Effectiveness of Coronary Sinus Reducer for Treatment of Refractory Angina: A Meta-analysis.

BACKGROUND: Refractory angina is a debilitating condition that affects the quality of life of patients worldwide, who after exhausting standard available therapies are regarded as "no option" patients. Recently, CS (coronary sinus) reducer (Neovasc Reducer) implantation became available and is gaining popularity in the treatment of refractory angina. The effectiveness of this therapy was demonstrated in 1 randomised sham-control trial and numerous uncontrolled prospective studies entailing several hundred patients altogether. We performed a meta-analysis to incorporate the data and elucidate its efficacy and safety. METHODS: A meta-analysis of prospective studies assessing the effects of CS narrowing published in English to June 2021 was performed. The primary outcome was the proportion of patients improving ≥ 1 class in the Canadian Cardiovascular Society (CCS) angina score. Other end points included proportion of patients improving ≥ 2 CCS classes, procedural success, periprocedural complications, changes in Seattle Angina Questionnaire (SAQ) scores, and 6-minute walk test (6MWT). RESULTS: Data from 9 studies including 846 patients were included. An improvement of ≥ 1 CCS class occurred in 76% (95% confidence interval [CI] 73%-80%) of patients. Improvement of ≥ 2 CCS classes was observed in 40% of patients (95% CI 35%-46%). Procedure success was 98%, with no major and 3% nonmajor periprocedural complications. Post procedural SAQ scores and 6MWT distance were significantly improved. CONCLUSIONS: In patients suffering from angina refractory to medical and interventional therapies, Reducer implantation improves symptoms and quality of life with a low complication rate. These results are consistent in 1 randomised trial and multiple prospective uncontrolled studies.

Interventional Cryoneurolysis: An Illustrative Approach.

The application of advanced imaging guidance and the interventional radiology skill set has expanded the breadth of nerve and nerve plexus targets in the body for potential cryoneurolysis. Advancement of the basic science supporting cryoneurolysis has further solidified proceduralists' confidence and ability to select and manage patients clinically. As these procedures continue to evolve, a structured approach to the wide variety of indications is necessary.

An evidence-based review of neuromodulation for the treatment and management of refractory angina.

Angina pectoris is defined as substernal chest pain that is typically exacerbated by exertion, stress, or other exposures. There are various methods of treatment for angina. Lifestyle modification and pharmacological management are considered as conservative treatments. If these medications do not result in the resolution of pain, more invasive approaches are an option, like coronary revascularization. Refractory angina (RA) is differentiated from acute or chronic angina based on the persistence of symptoms despite conventional therapies. Overall, the prevalence of RA is estimated to be 5%-15% in patients with coronary artery disease, which can account for up to 1,500,000 current cases and 100,000 new cases in the United States per year. Spinal cord stimulation treatment is a viable option for patients who are suffering from RA pain and are either not candidates for revascularization surgery or are currently not being well managed on more traditional treatments. Many studies show a positive result.

Cryoneurolysis in Patients with Dorsal Neuropathic Pain Secondary to Tumor Invasion.

PURPOSE: To evaluate the safety and efficacy of cryoneurolysis (CNL) in patients with refractory thoracic neuropathic pain related to tumor invasion. MATERIALS AND METHODS: Between January 2013 and May 2017, this single-center and retrospective study reviewed 27 computed tomography-guided CNLs performed on 26 patients for refractory thoracic neuropathic pain related to tumor invasion. Patients with cognitive impairment were excluded. Pain levels were recorded on a visual analog scale (VAS) before the procedure, on days 1, 7, 14, 28 and at each subsequent follow-up appointment. CNL was clinically successful if the postprocedural VAS decreased by 3 points or more. To determine the duration of clinical success, the end of pain relief was defined as either an increased VAS of 2 or more points, the introduction of a new analgesic treatment, a death with controlled pain, or for lost to follow-up patients, the latest follow-up appointment date with controlled pain. RESULTS: Technical success rate was 96.7% and clinical success rate was 100%. Mean preprocedural pain score was 6.4 ± 1.7 and decreased to 2.4 ± 2.4 at day 1; 1.8 ± 1.7 at day 7 (P < .001); 3.3 ± 2.5 at day 14; 3.4 ± 2.6 at day 28 (P < .05). The median duration of pain relief was 45 days (range 14-70). Two minor complications occurred. CONCLUSIONS: Cryoneurolysis is a safe procedure that significantly decreased pain scores in patients with thoracic neuropathic pain related to tumor invasion, with a median duration of clinical success of 45 days.

Measuring sensory and pain thresholds by Semmes-Weinstein monofilaments in patients with leg ulcers: a pilot study.

OBJECTIVE: Pain is a common and disabling symptom in patients with leg ulcers. Clinical quantification of pain mostly depends on subjective pain reports, which do not reveal underlying mechanisms. The aim of this pilot study is to identify mechanisms underlying the pain in patients with leg ulcers by documenting alterations in pain processing using quantitative sensory testing. METHODS: In nine ulcer patients the mechanical sensory thresholds and the mechanical pain thresholds were determined by Semmes-Weinstein monofilaments (SWM) at three different sites: on the contralateral (unaffected) leg, on the skin of the affected leg 10cm from the ulcer margin, and on the affected leg, close (1-2cm) to the ulcer margin. Besides the mechanical sensory thresholds and mechanical pain thresholds, pain at the site of the ulcer, using an 11-point numeric rating scale (NRS), was documented. RESULTS: Mechanical sensory thresholds were increased in all subjects. Almost half (44%) of patients consistently showed allodynia at the unaffected site. The lowering of mechanical pain thresholds correlated with higher scores on the NRS. CONCLUSION: All patients showed diminished touch and/or protective sensation, which might have contributed to ulcer development via (partial) loss of protective function. The allodynia at the unaffected site suggests the presence of central sensitisation of pain processing.

Functional Outcomes and New Vertebral Fractures in Percutaneous Vertebroplasty and Conservative Treatment of Acute Symptomatic Osteoporotic Vertebral Compression Fractures.

OBJECTIVE: The present study compared the clinical functional outcomes and new vertebral compression fractures (NVCFs) between percutaneous vertebroplasty (PVP) and conservative treatment (CT) in patients with severe pain due to acute osteoporotic vertebral compression fractures (OVCFs). PVP has been increasingly used for the treatment of pain in patients with OVCFs. However, the effectiveness of the procedure and whether it causes NVCFs has remained controversial. METHODS: A total of 544 eligible patients with OVCFs found on spinal radiographs and intractable back pain for ≤6 weeks were recruited from September 2012 to February 2018 and assigned to PVP (n = 280; 392 levels) or CT (n = 264; 366 levels). The visual analog scale and Oswestry Disability Index scores were determined before the intervention and at the 1-week and 1-, 3-, 6-, 12-, and 24-month follow-up examinations. In addition, monthly telephone follow-up interviews were performed. In the case of a sudden increase in back pain, the patient returned to the hospital for medical and magnetic resonance imaging examinations for NVCF detection. RESULTS: The PVP group had significantly lower visual analog scale and Oswestry Disability Index scores than those for the CT group at 1 week and 1, 3, and 6 months (P < 0.05). However, the differences after 6 months were not statistically significant (P > 0.05). Similar numbers of NVCFs (total and adjacent fractures) were found at 24 months in both groups (P > 0.05). CONCLUSIONS: Compared with CT, PVP provided a rapid decrease in pain and an early return to daily life activities, without an increase in the incidence of NVCFs.

Systematic Review and Neural Network Analysis to Define Predictive Variables in Implantable Motor Cortex Stimulation to Treat Chronic Intractable Pain.

Implantable motor cortex stimulation (iMCS) has been performed for >25 years to treat various intractable pain syndromes. Its effectiveness is highly variable and, although various studies revealed predictive variables, none of these were found repeatedly. This study uses neural network analysis (NNA) to identify predictive factors of iMCS treatment for intractable pain. A systematic review provided a database of patient data on an individual level of patients who underwent iMCS to treat refractory pain between 1991 and 2017. Responders were defined as patients with a pain relief of >40% as measured by a numerical rating scale (NRS) score. NNA was carried out to predict the outcome of iMCS and to identify predictive factors that impacted the outcome of iMCS. The outcome prediction value of the NNA was expressed as the mean accuracy, sensitivity, and specificity. The NNA furthermore provided the mean weight of predictive variables, which shows the impact of the predictive variable on the prediction. The mean weight was converted into the mean relative influence (M), a value that varies between 0 and 100%. A total of 358 patients were included (202 males [56.4%]; mean age, 54.2 ±13.3 years), 201 of whom were responders to iMCS. NNA had a mean accuracy of 66.3% and a sensitivity and specificity of 69.8% and 69.4%, respectively. NNA further identified 6 predictive variables that had a relatively high M: 1) the sex of the patient (M = 19.7%); 2) the origin of the lesion (M = 15.1%); 3) the preoperative numerical rating scale score (M = 9.2%); 4) preoperative use of repetitive transcranial magnetic stimulation (M = 7.3%); 5) preoperative intake of opioids (M = 7.1%); and 6) the follow-up period (M = 13.1%). The results from the present study show that these 6 predictive variables influence the outcome of iMCS and that, based on these variables, a fair prediction model can be built to predict outcome after iMCS surgery. PERSPECTIVE: The presented NNA analyzed the functioning of computational models and modeled nonlinear statistical data. Based on this NNA, 6 predictive variables were identified that are suggested to be of importance in the improvement of future iMCS to treat chronic pain.

Drug-induced paraspinal myositis mimicking acute bilateral sciatica.

Although cocaine induced myopathy and myotoxicity are described in the literature, we report a rare case of cocaine induced paraspinal myositis presenting with acute sciatic symptoms. A 35-year-old man presented with acute left-sided sciatica and was discharged from the emergency department (ED). He subsequently attended ED the following day in severe pain and bilateral sciatic symptoms, but denied symptoms of neurogenic bowel/bladder disturbance. Clinical examination was limited by severe pain: focal midline lumbar tenderness was elicited on palpation, per rectal and limb examinations were within normal limits with no significant neurological deficit. He was admitted for observation and pain management. His blood tests revealed a leucocyte count of 21.5×109/L, C reactive protein of 89 mg/L and deranged renal function with creatinine of 293 µmol/L. An urgent lumbar spine MRI was arranged to rule out a discitis or epidural abscess. Lumbar MRI did not demonstrate any features of discitis but non-specific appearances of paraspinal inflammation raised the suspicion of a paraspinal myositis. Creatinekinase (CK) was found to be 66329 IU/L and a detailed history revealed he was a cocaine user. Paraspinal muscle biopsy confirmed histological features compatible with myositis. Other serological tests were negative, including anti-GBM, ANCA, ANA, Rheumatoid factor, Hep B, Hep C, myositis specific ENA, Treponema pallidum, Borrelia burgdorferi, Rickettsia, Leptospira, EBV and CMV. There was good clinical response to treatment with prednisolone 20 mg OD with an improvement in renal function, CK levels and CRP. He had resumed normal activities and return to work at 6-week follow-up. A detailed social history including substance misuse is important in patients presenting to the ED-especially in cases of severe musculoskeletal pain with no obvious localising features. Drug induced myotoxicity, although rare, can result in symptomatic patients with severe renal failure.

Optogenetic exploration and modulation of pain processing.

Intractable pain is the single most common cause of disability, affecting more than 20% of the population world-wide. There is accordingly a global effort to decipher how changes in nociceptive processing in the peripheral and central nervous systems contribute to the onset and maintenance of chronic pain. The past several years have brought rapid progress in the adaptation of optogenetic approaches to study and manipulate the activity of sensory afferents and spinal cord neurons in freely behaving animals, and to investigate cortical processing and modulation of pain responses. This review discusses methodological advances that underlie this recent progress, and discusses practical considerations for the optogenetic modulation of nociceptive sensory processing.

Interventional Anesthetic Methods for Pain in Hematology/Oncology Patients.

This article reviews anesthetic interventional approaches to the management of pain in hematology and oncology patients. It includes a discussion of single interventions including peripheral nerve blocks, plexus injections, and sympathetic nerve neurolysis, and continuous infusion therapy through implantable devices, such as intrathecal pumps, epidural port-a-caths, and tunneled catheters. The primary objective is to inform members of hematology and oncology care teams regarding the variety of interventional options for patients with cancer-related pain for whom medical pain management methods have not been effective.

Defining refractory rheumatoid arthritis.

While biologic disease-modifying antirheumatic drugs (bDMARDs) have transformed outcomes of people with rheumatoid arthritis (RA), a proportion of patients are refractory to multiple bDMARDs. Definitions of refractory RA thus far have been arbitrary, and outcome data and impact of such cohorts remain limited. Extrapolation from randomised controlled trial and some real-life data suggest approximately 20% progress onto a third bDMARD with a more modest proportion failing additional bDMARDs. This viewpoint discusses an opinion of refractory RA disease and proposes key principles to accurately identify refractory cohorts. These include demonstrating presence of persistent inflammation despite multiple therapies and acknowledging development of antidrug antibody. Potential basis of refractory disease is summarised, and suggestions for an initial approach in the future evaluation of refractory disease are offered. Specific investigation of refractory RA disease is necessary to inform the clinical need and provide a basis for robust investigation of underlying mechanisms.

Surgical Treatment of Thoracic Spinal Tuberculosis: A Multicenter Retrospective Study.

OBJECTIVE: The aim of the present multicenter, retrospective study was to assess the safety and effectiveness of different surgery strategies for the treatment of thoracic tuberculosis and to provide a reference for surgical treatment of thoracic tuberculosis. MATERIALS AND METHODS: This study reviewed 394 patients with thoracic tuberculosis who were treated in 6 institutions between January 2000 and January 2015. There were 208 men and 186 women with an average age of 34.92 ± 13.14 years (range 5-76 years). A total of 73 patients underwent one-stage anterior surgery (group A); 84 underwent an anterior combined posterior surgery (group B); and 237 underwent one-stage posterior surgery (group C). Clinical outcome, laboratory indexes, and radiologic results were analyzed to observe the advantage of posterior approach surgery. RESULTS: All cases were followed up for about 26-60 months (average of 37 months). At the last follow-up, all patients reached bone fusion, pain relief, and neurologic recovery. There were significant differences before and after treatment in terms of the visual analog scale and Oswestry Disability Index scores (P < 0.05). Posterior approach significantly improved kyphosis (P < 0.05). CONCLUSIONS: Posterior fixation is superior to anterior fixation in the correction of kyphosis and maintenance of spinal stability. One-stage posterior surgery can achieve the same efficacy as anterior-only or combined surgery, with less trauma, less blood loss, and shorter operative times. However, for wide lesions or paraspinal abscesses, severe bone destruction, and anterior and middle column defects that are too large after debridement to require long segment bone grafting, the anterior combined posterior approach is indispensable.

Dietary Intake of Polyunsaturated Fatty Acids and Pain in Spite of Inflammatory Control Among Methotrexate-Treated Early Rheumatoid Arthritis Patients.

OBJECTIVE: To investigate potential associations between dietary intake of polyunsaturated fatty acids (FAs) and pain patterns in early rheumatoid arthritis (RA) patients after 3 months of methotrexate (MTX) treatment. METHODS: We included 591 early RA patients with MTX monotherapy from a population-based prospective case-control study, the Epidemiological Investigation of Rheumatoid Arthritis. Dietary data on polyunsaturated FAs (food frequency questionnaires) were linked with data on unacceptable pain (visual analog scale [VAS] >40 mm), noninflammatory/refractory pain (VAS >40 mm and C-reactive protein [CRP] level <10 mg/liter), and inflammatory pain (VAS >40 mm and CRP level >10 mg/liter) after 3 months. Statistical analysis included logistic regression. RESULTS: After 3 months of MTX treatment, 125 patients (21.2%) had unacceptable pain, of which 92 patients had refractory pain, and 33 patients had inflammatory pain. Omega-3 FA intake was inversely associated with unacceptable pain and refractory pain (odds ratio [OR] 0.57 [95% confidence interval (95% CI) 0.35-0.95] and OR 0.47 [95% CI 0.26-0.84], respectively). The omega-6:omega-3 FA ratio, but not omega-6 FA alone, was directly associated with unacceptable pain and refractory pain (OR 1.70 [95% CI 1.03-2.82] and OR 2.33 [95% CI 1.28-4.24], respectively). Furthermore, polyunsaturated FAs were not associated with either inflammatory pain or CRP level and erythrocyte sedimentation rate at followup. Omega-3 FA supplementation was not associated with any pain patterns. CONCLUSION: Omega-3 FA was inversely associated with, and the omega-6:omega-3 FA ratio was directly associated with, unacceptable and refractory pain, but not with inflammatory pain or systemic inflammation. The inverse association between omega-3 FA and refractory pain may have a role in pain suppression in RA.

Gamma Knife Surgery for Recurrent Trigeminal Neuralgia in Cases with Previous Microvascular Decompression.

BACKGROUND: Microvascular decompression (MVD) and Gamma Knife surgery (GKS) are the primary treatments for trigeminal neuralgia (TN). However, many patients require further surgical treatment after initial surgery for recurrent TN. The aim of this study was to evaluate efficacy and safety of GKS for recurrent TN cases with prior MVD. METHODS: From October 2008 to June 2015, 658 patients at West China Hospital underwent GKS as the only surgical treatment, and 42 patients underwent GKS with prior MVD. The single 4-mm isocenter was located at the cisternal portion of the trigeminal nerve in all patients. Median maximum prescription dose was 85 Gy (range, 70-90 Gy). RESULTS: Median follow-up time was 6.2 years (range, 1.1-10 years). The percentage of patients with or without previous MVD within 1 year was 56.81%, and the percentage of patients who were pain-free was 74.74%. The recurrence rates within 10 years were 49.11% and 43.74% for patients with and without MVD, respectively. Also, 9.52% and 11.04% of patients with and without previous MVD experienced complications as a result of GKS during the long-term follow-up period. Patients who underwent previous MVD showed a significantly lower pain-free rate compared with patients without previous MVD (P = 0.01). There was no statistical significance in the recurrence rate (P = 0.82) or the complications (P = 0.93) in the 2 groups during the long-term follow-up period. CONCLUSIONS: For patients with recurrent TN who previously underwent MVD, GKS remains an efficacious and safe mode of treatment.

Sonographic Signs of Adenomyosis Are Prevalent in Women Undergoing Surgery for Endometriosis and May Suggest a Higher Risk of Infertility.

OBJECTIVES: To determine the prevalence of ultrasound features suggestive of adenomyosis in women undergoing surgery for endometriosis compared with a control group of healthy women without endometriosis. METHODS: Retrospective case-control study comparing women with intractable pain or infertility, who underwent transvaginal ultrasound and subsequent laparoscopic surgery, with a control group of healthy women without a previous history of endometriosis. A diagnosis of adenomyosis on TVUS was made based on asymmetrical myometrial thickening, linear striations, myometrial cysts, hyperechoic islands, irregular endometrial-myometrial junction, parallel shadowing, and localized adenomyomas and analyzed for one sign and for three or more signs. RESULTS: The study and control groups included 94 and 60 women, respectively. In the study group, women were younger and had more dysmenorrhea and infertility symptoms. The presence of any sonographic feature of adenomyosis, as well as three or more signs, was found to be more prevalent in the study group, which persisted after controlling for age, for all features but linear striations. Women in the study group who had five or more sonographic features of adenomyosis had more than a threefold risk of suffering from infertility (OR = 3.19, p = 0.015, 95% CI; 1.25-8.17). There was no association with disease severity at surgery. CONCLUSIONS: Sonographic features of adenomyosis are more prevalent in women undergoing surgery for endometriosis compared to healthy controls. Women with more than five features had an increased risk of infertility.

Translation and cultural adaptation of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale into Arabic for use with patients with diabetes in Libya.

In Libya neuropathic pain is rarely assessed in patients with diabetes. The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale is used worldwide to screen for neuropathic pain. There is no Arabic version of LANSS for use in Libya. The aim of this study was to develop an Arabic version of LANSS and to assess its validity and reliability in diabetic patients in Benghazi, Libya. LANSS was translated into Arabic by four bilingual translators and back translated to English by a university academic. Validity and reliability of the Arabic LANSS was assessed on 110 patients attending a Diabetes Centre in Benghazi. Concurrent validity was tested and compared with the Self-completed Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS). Test-retest reliability was conducted 1-2 weeks later. Internal consistency and inter-class correlation (ICC) between LANSS and S-LANSS was also tested. Internal consistency within first completion of the Arabic LANSS was acceptable (Cronbach's alpha = 0.793) and similar to the Arabic S-LANSS (0.796) and the second completion of the Arabic LANSS (0.795). ICC between the Arabic LANSS and the Arabic S-LANSS was 0.999 (p < 0.001). Test-retest reliability (ICC) between first and second completions of the Arabic LANSS was 0.999 (p < 0.001). Kappa measurement of agreement between the two Arabic LANSS completions and S-LANSS was high on all seven items (Kappa >0.95, p < 0.0001). We concluded that the Arabic version of LANSS pain scale was valid and reliable for use on Libyan diabetic patients. This study provided results suggesting that the S-LANSS could also be used on diabetic patients.

[Spinal cord stimulation in 62 patients: Retrospective evaluation]. / Spinal kord stimülasyonu uygulanan 62 hastanin retrospektif degerlendirilmesi.

OBJECTIVES: Spinal cord stimulation (SCS) is used for various indications such as Failed Back Surgey Syndrome, peripheral causalgia, neuropathic pain, complex regional pain syndrome, reflex sympathetic dystrophy, peripheral vascular disease, ischemic heart disease and cancer pain. METHODS: This is a retrospective study. 62 patients applied SCS were included in retrospective study from february 2011-january 2015 in Akdeniz University medicine faculty algology department. We asked about patients' VAS values before and after procedure, analgesic medicine usings, sleep disorders, pleasure after procedure, daily activity improvement and time of going back to work. RESULTS: We found that decrease on the patients' pain severity and improvement on quality of sleep and daily activities. CONCLUSION: As a result; our study and the other studies show that SCS is reliable and effective procedure on chronic pain management.

The influence of continuous versus interval walking exercise on knee joint loading and pain in patients with knee osteoarthritis.

OBJECTIVE: To evaluate whether knee contact force and knee pain are different between continuous and interval walking exercise in patients with knee osteoarthritis (OA). METHODS: Twenty seven patients with unilateral symptomatic knee OA completed two separate walking exercise sessions on a treadmill at 1.3m/s on two different days: 1) a continuous 45min walking exercise session, and 2) three 15min bouts of walking exercise separated by 1h rest periods for a total of 45min of exercise in an interval format. Estimated knee contact forces using the OpenSim software and knee pain were evaluated at baseline (1st minute of walking) and after every 15min between the continuous and interval walking conditions. RESULTS: A significant increase from baseline was observed in peak knee contact force during the weight-acceptance phase of gait after 30 and 45min of walking, irrespective of the walking exercise condition. Additionally, whereas continuous walking resulted in an increase in knee pain, interval walking did not lead to increased knee pain. CONCLUSION: Walking exercise durations of 30min or greater may lead to undesirable knee joint loading in patients with knee OA, while performing the same volume of exercise in multiple bouts as opposed to one continuous bout may be beneficial for limiting knee pain.

Effect of an Anterior Cingulotomy on Pain, Cognition, and Sensory Pathways.

BACKGROUND: Anterior cingulotomy (AC) was originally used to treat patients with a psychiatric disorder, but it is also useful for treating patients with chronic intractable pain. We reviewed 24 patients at our hospital who underwent AC for chronic intractable pain to determine whether surgery influenced patient cognition and the pain circuit. METHODS: A visual analog scale (VAS) was used to evaluate patients' pain scale preoperatively, at 1 month and 3-6 months postoperatively, and at the final follow-up. Mini-Mental State Examination (MMSE) and Cognitive Abilities Screening Instrument (CASI) were used to evaluate postoperative cognitive function. The latencies of peaks P20 and P37 of the somatosensory evoked potential (SSEP) conductive time were used to evaluate the intactness of the thalamocortical tract after AC. RESULTS: The median preoperative VAS score was 8, MMSE score was 27, and CASI score was 86.8. Six patients underwent a reoperation because of recurrent pain. Pain was significantly reduced after AC, and the median VAS score at the last follow-up was 5. There was no significant pain improvement in patients who underwent a reoperation. There were no significant changes in MMSE and CASI scores or SSEP after cingulotomy. There were no operation-related complications in the patients. CONCLUSIONS: A stereotactic AC was safe and effective in resolving chronic refractory pain. It did not affect patient cognition or the sensory conductive pathway. However, patients who had recurrent intractable pain after a cingulotomy did not respond well to the reoperation.