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Background: Thoracotomy is considered one of the most painful surgical procedures and can cause debilitating chronic post-surgical pain lasting months or years postoperatively. Aggressive management of acute pain resulting from thoracotomy may reduce the likelihood of developing chronic pain. This trial compares the two most commonly used modes of acute analgesia provision at the time of thoracotomy (thoracic epidural blockade (TEB) and paravertebral blockade (PVB)) in terms of their clinical and cost-effectiveness in preventing chronic post-thoracotomy pain. Methods: TOPIC 2 is a multi-centre, open-label, parallel group, superiority, randomised controlled trial, with an internal pilot investigating the use of TEB and PVB in 1026 adult (≥ 18 years old) patients undergoing thoracotomy in up to 20 thoracic centres throughout the UK. Patients (N = 1026) will be randomised in a 1:1 ratio to receive either TEB or PVB. During the first year, the trial will include an integrated QuinteT (Qualitative Research Integrated into Trials) Recruitment Intervention (QRI) with the aim of optimising recruitment and informed consent. The primary outcome is the incidence of chronic post-surgical pain at 6 months post-randomisation defined as 'worst chest pain over the last week' equating to a visual analogue score greater than or equal to 40 mm indicating at least a moderate level of pain. Secondary outcomes include acute pain, complications of regional analgesia and surgery, health-related quality of life, mortality and a health economic analysis. Discussion: Both TEB and PVB have been demonstrated to be effective in the prevention of acute pain following thoracotomy and nationally practice is divided. Identification of which mode of analgesia is both clinically and cost-effective in preventing chronic post-thoracotomy pain could ameliorate the debilitating effects of chronic pain, improving health-related quality of life, facilitating return to work and caring responsibilities and resulting in a cost saving to the NHS. Trial registration: NCT03677856 [ClinicalTrials.gov] registered September 19, 2018. https://clinicaltrials.gov/ct2/show/NCT03677856. First patient recruited 8 January 2019. [ABSTRACT FROM AUTHOR]

Background Fibromyalgia syndrome (FMS) is a chronic widespread pain condition with mixed peripheral and central contributions. Patients display hypersensitivities to a spectrum of stimuli. Patients' blunt pressure pain thresholds are typically reduced, and sometimes (∼15%) gentle brushstroke induces allodynia. However, aftersensations after these stimuli have not, to our knowledge, been reported. Methods We examined the perception of blunt pressure and "pleasant touch" in FMS. Patients were first interviewed and completed standard psychometric questionnaires. We then measured their sensitivity to blunt pressure and perception of pleasant touch, including aftersensations; patients were followed up for 5 days to evaluate lingering pain from blunt pressure. Results We recruited 51 patients with FMS and 16 pain-free healthy controls (HCs) at a UK Pain Management Centre. Forty-four patients completed the aftersensation protocol. Most patients reported pain after the application of less mechanical pressure than the level of pressure at which HCs reported pain; median arm and leg thresholds for the patients with FMS were 167 kPa and 233 kPa, respectively. Eighty-four percent (31/37) of patients reported ongoing pain at the site of pressure application 1 day after testing, and 49% (18/37) still perceived pain at 5 days. Aftersensations after brushstroke were common in the FMS group, reported by 77% (34/44) of patients with FMS vs 25% (4/16) of HCs; 34% (15/44) of patients, but no HCs, perceived these aftersensations as uncomfortable. For patients with FMS who experienced aftersensations, brushstroke pleasantness ratings were reduced, and the skin was often an important site of pain. Conclusion Pain after blunt pressure assessment typically lingers for several days. Aftersensations after brushstroke stimulation are a previously unreported FMS phenomenon. They are associated with tactile anhedonia and might identify a clinically distinct subgroup. [ABSTRACT FROM AUTHOR]

Objective. Evaluate the effectiveness of oral steroids in relieving pain in patients with Complex Regional Pain Syndrome (CRPS) of more than 3 months duration. Design. Service evaluation/Open label uncontrolled trial. Setting. Two pain outpatient clinics specialized in CRPS diagnosis and treatment in the period 2009-2012. Subjects. Thirty-one patients diagnosed with CRPS with the Budapest criteria in two specialized centers, with a disease duration of more than 3 months and not responsive to standard treatment were included. Methods. Patients were treated with oral prednisolone in both centers [100 mg daily tapered by 25 mg every 4 days to zero (Σ1g) at center 1 (C1) and 60 mg daily for 2 weeks lowered 20 mg every 4 days to zero (Σ1.06g) at center 2 (C2)]. The average pain intensity was recorded by patients using a numeric rating scale before the treatment start, and 6 weeks after treatment onset (treatment duration was respectively 16 days and 22 days at the two centers). Results. Overall the authors observed no significant reduction in the average pain intensity (P = 0.059), but 2 patients had a consistent reduction in pain intensity with return to baseline pain levels 9 weeks after treatment onset, and 1 patient had ongoing stable pain relief of >50%. Conclusions. This study provides indications that the efficacy of oral corticosteroids is limited in treating CRPS of more than 3 months duration who did not respond to previous treatment. Randomized controlled studies (with enriched designs), or single subject designs would be required to identify the possible existence of a patient subgroup with a specific disease profile that may benefit from a steroid treatment. [ABSTRACT FROM AUTHOR]

Background The treatment of chronic pain is still unsatisfactory. Despite the availability of different drugs, most patients with chronic pain do not receive satisfactory pain relief or report side effects. Converging evidence implicates involvement of the immune system in the pathogenesis of different types of nociceptive and neuropathic chronic pain. Design At a workshop in Liverpool, UK ( October 2012), experts presented evidence suggesting immunological involvement in chronic pain and recent data supporting the concept that the established immune-modulating drug, polyvalent immunoglobulin G ( IgG), either given intravenously ( IVIg) or subcutaneously ( SCIg), may reduce pain in some peripheral neuropathies and a range of other pain disorders. Workshop's attendees discussed the practicalities of using IVIg and SCIg in these disorders, including indications, cost-effectiveness, and side effects. Results IgG may reduce pain in a range of nociceptive and neuropathic chronic pain conditions, including diabetes mellitus, Sjögren's syndrome, fibromyalgia, complex regional pain syndrome, post-polio syndrome, and pain secondary to pathological autoantibodies. Conclusions IgG is a promising treatment in several chronic pain conditions. IgG is a relatively safe therapeutic strategy, with uncommon and mild side effects but high costs. Randomized, controlled trials and predictive tests are needed to better support the use of IgG for refractory chronic pain. [ABSTRACT FROM AUTHOR]

Complex regional pain syndrome (CRPS) is a debilitating, painful condition in a limb associated with sensory,motor, autonomic, skin and bone abnormalities. Pain is typically the leading symptom, but is often associated with limb dysfunction and psychological distress. Prompt diagnosis and early treatment is required to avoid secondary physical problems related to disuse of the affected limb and the psychological consequences of living with undiagnosed chronic pain. UK guidelines have recently been developed for diagnosis and management in the context of primary and secondary care.1 The purpose of this concise guideline is to draw attention to these guidelines. Information in this article has been extracted from the main document and adapted to inform the management of CRPS as it presents to physicians in the course of their daily practice. [ABSTRACT FROM AUTHOR]

With few exceptions, anesthesiologists have not received training in the use of immune modulating drugs (IMDs); but recent evidence suggests that such drugs may be effective in reducing chronic pain. We therefore wished to learn how anesthesiologists working in pain medicine might envisage the treatment of their patients with IMDs in the future. We expected that anesthesiologists would want to refer patients for treatment with IMDs to medical colleagues, such as oncologists or rheumatologists, with prior experience in using these drugs, rather than treat these patients within their own practice. We conducted questionnaire surveys among anesthesiologists working in pain medicine in both the Netherlands and the U.K. to explore their views on using IMDs. Contrary to what we had expected, we found that a majority of the respondents would administer IMDs within their own practice, after appropriate training. The overall response rates were 30% and 23%, respectively; therefore, no firm conclusions can be drawn as to the views of the majority of practicing pain specialists. Our findings may have implications for the planning of both health service delivery and training in pain medicine. [ABSTRACT FROM AUTHOR]

Retrospective Observational Study. Lumbar radicular pain has a prevalence of 3–5%. Level 1 evidence has demonstrated equivalence between surgical and injection treatment. We assess the outcomes from a transforaminal epidural steroid injection clinic in a tertiary neuroscience referral centre. We performed an analysis of data from consecutive patients entered into a new internal referral database between August 2018 to May 2021. Radicular pain was classified as one of "first presentation" or "recurrence". Outcomes were obtained from follow up clinic letters and recorded in a binary manner of "positive result" or "negative result". Spinal pathology was documented from radiology reports and MRI images. We analysed 208 patients referred to the clinic. Excluding those who improved to a point of not requiring treatment, and those who underwent surgical intervention, 119 patients undergoing injection were included, of which 14 were lost to follow-up. 68 % of patients had a positive result from injection. Subgroup analysis demonstrated good outcomes for both hyperacute (<6 weeks) and chronic (>12 months). Contained disk pathologies had better outcomes than uncontained. There was no difference in outcomes across grades of compression, but previous same level surgery was associated with poorer response rates. There is a high rate of natural resolution of symptoms in patients with LSRP. In those where pain persists, TFESI is a valuable first line treatment modality. This study suggests the efficacy of TFESI is potentially independent of grade of stenosis and chronicity of symptoms. Contained disc pathologies respond better than uncontained. • Injection therapy is a cost effective modality in managing lumbosacral radicular pain. • 68 % of patients reported a positive outcome. • Those with a contained disc pathology where more likely to have better outcomes. • There was no correlation between severity of stenosis and outcome from injection. [ABSTRACT FROM AUTHOR]