Chronic post-traumatic neuropathic pain of brachial plexus and upper limb: a new technique of peripheral nerve stimulation.

The aim of the study was to evaluate the effect on pain relief in patients with peripheral neuropathic pain after brachial plexus injuries using an implanted peripheral nerve stimulator applied directly to the nerve branch involved into the axillary cavity. Seven patients with post-traumatic brachial plexus lesions or distal peripheral nerve complaining of severe intractable chronic pain were enrolled in a single-centre, open-label trial. Conventional drugs and traditional surgical treatment were not effective. Patients underwent careful neurological evaluation, pain questionnaires and quantitative sensory testing (QST). Surgical treatment consists of a new surgical technique: a quadripolar electrode lead was placed directly on the sensory peripheral branch of the main nerve involved, proximally to the site of lesion, into the axillary cavity. To assess the effect, we performed a complete neuroalgological evaluation and QST battery after 1 week and again after 1, 6 and 12 weeks. All patients at baseline experienced severe pain with severe positive phenomena in the median (5) and/or radial (2) territory. After turning on the neuro-stimulator system, all patients experienced pain relief within a few minutes (>75 % and >95 % in most), with long-lasting pain relief with a reduction in mean Numerical Rating Scale (NRS) of 76.2 % after 6 months and of 71.5 % after 12 months. No significant adverse events occurred. We recommend and encourage this surgical technique for safety reasons; complications such as dislocation of electrocatheters are avoided. The peripheral nerve stimulation is effective and in severe neuropathic pain after post-traumatic nerve injuries of the upper limbs.

Peripheral trigeminal nerve field stimulation: report of 6 cases.

OBJECT: Peripheral nerve field stimulation has been successfully used for many neuropathic syndromes. However, it has been reported as a treatment for trigeminal neuropathic pain or persistent idiopathic facial pain only in the recent years. METHODS: The authors present a review of the literature and their own series of 6 patients who were treated with peripheral nerve stimulation for facial neuropathic pain, reporting excellent pain relief and subsequent better social relations and quality of life. RESULTS: On average, pain scores in these patients decreased from 10 to 2.7 on the visual analog scale during a 17-month follow-up (range 0-32 months). The authors also observed the ability to decrease trigeminal pain with occipital nerve stimulation, clinically confirming the previously reported existence of a close anatomical connection between the trigeminal and occipital nerves (trigeminocervical nucleus). CONCLUSIONS: Peripheral nerve field stimulation of the trigeminal and occipital nerves is a safe and effective treatment for trigeminal neuropathic pain and persistent idiopathic facial pain, when patients are strictly selected and electrodes are correctly placed under the hyperalgesia strip at the periphery of the allodynia region.

The Italian Questionnaire for Cancer Breakthrough Pain Diagnosis, a Multicenter Validation Study.

INTRODUCTION: The literature lacks formally validated and reliable tools for the diagnosis of breakthrough cancer pain (BTcP). The Italian Questionnaire for BTcP diagnosis (IQ-BTP) is an 11-item questionnaire aimed at detecting potential-BTP and classifying it into three likelihood classes: high, intermediate, and low. METHODS: A multicenter, prospective, and observational study was designed to validate the IQ-BTP. In three consecutive visits with each cancer patient, the demographic and clinical details of the patient, the Brief Pain Inventory (BPI) scores, IQ-BTP outcomes, and clinicians' autonomous BTcP diagnosis (gold standard) and the agreement of this diagnosis with IQ-BTP outcomes were recorded. The assessed domains for IQ-BTP validation were: Validity, including content and face validity, construct validity (hypothesis testing, and cross-cultural validity\measurement invariance), and criterion validity; Reliability (internal consistency, reliability, and measurement error); Interpretability, and Responsiveness. RESULTS: Seven palliative and pain management facilities in Italy recruited 280 patients, yielding 753 evaluations. Using the IQ-BTP, the rate of potential-BTcP was 27.2%, of which its likely presence was high in 52.7% of patients, intermediate in 38.5, and low in 8.8%. The BPI item scores differed significantly between the two IQ-BTP classes (no-BTcP and potential-BTcP classes). The correlation of the latter class with BPI items was significant but low. The IQ-BTcP showed two principal components, accounting for 66.6% of the variance. Cronbach's α was 0.71. The agreement rate between the gold standard and IQ-BTP outcomes was 82%. Cohen's [Formula: see text] was 0.535. The IQ-BTP showed sensitivity and specificity of 69 and 86%, respectively. CONCLUSIONS: The IQ-BTP extensive formal validation showed satisfactory psychometric and validity properties. Its content, face, construct, and criterion validities and its reliability, interpretability, and responsiveness were shown. Its use enabled potential-BTcP to be identified and differentiated into three likelihood classes with direct therapeutic and epidemiological implications. The latter may be confirmed in future studies.

The management of pain from collapse of osteoporotic vertebrae with continuous intrathecal morphine infusion.

Objectives. Vertebral fractures are the most common consequences of severe osteoporosis. The chronic pain from collapse of osteoporotic vertebrae affects quality of life (QoL) and autonomy of patients. The management of pain with oral or transdermal opiates can cause severe side-effects. Continuous intrathecal administration of morphine through an implantable pump might represent an alternative therapy to conventional oral or transdermal administration of opioids and has some advantages and disadvantages for pain relief and improvement in QoL when compared to conventional opioid delivery. It is our objective to report our experience using intrathecal delivery of analgesics in a population of patients with refractory pain due to vertebral fractures. Materials and Methods. In 24 patients, refractory to conventional delivery of opioids, we used intrathecal analgesic therapy. To test for efficacy and improvement in QoL, we administered the visual analog scale (VAS) for pain and the Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO). Before patients were selected for pump implantation, an intraspinal drug delivery trial was performed to monitor side-effects and responses to intrathecal therapy. Results. Significant pain relief was obtained in all implanted patients. Using the QUALEFFO, we observed significant improvement of all variables such as QDL (quality of daily life), DW (domestic work), ambulation, and PHS (perception of health status), before and after one year after pump implantation. With intrathecal morphine infusion, none of the 24 patients required additional systemic analgesic medication. The mean morphine dose during the spinal trial was 11.28 mg/day, 7.92 mg/day at pump implantation, and 16.32 mg/day at one-year follow-up. Conclusions. Our results show that intrathecal administration of morphine efficiently relieves the symptoms of pain and improves QoL. Continuous intrathecal administration of morphine appears to be an alternative therapy to conventional analgesic drug delivery and has advantages in those patients who have severe side-effects with systemic administration of analgesics.