Inferior vena cava ultrasound to predict hypotension after general anesthesia induction: a systematic review and meta-analysis of observational studies.

PURPOSE: Hypotension after induction of general anesthesia is common and is associated with significant adverse events. Identification of patients at high risk can inform the use of preoperative mitigation strategies. We conducted a systematic review and meta-analysis to assess the diagnostic accuracy of the inferior vena cava collapsibility index (IVC-CI) and maximal diameter (dIVCmax) in predicting postinduction hypotension and to identify their predictive performance across different threshold ranges. METHODS: We searched MEDLINE, PubMed®, and Embase from inception to March 2023 for prospective observational studies exploring the performance of IVC-CI and dIVCmax in predicting postinduction hypotension in adults presenting for elective surgery under general anesthesia. We excluded studies reporting on IVC parameters predicting postinduction hypotension in the obstetric patient population or exclusively in patients with obesity. Trials screening and data extraction were conducted independently. We performed meta-analyses to identify the performance of IVC parameters in predicting postinduction hypotension, followed by subgroup analyses that sought the IVC-CI range with the highest hierarchical summary receiver-operating characteristic area under the curve (HSROC-AUC). We used a bivariate random effects model to calculate summary estimates. We evaluated study quality using Newcastle-Ottawa scores and certainty of evidence using the GRADE framework. RESULTS: We included 14 studies involving 1,166 patients. Pooled sensitivity and specificity of the IVC-CI to predict postinduction hypotension was 0.68 (95% confidence interval [CI], 0.55 to 0.79; coverage probability, 0.91) and 0.78 (95% CI, 0.69 to 0.85; coverage probability, 0.9), respectively, with an HSROC-AUC of 0.80 (95% CI, 0.68 to 0.85, high quality of evidence). An IVC-CI threshold range of 40-45% had an HSROC-AUC of 0.86 (95% CI, 0.69 to 0.93, high quality of evidence). CONCLUSIONS: Preoperative IVC-CI is a strong predictor of postinduction hypotension. We recommend that future studies use an IVC-CI threshold of 40-45% (low certainty of evidence). Future studies are needed to establish whether ultrasound-guided preoperative optimization improves outcomes in high-risk patients. STUDY REGISTRATION: PROSPERO ( CRD42022316140 ); first submitted 10 March 2022.

RéSUMé: OBJECTIF: L'hypotension après l'induction de l'anesthésie générale est fréquente et est associée à des effets indésirables importants. L'identification des patient•es à haut risque peut éclairer l'utilisation de stratégies préopératoires d'atténuation. Nous avons réalisé une revue systématique et une méta-analyse pour évaluer la précision diagnostique de l'indice de collapsibilité de la veine cave inférieure (IC-VCI) et du diamètre maximal (dVCImax) pour prédire l'hypotension post-induction et identifier leurs performances prédictives dans différentes plages de seuils. MéTHODE: Nous avons fait des recherches dans les bases de données MEDLINE, PubMed® et Embase de leur création jusqu'en mars 2023 pour en extraire les études observationnelles prospectives explorant les performances de l'IC-VCI et du dVCImax pour la prédiction de l'hypotension post-induction chez des adultes se présentant pour une chirurgie non urgente sous anesthésie générale. Nous avons exclu les études rapportant des paramètres de VCI prédisant l'hypotension post-induction dans la population obstétricale ou exclusivement chez des personnes obèses. Le tri des études et l'extraction des données ont été menés indépendamment. Nous avons réalisé des méta-analyses pour identifier la performance des paramètres de VCI dans la prédiction de l'hypotension post-induction, suivies d'analyses de sous-groupes qui ont recherché la plage d'IC-VCI avec le plus haut niveau de hiérarchie de l'aire sous la courbe de la courbe ROC (HSROC-AUC). Nous avons utilisé un modèle bivarié à effets aléatoires pour calculer des estimations sommaires. Nous avons évalué la qualité des études à l'aide des scores de Newcastle-Ottawa et la certitude des données probantes à l'aide de l'outil GRADE. RéSULTATS: Quatorze études portant sur 1166 patient·es ont été incluses. La sensibilité et la spécificité combinées de l'IC-VCI pour prédire l'hypotension post-induction étaient de 0,68 (intervalle de confiance [IC] à 95 %, 0,55 à 0,79; probabilité de couverture, 0,91) et 0,78 (IC 95 %, 0,69 à 0,85; probabilité de couverture, 0,9), respectivement, avec une HSROC-AUC de 0,80 (IC 95 %, 0,68 à 0,85, données probantes de haute qualité). Une plage de seuils d'IC-VCI de 40 à 45 % avait une HSROC-AUC de 0,86 (IC 95 %, 0,69 à 0,93, haute qualité des données probantes). CONCLUSION: L'IC-VCI préopératoire est un bon prédicteur de l'hypotension post-induction. Nous recommandons que les études futures utilisent un seuil d'IC-VCI de 40 à 45 % (faible certitude des données probantes). De futures études sont nécessaires pour déterminer si l'optimisation préopératoire échoguidée améliore les devenirs chez la patientèle à risque élevé. ENREGISTREMENT DE L'éTUDE: PROSPERO ( CRD42022316140 ); première soumission le 10 mars 2022.

The Role of Virtual Reality and Artificial Intelligence in Cognitive Pain Therapy: A Narrative Review.

PURPOSE OF REVIEW: This review investigates the roles of artificial intelligence (AI) and virtual reality (VR) in enhancing cognitive pain therapy for chronic pain management. The work assesses current research, outlines benefits and limitations and examines their potential integration into existing pain management methods. RECENT FINDINGS: Advances in VR have shown promise in chronic pain management through immersive cognitive therapy exercises, with evidence supporting VR's effectiveness in symptom reduction. AI's personalization of treatment plans and its support for mental health through AI-driven avatars are emerging trends. The integration of AI in hybrid programs indicates a future with real-time adaptive technology tailored to individual needs in chronic pain management. Incorporating AI and VR into chronic pain cognitive therapy represents a promising approach to enhance management by leveraging VR's immersive experiences and AI's personalized tactics, aiming to improve patient engagement and outcomes. Nonetheless, further empirical studies are needed to standardized methodologies, compare these technologies to traditional therapies and fully realize their clinical potential.

PRECISE trial (Pain RElief Combination Intervention StratEgies): protocol for the clinical trial of a pregabalin-melatonin combination for fibromyalgia.

INTRODUCTION: Fibromyalgia is associated with chronic widespread pain and disturbed sleep. Multidisciplinary, multimodal management often includes pharmacotherapy; however, current drugs used to treat fibromyalgia provide meaningful benefit to only 30-60% of treated individuals. Combining two or more different drugs is common in clinical practice with the expectation of better efficacy, tolerability or both; however, further research is needed to identify which combinations actually provide added benefit. Thus, we are planning a clinical trial to evaluate melatonin (MLT)-pregabalin (PGB) combination in participants with fibromyalgia. METHODS AND ANALYSIS: This will be a single-centre, double-blind, randomised, double-dummy, three-period, crossover trial comparing a MLT-PGB combination to each monotherapy in 54 adult participants satisfying the 2016 American College of Rheumatology criteria for fibromyalgia. Participants will receive maximally tolerated doses of MLT, PGB and MLT-PGB combination for 6 weeks. The primary outcome will be daily pain intensity (0-10); secondary outcomes will include the Fibromyalgia Impact Questionnaire, SF-36 survey, Medical Outcomes Study Sleep Scale, Beck Depression Inventory (BDI-II), adverse events and other measures. Analysis of the primary and secondary outcomes will involve a linear mixed model with sequence, period, treatment, the first-order carryover and baseline pain score as fixed effects and participant as a random effect to test whether there are any treatment differences among three treatments and to estimate the least square mean of the mean daily pain intensity for each treatment, adjusting for carryover as well as period effects (ie, stability of pain levels). ETHICS AND DISSEMINATION: This trial has been registered with the International Standard Randomised Controlled Trial Number Registry, ISRCTN #18278231, has been granted ethical approval by the Queen's University Health Sciences Research Ethics Board (Queen's HSREB Protocol #6040998) and is currently under review for a Clinical Trial Application to Health Canada Natural and Non-prescription Health Products Directorate. All participants will provide written informed consent prior to trial participation. Following trial completion, results will be disseminated in one or more biomedical journal publications and presented at one or more scientific meetings. TRIAL REGISTRATION NUMBER: This trial has been registered with the International Standard Randomised Controlled Trial Number Registry, ISRCTN18278231.

Prevention of persistent pain with lidocaine infusions in breast cancer surgery (PLAN): study protocol for a multicenter randomized controlled trial.

BACKGROUND: Persistent pain is a common yet debilitating complication after breast cancer surgery. Given the pervasive effects of this pain disorder on the patient and healthcare system, post-mastectomy pain syndrome (PMPS) is becoming a larger population health problem, especially as the prognosis and survivorship of breast cancer increases. Interventions that prevent persistent pain after breast surgery are needed to improve the quality of life of breast cancer survivors. An intraoperative intravenous lidocaine infusion has emerged as a potential intervention to decrease the incidence of PMPS. We aim to determine the definitive effects of this intervention in patients undergoing breast cancer surgery. METHODS: PLAN will be a multicenter, parallel-group, blinded, 1:1 randomized, placebo-controlled trial of 1,602 patients undergoing breast cancer surgery. Adult patients scheduled for a lumpectomy or mastectomy will be randomized to receive an intravenous 2% lidocaine bolus of 1.5 mg/kg with induction of anesthesia, followed by a 2.0 mg/kg/h infusion until the end of surgery, or placebo solution (normal saline) at the same volume. The primary outcome will be the incidence of persistent pain at 3 months. Secondary outcomes include the incidence of pain and opioid consumption at 1 h, 1-3 days, and 12 months after surgery, as well as emotional, physical, and functional parameters, and cost-effectiveness. DISCUSSION: This trial aims to provide definitive evidence on an intervention that could potentially prevent persistent pain after breast cancer surgery. If this trial is successful, lidocaine infusion would be integrated as standard of care in breast cancer management. This inexpensive, widely available, and easily administered intervention has the potential to reduce pain and suffering in an already afflicted patient population, decrease the substantial costs of chronic pain management, potentially decrease opioid use, and improve the quality of life in patients. TRIAL REGISTRATION: This trial has been registered on clinicaltrials.gov (NCT04874038, Dr. James Khan. Date of registration: May 5, 2021).

Comparative benefits and harms of perioperative interventions to prevent chronic pain after orthopedic surgery: a systematic review and network meta-analysis of randomized trials.

BACKGROUND: Chronic postsurgical pain (CPSP) is common following musculoskeletal and orthopedic surgeries and is associated with impairment and reduced quality of life. Several interventions have been proposed to reduce CPSP; however, there remains uncertainty regarding which, if any, are most effective. We will perform a systematic review and network meta-analysis of randomised trials to assess the comparative benefits and harms of perioperative pharmacological and psychological interventions directed at preventing chronic pain after musculoskeletal and orthopedic surgeries. METHODS: We will search MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from inception to present, without language restrictions. We will include randomised controlled trials that as follows: (1) enrolled adult patients undergoing musculoskeletal or orthopedic surgeries; (2) randomized them to any pharmacological or psychological interventions, or their combination directed at reducing CPSP, placebo, or usual care; and (3) assessed pain at 3 months or more after surgery. Screening for eligible trials, data extraction, and risk-of-bias assessment using revised Cochrane risk-of-bias tool (RoB 2.0) will be performed in duplicate and independently. Our main outcome of interest will be the proportion of surgical patients reporting any pain at ≥ 3 months after surgery. We will also collect data on other patient important outcomes, including pain severity, physical functioning, emotional functioning, dropout rate due to treatment-related adverse event, and overall dropout rate. We will perform a frequentist random-effects network meta-analysis to determine the relative treatment effects. When possible, the modifying effect of sex, surgery type and duration, anesthesia type, and veteran status on the effectiveness of interventions will be investigated using network meta-regression. We will use the GRADE approach to assess the certainty evidence and categorize interventions from most to least beneficial using GRADE minimally contextualised approach. DISCUSSION: This network meta-analysis will assess the comparative effectiveness of pharmacological and psychological interventions directed at preventing CPSP after orthopedic surgery. Our findings will inform clinical decision-making and identify promising interventions for future research. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42023432503.

Prevention of hypotension after induction of general anesthesia using point-of-care ultrasound to guide fluid management: a randomized controlled trial.

PURPOSE: Hypotension after induction of general anesthesia (GAIH) is common and is associated with postoperative complications including increased mortality. Collapsibility of the inferior vena cava (IVC) has good performance in predicting GAIH; however, there is limited evidence whether a preoperative fluid bolus in patients with a collapsible IVC can prevent this drop in blood pressure. METHODS: We conducted a single-centre randomized controlled trial with adult patients scheduled to undergo elective noncardiac surgery under general anesthesia (GA). Patients underwent a preoperative point-of-care ultrasound scan (POCUS) to identify those with a collapsible IVC (IVC collapsibility index ≥ 43%). Individuals with a collapsible IVC were randomized to receive a preoperative 500 mL fluid bolus or routine care (control group). Surgical and anesthesia teams were blinded to the results of the scan and group allocation. Hypotension after induction of GA was defined as the use of vasopressors/inotropes or a decrease in mean arterial pressure < 65 mm Hg or > 25% from baseline within 20 min of induction of GA. RESULTS: Forty patients (20 in each group) were included. The rate of hypotension after induction of GA was significantly reduced in those receiving preoperative fluids (9/20, 45% vs 17/20, 85%; relative risk, 0.53; 95% confidence interval, 0.32 to 0.89; P = 0.02). The mean (standard deviation) time to complete POCUS was 4 (2) min, and the duration of fluid bolus administration was 14 (5) min. Neither surgical delays nor adverse events occurred as a result of the study intervention. CONCLUSION: A preoperative fluid bolus in patients with a collapsible IVC reduced the incidence of GAIH without associated adverse effects. STUDY REGISTRATION: ClinicalTrials.gov (NCT05424510); first submitted 15 June 2022.

RéSUMé: OBJECTIF: L'hypotension après induction de l'anesthésie générale (AG) est fréquente et est associée à des complications postopératoires, notamment à une augmentation de la mortalité. La collapsibilité de la veine cave inférieure (VCI) a été utilisée avec succès pour prédire la l'hypotension post-induction de l'AG; cependant, il existe peu de données probantes qu'un bolus liquidien préopératoire chez les patient·es présentant une collapsibilité de la VCI puisse prévenir cette baisse de la tension artérielle. MéTHODE: Nous avons réalisé une étude randomisée contrôlée monocentrique auprès de patient·es adultes devant bénéficier d'une chirurgie non cardiaque non urgente sous anesthésie générale. Les patient·es ont passé une échographie préopératoire ciblée (POCUS) pour identifier les personnes présentant une collapsibilité de la VCI (indice de collapsibilité de la VCI ≥ 43 %). Les personnes présentant une collapsibilité de la VCI ont été randomisées à recevoir un bolus de liquide préopératoire de 500 mL ou des soins de routine (groupe témoin). Les équipes chirurgicales et d'anesthésie ne connaissaient pas les résultats de l'examen ni l'attribution des groupes. L'hypotension après induction de l'AG a été définie comme l'utilisation de vasopresseurs/inotropes ou une diminution de la tension artérielle moyenne < 65 mm Hg ou > 25 % par rapport aux valeurs de base dans les 20 minutes suivant l'induction de l'AG. RéSULTATS: Quarante patient·es (20 dans chaque groupe) ont été inclus·es. Le taux d'hypotension après induction de l'AG était significativement réduit chez les personnes recevant des liquides préopératoires (9/20, 45 % vs 17/20, 85 %; risque relatif, 0,53; intervalle de confiance à 95 %, 0,32 à 0,89; P = 0,02). Le temps moyen (écart type) pour compléter l'échographie ciblée était de 4 (2) min, et la durée de l'administration du bolus liquidien était de 14 (5) min. Ni retards chirurgicaux ni effets indésirables ne sont survenus à la suite de l'intervention à l'étude. CONCLUSION: Un bolus liquidien préopératoire chez les patient·es présentant une collapsibilité de la VCI a réduit l'incidence d'hypotension après l'induction de l'anesthésie générale sans effets indésirables associés. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT05424510); première soumission le 15 juin 2022.

Peripheral magnetic stimulation for chronic peripheral neuropathic pain: A systematic review and meta-analysis.

OBJECTIVES: To provide a systematic review of the literature on the effects of peripheral magnetic stimulation (PMS) in the treatment of chronic peripheral neuropathic pain. METHODS: A systematic search of MEDLINE, EMBASE, CENTRAL, CINHAL, Web of Science, and ProQuest was conducted from inception to July 2023 to identify studies of any design published in English language that enrolled adult patients (≥18 years) that received PMS for treatment of a chronic peripheral neuropathic pain disorder (pain > 3 months). RESULTS: Twenty-three studies were identified which included 15 randomized controlled trials (RCTs), five case series, two case reports, and one non-randomized trial. PMS regimens varied across studies and ranged from 5 to 240 min per session over 1 day to 1 year of treatment. Results across included studies were mixed, with some studies suggesting benefits while others showing no significant differences. Of nine placebo-controlled RCTs, four reported statistically significant findings in favor of PMS use. In the meta-analysis, PMS significantly reduced pain scores compared to control within 0-1 month of use (mean difference -1.64 on a 0-10 numeric rating scale, 95% confidence interval -2.73 to -0.56, p = 0.003, I2 = 94%, 7 studies [264 participants], very low quality of evidence), but not at the 1-3 months and >3 months of PMS use (very low and low quality of evidence, respectively). Minimal to no adverse effects were reported with PMS use. DISCUSSION: There is limited and low-quality evidence to make definitive recommendations on PMS usage, however, the available data is encouraging, especially for short-term applications of this novel modality. Large high-quality randomized controlled trials are required to establish definitive efficacy and safety effects of PMS.

End-on versus parallel radiofrequency lesioning for neurotomy of the cervical medial branch nerves: a study protocol of a prospective, randomized, double-blind clinical trial: the "EndPaRL" study.

BACKGROUND: Cervical facet joint disease is a common source of neck pain and its prevalence increases with aging. Conservative multimodal management options (e.g., strengthening of neck muscles, non-steroidal anti-inflammatory medications, massage, and thermal modalities) often fail to relieve pain. Cervical medial branch nerve (CMBN) radiofrequency neurotomy (RFN) is an effective minimally invasive technique for treating chronic neck pain secondary to facet joint disease. An end-on approach for this procedure has been proposed that may be technically easier and require less time while reducing post-procedural discomfort. The protocol presented here is for a study that aims to compare the efficacy of a new end-on approach using multi-tined cannulae, against the conventional parallel technique that employs straight cannulae for RFN of the CMBN in patients with chronic neck pain due to cervical facet joint disease. METHODS: A multicentre randomized, non-inferior, active comparator-controlled trial will be conducted with two parallel groups and blinding of participants and outcome assessor. The study will include 72 adults with chronic neck pain secondary to facet joint disease who are candidates for RFA of the CMBN. Participants will be randomized to either the conventional parallel or the end-on approach in a 1:1 ratio. The intensity of pain and pain-related domains (function, quality of life, sleep, adverse effects of the interventions, analgesic intake) will be measured at 1, 3, 6, and 12 months after the procedure. DISCUSSION: Neck pain secondary to cervical facet joint disease is prevalent and RFA of the CMBN is a validated treatment for relieving it. The conventional parallel technique can be technically challenging, and it can be associated with adverse effects while the newer end-on approach has the potential of being a simpler technique with less adverse effects. This trial will be the first non-inferiority study to compare the clinical efficacy of the end-on approach against the conventional parallel approach for RFN of CMBN in patients with chronic neck pain due to cervical facet joint disease. TRIAL REGISTRATION: ClinicalTrials.gov NCT05818774. Registered on April 20, 2023.

Point-of-Care Ultrasound (PoCUS) and Its Potential to Advance Patient Care in Low-Resource Settings and Conflict Zones.

Point-of-care ultrasound (PoCUS) is used by health care professionals of various specialties worldwide, with excellent results demonstrating significant potential to advance patient care. However, in low resource areas of the world, where other imaging modalities are scarce and the potential of handheld pocket-sized PoCUS devices with great versatility and increasing affordability seems most significant, its use is far from being widespread. In this report, our group of Chadian, Israeli, and Canadian physicians with experience in rural, military, and conflict zone medical aid, discusses the barriers to the implementation of PoCUS in low resource areas and offers potential solutions.

Disparities in Pain Management.

Health disparities in pain management remain a pervasive public health crisis. Racial and ethnic disparities have been identified in all aspects of pain management from acute, chronic, pediatric, obstetric, and advanced pain procedures. Disparities in pain management are not limited to race and ethnicity, and have been identified in multiple other vulnerable populations. This review targets health care disparities in the management of pain, focusing on steps health care providers and organizations can take to promote health care equity. A multifaceted plan of action with a focus on research, advocacy, policy changes, structural changes, and targeted interventions is recommended.

Prevalence and Risk Factors for Chronic Postsurgical Pain after Cardiac Surgery: A Single-center Prospective Cohort Study.

BACKGROUND: Chronic postsurgical pain is a common complication of surgery. The role of psychologic risk factors like depression and anxiety is substantially understudied in cardiac surgery. This study sought to identify perioperative factors associated with chronic pain at 3, 6, and 12 months after cardiac surgery. The authors hypothesize that baseline psychologic vulnerabilities have a negative influence on chronic postsurgical pain. METHODS: The authors prospectively collected demographic, psychologic, and perioperative factors in a cohort of 1,059 patients undergoing cardiac surgery at the Toronto General Hospital between 2012 and 2020. Patients were followed and completed chronic pain questionnaires at 3, 6, and 12 months after surgery. RESULTS: The study included 767 patients who completed at least one follow-up questionnaire. The incidence of postsurgical pain (more than 0 out of 10) at 3, 6, and 12 months after surgery was 191 of 663 (29%), 118 of 625 (19%), and 89 of 605 (15%), respectively. Notably, among patients reporting any pain, the incidence of pain compatible with a neuropathic phenotype increased from 56 of 166 (34%) at 3 months to 38 of 97 (39%) at 6 months and 43 of 67 (64%) at 12 months. Factors associated with postsurgical pain scores at 3 months include female sex, pre-existing chronic pain, previous cardiac surgery, preoperative depression, baseline pain catastrophizing scores, and moderate-to-severe acute pain (4 or more out of 10) within 5 postoperative days. CONCLUSIONS: Nearly one in three patients undergoing cardiac surgery reported pain at 3 months of follow-up, with approximately 15% reporting persistent pain at 1 yr. Female sex, pre-existing chronic pain, and baseline depression were associated with postsurgical pain scores across all three time periods.

Effect of Peripheral Magnetic Stimulation on Acute and Chronic Pain After Surgery: A Systematic Review and Meta-Analysis.

Peripheral magnetic stimulation (PMS) is a potentially promising modality to help manage postoperative pain. We systematically reviewed the effect of PMS on acute and chronic postoperative pain. MEDLINE, Cochrane CENTRAL, EMBASE, ProQuest Dissertations, and clinical trials.gov were searched from inception until May 2021. We included studies of any study design that included patients ≥18 years of age undergoing any type of surgery that administered PMS within the perioperative period and evaluated postoperative pain. Seventeen randomized controlled trials and 1 nonrandomized clinical trial were included into the review. Thirteen out of the 18 studies found a positive effect with PMS on postoperative pain scores. In our meta-analysis, peripheral magnetic stimulation was more efficacious than sham or no intervention within the first 7 postoperative days (mean difference [MD] -1.64 on a 0 to 10 numerical rating score, 95% confidence interval [CI] -2.08 to -1.20, I2 = 77%, 6 studies, 231 patients). This was also true at 1 and 2 months after surgery (MD -1.82, 95% CI -2.48 to -1.17, I2 = 0%, 3 studies, 104 patients; and MD -1.96, 95% CI -3.67 to -.26, I2 = 84%, 3 studies, 104 patients, respectively). A difference was not seen with persistent pain at 6 and 12-months after surgery, acute postoperative opioid consumption, or adverse events between groups. Results are limited by heterogeneity and generally low-quality studies, as well as low or very low quality of evidence. High-quality and adequately blinded trials are needed to definitively confirm the benefits of peripheral magnetic stimulation administered in the perioperative period. PERSPECTIVE: This review evaluates the efficacy and safety of PMS on postoperative pain. The results help elucidate PMS' role in postoperative pain management and identify gaps where more research is required.

Ultrasound-guided repetitive pulsed peripheral magnetic stimulation provides pain relief in refractory glossopharyngeal neuralgia: A case report.

Aims: Repetitive peripheral magnetic stimulation (rPMS) is a novel nonpharmacological treatment modality. This noninvasive approach can stimulate peripheral nerves to provide analgesia through neuromodulation. We report the first case of ultrasound-guided rPMS to treat a case of severe refractory glossopharyngeal neuralgia. Methods: A 70-year-old female with an 8-year history of glossopharyngeal neuralgia reported refractory pain unresponsive to pharmacological and interventional treatments. After consenting to treatment, the patient received high-frequency rPMS in three different sessions using intermittent theta burst stimulation below motor thresholds. rPMS was applied over the skin directed at the glossopharyngeal nerve identified using ultrasound guidance. Session 1 included 20 min of continuous treatment, session 2 included 40 min of treatment (two 20-min treatments separated by a 10-min break), session 3 included 40 min of treatment (similar to Session 2) repeated daily for 5 days. Pre- and postintervention pain levels were collected with a daily 1-week pain diary and pain questionnaires. Results: Session 1 led to an immediate 30% decrease in pain after treatment. Session 2 led to a 75% decrease in pain immediately after treatment that remained reduced for approximately 2 days. Session 3 produced complete pain relief immediately after treatment and remained lower for 5 days after treatment and returned to baseline levels at 1 week. Conclusion: rPMS provided immense but temporary relief in a severe case of refractory glossopharyngeal neuralgia. Further work is needed to determine the most effective regimen to treat complex pain disorders in the head and neck.

La stimulation magnétique périphérique répétitive (SPMr) est une nouvelle modalité de traitement non pharmacologique. Cette approche non invasive peut stimuler les nerfs périphériques pour fournir une analgésie par le truchement de la neuromodulation. Nous rapportons le premier cas de SPMR guidée par ultrasons pour traiter un cas de névralgie glossopharyngée réfractaire sévère.Méthodes: Une femme de 70 ans avec une histoire de huit ans de névralgie glossopharyngée a fait état d'une douleur réfractaire ne répondant pas aux traitements interventionnels pharmacologiques. Après avoir consenti au traitement, la patiente a reçu une SMPr à haute fréquence au cours de trois séances différentes en utilisant la stimulation thêta-burst intermittente en-deçà des seuils moteurs. La SMPr a été appliquée sur la peau en ciblant le nerf glossopharyngé identifié à l'aide d'un guidage par ultrasons. La séance 1 comprenait 20 minutes de traitement continu, la séance 2 comprenait 40 minutes de traitement (deux traitements de 20 minutes séparés par une pause de 10 minutes), la séance 3 comprenait 40 minutes de traitement (similaire à la séance 2) répétées quotidiennement pendant cinq jours. Les niveaux de douleur pré et post-intervention ont été collectés à l'aide de questionnaires sur la douleur et consignés dans un journal quotidien de la douleur échelonné sur une semaine.Résultats: La séance 1 a entraîné une diminution immédiate de 30 % de la douleur après le traitement. La séance 2 a conduit à une diminution de 75 % de la douleur immédiatement après le traitement et cette diminution s'est maintenue pendant environ deux jours. La séance 3 a donné lieu à un soulagement complet de la douleur immédiatement après le traitement; la douleur est ensuite restée plus faible pendant cinq jours après et est revenue aux niveaux de départ au bout d'une semaine.Conclusion: La SMPr a procuré un soulagement immense mais temporaire dans un cas grave de névralgie glossopharyngée réfractaire. Des travaux supplémentaires sont nécessaires pour déterminer le régime de traitement le plus efficace pour traiter les troubles douloureux complexes de la tête et du cou.

Genitofemoral peripheral nerve stimulator implantation for refractory groin pain: a case report.

PURPOSE: Genitofemoral neuralgia (GFN) is a chronic pain condition that may be refractory to commonly employed treatment modalities. Implantation of a peripheral nerve stimulator (PNS) may provide significant pain relief; however, few reports have described placement of and response to a GFN PNS implant. CLINICAL FEATURES: We implanted a StimRouter® PNS in a 42-yr-old male with severe GFN that did not respond to pharmacologic and interventional pain management modalities and impaired all aspects of his function and quality of life. The often-challenging sonographic visualization of the genitofemoral nerve was aided by intraprocedural sensory mapping using a stimulating probe. Preoperatively, the patient's average pain was rated as 7 on a 0 to 10 numeric rating scale. Following the procedure, the patient experienced over 90% pain relief after one week. At one and five months post implantation, the patient's average pain scores were 1 and 0.5, respectively. The patient also reported substantial improvement in the physical component scores on the 12-Item Short Form Survey (SF-12), which remained similar at the five-month follow-up (from 26.1 preop to 57.2 at one month and 49.7 at five months). CONCLUSIONS: Peripheral nerve stimulator implantation may be a promising intervention when other analgesic modalities fail to manage refractory GFN. Further research to verify the effectiveness of this intervention and evaluate for appropriate integration in patient care is required.

RéSUMé: OBJECTIF: La névralgie génito-crurale (NGC) est une douleur chronique pouvant être réfractaire aux modalités de traitement couramment utilisées. L'implantation d'un stimulateur nerveux périphérique (SNP) peut apporter un soulagement significatif de la douleur. Cependant, peu de présentations de cas ont décrit la mise en place et la réponse à l'implantation d'un SNP pour soulager une névralgie génito-crurale. CARACTéRISTIQUES CLINIQUES: Nous avons implanté un SNP StimRouter® chez un homme de 42 ans atteint d'une NGC grave qui ne répondait pas aux modalités pharmacologiques et interventionnelles de prise en charge de la douleur et entravait tous les aspects fonctionnels et de qualité de vie. La visualisation échographique souvent difficile du nerf génito-crural a été facilitée grâce à une cartographie sensorielle intraprocédurale, réalisée à l'aide d'une sonde de stimulation. Avant la procédure, la douleur moyenne du patient a été évaluée à 7 sur une échelle d'évaluation numérique de 0 à 10. Suite à l'intervention, le patient a ressenti un soulagement de la douleur de plus de 90 % après une semaine. À un et à cinq mois suivant l'implantation, les scores moyens de douleur du patient étaient de 1 et 0,5, respectivement. Le patient a également rapporté une amélioration substantielle des scores de la composante physique du questionnaire SF-12, scores qui sont restés similaires au suivi à cinq mois (de 26,1 avant l'intervention à 57,2 à un mois et 49,7 à cinq mois). CONCLUSION: L'implantation d'un stimulateur nerveux périphérique pourrait être une intervention prometteuse lorsque d'autres modalités analgésiques ne parviennent pas à prendre en charge une névralgie génito-crurale réfractaire. D'autres recherches sont nécessaires pour vérifier l'efficacité de cette intervention et évaluer son intégration appropriée dans les soins aux patients.

Review of Opioid Sparing Interventional Pain Management Options and Techniques for Radiofrequency Ablations for Sacroiliac Joint Pain.

PURPOSE OF REVIEW: The goal of this clinical review was to provide an update about the existing treatment options and associated evidence for various radiofrequency ablation techniques for sacroiliac joint pain. An electronic literature search on radiofrequency for the treatment of sacroiliac joint pain was conducted using PubMed, NCBI and Google Scholar. The following search keywords were used: radiofrequency ablation (cooled, pulsed, conventional, bipolar, intra-articular), sacroiliac joint and sacroiliac pain. The search was limited to human subjects, English language and articles with available full text. The bibliographic sections of all manuscripts were further searched for additional relevant citations. The full text of the relevant articles was reviewed by all the authors. RECENT FINDINGS: Our study showed that radiofrequency ablation is a safe and effective treatment option that can be utilized to manage sacroiliac joint pain. It offers accessibility to the primary care physician, reduces office visits with "pain" as the primary complaint and provides the added benefit of acting as a non-opioid sparing means of analgesia.

Clinical Radiofrequency Ablation Outcomes of Combined Sensory Nerve Branch and Dorsal Entry Root Zone Complex Lesions for Sacroiliac Joint Complex Pain.

BACKGROUND: Chronic lower back pain (LBP) with or without leg pain (LP) is the most commonly reported anatomical site of pain among Canadian adults with chronic pain. A common cause for LBP and LP arises from dysfunction of the sacroiliac joint (SIJ) complex. When conventional medical management or rehabilitative efforts for SIJ-related LBP and LP fail to provide analgesia, pulsed radiofrequency (PRF) and/or radiofrequency ablation (RFA) of the dorsal entry root zone complex lesions (DREZC) and/or their more peripheral branches can also be a suitable means for treatment. Both PRF and RFA are interventional techniques that utilize heat to attenuate or ablate transmission of painful signals, respectively. The purpose of this chart review is to explore the clinical outcomes of patients experiencing SIJ-related pain who have undergone procedures with combined sensory nerve branch RFA and DREZC PRF lesions targeting the SIJ complex. METHODS: Following institutional review board approval, a retrospective chart review was performed from June 2018 to February 2021 for patients with LBP and/or LP refractory to physical rehabilitative efforts and medical management that underwent combined PRF and RF treatments for a diagnosis of SIJ complex pain. RF and PRF procedures were anatomically guided with the addition of sensory stimulation to ensure appropriate needle placement. Charts were reviewed for percentage of analgesia at final follow-up, duration of effect, degree of analgesia, patients' functional improvements, and changes in medication use patterns. RESULTS: Data was reviewed from 180 patients with LBP or LP who underwent combined PRF and RF treatments for a diagnosis of SIJ complex pain. The group consisted of 69 men and 111 women with a mean age of 59 years. All patients had lesions to their dorsal roots and/or branches (lumbar medial and sacral lateral), as determined using their pain profile as well as sensory stimulation. In the sample of 180 patients a total of 276 SIJs were treated over the period of data collection. Overall, 85.0% (n = 234) of procedures were considered successful with more than 50% analgesic relief at final follow-up. Of 234 successful outcomes, 110 reported ongoing analgesia (mean = 80.3% pain relief, SD ± 18.0) on the last date of follow up (mean = 53.2 days, SD ± 41.8) prior to being lost to follow-up. For patients not lost to follow-up, the mean amount of analgesia was reported to be 83.9% with an average duration of 86.3 days. Among all treatments, 6.9% (n = 19) provided no analgesic effect. Among the successful procedure outcomes, 54.4% (n = 150) reported increased activity/mobility, 24.3% (n = 67) reported improved sleep, 49.3% (n = 136) reported improved mood, and 11.6% (n = 32) reported decreased medication usage. Nine patients reported complications following the procedure. Complications included transient soreness, bruising, tenderness, myofascial pain, and two mild vagal responses without lasting sequelae. CONCLUSION: This review suggests that combined sensory nerve branch RFA and DREZC PRF lesions targeting the SIJ complex is a suitable intervention to treat SIJ-related LBP and/or LP refractory to physical rehabilitative efforts and medical management. Approximately 85% of these cases were successfully treated with the majority of patients report lasting analgesic effects with minimal complications, supporting the use of sensory stimulation-guided combined RF and PRF lesions for treatment of refractory SIJ complex pain.

Strategies to Promote Racial Healthcare Equity in Pain Medicine: A Call to Action.

In the past several years, many national events have illuminated the inequities faced by the Black community in all aspects of life, including healthcare. To close the gap in healthcare equity, it is imperative that clinicians examine their practices for disparities in the treatment of minority patients and for racial injustice and take responsibility for improving any issues. As leaders in pain medicine, we can start by improving our understanding of healthcare disparities and inequities among racial and ethnic minorities and translating that knowledge into a cultural transformation to improve the care of those impacted. In this paper, we identify the areas of medicine in which pain assessment and treatment are not equitably delivered. As we acknowledge these disparities, we will highlight reasons for these incongruences in care and clarify how clinicians can act to ensure that all patients are treated equitably, with equal levels of compassion.

Persistent Incisional Pain after Noncardiac Surgery: An International Prospective Cohort Study.

BACKGROUND: The purpose of this study was to determine the incidence, characteristics, impact, and risk factors associated with persistent incisional pain. The hypothesis was that patient demographics and perioperative interventions are associated with persistent pain. METHODS: This was a secondary analysis of an international prospective cohort study from 2012 to 2014. This study included patients who were 45 yr of age or older who underwent major inpatient noncardiac surgery. Data were collected perioperatively and at 1 yr after surgery to assess for the development of persistent incisional pain (pain present around incision at 1 yr after surgery). RESULTS: Among 14,831 patients, 495 (3.3%; 95% CI, 3.1 to 3.6) reported persistent incisional pain at 1 yr, with an average pain intensity of 3.6 ± 2.5 (0 to 10 numeric rating scale), with 35% and 14% reporting moderate and severe pain intensities, respectively. More than half of patients with persistent pain reported needing analgesic medications, and 85% reported interference with daily activities (denominator = 495 in the above proportions). Risk factors for persistent pain included female sex (P = 0.007), Asian ethnicity (P < 0.001), surgery for fracture (P < 0.001), history of chronic pain (P < 0.001), coronary artery disease (P < 0.001), history of tobacco use (P = 0.048), postoperative patient-controlled analgesia (P < 0.001), postoperative continuous nerve block (P = 0.010), insulin initiation within 24 h of surgery (P < 0.001), and withholding nonsteroidal anti-inflammatory medication or cyclooxygenase-2 inhibitors on the day of surgery (P = 0.029 and P < 0.001, respectively). Older age (P < 0.001), endoscopic surgery (P = 0.005), and South Asian (P < 0.001), Native American/Australian (P = 0.004), and Latin/Hispanic ethnicities (P < 0.001) were associated with a lower risk of persistent pain. CONCLUSIONS: Persistent incisional pain is a common complication of inpatient noncardiac surgery, occurring in approximately 1 in 30 adults. It results in significant morbidity, interferes with daily living, and is associated with persistent analgesic consumption. Certain demographics, ethnicities, and perioperative practices are associated with increased risk of persistent pain.

Efficacy and Safety of N-Acetylcysteine for the Management of Chronic Pain in Adults: A Systematic Review and Meta-Analysis.

OBJECTIVE: To assess the efficacy and safety of N-acetylcysteine in the treatment of chronic pain. METHODS: A systematic search was carried out until April 2020 for clinical studies of N-acetylcysteine in the management of any persistent or recurrent chronic pain condition for adults ≥ 18 years old. Risk of bias was assessed using the validated risk of bias tools. When appropriate, a meta-analysis using a random-effects model was performed, with a fixed-effect model for sensitivity analysis. RESULTS: Nine studies (n = 863) were included (five randomized controlled trials [RCTs], two open-label non-comparative studies and two comparative studies), that evaluated patients with sickle cell disease (3), complex regional pain syndrome (1), pelvic pain/endometriosis (2), rheumatoid arthritis (1), diabetic neuropathy (1), and chronic neuropathic pain (1). In the pooled analysis of three RCTs, N-acetylcysteine did not reduce pain intensities (SMD -0.21, 95% confidence interval [CI]: -0.33 to 0.75, random-effects), improve functional outcomes (SMD 0.21, 95% CI -0.33 to 0.75) or quality of life (SMD 0.60, 95% CI: -4.44 to 5.64); however, sensitivity analysis with a fixed effect model demonstrated an effect for pain intensities and function. Due to adverse events being inconsistently reported, no conclusion could be made regarding safety of N-acetylcysteine in chronic pain. CONCLUSIONS: While there is some evidence to indicate N-acetylcysteine may provide analgesic efficacy for certain pain conditions, there is insufficient evidence to provide definitive evidence on NAC in chronic pain management. Larger-size RCTs spanning a variety of chronic pain conditions are needed to determine N-acetylcysteine's role, if any, in pain medicine.