Site matters: Central neuropathic pain characteristics and somatosensory findings after brain and spinal cord lesions.

BACKGROUND: It is unknown if different etiologies or lesion topographies influence central neuropathic pain (CNP) clinical manifestation. METHODS: We explored the symptom-somatosensory profile relationships in CNP patients with different types of lesions to the central nervous system to gain insight into CNP mechanisms. We compared the CNP profile through pain descriptors, standardized bedside examination, and quantitative sensory test in two different etiologies with segregated lesion locations: the brain, central poststroke pain (CPSP, n = 39), and the spinal cord central pain due to spinal cord injury (CPSCI, n = 40) in neuromyelitis optica. RESULTS: Results are expressed as median (25th to 75th percentiles). CPSP presented higher evoked and paroxysmal pain scores compared to CPSCI (p < 0.001), and lower cold thermal limen (5.6°C [0.0-12.9]) compared to CPSCI (20.0°C [4.2-22.9]; p = 0.004). CPSCI also had higher mechanical pain thresholds (784.5 mN [255.0-1078.0]) compared to CPSP (235.2 mN [81.4-1078.0], p = 0.006) and higher mechanical detection threshold compared to control areas (2.7 [1.5-6.2] vs. 1.0 [1.0-3.3], p = 0.007). Evoked pain scores negatively correlated with mechanical pain thresholds (r = -0.38, p < 0.001) and wind-up ratio (r = -0.57, p < 0.001). CONCLUSIONS: CNP of different etiologies may present different pain descriptors and somatosensory profiles, which is likely due to injury site differences within the neuroaxis. This information may help better design phenotype mechanism correlations and impact trial designs for the main etiologies of CNP, namely stroke and spinal cord lesions. This study provides evidence that topography may influence pain symptoms and sensory profile. The findings suggest that CNP mechanisms might vary according to pain etiology or lesion topography, impacting future mechanism-based treatment choices.

Interdigital direct neurorrhaphy for treatment of painful neuroma due to finger amputation.

BACKGROUND: Painful neuroma following amputation is a disabling condition for which treatments are not usually satisfactory. The aim of this study is to retrospectively evaluate the results of interdigital neurorrhaphy after neuroma resection as an option for the surgical treatment of painful digital neuroma. METHOD: We retrospectively analyzed data from seven patients submitted to interdigital neurorrhaphy for treatment of digital neuroma. For evaluation of the results, the visual analog scale (VAS) for pain assessment, measurements with Simmens-Weinstein filaments and a handgrip dynamometer, and quantification of the Disabilities of the Arm, Shoulder and Hand (DASH) score were all performed. The mean improvements on the VAS and DASH scores were calculated. RESULTS: The mean follow-up was 28.3 months. All patients presented some degree of improvement in upper limb functionality and pain, and handling the affected finger was possible in all cases. The mean improvement on the VAS and DASH scores was 29.8 and 55.5 %, respectively. No patients presented long-term complications. CONCLUSION: Although this study was based on a small number of patients, it indicates that interdigital neurorrhaphy seems to be a feasible surgical treatment for painful digital neuroma.

Location of Trigger Points in a Group of Police Working Dogs: A Preliminary Study.

This study examined the percentage and location of trigger points in police working dogs. Twelve dogs housed at a military police kennel were selected through convenience sampling. Only active dogs with no comorbidities or radiographic changes doing 6 hours of intense physical activity per day were included. After orthopedic and neurological examination, dogs were palpated for the detection of trigger points (TPs), carried out by two independent examiners, with criteria of palpations previously standardized. TPs were recorded using an anatomy reference image according to the corresponding anatomical location. The percentage of TPs was highest in the lumbar portion of the longissimus dorsi muscle (42%), followed by the latissimus dorsi, pectineus, quadriceps femoris, and sartorius (33%) muscles. Most TPs were located on the right side of the body. This study's percentage of TPs in police working dogs was higher in spinal and hind limb muscles, especially on the right side. The major criteria for identifying TPs in dogs were the pain responses to palpation and contractile local response. The findings of this study could be used to refine myofascial pain prevention to reduce early retirement due to musculoskeletal pain and draw attention to this kind of problem that can also affect dogs.

Corticomotor excitability is altered in central neuropathic pain compared with non-neuropathic pain or pain-free patients.

OBJECTIVES: Central neuropathic pain (CNP) is associated with altered corticomotor excitability (CE), which can potentially provide insights into its mechanisms. The objective of this study is to describe the CE changes that are specifically related to CNP. METHODS: We evaluated CNP associated with brain injury after stroke or spinal cord injury (SCI) due to neuromyelitis optica through a battery of CE measurements and comprehensive pain, neurological, functional, and quality of life assessments. CNP was compared to two groups of patients with the same disease: i. with non-neuropathic pain and ii. without chronic pain, matched by sex and lesion location. RESULTS: We included 163 patients (stroke=93; SCI=70: 74 had CNP, 43 had non-neuropathic pain, and 46 were pain-free). Stroke patients with CNP had lower motor evoked potential (MEP) in both affected and unaffected hemispheres compared to non- neuropathic pain and no-pain patients. Patients with CNP had lower amplitudes of MEPs (366 µV ±464 µV) than non-neuropathic (478 ±489) and no-pain (765 µV ± 880 µV) patients, p < 0.001. Short-interval intracortical inhibition (SICI) was defective (less inhibited) in patients with CNP (2.6±11.6) compared to no-pain (0.8±0.7), p = 0.021. MEPs negatively correlated with mechanical and cold-induced allodynia. Furthermore, classifying patients' results according to normative data revealed that at least 75% of patients had abnormalities in some CE parameters and confirmed MEP findings based on group analyses. DISCUSSION: CNP is associated with decreased MEPs and SICI compared to non-neuropathic pain and no-pain patients. Corticomotor excitability changes may be helpful as neurophysiological markers of the development and persistence of pain after CNS injury, as they are likely to provide insights into global CE plasticity changes occurring after CNS lesions associated with CNP.

Dissecting central post-stroke pain: a controlled symptom-psychophysical characterization.

Central post-stroke pain affects up to 12% of stroke survivors and is notoriously refractory to treatment. However, stroke patients often suffer from other types of pain of non-neuropathic nature (musculoskeletal, inflammatory, complex regional) and no head-to-head comparison of their respective clinical and somatosensory profiles has been performed so far. We compared 39 patients with definite central neuropathic post-stroke pain with two matched control groups: 32 patients with exclusively non-neuropathic pain developed after stroke and 31 stroke patients not complaining of pain. Patients underwent deep phenotyping via a comprehensive assessment including clinical exam, questionnaires and quantitative sensory testing to dissect central post-stroke pain from chronic pain in general and stroke. While central post-stroke pain was mostly located in the face and limbs, non-neuropathic pain was predominantly axial and located in neck, shoulders and knees (P < 0.05). Neuropathic Pain Symptom Inventory clusters burning (82.1%, n = 32, P < 0.001), tingling (66.7%, n = 26, P < 0.001) and evoked by cold (64.1%, n = 25, P < 0.001) occurred more frequently in central post-stroke pain. Hyperpathia, thermal and mechanical allodynia also occurred more commonly in this group (P < 0.001), which also presented higher levels of deafferentation (P < 0.012) with more asymmetric cold and warm detection thresholds compared with controls. In particular, cold hypoesthesia (considered when the threshold of the affected side was <41% of the contralateral threshold) odds ratio (OR) was 12 (95% CI: 3.8-41.6) for neuropathic pain. Additionally, cold detection threshold/warm detection threshold ratio correlated with the presence of neuropathic pain (ρ = -0.4, P < 0.001). Correlations were found between specific neuropathic pain symptom clusters and quantitative sensory testing: paroxysmal pain with cold (ρ = -0.4; P = 0.008) and heat pain thresholds (ρ = 0.5; P = 0.003), burning pain with mechanical detection (ρ = -0.4; P = 0.015) and mechanical pain thresholds (ρ = -0.4, P < 0.013), evoked pain with mechanical pain threshold (ρ = -0.3; P = 0.047). Logistic regression showed that the combination of cold hypoesthesia on quantitative sensory testing, the Neuropathic Pain Symptom Inventory, and the allodynia intensity on bedside examination explained 77% of the occurrence of neuropathic pain. These findings provide insights into the clinical-psychophysics relationships in central post-stroke pain and may assist more precise distinction of neuropathic from non-neuropathic post-stroke pain in clinical practice and in future trials.

Pain relief and functional recovery in patients with complex regional pain syndrome after motor cortex stimulation.

In addition to pain and neurovegetative symptoms, patients with severe forms of complex regional pain syndrome (CRPS) develop a broad range of symptoms, including sensory disturbances, motor impairment and dystonic posturing. While most patients respond to medical therapy, some are considered refractory and become surgical candidates. To date, the most commonly used surgical procedure for CRPS has been spinal cord stimulation. This therapy often leads to important analgesic effects, but no sensory or motor improvements. We report on 2 patients with pain related to CRPS and severe functional deficits treated with motor cortex stimulation (MCS) who not only had significant analgesic effects, but also improvements in sensory and motor symptoms. In the long term (27 and 36 months after surgery), visual analog scale pain scores were improved by 60-70% as compared to baseline. There was also a significant increase in the range of motion in the joints of the affected limbs and an improvement in allodynia, hyperpathia and hypoesthesia. Positron emission tomography scan in both subjects revealed that MCS influenced regions involved in the circuitry of pain.

Dry needling has lasting analgesic effect in shoulder pain: a double-blind, sham-controlled trial.

INTRODUCTION: Myofascial pain syndrome (MPS) affects most patients with chronic shoulder pain. Dry needling (DN) is a common treatment for MPS, but its temporal pattern and sensory effects remain unknown. OBJECTIVES: We evaluated in a randomized, sham-controlled study the pattern of analgesic efficacy and local sensory changes of a single session of DN for MPS in patients with chronic shoulder pain. METHODS: Patients with chronic shoulder pain were randomized into active (n = 20) or sham (n = 21) groups. A single DN was performed by a researcher blinded to group assignment and pain outcomes. Pain intensity was assessed by the numeric rating score, and sensory thresholds were evaluated with a quantitative sensory testing protocol, including the area of tactile sensory abnormalities 7 days before needling, right before, and 7 days after the intervention. RESULTS: Dry needling led to significant larger pain intensity reduction (from 6.30 ± 2.05 to 2.40 ± 2.45 in the active group; P = 0.02, effect size = -1.3 (95% CI [-2.0 to -0.68]); (number necessary to treat = 2.1). Pain reduction scores were significantly different on the second day after needling and persisted so until the seventh day and were accompanied by improvement in other dimensions of pain and a decrease in the area of mechanical hyperalgesia in the active DN group alone (P < 0.05). CONCLUSION: Active trigger points DN provided analgesic effects compared with sham and decreased the area of local mechanical hyperalgesia. These findings have practical clinical implications and may provide mechanistic insights behind MPS.

Prevalence of chronic pain in developing countries: systematic review and meta-analysis.

Chronic pain (CP) is prevalent worldwide. Current reports on its prevalence in developing countries are heterogeneous, and to date, there is no quantitative synthesis providing a general estimation of its magnitude in the developing world. The goal of this study was to estimate the pooled prevalence of CP in the general population in developing countries. This was a PROSPERO-registered CRD42019118680 systematic review including population-based cross-sectional studies on CP from countries with ≤0.8 human developing index. We calculated prevalence using both random effects and fixed effects. Heterogeneity was calculated by the Cochran Q test and the I2 statistic. Publication bias was evaluated by visual inspection of the Egger funnel plot, as well as by the Begg rank test and the Egger linear test. Sources of heterogeneity were also explored in subgroup analyses. Twelve studies with a total of 29,902 individuals were included in this meta-analysis, of which 7263 individuals were identified with CP. The overall pooled prevalence of CP after correction for publication bias was 18% (95% confidence interval: 10%-29%), the sample presenting significant heterogeneity (I2 = 100%, P < 0.001). Subgroup analyses demonstrated that year of publication and the adopted threshold for pain chronicity could partially explain the observed heterogeneity (P < 0.05). The proportion of individuals with CP in the general population of developing countries was 18%. However, reports of prevalence have high variability, especially related to year of publication and the threshold level adopted for pain chronicity.

Prognostic model for patients with traumatic brain injuries and abnormal computed tomography scans.

Traumatic brain injury (TBI) is an important cause of death and disability worldwide. The prognosis evaluation is a challenge when many variables are involved. The authors aimed to develop prognostic model for assessment of survival chances after TBI based on admission characteristics, including extracranial injuries, which would allow application of the model before in-hospital therapeutic interventions. A cohort study evaluated 1275 patients with TBI and abnormal CT scans upon admission to the emergency unit of Hospital das Clinicas of University of Sao Paulo and analyzed the final outcome on mortality. A logistic regression analysis was undertaken to determine the adjusted weigh of each independent variable in the outcome. Four variables were found to be significant in the model: age (years), Glasgow Coma Scale (3-15), Marshall Scale (MS, stratified into 2,3 or 4,5,6; according to the best group positive predictive value) and anysochoria (yes/no). The following formula is in a logistic model (USP index to head injury) estimates the probability of death of patients according to characteristics that influence on mortality. We consider that our mathematical probability model (USP Index) may be applied to clinical prognosis in patients with abnormal CT scans after severe traumatic brain injury.

Retrato da Dor: um caminho para entender o sofrimento do indivíduo / Pain Portrait: a way to understand individual suffering

Resumo Este estudo tem por objetivo verificar o sofrimento associado às dores crônicas, por meio do instrumento projetivo "Retrato da Dor". Trata-se de um estudo descritivo, realizado com 126 pacientes com dores crônicas de diversas etiologias. As respostas foram analisadas de acordo com o método de análise de conteúdo de Bardin e testes estatísticos. Foram encontrados pacientes: que acreditam que nenhum sofrimento se compara com a sua dor (34,9%); que comparam sua dor a outras dores ou doenças já experienciadas (16,6%); e os que comparam a dor a situações de sofrimento emocional (48,4%). Este estudo evidenciou que os aspectos emocionais desempenham um papel importante na maneira como o indivíduo irá interpretar e utilizar recursos próprios para lidar com suas dores.

Abstract This study aims to verify the suffering associated with chronic pain through the projective instrument "Pain Portrait". It is a descriptive study carried out with 126 patients with chronic pain of different etiologies. Responses were analyzed according to the Bardin content analysis method and statistical tests. Patients were found: who believe that no suffering compares to their pain (34.9%); Who compare their pain to other pains or diseases already experienced (16.6%); And those who compare pain to situations of emotional distress (48.4%). This study showed that emotional aspects play an important role in how the individual will interpret and use his or her own resources to deal with their pain.

Temporomandibular disorders in fibromyalgia patients: are there different pain onset?

OBJECTIVE: To identify temporomandibular disorders (TMD) symptoms in two groups of fibromyalgia patients according to the temporal relation between the onset of facial pain (FP) and generalized body pain (GBP). CROSS-SECTIONAL STUDY DESIGN: Fifty-three consecutive women with fibromyalgia and FP were stratified according to the onset of orofacial pain: Group-A (mean age 47.30 ± 14.20 years old), onset of FP preceded GBP; Group-B (mean age 51.33 ± 11.03 years old), the FP started concomitant or after GBP. CLINICAL ASSESSMENT: Research Diagnostic Criteria for Temporomandibular Disorders and the Visual Analogue Scale. RESULTS: Myofascial pain with mouth opening limitation (p = 0.038); right disc displacement with reduction (p = 0.012) and jaw stiffness (p = 0.004) were predominant in Group A. Myofascial pain without mouth opening limitation (p = 0.038) and numbness/burning were more common in Group B. CONCLUSION: All patients had temporomandibular joint symptoms, mainly muscle disorders. The prevalence of myofascial pain with limited mouth opening and right TMJ disc displacement with reduction were higher in Group A.

Cavernous carotid artery aneurysms: epidemiology, natural history, diagnostic and treatment. An experience of a single institution.

BACKGROUND: Cavernous carotid aneurysms (CCA) account for 2-9% of all intracranial aneurysms. They have been considered benign lesions, most often asymptomatic, and to have a natural history with a low risk of life-threatening complications. These aneurysms are unique, their rupture can present in many different forms, they can suffer spontaneous thrombotic changes and the symptomatology related to the mass effect involves the neuro-ophthalmologic system. In this scenario the natural history and clinical presentation are largely different from other intracranial aneurysms. Some investigators advocate treatment of both symptomatic and asymptomatic CCAs, others recommend no treatment. The reason for this controversy relates to a lack of information on the long term natural history of these aneurysms, as well as on the long term results of treatment. METHODS: In this article the authors discuss their single institution experience in diagnosis, natural history and management of 123 asymptomatic and oligosympotomatic aneurysms located in the cavernous portion of internal carotid artery. CONCLUSIONS: According to our results asymptomatic or olygosymptomatic (pain) CCAs should be conservatively managed with serial images while the others presentations should be analyzed by a multidisciplinary team, involving the neuroendovascular and microsurgical services.

Thoracic sympathetic block for the treatment of complex regional pain syndrome type I: a double-blind randomized controlled study.

Pain relief in complex regional pain syndrome (CRPS) remains a major challenge, in part due to the lack of evidence-based treatment trials specific for this condition. We performed a long-term randomized, double-blinded active-control study to evaluate the efficacy of thoracic sympathetic block (TSB) for upper limb type I CRPS. The study objective was to evaluate the analgesic effect of TSB in CRPS. Patients with CRPS type I were treated with standardized pharmacological and physical therapy and were randomized to either TSB or control procedure as an add-on treatment. Clinical data, pain intensity, and interference (Brief Pain Inventory), pain dimensions (McGill Pain Questionnaire [MPQ]), neuropathic characteristics (Neuropathic Pain Symptom Inventory [NPSI]), mood, upper limb function (Disabilities of Arm, Shoulder and Hand), and quality of life were assessed before, and at 1 month and 12 months after the procedure. Thirty-six patients (19 female, 44.7 ± 11.1 years of age) underwent the procedure (17 in the TSB group). Average pain intensity at 1 month was not significantly different after TSB (3.5 ± 3.2) compared to control procedure (4.8 ± 2.7; P=0.249). At 12 months, however, the average pain item was significantly lower in the TSB group (3.47 ± 3.5) compared to the control group (5.86 ± 2.9; P=0.046). Scores from the MPQ, evoked-pain symptoms subscores (NPSI), and depression scores (Hospital Anxiety and Depression Scale) were significantly lower in the TSB group compared to the control group at 1 and at 12 months. Other measurements were not influenced by the treatment. Quality of life was only slightly improved by TSB. No major adverse events occurred. Larger, multicentric trials should be performed to confirm these original findings.

Use of low intensity laser treatment in neuropathic pain refractory to clinical treatment in amputation stumps.

Debilitating stump pain following amputation surgery is a major problem when it affects the patient's quality of life, often making the patient totally dependent on others for their day-to-day care. Attempts have been made to treat those patients through pharmacological, psychological, and physical therapies, but in many cases these fail to relieve the pain. This article focuses on three patients with chronic, intense, and debilitating stump pain who were previously treated with pain medications, but with little success. These patients underwent nine sessions of low-intensity laser therapy (LILT) to the stump - this is a new treatment that has been used to treat other pain disorders. All patients reported a decrease in the intensity of their pain and increased ability to perform daily living activities during a 4-month follow-up.

Concept of acute neuropathic pain. The role of nervi nervorum in the distinction between acute nociceptive and neuropathic pain / Conceito de dor neuropática aguda. O papel do nervi nervorum na distinção entre dores agudas nociceptiva e neuropática

ABSTRACT BACKGROUND AND OBJECTIVES: Several pathophysiological mechanisms are involved in the genesis of neuropathic pain. However, available justifications for its onset are unsatisfying and do not explain the participation of nervi nervorum and nervi vasorum abnormalities on functional aberrations which characterize pain generated by injuries to the peripheral nervous system. There are evidences that nervi nervorum contribute to the development and justify many clinical findings and prophylactic, therapeutic and rehabilitation alternatives related to neuropathic pain. This study aimed at presenting a review of anatomic and functional studies and theories about their objectives and at giving examples of conditions in which nervi nervorum have markedly participated in neuropathic pain generation and maintenance. CONTENTS: Nervi nervorum are a set of unmyelinated or poorly myelinated fibers located in peripheral nerves sheaths which, among other functions, seem to participate in the transmission of evoked sensory information and in the environmental regulation of peripheral nervous system structures. CONCLUSION: Nervi nervorum structural and functional abnormalities may contribute to the onset, maintenance and worsening of neuropathic pain and "demodulatory" painful syndromes. Further studies, especially with the application of more specific and sensitive histological, biochemical and electrophysiological methods are necessary to clarify the realities of their biologies.

RESUMO JUSTIFICATIVA E OBJETIVOS: Diversos mecanismos fisiopatológicos estão envolvidos na gênese das dores neuropáticas. Entretanto as justificativas disponíveis para sua ocorrência são insatisfatórias e em nada esclarecem a ocorrência das assim chamadas dores desmodulatórias. Há crescente interesse em se compreender a participação das anormalidades dos nervi nervorum e nervi vasorum nas aberrações funcionais que caracterizam as dores geradas pelas lesões que acometem o sistema nervoso periférico. Há evidências de que os nervi nervorum contribuem para desenvolvimento e justificam muitos dos resultados clínicos e as alternativas profiláticas, terapêuticas e reabilitacionais relacionadas às dores neuropáticas. O objetivo deste estudo foi apresentar uma revisão sobre os estudos anatômicos e funcionais e as teorias sobre suas finalidades e exemplificar condições em que os nervi nervorum participam de modo marcante na sua geração e manutenção da dor neuropática. CONTEÚDO: Os nervi nervorum são um conjunto de fibras amielínicas ou pouco mielinizadas localizadas nas bainhas dos nervos periféricos que, dentre outras funções, parecem participar da veiculação de informações sensitivas evocadas assim como da regulação do meio ambiente nas estruturas do sistema nervoso periférico. CONCLUSÃO: As anormalidades estruturais ou funcionais dos nervi nervorum podem contribuir para a ocorrência, manutenção e agravamento das dores neuropáticas e das síndromes dolorosas "desmodulatórias". Mais estudos, em especial com a aplicação de métodos histológicos, bioquímicos e eletrofisiológicos mais específicos e sensíveis são necessários para esclarecer as realidades de suas biologias.

Failed back surgery pain syndrome: therapeutic approach descriptive study in 56 patients.

OBJECTIVE: The authors show the clinical evaluation and follow-up results in 56 patients diagnosed with a failed back surgery pain syndrome. METHODS: Descriptive and prospective study conducted over a one-year period. In this study, 56 patients with a failed back surgery pain syndrome were assessed in our facility. The age ranged from 28 to 76 years (mean, 48.8 ± 13.9 years). The pain was assessed through a Visual Analog Scale (VAS). RESULTS: Postoperative pain was more severe (mean VAS score 8.3) than preoperative pain (7.2). Myofascial pain syndromes (MPS) were diagnosed in 85.7% of patients; neuropathic abnormalities associated or not with MPS were found in 73.3%. Drug therapy associated with physical medicine treatment provided > 50% pain improvement in 57.2% of cases; trigger point injection in 60.1%, and epidural infusion of morphine with lidocaína in 69.3% of refractory cases. CONCLUSION: In patients with a post-laminectomy syndrome, postoperative pain was more severe than preoperative pain from a herniated disk. A miofascial component was found in most patients.

Temporomandibular disorders in fibromyalgia patients: are there different pain onset? / Disfunção termomandibuar em doentes com fibromialgia: há diferença no início das dores?

ABSTRACT Objective To identify temporomandibular disorders (TMD) symptoms in two groups of fibromyalgia patients according to the temporal relation between the onset of facial pain (FP) and generalized body pain (GBP). Cross-sectional study design: Fifty-three consecutive women with fibromyalgia and FP were stratified according to the onset of orofacial pain: Group-A (mean age 47.30 ± 14.20 years old), onset of FP preceded GBP; Group-B (mean age 51.33 ± 11.03 years old), the FP started concomitant or after GBP. Clinical assessment Research Diagnostic Criteria for Temporomandibular Disorders and the Visual Analogue Scale. Results Myofascial pain with mouth opening limitation (p = 0.038); right disc displacement with reduction (p = 0.012) and jaw stiffness (p = 0.004) were predominant in Group A. Myofascial pain without mouth opening limitation (p = 0.038) and numbness/burning were more common in Group B. Conclusion All patients had temporomandibular joint symptoms, mainly muscle disorders. The prevalence of myofascial pain with limited mouth opening and right TMJ disc displacement with reduction were higher in Group A.

RESUMO Objetivo Identificar sintomas de disfunção temporomandibular (DTM) em dois grupos de pacientes fibromiálgicas, segundo a relação temporal entre o início da dor facial (DF) e das dores generalizadas no corpo (DGC). Estudo transversal: 53 pacientes consecutivas com fibromialgia e DF foram divididas de acordo com o início da dor orofacial: Grupo A (média de idade 47,30 ± 14,20anos), o início da DF precedeu o da DGC; Grupo-B (idade média 51,33 ± 11,03anos), a DF iniciou concomitantemente ou após a DGC. Avaliação clínica: Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) e escala visual analógica (EVA). Resultados Dor miofascial com limitação de abertura bucal (p = 0,038); deslocamento de disco à direita com redução (p = 0,012) e rigidez mandibular (p = 0,004) foram predominantes no Grupo A. Dor miofascial sem limitação de abertura bucal (p = 0,038) e dormência/queimação foram mais comuns no Grupo-B. Conclusão Todos os pacientes tiveram sintomas de DTM, principalmente disfunção muscular. A prevalência de dor miofascial com limitação de abertura bucal e deslocamento de disco à direita com redução foi maior no Grupo A.

Repetitive transcranial magnetic stimulation is efficacious as an add-on to pharmacological therapy in complex regional pain syndrome (CRPS) type I.

UNLABELLED: Single-session repetitive transcranial magnetic stimulation (rTMS) of the motor cortex (M1) is effective in the treatment of chronic pain patients, but the analgesic effect of repeated sessions is still unknown. We evaluated the effects of rTMS in patients with refractory pain due to complex regional pain syndrome (CRPS) type I. Twenty-three patients presenting CRPS type I of 1 upper limb were treated with the best medical treatment (analgesics and adjuvant medications, physical therapy) plus 10 daily sessions of either real (r-) or sham (s-) 10 Hz rTMS to the motor cortex (M1). Patients were assessed daily and after 1 week and 3 months after the last session using the Visual Analogical Scale (VAS), the McGill Pain Questionnaire (MPQ), the Health Survey-36 (SF-36), and the Hamilton Depression (HDRS). During treatment there was a significant reduction in the VAS scores favoring the r-rTMS group, mean reduction of 4.65 cm (50.9%) against 2.18 cm (24.7%) in the s-rTMS group. The highest reduction occurred at the tenth session and correlated to improvement in the affective and emotional subscores of the MPQ and SF-36. Real rTMS to the M1 produced analgesic effects and positive changes in affective aspects of pain in CRPS patients during the period of stimulation. PERSPECTIVE: This study shows an efficacy of repetitive sessions of high-frequency rTMS as an add-on therapy to refractory CRPS type I patients. It had a positive effect in different aspects of pain (sensory-discriminative and emotional-affective). It opens the perspective for the clinical use of this technique.

Hematoma epidural diagnosticado por diplopia - Relato de caso / Epidural Hematoma Diagnosed by Diplopia - Case Report

Os autores relatam e discutem o mecanismo pelo qual um paciente de 33 anos, com relato de traumatismo crânio encefálico ocorrido 5 dias antes comperda de consciência no momento do traumatismo, e assintomático nos 4 dias sequentes, iniciou diplopia no quinto dia após o traumatismo, sintoma que provocou sua ida ao pronto-socorro, a realização de exame físico neurológico normal e de tomografia do crânio devido a história e mecanismo de traumatismo, que revelou hematoma epidural occipital, prontamente operado, com o sintoma de diplopia tendo desaparecido no 14o dia após a cirurgia, já com o paciente em casa.

The authors report a male of 33 years that after head trauma occurred 5 days before developed diplopia, which motivated him to go to the emergency room, where even without changes in neurological examination, brain CT scan performed revealed an epidural hematoma occipital, operated with good functional outcome.

[Pharmacological treatment of neuropathic pain]. / Tratamento farmacologico da dor neuropatica.

Neuropathic pain (NP), in view of its non-nociceptive component, is not caused by physiological lesions but by problems in the nervous system itself, whether in the central nervous system (CNS) or peripheral nervous system (PNS). This particular action mechanism makes NP a very difficult-to-treat condition, resistant to most of the commonly used analgesic drugs. A recent study stated that NP has an incidence of 1.24% over the general population, and this percentage increases if we consider acute radiculopathies and some recurrent neuropathies, frequently considered not only neuropathic pain but also nociceptive. Thus, the improvement of NP treatment has become a public health necessity. While WHO recommendations include a three-lined scale in pain treatment -including NSAIDs as the first-line drugs, soft opioids (tramadol or codein) as the second-line, and strong opioids (morphine, oxycodone, and phentanyl) as the third-line- some studies have found this rationale not useful in NP treatment. Based on several studies as STEP, Spanish Pain Society recommendations included antidepressant and anticonvulsant drugs as the first line treatment. Pregabalin, a new neuromodulators class drug, provides a pharmacokinetic profile than its predecessors (phenytoin, carbamazepine, gabapentin, topiramate, oxcarbazepine, and lamotrigine), and showed effectiveness controlling peripheral neuropathic pain. Thus, pregabalin opened the door to a new approach to NP. Other pain societies, such as the Canada Pain Society, have also included pregabalin in the first line treatment of NP. In fact, gabapentin and pregabalin are the current standard care in most of NP-associated diseases.