering for patients, their significant others and society over years and even decades and increases healthcare utilization resources including the cost of medical care, loss of productivity and provision of disability services. Primary care providers are at the frontline in the identification and management of patients with chronic pain, as the majority of patients enter the healthcare system through primary care and are managed by primary care providers. Due to the complexity of chronic pain and the range of issues involved, the accurate diagnosis of the causes of pain and the formulation of effective treatment plans presents significant challenges in the primary care setting. In this review, we use the classification of pain types based on pathophysiology as the template to guide the assessment, treatment, and monitoring of patients with chronic pain conditions. We outline key methods that can be used to efficiently and accurately diagnose the putative pathophysiological mechanisms underlying chronic pain conditions and describe how this information should be used to tailor the treatment plan to meet the patient's needs. We discuss methods to evaluate patients and the impact of treatment plans over a series of consultations, with a particular focus on strategies to improve the patient's ability to self-manage their pain and related symptoms and perform daily functions despite persistent pain. Finally, we introduce the mnemonic RATE (Recognize, Assess, Treat, and Evaluate) as a general strategy that healthcare providers can use to aid their management of patients presenting with chronic pain. [ABSTRACT FROM AUTHOR]

• Pain is common in MS; little is known of its presence in the MS prodrome. • We examined anticonvulsant and gabapentinoid prescriptions 5 years pre-MS onset. • Odds of filling ⩾1 anticonvulsant was 3.1 higher for cases versus controls. • Odds of filling ⩾1 gabapentinoid (with/out an anticonvulsant) was ≥3.9 higher. • Findings suggest that pain symptom management was evident before classical MS onset. Before disease onset, multiple sclerosis (MS) persons fill more prescriptions than controls, including for pain. However, knowledge regarding neuropathic pain-related medications is lacking Compare odds of anticonvulsant/gabapentinoid prescriptions for 4,862 MS-cases versus 22,669 controls, pre-MS onset (defined as first demyelinating disease-related event). Matched-cohort study using administrative data (1996–2013), comparing the odds of anticonvulsant/gabapentinoid prescriptions pre-MS onset using multivariable logistic regression. Versus controls, MS-cases were more likely to fill prescriptions for anticonvulsants (aOR[adjusted odds ratios] = 3.1,95 % confidence interval[CI]:2.8,3.4), gabapentinoids (aOR = 4.1,95 %CI:3.6,4.6), and gabapentinoids without anticonvulsants (aOR = 3.9,95 %CI:3.4,4.5). MS-cases filled anticonvulsant and gabapentinoid prescriptions more than matched controls pre-MS onset. [ABSTRACT FROM AUTHOR]

Vincristine is a frequently used antineoplastic drug for treating a variety of malignancies, although its usage has been restricted by the painful neuropathy it induces. A more profound comprehension of the pathogenesis of vincristine-induced painful neuropathy (VIPN) is crucial for developing efficient preventive and therapeutic approaches. With its well-established anti-inflammatory and immunomodulatory actions, curcumin (nanoemulsion form) was utilized in our work as a protective and therapeutic tool for VIPN. This study aims to clarify the mechanisms behind curcumin's neuroprotective effects against vincristine-induced neurotoxicity. For painful neuropathy induction, rats were injected with vincristine sulfate (150µg/kg/i.p.: once every two days) for five injections. For treatment, pregabalin (30 mg/kg/p.o.), curcumin (30mg/kg/p.o.) and curcumin nanoemulsion (30mg/kg/p.o.) were administered daily for 14 consecutive days. Our results showed that curcumin nanoemulsion significantly reduced cold allodynia and thermal hyperalgesia. It also increased the sciatic nerve levels of [CAT, SOD, and IL-10] and the spinal cord PPAR-γ. Additionally, immunostaining of the sciatic nerve revealed a reduction in NF-κ B expression and an increase in HSP70 expression. These findings suggest that curcumin has neuroprotective effects against VIPN, which might be attributed to its interference with the PPAR-γ, HSP70 and IL-10 signaling pathways. [ABSTRACT FROM AUTHOR]

OBJECTIVE: In animal models and humans, mutations in voltage-dependent calcium channel gamma-2 subunit gene (CACNG2) have been associated with neuronal hyperexcitability, including neuropathic pain. The objective of this study was to determine the allelic and genotypic frequencies of CACNG2 polymorphisms (rs4820242, rs2284015 and rs2284017) and their association with the risk of chronic peripheral neuropathic pain (CPNP) in the Mexican population. PATIENTS AND METHODS: Single nucleotide polymorphisms (SNPs) were determined by real-time PCR, and allelic and genotypic frequencies were compared between healthy Mexican subjects and CPNP patients. The risk of association of CACNG2 SNPs with the presence of CPNP and its characteristics was evaluated. RESULTS: The allele G (OR 2.08, p = 0.01) of rs2284015 was observed as a risk factor for developing CPNP. The allele A of rs4820442 showed a risk of association with a history of surgery (OR 3.92, p = 0.04), radiculopathy (OR 4.29, p = 0.0001), bilateral presentation of pain (OR 3.15, p = 0.003), and neuropraxia (OR 0.36, p = 0.01). The allele C of rs2284015 was associated with an increased risk of burning and allodynia. In the analysis of the association of genotype frequencies and inheritance patterns, as well as in the analysis of interaction with sex, a modification of risk was observed. CONCLUSIONS: The allele G of rs2284015 and the AGC haplotype of CACNG2 rs4820242, rs2284015 and rs2284017, regardless of sex and etiology could contribute to the risk of CPNP. Certain alleles and genotypes could constitute severity markers in CPNP with sex-biased effects; however, further studies are required to confirm these observations. [ABSTRACT FROM AUTHOR]

Ketamine at sub-anesthetic doses is a potent analgesia. Its use in cancer pain remains equivocal with protocols varying in patient selection, starting dose, titration, duration of use and adjustment of co-analgesics. To study the impact of a standardised Ketamine Step Protocol on cancer pain in a Palliative Care Unit (PCU). This is a prospective cohort study of a standardised Ketamine Step Protocol which was developed in a PCU for use in cancer pain. The subcutaneous ketamine infusion was standardised at a starting dose of 75 mg over 24 hours with Haloperidol 5 mg as prophylaxis against psycho-mimetic side effects. Incremental doses of ketamine followed the daily stepwise protocol. Of the 48 patients analysed, 41 (85.4%) had neuropathic cancer pain. The median Palliative Performance Scale score (PPSv2) was 40%. Mean Numerical Rating Score (NRS) improved from 6.74 to 2.61 (P < 0.0001) with a mean percentage reduction of 58.05%. The final mean daily ketamine dose needed to achieve stable pain control was 137.50 mg/day (±81.54). 31(62.5%) patients achieved pain control by day 3. The mean Morphine Equivalent Daily Dose (MEDD) reduction was from 130.34 mg to 107.33 mg (P < 0.002) with a percentage reduction of 18.85%. More than half of our patients completed the 5 d protocol with mild to moderate side effects not warranting urgent medical intervention nor termination of the ketamine protocol. Use of a standardised Ketamine Step Protocol showed a statistically significant reduction in pain and MEDD in patients with predominantly neuropathic cancer pain. It also demonstrated a safe and effective method for opioid reduction after commencement of parenteral ketamine. Our study shows that: Parenteral ketamine is a potent analgesic which significantly reduced pain in patients with cancer neuropathic pain. This study also demonstrated a safe and effective method for titration of opioids after parenteral ketamine is started. Concurrent use of psychotropics also helps to reduce psycho-mimetic side effects, increasing tolerability to ketamine. [ABSTRACT FROM AUTHOR]

Pain contributes substantially to reduced quality of life in individuals living with hidradenitis suppurativa (HS). Although improved understanding of HS pathogenesis and treatment has resulted in improved evidence-based HS management guidelines, comprehensive pain management guidelines have yet to be developed. Few HS-specific data exist to guide pharmacologic analgesia; however, recognizing HS pain as either acute or chronic and predominantly nociceptive (aching and gnawing pain due to tissue damage) versus neuropathic (burning-type pain due to somatosensory nervous system dysfunction) provides a conceptual framework for applying outside pain management practices to HS management. This article incorporates the best available evidence from the HS and pain literature to propose an HS pain algorithm that integrates psychological, pharmacologic, and complementary and alternative treatment modalities. [ABSTRACT FROM AUTHOR]

To assess the cost-effectiveness of 30 mg of mirogabalin versus no treatment or 300 mg of pregabalin in patients with diabetic peripheral neuropathic pain (DPNP) from a third-party perspective in Taiwan. A Markov model, developed with cycles of 2-week and a 1-year timeframes, consisted of 3 health states: mild, moderate, and severe pain. Average daily pain score (ADPS) was assessed at the end of each 2-week cycle. All patients entered the model in moderate (4 ≤ ADPS < 7) or severe (7 ≤ ADPS ≤ 10) pain health states. At the end of each cycle, patients remained in their assigned health state or transitioned to a different health state according to their pain score change. Efficacy data were informed by the pivotal phase III clinical trial (J303, NCT02318706) or by a network meta-analysis. Utility values were obtained from published literature, and resource use and cost data from Taiwanese clinical experts and Taiwan National Health Insurance Administration. One-way sensitivity, scenario, and probabilistic analyses were conducted to test the robustness of the results. A head-to-head analysis demonstrated that 30 mg of mirogabalin is a cost-effective treatment option versus placebo for DPNP. The base-case deterministic analysis estimated quality-adjusted life years (QALY) gains of 0.02 at an incremental cost of 9697 New Taiwan dollars (NT$) (equal to $323) versus placebo (incremental cost-effectiveness ratio [ICER]: 489 310 NT$/QALY [$15 860/QALY]). Mirogabalin was also cost-effective compared with 300 mg of pregabalin (ICER: 18 476 NT$/QALY [$600/QALY]). Sensitivity and scenario analyses results confirmed the robustness. Economic analysis suggests that mirogabalin 30 mg, a potent and selective α2δ ligand, is a cost-effective treatment option for DPNP in Taiwan, with an ICER below the willingness-to-pay threshold. • Diabetic peripheral neuropathy (DPN) is one of the most frequent complications associated with both type I and type II diabetes, and 11% of these patients are reported to have burning, shooting, or aching type pain called diabetic peripheral neuropathic pain (DPNP). • Mirogabalin besilate (Tarlige®) is a potent and selective α 2 δ ligand for the management of diabetic peripheral neuropathic pain and postherpetic neuralgia. • Based on a Markov model, within a 1-year time horizon, 30 mg of mirogabalin was found to be a cost-effective treatment option for the management of DPNP compared with 300 mg of pregabalin and placebo in Taiwan. [ABSTRACT FROM AUTHOR]

The purpose of this study was to assess the intra- and inter-reader reliability of the 2 Charcot neuroarthropathy classifications (Sanders-Frykberg and Brodsky-Trepman), as well as Eichenholtz staging. We hypothesized that the inter-reader reliability, with respect to these 3 classification systems, would be moderate at best. Digital radiographic images were organized in a digital slide presentation without clinical information. All 5 reviewers underwent a standard training session administered by the principal investigator, reviewing 5 cases of Charcot neuroarthropathy. Images of 55 cases of Charcot neuroarthropathy and 5 normal cases were distributed to each of the 5 physicians electronically, who independently rated all 60 cases according to the 3 classification systems. The 95% confidence interval of the intraclass correlation coefficient estimate for Sanders-Frykberg was 0.9601 to 0.9833 at week 0 and 0.9579 to 0.9814 at week 8, which can be regarded as "excellent" reliability. For Trepman-Brodsky, the 95% confidence interval of the intraclass correlation coefficient estimate was 0.8463 to 0.9327 at week 0 and 0.8129 to 0.9226 at week 8, which can be regarded as "good" to "excellent" reliability. For Eichenholtz, the 95% confidence interval of the intraclass correlation coefficient estimate was 0.6841 to 0.8640 and 0.6931 to 0.8730 at weeks 0 and 8, respectively, which can be regarded as "moderate" to "good" reliability. The classification systems of Charcot neuroarthropathy are an important tool for communication among physicians. Based on the results at our institution, the Sanders-Frykberg classification exhibited the best inter-reader performance. The Trepman-Brodsky classification exhibited good to excellent reliability as well. The intraclass correlation coefficient of the Eichenholtz classification was moderate to good. [ABSTRACT FROM AUTHOR]

Ulcerations under the medial column in patients with acquired neuropathic pes planus may be intractable to conservative techniques such as regular debridement, offloading, bracing, and accommodative shoes. When surgery becomes necessary for these patients, the foot and ankle surgeon has the option of exostectomy, medial column beaming, medial column fusion, and external fixation, among others. In the case of a flexible midfoot collapse, the option of arthroereisis for indirect medial column support may be warranted. In this preliminary report, the authors detail a technique of Achilles tendon lengthening, arthroereisis implantation, and advanced cellular tissue product application in an attempt at wound coverage and prevention of recurrence. Three patients presenting with intractable medial column ulcerations of ∼1 year's duration underwent this procedure, and within 7 weeks (range 5 to 7), all medial column ulcerations healed. These patients remained healed at last follow-up (average 29 months; range 8 to 44). This preliminary report provides evidence for a minimally invasive procedure aimed at offloading, healing, and preventing recurrence of medial column ulcerations in patients with flexible neuropathic pes planus. [ABSTRACT FROM AUTHOR]

To explore perceptions and use of clinical pain mechanism assessment by physical therapists managing musculoskeletal pain. This was a cross-sectional survey study. The survey was completed electronically by physical therapists in the United States. This was a convenience sample of physical therapists from a professional membership organization in the United States. Members were invited via email to participate if they evaluate and treat musculoskeletal pain. Not applicable. Two primary outcomes were assessed: respondent beliefs/opinions related to and utilization of clinical pain mechanism assessments. Likert-type questions exploring degree of agreement were provided to capture relevant data. In total, 148 respondents completed all aspects of the survey. Respondent age ranged from 26 to 73 years, with a mean of 43.9 (12.0). Most respondents (70.8%) reported performing clinical pain mechanism assessments at least 'sometimes'. A majority (80.4%) believed clinical pain mechanism assessments are useful in guiding management strategies while 79.8% reported specifically choosing interventions to alter aberrant pain mechanisms. The most commonly used pain severity, physical examination testing and questionnaires were the numeric pain rating scale, pressure pain thresholds and pain diagrams, respectively. However, the vast majority of instruments available to clinically assess pain mechanisms were performed by a small proportion of respondents (< 30%). There were no significant correlations between age, years of experience, highest earned degree, completion of advanced training or specialist certification and testing frequency. The evaluation of pain mechanisms involved in the pain experience is becoming common in research. However, the clinical application of pain mechanism assessment is unclear. Based on the results of this survey, physical therapists in the orthopedic setting believe pain mechanism assessment is useful, but data suggests it is infrequently performed. Additional qualitative inquiry regarding motivations for or against using clinical pain mechanism assessment could be useful in the knowledge translation process. None to report. [ABSTRACT FROM AUTHOR]

Acute and chronic pain states overlap in chronology and pathophysiology but both can remain under-managed. Assessment aims to elucidate underlying diagnosis and/or pain generators that can then guide treatment strategies. Assessment should be repeated to assess efficacy of treatments and the presence of side effects. Self-report questionnaires are available to assist in diagnosis and monitoring of pain and its related dimensions but they do not replace a thorough assessment by an experienced clinician. [ABSTRACT FROM AUTHOR]

To educate and discuss pain mechanisms (nociceptive, neuropathic, nociplastic) illuminating its possible impact when measuring different outcomes, which may modify, confound and potentially bias the outcome measures applied across various aspects of Rheumatic Musculoskeletal Diseases (RMDs) clinical trials. In the plenary presentations, PM lectured on different pain mechanisms and impact on disease activity assessment. Data from two data sets of RMDs patients, which assessed the prevalence and impact of nociplastic pain were presented and reviewed. Audience breakout group sessions and polling were conducted. Mixed pain etiologies may differentially influence disease activity assessment and therapeutic decision-making. Polling demonstrated a consensus on the need to assess different types of pain as a phenotype, as it constitutes an important contextual factor (a variable that is not an outcome of the trial, but needs to be recognized [and measured] to understand the study results), and to standardize across RMDs. There is need for a standardized pain measure that can differentiate underlying pain mechanisms. [ABSTRACT FROM AUTHOR]

Highlights • Pain is a very common symptom among persons with multiple sclerosis. • Pain frequency is high as 76.7% among persons with multiple sclerosis. • Neuropathic pain is associated with health-related lower quality of life. • Neuropathic pain is associated with higher depression, fatigue and sleepiness. • Musculoskeletal pain was most common in the spine area. Abstract Background Although there is accumulating evidence on neuropathic pain in persons with multiple sclerosis (pwMS), little is known about musculoskeletal pain. The aim was to examine the frequency, type, distribution of pain and related factors in pwMS. Methods This cross-sectional study included 223 pwMS. The Nordic Musculoskeletal Questionnaire and painDETECT Questionnaire were used to assess pain. Depression, fatigue, sleepiness, and health-related quality of life were assessed. Results 23.3% of participants did not have pain, 55.6% had musculoskeletal pain and 21.1% had neuropathic pain. There was no significant difference between the groups in age, gender, disease duration, employment status, marital status and education level (p >.05). The participants without pain had lower Expanded Disability Status Scale (EDSS) scores compared to those with neuropathic pain (p =.024). In addition, the participants with musculoskeletal pain had lower EDSS scores compared to those with neuropathic pain (p =.027). Depression, fatigue, sleepiness and quality of life scores were significantly different between the groups (p <.05). Participants with neuropathic pain had significantly lower quality of life, and higher fatigue, depression and sleepiness compared to participants with musculoskeletal pain and without pain (p <.05). Musculoskeletal pain was most common in low back (52.4%), neck (51.6%), and upper back (45.2%). Conclusions This study suggests that pain is a very common symptom among pwMS. Pain frequency is high as 76.7%. In particular, the presence of neuropathic pain is associated with lower health-related quality of life and higher levels of depression, fatigue and sleepiness. Musculoskeletal pain was most common in the spine area including neck, upper back, and low back. [ABSTRACT FROM AUTHOR]

The present study was part of a larger mixed-methods study concerning facilitators and barriers to living with chronic pain after spinal cord injury. The agreement with themes obtained in qualitative interviews were quantified in a large online survey and overarching themes were defined by factor analysis. The present study aimed to define subgroups based on cluster analysis of the overarching themes' factor scores and to compare the subgroups on pain-related variables. Three subgroups-high pain impact, moderate pain impact, and low pain impact-emerged. The high pain impact subgroup experienced severe pain with neuropathic pain characteristics; used pain medication, multiple coping strategies, and self-remedies; and considered information about pain and its management critical, but were not able to communicate well about their pain. The moderate pain impact subgroup carried on despite pain, considered pain information important, and used multiple approaches to manage their pain, but used less medication owing to concerns about side effects and addiction. The low pain impact subgroup considered information about pain, pain treatments, and communication regarding pain less important than the other subgroups did. This study suggests that treatment approaches need to be individually tailored not only to type of pain, but also to personal factors and preferences. PERSPECTIVE: People who experience significant pain impact after spinal cord injury use multiple approaches to manage their pain. Many have concerns about side effects and addiction, and consider information about pain and its management, including pharmacologic, nonpharmacologic, and self-remedies, a high priority. Therefore, patients' personal preferences may provide additional tailoring options for patient-centered treatments. [ABSTRACT FROM AUTHOR]

Background: Neuropathic (Charcot) arthropathy of the hip is rare but can lead to joint destruction, bone loss, and dysfunction. While total hip arthroplasty (THA) may be considered a treatment option, only very limited data in the form of case reports are available on the results of THA. The goal of this study was to analyze the outcomes of primary THA for Charcot arthropathy with emphasis on implant survivorship, complications, and clinical outcomes.Methods: Eleven patients undergoing 12 primary THAs for Charcot arthropathy from 2007 to 2014 were retrospectively reviewed. All patients had a severe underlying neuropathy and clear radiographic evidence of Charcot arthropathy. Mean age was 54 years with 4 patients being female. Mean follow-up was 5 years.Results: Survivorship free of any revision was 75% at both 2 and 5 years. Three THAs (3/12) were revised: 2 for recurrent instability and 1 for femoral component loosening. Survivorship free of any reoperation was 67% at both 2 and 5 years. One additional THA underwent open reduction and internal fixation of a Vancouver B1 periprosthetic fracture. The overall complication rate (including revisions and reoperations) was high at 58% with 3 recurrent dislocations, 2 periprosthetic fractures, 1 femoral component loosening, and 1 delayed wound healing. Harris Hip Scores improved from a mean of 43 preoperatively to 81 postoperatively (P < .001).Conclusion: In this study, the largest to date, we found that patients undergoing primary THA for Charcot arthropathy have a significant improvement in clinical outcomes but that there was a high risk of early complications and revisions, mostly related to recurrent instability. Specific precautions to avoid early complications, namely utilization of components that provide robust fixation and strategies that provide enhanced hip stability, should be considered.Level Of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

Résumé La chirurgie pelvi-périnéale entraîne des risques de douleur chronique qui sont trop souvent méconnus. La chirurgie prothétique est pourvoyeuse de douleur chroniques avec en particulier les plaques de hernie, les bandelettes sous-urétrales, les prothèses pour la chirurgie du prolapsus. L'exploration est basée essentiellement sur l'anamnèse, l'interrogatoire et l'examen clinique. L'apparition des douleurs immédiatement ou quelques jours après la chirurgie est un élément clé pour imputer les douleurs au geste chirurgical. Ces douleurs sont essentiellement des douleurs neuropathiques et/ou myofasciales. Il faut aussi rechercher des signes de sensibilisation centrale avec des douleurs plus diffuses. Le traitement repose avant tout par une reprise chirurgicale pour une ablation du matériel avec une amélioration dans 2/3 des cas. En cas d'échec une prise en charge algologique plus complète avec de la relaxation musculaire en cas de douleurs myofascial et/ou une prise en charge médicale spécifique des douleurs neuropathiques et de la sensibilisation pelvienne. Summary Pelvic-perineal surgery induces risks of chronic pain often unappreciated. Prosthetic surgery is a source of chronic pain, in particular prosthetic mesh for hernia or prolapse, sub-urethral slings for incontinence. The exploration is based essentially on the anamnesis, the clinical reports and the clinical examination. The occurrence of pain immediately or a few days after surgery is a key point in attributing pain to the surgical procedure. The characteristics of pain are essentially neuropathic and/or myofascial. Signs of central sensitization with more diffuse pain could be also present. The treatment is based primarily on surgical revision for ablation of the mesh with an improvement in 2/3 of cases. In case of failure, algological management with muscle relaxation in case of myofascial pain and/or specific medical management of neuropathic pain and pelvic sensitization could be proposed. [ABSTRACT FROM AUTHOR]

Longitudinal assessment of chronic geriatric pain is complicated by an age-associated plateau in pain severity and increase in widespread pain, calling for innovative measures such as pain quality descriptors that characterize how pain may feel. We characterized persistence of pain quality and its relation to severity, activity interference and distribution of sites, in a population-based sample of adults aged≥70 years with chronic pain (n = 398). Persistent pain quality was defined as reporting descriptors within the same category: sensory, cognitive/affective, or neuropathic at baseline and 18 months. A count variable indicated number of persistent categories. Pain quality was highly persistent. Adjusted for baseline covariates, individuals endorsing 3 persistent categories were 2-2.5x more likely to experience more widespread pain at 18 months compared to fewer persistent categories. No associations were noted in changes in pain severity or interference. A comprehensive pain assessment that includes diverse pain quality descriptors may improve individualized pain management. [ABSTRACT FROM AUTHOR]

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Objective: The Chronic Pain Questions (CPQ) were developed for clinical use with the aim of supporting primary care physicians in the screening, assessment and monitoring of patients with chronic pain. the purpose of this study was to examine the ability of the cpq CPQ to discriminate between patients with neuropathic pain (nep) versus those with sensory hypersensitivity (sh).Methods: Adult men and women with a diagnosis of a NeP or SH condition were recruited from 5 clinical sites across the United States. Participants completed a series of self-administered questionnaires, including the CPQ. Continuous variables were compared between groups with independent t-tests; categorical variables were compared with chi-square analyses. A series of exploratory logistic regressions were performed to discern optimal screening criteria for SH using CPQ responses.Results: 98 participants, 68 with physician-confirmed diagnoses of SH and 30 with NeP, participated. 81.6% were female, 73.5% Caucasian, and mean (± SD) age was 58.4 ± 12.6 years. SH participants included significantly more females compared to the NeP group (94.1% vs. 53.3%). Differences in CPQ responses between groups were statistically significant for six of the 14 CPQ items with SH participants having significantly lower scores on specific pain quality questions and significantly higher scores on trouble thinking/remembering (5.3 ± 3.5 vs. 3.0 ± 2.8) and sensitivity to lights/noises/smells (4.8 ± 3.5 vs. 2.7 ± 3.0). No significant differences were found between groups for chronic pain intensity, pain made worse with touch, pain limited to joints, or pain interference with usual activity, sleep or mood. Logistic regression analyses revealed strong c indices (≥0.89) for all models. Consistent findings demonstrated that younger age, female gender, and scores ≥6 for the CPQ question on sensitivity to lights/noises/smells were all predictive of SH.Conclusions: The CPQ can help differentiate between patients with NeP and SH. More research is warranted. [ABSTRACT FROM AUTHOR]

Background: Chronic itch is a disruptive and disabling condition that can lead to psychological stress and depression.Objective: We sought to describe an entity of generalized, symmetric, neuropathic pruritus, which we term "multilevel symmetric neuropathic pruritus," and offer possible explanations accounting for its pathogenesis.Methods: A case series of 14 patients was evaluated at academic institutions from 2011 to 2015.Results: All patients exhibited detectable degenerative vertebral changes, as seen by spinal x-ray or magnetic resonance imaging. In 12 of 14 (85.7%) subjects, the radiographic imaging abnormalities directly correlated with the distribution of their cutaneous findings. Twelve of 14 (85.7%) patients had cutaneous findings along the C5 to C6 and/or C6 to C7 dermatomal distributions. Eleven of 14 (78.5%) patients were overweight or obese, and 14 of 14 (100%) patients had at least 4 risk factors for the development of atherosclerosis. Twelve of 14 (85.7%) patients noted complete or near complete resolution after treatment with gabapentin (300-1200 mg daily).Limitations: No healthy age-matched control group without pruritus was investigated.Conclusion: A combination of multilevel degenerative disc disease of the spine, spinal nerve root impingement, and/or nerve root traction may play a pivotal role in the cause of multilevel symmetric neuropathic pruritus. [ABSTRACT FROM AUTHOR]

Pruritus is a common complaint associated with many conditions. It negatively impacts sleep, quality of life, and mortality. Itch is transmitted along both histaminergic and non-histaminergic pathways with a complex interplay between keratinocytes, immune cells and cutaneous neurons. Individuals who present with pruritus should undergo a thorough assessment, especially those over 65 years old, to exclude underlying malignancy. Treatment no longer consists of antihistamines alone. Physicians now have an array of therapies in their armamentarium, to help alleviate this distressing symptom. [ABSTRACT FROM AUTHOR]

Acute and chronic pain states overlap in chronology and pathophysiology but both can remain under-managed. Assessment aims to elucidate underlying pain generators that can then guide treatment strategies. Assessment should be regularly repeated to assess efficacy of treatments and the presence of side effects. Self-report questionnaires are available to assist in diagnosis and monitoring of pain and its related dimensions but they do not replace a thorough assessment by an experienced clinician. [ABSTRACT FROM AUTHOR]

Objective: The objective of this article is to assess the effect of intravesical onabotulinum toxin A (OBTX-A) injections in patients with persistent/refractory symptomatic detrusor overactivity (DO) and urge urinary incontinence (UUI) following previous augmentation enterocystoplasty. Patients and methods: We conducted a retrospective review of all patients with previous augmentation enterocystoplasty having intravesical OBTX-A for persistent/refractory DO and UUI. Information on demographics, original diagnosis, date and technique of enterocystoplasty, dose of OBTX-A and symptomatic outcomes was recorded. Results: Fifteen patients (three men) with mean age 42 years were studied. Eight out of 15 (53%) reported complete continence or significant improvement, while the remaining seven (47%) noticed no difference in their symptoms. Urodynamics were repeated in these seven patients and persistent DO was confirmed. Four out of five (80%) NDO patients who received 300 U of OBTX-A reported a favourable outcome, whereas a favourable response was noted in only four out of 10 IDO (40%) when smaller amounts of OBTX-A (100 U or 200 U) were used. Conclusions: Intravesical OBTX-A injections completely resolved or significantly improved persistent/recurrent symptoms of DO in 53% of patients with a previous augmentation enterocystoplasty. The success rate was higher for those receiving the higher dose of 300 U and/or those with NDO. [ABSTRACT FROM AUTHOR]

Background Caused by a lesion or disease of the somatosensory system, neuropathic pain is notoriously difficult to treat with conventional analgesics. It has been suggested that inflammatory cytokines play a role in the development and maintenance of neuropathic pain. But human studies of these substances are relatively few and partly contradictory. Objectives To simultaneously investigate the plasma levels of chemokine interleukin 8 (IL-8) and the cytokines IL-6, IL-1β, and Granulocyte macrophage colony-stimulating factor (GM-CSF) in patients with peripheral neuropathic pain (most of whom due to failed back surgery syndrome) ( n = 14) compared to controls ( n = 17). Results IL-6 was significantly higher in patients than in controls (0.92 ± 0.12 pg/ml vs. 0.57 ± 0.08 pg/ml, p = 0.012). IL-1β, IL-8, and GM-CSF levels did not differ between the two groups. A multivariate analysis showed a tendency for patients also to have higher GM-CSF plasma levels than controls. Conclusions This study found an increased level of IL-6 in plasma in patients with neuropathic pain, but not for the other pro-inflammatory substances investigated. There are several possible confounders not registered or controlled for in this and other studies of neuropathic pain. Implications Larger studies that take several possible confounders into consideration are needed to further investigate the levels of plasma cytokines in different pain conditions. [ABSTRACT FROM AUTHOR]

Background: The hydro-ethanolic extract of Synedrella nodiflora (L.) Gaertn whole plant has demonstrated analgesic effects in acute pain models. The extract has also demonstrated anticonvulsant effects in murine models of experimental epilepsy. The present study illustrates an evaluation of the hydro-ethanolic extract of the plant for possible analgesic properties in hyperalgesia and allodynia associated with vincristine-induced neuropathy in rats. Methods: Neuropathic pain was induced in Sprague-Dawley rats by injecting 100 µg/kg of vincristine sulphate on alternative days for 6 days (days 0, 2, 4, 8, 10 and 12). Vincristine- induced cold allodynia, mechanical hyperalgesia and thermal hyperalgesia were measured pre-vincristine administration and on days 15, 17 and 19 post-vincristine administration. The rats were then treated with S. nodiflora extract (SNE) (100, 300 and 1000 mg/kg), pregabalin (10, 30 and 100 mg/kg) and distilled water as vehicle daily for 5 days and pain thresholds were measured on alternate days for 3 days. Results: SNE and pregabalin produced analgesic properties observed as increased paw withdrawal latencies to mechanical, tactile, cold water stimuli and thermal hyperalgesic tests during the 5 days of treatment. Conclusions: The findings suggest that hydro-ethanolic extract of S. nodiflora possesses anti-hyperalgesic and anti-allodynic effects in vincristine-induced neuropathic pain in rats. [ABSTRACT FROM AUTHOR]

Copyright of Universitas Médica is the property of Pontificia Universidad Javeriana and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Mechanism-based therapy for chronic pain is desperately needed. Recent basic science research demonstrated that remifentanil can reverse long-term potentiation at C-fiber synapses in the dorsal horn of rats. In this exploratory, single group study, patients with chronic post-herpetic pain were treated with a single, one-hour, high-dose remifentanil infusion. The mean overall change of pain intensity seven days after treatment was −18 (−7.5; −28.5, 95%CI, p < 0.001) points on the numeric rating scale (0–100) (−33 (±11) points amongst responders only). Eleven of 20 patients responded to treatment (≥30% reduction in pain), the mean relative reduction in pain from baseline amongst responders was 61.0%. These promising preliminary results suggest that a mechanism-based reversal of chronic pain may be impending. [ABSTRACT FROM AUTHOR]

Abstract: Chronic pain has now been recognized as a disease entity in its own right. Significant numbers of patients suffer from intractable chronic pain. Neuromodulation has been defined by the International Neuromodulation Society as ‘the therapeutic alteration of activity in the central or peripheral nervous system either electrically or pharmacologically’. It can be achieved either by electrical stimulation of peripheral nerves, spinal cord or brain, or by delivering pharmacological agents directly into the intrathecal, epidural or intracerebroventricular sites. Neuromodulation is expensive, invasive and not without complications. Patients requiring neuromodulation should undergo multidisciplinary assessment for suitability. Clinical effectiveness is possible with appropriate patient selection and attention to technical details. [Copyright &y& Elsevier]

Abstract: Pain is ultimately a perceptual phenomenon. It is built from information gathered by specialized pain receptors in tissue, modified by spinal and supraspinal mechanisms, and integrated into a discrete sensory experience with an emotional valence in the brain. Because of this, studying intact animals allows the multidimensional nature of pain to be examined. A number of animal models have been developed, reflecting observations that pain phenotypes are mediated by distinct mechanisms. Animal models of pain are designed to mimic distinct clinical diseases to better evaluate underlying mechanisms and potential treatments. Outcome measures are designed to measure multiple parts of the pain experience, including reflexive hyperalgesia measures, sensory and affective dimensions of pain, and impact of pain on function and quality of life. In this review, we discuss the common methods used for inducing each of the pain phenotypes related to clinical pain syndromes as well as the main behavioral tests for assessing pain in each model. Perspective: Understanding animal models and outcome measures in animals will assist in translating data from basic science to the clinic. [Copyright &y& Elsevier]

Abstract: Pain is a complex perceptual experience. The transmission of pain involves both peripheral and central processes that can be modulated at many levels. Peripheral sensitization causes increased afferent input to the spinal cord. Numerous receptors and ion channels are involved. Physiological and anatomical changes within the nervous system are implicated in the development of neuropathic and visceral pain states. The complexity of pain transmission means there are many pharmacological targets and multimodal therapy is required to optimize pain control. [Copyright &y& Elsevier]

Abstract: Objective: To determine our single centre experience of long term renal function and mortality rates of our cohort of spina bifida patients born since 1970. Materials and methods: We collected a prospective database and included all patients born with spina bifida between 1970 and 2011 managed by our centre. Data we collected included the glomerular filtration rates, results of renal tract imaging, management strategies and mortalities. Results: Of 160 patients identified, 120 were included for analysis with a mean age of 20 years. In our cohort 48% (58/120) had normal renal function and only 1.6% (2/120) had severe renal impairment or end stage renal failure. There was a mortality rate of 4.4% and there were no deaths from renal failure. Conclusion: Spina bifida patients have been reported to have high mortality rates and high morbidity secondary to renal failure. Historical data does not appear to reflect current advancements and we would therefore be more optimistic when counselling families about long term survival into adulthood. [Copyright &y& Elsevier]

Purpose: Osteoarthritic pain is largely considered to be inflammatory pain. Sensory nerve fibers innervating the knee have been shown to be significantly damaged in rat models of knee osteoarthritis (OA) in which the subchondral bone junction is destroyed, and this induces neuropathic pain (NP). Pregabalin was developed as a pain killer for NP; however, there are no reports on pregabalin use in OA patients. The purpose of this study was to investigate the efficacy of pregabalin for pain in OA patients. Materials and Methods: Eighty-nine knee OA patients were evaluated in this randomized prospective study. Patients were divided into meloxicam, pregabalin, and meloxicam+pregabalin groups. Pain scores were evaluated before and 4 weeks after drug application using a visual analogue scale (VAS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Pain scales among groups were compared using a Kruskal-Wallis test. Results: Before drug application, there was no significant difference in VAS and WOMAC scores among the three groups (p>0.05). Significant pain relief was seen in the meloxicam+pregabalin group in VAS at 1, 2, and 4 weeks, and WOMAC score at 4 weeks, compared with the other groups (p<0.05). No significant pain relief was seen in the meloxicam only group in VAS during 4 weeks and WOMAC score at 4 weeks compared with the pregabalin only group (p>0.05). Conclusion: Meloxicam+pregabalin was effective for pain in OA patients. This finding suggests that OA pain is a combination of inflammatory and NP. [ABSTRACT FROM AUTHOR]

Copyright of Arquivos de Neuro-Psiquiatria is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The article focuses on screening and treatment of persistent postsurgical pain (PPP). A study was performed on 40,000 patients in Great Britain, where 5 to 10 percent of them will experience severe PPP as they struggle due to lack of awareness and clear definition. The diagnosis and treatment of PPP has been evaluated on patients who had various operative methods including chemoradiotherapy, breast conservation surgery, and thoracic surgery.

The article compares the existing studies that focus on handling neuropathic pain in children who suffer from cancer. The evaluation was meant to show potential pediatric treatment strategies for managing acute and neuropathic pain, as there were no published randomized controlled tests for them. Various drugs that can provide pediatric treatment for neuropathic pain include opioids, tricyclic antidepressants and gabapentinoids.

Abstract: This article is to provide insights into the mechanisms underlying chronic pain from whiplash injury. Studies show that injury produces plasticity changes of different neuronal structures that are responsible for amplification of nociception and exaggerated pain responses. There is consistent evidence for hypersensitivity of the central nervous system to sensory stimulation in chronic pain after whiplash injury. Tissue damage, detected or not by the available diagnostic methods, is probably the main determinant of central hypersensitivity. Different mechanisms underlie and co-exist in the chronic whiplash condition. Spinal cord hyperexcitability in patients with chronic pain after whiplash injury can cause exaggerated pain following low intensity nociceptive or innocuous peripheral stimulation. Spinal hypersensitivity may explain pain in the absence of detectable tissue damage. Whiplash is a heterogeneous condition with some individuals showing features suggestive of neuropathic pain. A predominantly neuropathic pain component is related to a higher pain/disability level. [Copyright &y& Elsevier]

Abstract: Glutamate is the major excitatory amino acid in the mammalian CNS and is involved in transmission of pain together with processes for cognition, memory and learning. In order to terminate glutamatergic neurotransmission and avoid excitotoxic damage, a balanced glutamate homeostasis is of critical importance. The level of glutamate in the synaptic cleft is regulated through the action of five subtypes of excitatory amino acid transporters (EAAT1-5). Ceftriaxone, a β-lactam, induces EAAT-2 and has proven effect for the treatment of neuropathic pain. This pilot study investigated the effects of ceftriaxone upon acute and inflammatory pain and additionally, the analgesic effect of ceftriaxone after introduction of neuropathic pain. Methods: Rats were tested before, during and after treatment of ceftriaxone for changes in response to both mechanical and thermal stimuli, using calibrated von Frey filaments and Hargreaves instrument, respectively. Inflammatory responses were investigated by assessing the response to intra-plantar injections of formalin; lastly, neuropathic pain was introduced using the spinal nerve ligation (SNL) model after which changes in both mechanical and thermal responses were again investigated. Results: A significant increase in mechanical withdrawal threshold was observed following acute pain inducement in ceftriaxone treated rats. A marked increase in thermal withdrawal latency was also observed. In response to intra plantar administered formalin, ceftriaxone delayed the intensity of nocifensive behaviours. Applying the SNL model of neuropathic pain on naive rats created significant mechanical allodynia, but only a negligibly different response to thermal stimulation. After treatment with ceftriaxone the treated rats developed a hypoalgesic response to thermal stimulation, whilst the response to mechanical pain was insignificant. Conclusion: In conclusion, ceftriaxone clearly interfered in the transmission of noxious signalling and proved in this study to have an effect upon acute thermal and mechanical pain thresholds as well as pathologic pain conditions. The present results are a piece in the large puzzle where administration route, dosage and pain models must be thoroughly investigated before a study can be planned for a proof of concept in different clinical pain states. Implications: The current study demonstrates that ceftriaxone has a mitigating effect upon many pain modalities including acute and inflammatory, and that these modalities should be included in future studies characterising the anti-nociceptive effect of beta-lactams such as ceftriaxone. The fact that β-lactams also has antibiotic properties implies that similar chemical structures could be identified with the positive effect upon expression levels of EAAT2, but lacking the antibiotic side effect. [Copyright &y& Elsevier]

Abstract: Pain is a complex perceptual experience. The transmission of pain involves both peripheral and central processes and can be modulated at many levels. Peripheral sensitization causes increased afferent input to the spinal cord. Numerous receptors and ion channels are involved. Pain can induce physiological and anatomical changes within the nervous system which are implicated in the development of neuropathic and visceral pain states. The complexity of pain transmission means there are many pharmacological targets and multimodal therapy is required to optimize pain control. [Copyright &y& Elsevier]

Resumo Justificativa e objetivos O bloqueio da fáscia do músculo quadrado lombar foi descrito por R. Blanco nas suas duas abordagens ( I e II ). A deposição de anestésico local nessa localização pode conferir bloqueio dos dermátomos T6‐L1. Os autores fizeram esse bloqueio de fáscia, guiado por ultrassom, para tratamento de uma dor crônica neuropática da parede abdominal. Relato de caso Paciente do gênero masculino, 61 anos, 83 kg, com antecedentes de trombocitopenia por hepatopatia alcoólica, entre outros, apresentava dor crônica da parede abdominal após hernioplastias abdominais múltiplas havia um ano e meio, com má resposta ao tratamento com neuromoduladores e opioides. No exame clínico, apresentava uma dor neuropática, com predomínio de alodinia ao toque, que abrangia toda a parede abdominal anterior, desde os dermátomos T7 a T12. Optou‐se pela realização de um bloqueio do quadrado lombar tipo II bilateral, guiado por ultrassom, com administração de 25 mL de ropivacaína 0,2% e 20 mg de metilprednisolona depot (ampola) em cada um dos lados. O procedimento conferiu alívio imediato da sintomatologia e, após seis meses, o paciente mantinha redução significativa da alodinia, sem compromisso da qualidade de vida. Conclusões Os autores consideram que a realização do bloqueio do quadrado lombar tipo II foi uma opção analgésica relevante no tratamento de um paciente com dor crônica pós‐hernioplastia abdominal e salientaram os efeitos da dispersão do anestésico local até o espaço paravertebral torácico. A técnica mostrou ser segura e bem tolerada. É desejável a publicação de mais casos clínicos que reproduzam a eficácia desse bloqueio no contexto de dor crônica. Background and objectives The quadratus lumborum blockade was described by R. Blanco in its two approaches ( I and II ). The local anesthetic deposition in this location can provide blockade to T6‐L1 dermatomes. We performed this fascia blockade guided by ultrasound for treating a chronic neuropathic pain in the abdominal wall. Case report Male patient; 61 years old; 83 kg; with a history of thrombocytopenia due to alcoholic cirrhosis, among others; had chronic pain in the abdominal wall after multiple abdominal hernia repairs in the last year and a half, with poor response to treatment with neuromodulators and opioids. On clinical examination, he revealed a neuropathic pain, with prevalence of allodynia to touch, covering the entire anterior abdominal wall, from T7 to T12 dermatomes. We opted for a quadratus lumborum block type II , guided by ultrasound, with administration of 0.2% ropivacaine (25 mL) and depot (vial) methylprednisolone (20 mg) on each side. The procedure gave immediate relief of symptoms and, after six months, the patient still had a significant reduction in allodynia without compromising the quality of life. Conclusions We consider that performing the quadratus lumborum block type II was an important analgesic option in the treatment of a patient with chronic pain after abdominal hernia repair, emphasizing the effects of local anesthetic spread to the thoracic paravertebral space. The technique has proven to be safe and well tolerated. The publication of more clinical cases reporting the effectiveness of this blockade for chronic pain is desirable. [ABSTRACT FROM AUTHOR]

Bladder calculi are a common complication of urinary tract augmentation with an incidence of up to 50%.1 Aside from traditional transurethral approaches, management options include lithotripsy,2 or hybrid techniques using a combination of endoscopic and laparoscopic approaches. 3 Although Mitrofanoff cystolitholopaxy has been previously described,4 we describe a further modification of the technique with concomitant bladder biopsy in a neuropathic patient using a mini-percutaneous nephrolithotomy (mini-PCNL) kit. [ABSTRACT FROM AUTHOR]

Abstract: The protein kinase mammalian target of rapamycin (mTOR) regulates mRNA translation and is inhibited by rapamycin. Signaling pathways involving mTOR are implicated in physiological and pathophysiological processes. We determined the spinal effects of the rapamycin analogue cell cycle inhibitor (CCI)-779 on neuronal responses and behavioral hypersensitivity in a model of persistent neuropathic pain. We also assessed the anatomical distribution of spinal mTOR signaling pathways. Specifically, we ligated rat spinal nerves L5 and L6 to produce a model of neuropathic pain. After confirming neuropathy with behavioral testing, we obtained in vivo single-unit extracellular stimulus-evoked recordings from deep dorsal horn spinal neurons. We applied CCI-779 spinally in electrophysiological and behavioral studies and assessed its effects accordingly. We also used immunohistochemistry to probe for mTOR signaling pathways in dorsal root ganglia (DRG) and the spinal cord. We found that spinally administered CCI-779 rapidly attenuated calibrated mechanically but not thermally evoked neuronal responses and mechanically evoked behavioral responses. Immunohistochemistry showed presence of mTOR signaling pathways in nociceptive-specific C-fiber DRG and in neurons of inner lamina II of the spinal cord. We conclude that alterations in the activity of spinal mTOR signaling pathways are crucial to the full establishment of spinal neuronal plasticity and behavioral hypersensitivity associated with nerve injury. Perspective: This study is consistent with growing evidence implicating mTOR signaling pathways as important modulators of persistent pain, providing novel insights into the molecular mechanisms of pain maintenance and potential for novel approaches into treating chronic pain. [ABSTRACT FROM AUTHOR]

Abstract: Activation of Rho kinase (ROCK) has been shown to play a role in neuronal regeneration and development of posttraumatic neuropathic pain. The ROCK inhibitor Fasudil, used clinically for the treatment of vasospasm, was used to investigate the analgesic profile of a ROCK inhibitor. Fasudil was evaluated in different preclinical models of neuropathic, osteoarthritic (OA), and inflammatory pain as well as capsaicin-induced acute pain and secondary mechanical hypersensitivity. In addition, Fasudil was tested in in vivo electrophysiology to determine the mechanism by which Fasudil produces analgesia. Fasudil at the highest dose tested (30 mg/kg) significantly attenuated mechanical allodynia in spinal-nerve ligation (SNL; 77%), chronic constriction injury (CCI; 53%), capsaicin-induced secondary mechanical hypersensitivity (63%), sodium iodoacetate-induced OA pain (88%), and capsaicin-induced acute flinching behaviors (56%). However, Fasudil (at 30 mg/kg) failed to attenuate or had only modest effects on inflammatory thermal hyperalgesia following carrageenan injection and mechanical allodynia following Complete Freund''s Adjuvant (CFA) injection. Fasudil produced ED50 of 10.8 mg/kg in the SNL, and 5.7 mg/kg in the OA pain models. The ED50 and 95% CI could not be obtained in the other models. Furthermore, administration of Fasudil (10 mg/kg, iv) significantly reduced both spontaneous and evoked firing of wide dynamic range (WDR) neurons in SNL, but not sham rats. Finally, Fasudil significantly decreased exploratory behaviors at 30 mg/kg. These results suggest that the acute administration of a ROCK inhibitor produces efficacy in both neuropathic and nociceptive pain states at doses devoid of locomotor side effects, with specific effects on WDR neurons. Perspective: In this article, the potential analgesic effects of Fasudil in a range of preclinical pain models were assessed. Fasudil was shown to have efficacy in neuropathic and nociceptive pain models. These findings may help identify new therapeutic treatments for pain in the clinic. [Copyright &y& Elsevier]