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Background/objective: In clinical trials, tapentadol prolonged release (PR) showed a more favourable gastrointestinal tolerability profile compared to other strong opioids in the treatment of pain. The present analysis compared tapentadol PR and classical WHO-III PR opioids in routine clinical practice., Method: Retrospective cohort study (matched pair approach) using anonymised health insurance data of patients with chronic low back pain who were prescribed strong opioids following pretreatment with WHO-I/II analgesics. Data were analysed from the date of first prescription in 2015 over a maximum period of two years. The primary analysis parameter was the prescription of laxatives., Results: Data of 227 patients per cohort could be included in the analysis. Significantly fewer tapentadol PR than WHO-III PR patients were prescribed laxatives (20.3% vs. 37%; p < 0.0001). In addition, laxative dosages were significantly lower in the tapentadol PR cohort (26.4 vs. 82.5 defined daily doses; p < 0.0001). A significant difference in laxative prescription was also observed under long-term treatment (tapentadol PR patients 27.7% vs. WHO-III PR patients 50%; p = 0.0029)., Conclusion: Routine clinical practice indirectly confirmed the more favourable gastrointestinal tolerability of tapentadol PR in the treatment of chronic pain which had previously been demonstrated in clinical trials and non-interventional studies., (© 2022. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Noninvasive Treatments for Acute and Chronic Back Pain Abstract. The therapy of back pain - especially the medication with opioids - can be challenging for the treating physician. Specific back pain can often be diagnosed by imaging and successfully treated by surgery or medication. In contrast, nonspecific back pain can be worsened by inappropriate imaging, questionable surgical indications and uncontrolled drug use. For the therapy of nonspecific back pain, maintaining daily activity and exercise therapy is central. Opioids are effective drugs for short-term use. However, long-term use often leads to opioid-induced hyperalgesia and hormonal dysfunction with decreased quality of life and libido. Furthermore, opioids can lead to abuse and addiction. After an ineffective treatment with non-opioids, opioids may be given for a limited time period (if possible shorter than four weeks) according to international guidelines.

Osteoporosis is a very common disease all over the world, in which a reduction in bone density can lead to an increased risk of fractures and a diminished physical height. Osteoporosis is also associated with acute and chronic pain, which especially occurs in the back and can significantly reduce the quality of life. To provide sufficient care for affected patients, it is essential to know the particularities of pain management in osteoporosis, such as pharmacological and nonpharmacological treatment options. This article gives a comprehensive review of pain management in osteoporosis and also explains the underlying pathomechanisms, risk factors, and diagnostic procedures.

Background: In industrialized countries, chronic back pain is referred to as the "number one common disease"., Objectives: Are there any indications of different outcomes of chronic back pain patients when treated with a multimodal, interdisciplinary pain therapy (MMSTh) compared to physiotherapy-physical therapy?, Materials and Methods: Entrance and final examination by means of survey, questionnaires and physical tests in the intervention and control group, evaluation and comparison of the results., Results: The intervention group showed very significant improvements in all tests. In contrast, the control group achieved only partial improvements in physical parameters and quality of life. This resulted in clear group differences in favor of the MMSTh. In terms of patient satisfaction, the control group showed a better result than the intervention group., Conclusions: Treatment with MMSTh is superior to standard physiotherapy-physical. Due to the extensive, proven positive effect on many pain-causing and pain-preserving factors, multimodal pain centers should be used more frequently in chronic back pain patients.

History: A 23 years old, previously healthy woman was admitted to our clinic with neutropenic fever to rule out acute leukemia. Upon admission the patient reported that a few days ago the carcass of a pig had fallen on her from above, so that she experienced strong back pain., Findings and Diagnosis: The blood count showed thrombocytopenia and marked neutropenia of 0.04G/L. Moreover, laboratory work up demonstrated increased C-reactive protein, procalcitonin as well as serum creatinine levels., Therapy and Course: Broad antiinfective therapy was initiated immediately. During the further course of disease the patient developed signs of acute cholecystitis, which was managed conservatively. Only after repeated specific investigation and after initially denying, the patient reported to have taken 1 g of metamizole as self-medication after her initial accident. All symptoms and laboratory parameters gradually improved and finally completely resolved to normal, and the patient could be released from hospital after seven days., Conclusions: In retrospect all signs and symptoms reported here can be interpreted as an infectious complication during an episode of agranulocytosis caused by a single dose of metamizole, underscoring the importance of carefully judging indication when using this otherwise highly useful substance., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: There is currently a lack of data on chronic pain in general practice., Methods: Over a period of 2 years, data from 12,271 patients visiting a pain specialist on an outpatient basis were collected. All patients had documented their pain history (German pain questionnaire) via tablet/computer into a databank., Results: Data from 12,246 patients from 30 pain clinics could be evaluated. The proportion of women was higher (67%). The majority of patients suffered from back pain (52%). The majority of patients were treated with injections (73%), and the majority of physicians were orthopedic surgeons (71%). A minority of patients had received psychological treatment (< 30%)., Conclusion: Comprehensive pain documentation by the patients themselves is possible by means of a computer-based program. Back pain is the main problem in patients visiting a pain specialist. Invasive methods are the mainstay of treatment approaches. The psychosocial background of chronic pain seems to be underestimated in the treatment.

Background: The prevalence of chronic pain has been estimated to be 19% in the European population and criteria for disabling chronic pain were found in approximately 7% of the German population. Clinical care for these patients is provided in ambulant and hospital-associated facilities. In this context, invasive interventions are part of the diagnosis and treatment of several specific diseases. Current data on the structure of clinical care based regional anesthesia for chronic pain patients in Germany are not available., Objective: This study focused on the application and practice of interventional procedures in the context of pain management., Material and Methods: An internet-based survey addressing pain facilities and pain specialists in Germany was carried out. The response rate achieved 54%., Results: Overall 79% of the pain therapists who responded included regional anesthesia techniques in the therapeutic spectrum in up to 25% of patients. The leading indications for invasive procedures were back pain and neuropathic pain. Two thirds of the therapists reported performing a series of blocks. A reduction of pain intensity of 30-50% was often reported as a sufficient criterion for the success of regional anesthesia interventions. Typically, approximately 40% of the chronic pain patients undergoing a series of blocks achieved sufficient pain relief which lasted most commonly for 12 weeks up to 6 months., Conclusion: This survey describes the current structures of specialized pain facilities for regional anesthesia in Germany including responses from predominantly anesthesiologists in a hospital-associated setting. In light of the limited evidence in the literature there is no consensus on the interventional therapeutic management of chronic pain. Especially the application of a series of blocks and the frequency as well as criteria to support continuing or terminating a series of regional anesthesia interventions are not sufficiently evaluated. This survey also gives an incentive for a possible revision of the existing practice in regional anesthesia in the context of multimodal therapy and currently existing guidelines in future clinical studies.

Study Objective: This subgroup analysis of a prospective, non-interventional study involving general practitioners and internists investigated the administration of tapentadol prolonged release (tapentadol PR; Palexia retard) for the treatment of patients who have previously received oxycodone/naloxone., Methods: From the overall effectiveness sample (n = 5,002) data of all patients who were previously treated with oxycodone/naloxone in a fixed combination (n = 382) were included in this analysis. Data collection during the 3-month observation period included previous and concomitant analgesic treatment, tapentadol PR dosage, pain intensity, functional impairment, and tolerability of tapentadol PR. Health related quality of life was documented at baseline and at the end of observation by patients using the SF-12 questionnaire., Results: Back pain was the most common cause of pain. Including all pain diagnoses, mixed type of pain (nociceptive and neuropathic) predominated. The oxycodone/naloxone pretreatment was multifold combined with strong opioids (10.2%), weak opioids (29.3%), non- opioids (78.3%), co-analgesics (56.0%) and analgesic rescue medication (26.9%). Switching to tapentadol PR resulted in a mean pain reduction of 3.41 points from 7.29 ± 1.40 at baseline to 3.88 ± 1.86 at end of observation (NRS 11, 11-point pain scale; descriptive p value ≤ 0.001; n = 373), using a final average daily dosage of 252.9 mg tapentadol PR. In all four categories assessing the pain-related functional impairment, significant improvements have been achieved. In addition to significantly reduced pain-related impairments of everyday activities patients' data documented significant improvements in physical and mental SF-12 total scores, which initially were already at critically low range. A good tolerability of tapentadol PR therapy was reported., Conclusions: Patients, who were previously treated with oxycodone/naloxone, benefit from a tapentadol PR therapy as well: data analysis shows a clinically relevant improvement of analgesia, functionality and quality of life. Furthermore, the previous analgesic "co"-medication could be reduced during tapentadol PR therapy.

Background: Current restrictions in use of flupirtine-containing medicines for a maximum of 14 days endorsed by the European Medicines Agency were followed by uncertainty/ambiguity of its analgesic efficacy for the treatment of acute low/back pain., Methods: Post-hoc selection of patient-level data from non-interventional studies with flupirtine MR and diclofenac with respect to patient age (> or = 18 years), duration of treatment (14 +/- 2 days), indication (acute/subacute low/back pain) and first-line use. Primary endpoint: average 24-hr. pain intensity; secondary endpoints: pain-related disabilities in daily life, 30/50/70% response with respect to pain and pain-related restrictions, frequency of untoward side effects/treatment emergent adverse events., Results: 318/31 patients treated with flupirtine MR/diclofenac fulfilled the inclusion criteria for this subgroup analysis. Starting from comparable demographic and baseline characteristics both treatments were followed by significant effects (p < 0.001). Subgroup comparisons revealed superior effects for flupirtine MR vs. diclofenac for pain relief (p = 0.001), improvement of pain-related restrictions in daily life (p = 0.023), and gastrointestinal/overall tolerability (p < 0.001)., Conclusions: Even for short-term use in patients suffering from muscle-related acute low/back pain, flupirtine MR is superior effective and tolerated compared with the nsaid diclofenac.

In recent years, it is increasingly clear that back pain is not only caused by biomechanical problems. Currently, biologically-based local therapy concepts for the treatment of affected spinal regions as an alternative to the standard treatment with steroids are in development or in early stages of clinical application. The common features of these new therapies are to intervene in the regulation of homeostasis at various key points at the affected region and specifically to suppress or block catabolic influences as well as to provide with anti-inflammatory substances and growth factors. These include on one hand the genetically produced Biologicals such as TNF-α inhibitors and cytokine antagonists and on the other hand therapies with autologous blood preparations (Autologous Conditioned Serum [ACS], and Platelet Rich Plasma formulations [PRP]). This article presents the individual methods, gives an overview of developments and results of various studies and discusses current recommendations.

A 64-year-old man with chronic low back pain had been treated with tramadol, meloxicam and metamizole for several years. Due to additional neuropathic pain in the lower extremities, the medication was complemented with carbamazepine. After 5 weeks of treatment, the patient developed maculopapulose exanthema and fever, followed by hepatitis, leukocytosis and eosinophilia. The patient was diagnosed with so-called DRESS (drug rash with eosinophilia and systemic symptoms) syndrome, a severe anaphylactic reaction to carbamazepine treatment. Immunosuppressive therapy was complicated by an additional septic reaction. After recovery, the patient was referred to our clinic for a multimodal pain therapy. Fear, depressive episodes and fear-avoidance behavior were additional social factors responsible for the chronic pain syndrome of the patient. The previously diagnosed neuropathic pain syndrome cannot be verified. After appropriate modification of therapy, the patient's pain perception was significantly reduced, allowing for complete withdrawal of pain-relieving medication. This case report illustrates that merely pharmacological treatment of chronic pain syndromes bears only little prospect of success but increased risk of side effects.

Background: A patient-orientated therapy management for patients with severe chronic pain includes effective analgesia, improvement of health related quality of life and improvement of functionality., Patients and Method: In this prospective, non-interventional trial in 630 patients with severe chronic pain mostly due to chronic low back pain or gonarthrosis, treatment with tapentadol retard was evaluated with respect to its effects on analgesia, functionality and quality of life. Collected data included pain intensity, painDETECT,SF-12, FFbH-R and FFbH-OA., Results: Mean pain intensity decreased significantly (NRS-3: -3.2 points, p < or = 0.001) and in 47.9% of the patients the mean pain intensity was reduced by at least 50%. Health-related quality of life and functionality improved significantly. Tolerability was good. The known tolerability profile of tapentadol retard could be confirmed., Conclusion: In this study in real-life-setting tapentadol was effective in terms of analgesic effect but also in terms of improvementof health-related quality of life and functionality, leading to a benefit for the patient in daily life.

As a rule vertebroplasty and kyphoplasty can prevent further collapse of a previously broken vertebra. Pain is probably caused by collapse of the porous bone resulting in instability of the vertebra. Stabilization of the vertebra by injecting cement results in a clear improvement in the complaint and a clear reduction in pain resulting in better mobilization. Recent results have, however, cast doubt on the effectiveness of this therapy. Diagnostic nerve blocks on the spinal column are important because the pain is mostly clinically uncharacteristic, the innervation is complex and the pain is subjective. An exact classification can be made using special nerve blocks. Prerequisites for the use of diagnostic nerve blocks are an extensive clinical history and examination of the patient before nerve blocks are carried out. In approximately 15-45% of patients the zygapophyseal joint is the cause of the back pain. Anesthesia of the zygapophyseal joint can be carried out by direct intra-articular application of a local anesthetic or by a block of the medial branch of the posterior branch of each of two spinal nerves. The simplest method is by computed tomography-guided zygapophyseal block.

This study features an analysis of the analgesic therapy of patients with back pain focusing on opioid administration. Using claims data of a German statutory health insurance fund the analysis focuses on prescription patterns, the association between opioids and antiemetics as well as between opioid therapy and work disability. Based on typical diagnosis patterns three types of back pain could be identified: (other) specific back pain (46.0%), pain due to spinal disc diseases (23.5%) and non-specific back pain. The proportion of patients receiving continuous opioid therapy ranged between 24.3% and 48.8%. The prescription of antiemetics was associated with a higher chance of continuous opioid therapy (odds ratio [OR] 1.93; 95% confidence interval [CI] 1.79-2.08). The chance of continuous opioid therapy was higher in pain patients with spinal disc diseases and patients with (other) specific back pain (OR 1.62 and 1.76, respectively; 95% CI 1.56-1.69 and 1.69-1.83, respectively). Continuous opioid therapy appears to increase the probability of a lower number of days off work due to disability (incidence rate ratio [IRR] 0.76; 95% CI 0.70-0.84). Adequate prospective studies should test if the associations found can be confirmed., (© Deutsche Gesellschaft zum Studium des Schmerzes)

Objective: Lumbar spinal stenosis (LSS) is a common cause of chronic lumbar pain and disability. Conventional therapy approaches include analgesics and spinal surgery. Topical cantharidin applications are used for the treatment of severe chronic lumbar pain in traditional European medicine (TEM). We tested the pain-relieving effect of lumbar cantharidin blisters in a non-randomised controlled pilot study., Patients and Methods: 28 consecutive patients with manifest LSS were included. The first 20 patients received a cantharidin blister, 8 patients served as controls (waiting list). Pain was assessed by means of a numeric visual analogue scale (VAS; 0 indicating no pain, 10 indicating strongest pain). Treatment started after a 3-day run-in phase, the blister was applied once for 12 h., Results: Patients were comparable with respect to baseline pain. In the blister group, the pain score continuously improved from 7.2 +/- 2.1 at baseline to 2.9 +/- 2.3 (VAS) at day 7, whereas the score remained unchanged in control patients. Adjusted for baseline, the difference between the blister and the control group was estimated at 4.1 (95% CI: 2.4-5.9, p < 0.0001). The use of analgesics was slightly higher in the control group. No serious adverse events were observed., Conclusion: In this first study on the efficacy of cantharidin blisters, a clinically relevant pain-relieving short-term effect on LSS was observed. As the trial was non-randomised and only included a limited number of patients, the results should be interpreted with caution., (Copyright 2009 S. Karger AG, Basel.)

Introduction: It has been shown that long-term treatment with opioids does not necessarily impair driving ability in patients suffering from chronic pain. However, few studies are so far available on how increases in daily opioid dosage affect driving ability., Methods: A prospective trial was conducted in patients suffering from chronic noncancer pain, to examine the effects of the daily dose of opioids on psychomotor and cognitive functions. A computerized test system was administered to patients before and 7 days after alteration of their opioid therapy, to determine performance affecting driving ability at each time point. The test design was based on both international and national recommendations for the examination of driving safety., Results: Raising the daily dose of opioids and/or changing to an opioid at a higher WHO level had no effect on the functions relevant to driving ability in the group context. Pain intensity and serum concentrations of morphine influenced only few items in the test battery., Conclusion: Seven days after an increase in the daily dose of an opioid or after the initiation of opioid therapy there was no general deterioration in patients' driving ability at group level.

Background: Electronic pain diaries are of increasing interest to patients and physicians. The goal of the present pilot study was to evaluate the feasibility of standardized telephone interviews in patients with refractory pain who had been switched to oxycodone in the setting of daily practice., Patients and Methods: Once a week for 3 consecutive weeks, 33 female and male patients answered a standardized telephone interview derived from the ICF (International Classification of Functioning) about the impact of pain on their daily activities., Results: After 3 weeks, complete datasets were available for 70% of all participants. With flawless technicalities, the following aspects appeared to be worth improving: non-uniform response categories, limited language choice, and handling instructions to physicians and patients. The efficacy (pain relief and improved limitations in the activities of daily living) and good tolerability of oxycodone were comparable with findings reported in clinical trials. More than 95% of patients accepted the anonymous storage of their data for quality control purposes., Conclusion: Standardized telephone interviews aimed at documenting the evolution of pain are feasible in a daily practice setting. They should however be simplified for user-friendliness.

Background: Chronic back pain is mainly caused by painful tension in the back muscles. Thus, analgesics with muscle tone decreasing effects that apparently normalize increased muscle tonus through specific modes of action without disturbing normal muscular movement are an important therapeutic option. Flupirtine retard (Katadolon S long) has provided such an option since 2006., Objectives: To impartially evaluate the muscle tonus normalizing effects of flupirtine retard by applying specific, objective test methods in patients with chronic musculoskeletal pain under routine practice conditions., Methods: Prospective standardized evaluation of a treatment with flupirtine retard in 30 patients with continuous chronic, therapy refractory back pain. Measurement of general pain intensity, pain pressure threshold and pain pressure tolerance for trigger-point related pain and muscle tension in the affected back muscles before and during flupirtine retard treatment were performed in a standardized manner., Results: In comparison to the reproducible, constant initial values, the two-week treatment with flupirtine retard led to a significant improvement in all measured muscle-specific indicators: pain pressure threshold (+48%), pain pressure tolerance (+27%) and depth of penetration in the muscle (+18%) (all values p < 0.001). These were also correlated with a clinically observable and statistically significant pain relief from an initial level of 7.0 +/- 1.3 to 3.0 +/- 1.4., Conclusion: Flupirtine retard was shown to be a useful, effective and very tolerable therapeutic option for patients with chronic back pain. The improvement of muscle disturbances which are responsible for the pain in addition to pain relief was shown firstly by objective measure methods.

Unlabelled: An overview of the results of a clinical study is presented in which efficacy, tolerability and patient benefit of a therapy with OROS (ORal OSmotic) hydromorphone (Jurnista) in patients with chronic pain was investigated., Results: Changing patients to the oral osmotic system with hydromorphone at a ratio of 1:5 morphine equivalents usually led to good analgesia in one or two titration steps. In a randomized, controlled study in patients with chronic osteoarthritis pain, the therapeutic results with oral osmotic hydromorphone once daily were comparable to those of oxycodone twice daily. In addition, the patients in this study showed clear improvement in the quality of life (WOMAC Osteoarthritis Index) and sleep (MOS Sleep Assessment Questionnaire). Patients with chronic back pain showed significantly reduced pain intensity, improved quality of life (SF-36) and sleep (MOS Sleep Assessment Questionnaire) when treated with oral osmotic hydromorphone. The side effect profile of oral osmotic hydromorphone corresponded to that of the known profile for opioids and also improved significantly during long-term therapy (six months)., Conclusion: The results emphasize the clinical effectiveness of oral osmotic hydromorphone in the treatment of chronic, intense pain.

X-ray fluoroscopy and computed tomography are frequently used to perform percutaneous interventions in pain therapy. The development of MR-compatible therapy needles now allows these interventions to be performed under MR imaging guidance. MR-guided interventions may be performed using most clinical MR scanners; however, systems with an open configuration are advantageous. Multiplanar pre- and intra-procedural MR imaging provides the interventionalist with essential information, such as evaluation of anatomy and pathology, as well as the planning of the procedure and monitoring of fluid distribution without the use of contrast agents. With the use of non-ionizing radiation, interventional MR imaging is especially suited for the treatment of children and young adults as well as for serial injection therapy. For spinal MR interventions, passive needle visualization is an easily achievable and reliable method. The resulting needle artifact is influenced by several factors such as the alloy of the needle, the strength of the static magnetic field, the sequence type, the spatial orientation of the therapy needle as well as the echo time and may further be optimized during the intervention by alteration of the last three factors. Fast acquisition techniques and image processing allow for continuous, near real-time MR imaging (so-called MR fluoroscopy) and interactive needle navigations, comparable to X-ray fluoroscopy and CT fluoroscopy. The purpose of this review is to illustrate and discuss general concepts of interventional MR imaging. A spectrum of interventional MR imaging procedures in spinal pain therapy is described and illustrated, including procedures such as lumbar facet joint injections, sacroiliac joint injections, lumbar spinal nerve root infiltrations and drug delivery to the lumbar sympathetic chain.

We report on a young woman suffering from SAPHO syndrome with back pain and arthritis of the sternoclavicular joints. This inflammatory disorder of the osteoarticular system (synovitis, osteitis, and hyperostosis) is associated with severe acne or palmoplantar pustulosis. The patient was treated with pamidronate, NSAID and physiotherapy which improved the musculoskeletal symptoms completely. The acne was treated with isotretinoin.

The specific minimal-invasive injection therapy is a key-procedure for cervical spine syndromes when performing a multimodal pain-therapy. Due to the exactly placed injections pain can be overcome. Indication is given in cases of continuing spine pain and is an alternative to operative procedure, as for as no absolute indication for operation is given. The complex injection technique affords knowledge and expertise. The exact application and the specific complications are presented in detail.