The Role of Orthoses in Chronic Axial Spinal Conditions.

PURPOSE OF REVIEW: Bracing represents a prevalent conservative, non-surgical approach used in the management of chronic spinal conditions such as spondylosis, degenerative disc disease, and spondylolisthesis. A wide variety of orthoses are available to aid in addressing cervical, thoracic, lumbar, thoracic, and SI joint pain. In this review, we aim to comprehensively examine brace types with their current applications and implications of usage. RECENT FINDINGS: There are multiple cervical bracing options, such as soft and rigid collars, to assist in managing acute trauma and chronic degenerative conditions. The review highlights the nuanced decision-making process between hard and soft collars based on the severity of bone or ligamentous injury and neurological findings. Orthoses for low back pain are commonly used. The review highlights the challenges of chronic neck and lower back pain, emphasizing the importance of clinicians exploring all treatment strategies including braces which can improve function and reduce pain.

Diabetic Neuropathy: Pathophysiology Review.

PURPOSE OF REVIEW: Diabetic neuropathy is a debilitating complication of diabetes mellitus that affects millions of individuals worldwide. It is characterized by nerve damage resulting from prolonged exposure to high blood glucose levels. Diabetic neuropathy may cause a range of symptoms, including pain, numbness, muscle weakness, autonomic dysfunction, and foot ulcers, potentially causing significant impairment to the quality of life for those affected. This review article aims to provide a comprehensive overview of the pathophysiology of diabetic neuropathy. The etiology of diabetic neuropathy will be discussed, including risk factors, predisposing conditions, and an overview of the complex interplay between hyperglycemia, metabolic dysregulation, and nerve damage. Additionally, we will explore the molecular mechanisms and pathways of diabetic neuropathy, including the impact of hyperglycemia on nerve function, abnormalities in glucose metabolism, the role of advanced glycation end products (AGEs), and inflammatory and immune-mediated processes. We will provide an overview of the various nerve fibers affected by diabetic neuropathy and explore the common symptoms and complications associated with diabetic neuropathy in the pain medicine field. RECENT FINDINGS: This review highlights advances in understanding the pathophysiology of diabetic neuropathy as well as reviews potential novel therapeutic strategies and promising areas for future research. In conclusion, this review article aims to shed light on the pathophysiology of diabetic neuropathy, its far-reaching consequences, and the evolving strategies for prevention and management. In understanding the mechanisms of diabetic neuropathy and the ongoing research in this area, healthcare professionals can better serve patients with diabetes, ultimately improving well-being and reducing complications.

Interventional Treatment Modalities for Chronic Abdominal and Pelvic Visceral Pain.

PURPOSE OF REVIEW: Chronic abdominal and pelvic visceral pain is an oftentimes difficult to treat pain condition that requires a multidisciplinary approach. This article specifically reviews the interventional treatment options for pain resulting from visceral abdominal and pelvic pain. RECENT FINDINGS: Sympathetic nerve blocks are the main interventional option for the treatment of chronic abdominal and pelvic visceral pain. Initially, nerve blocks are performed, and subsequently, neurolytic injections (alcohol or phenol) are longer term options. This review describes different techniques for sympathetic blockade. Neuromodulation is a potential option via dorsal column stimulation or dorsal root ganglion stimulation. Finally, intrathecal drug delivery is sometimes appropriate for refractory cases. This paper will review interventional options for the treatment of chronic abdominal and pelvic visceral pain.

Comprehensive Review of Topical Analgesics for Chronic Pain.

PURPOSE OF REVIEW: Topical analgesics are a non-opioid option for the treatment of chronic pain conditions including neuropathic pain, musculoskeletal pain, and osteoarthritis. There are many topical medications available; however their efficacy is variable. This article reviews the various topical analgesics, their mechanisms of action, and their efficacy. RECENT FINDINGS: Studies have found topical NSAIDs are useful in treating acute musculoskeletal pain syndromes (strains and sprains) and show some efficacy in treating hand and knee osteoarthritis (Derry et al. Cochrane Database Syst Rev 5:CD008609, 2017). Topical capsaicin 8% has been shown to be efficacious in the treatment of postherpetic neuralgia, painful diabetic peripheral neuropathy, and HIV-neuropathy (Derry et al. Cochrane Database Syst Rev 1:CD007393, 2017). Topical lidocaine has been widely studied and found to reduce pain in patients with postherpetic neuralgia (Knezevic et al. Pain Manag 7:537-58, 2017). Although many other topical analgesics are available, there is limited data to support the efficacy of other agents. Topical analgesics are a relatively benign treatment for chronic pain conditions including neuropathic pain, musculoskeletal, and myofascial pain. There is evidence to support the use of topical NSAIDs, high concentration topical capsaicin, and topical lidocaine for various painful conditions.

Interventional Modalities to Treat Complex Regional Pain Syndrome.

PURPOSE OF REVIEW: Complex regional pain syndrome (CRPS) is a debilitating pain condition that often requires a multidisciplinary approach including medication, physical therapy, occupational therapy, psychological therapy, and interventional procedures to restore the patient's quality of life. This article reviews the interventional treatments for pain resulting from CRPS. RECENT FINDINGS: Sympathetic nerve blocks (stellate ganglion and lumbar sympathetic) are the first-line interventional treatment options for patients with CRPS of the upper and lower extremities, respectively. Fluoroscopic techniques for lumbar sympathetic blocks have not significantly changed throughout the years. However, both novel fluoroscopic and ultrasound approaches to stellate ganglion blockade have arisen. In addition, novel neuromodulation therapies to treat CRPS have been developed to include new waveforms with dorsal column stimulation and entirely new nerve targets such as dorsal root ganglion stimulation. This paper will review the latest interventional treatment options available for the treatment of CRPS.

Mechanism of Action of Peripheral Nerve Stimulation.

PURPOSE OF REVIEW: The number of applications for peripheral nerve stimulation (PNS) in the pain management field is ever-growing. With the increasing number of clinical applications for peripheral nerve stimulation, the purpose of this article is to review the mechanism of action surrounding PNS, the recent literature from January 2018 to January 2021, and pertinent clinical outcomes. RECENT FINDINGS: The authors searched articles identified from PubMed (January 2018-January 2021), Cochrane Central Register of Controlled Trials databases (January 2018-January 2021), and Scopus (January 2018-January 2021) databases, and manually searched references of identified publications. Broad MeSH terms and Boolean operators were queried in each search, including the following terms and their respective synonyms: peripheral nerve stimulation, mechanism of action, biochemical pathway, and pain pathway. 15 consensus articles were selected for in-depth review and inclusion for qualitative analysis. PNS may activate and modulate higher central nervous system (CNS) centers, including the dorsal lateral prefrontal cortex, somatosensory cortex, anterior cingulate cortex, and parahippocampal areas. Neuromodulatory effects from PNS may also extend into the spinal columns. Also, PNS may lead to changes in endogenous neurotransmitters and affect the plasticity of NMDA pathways.

The Impact of the Quantity and Quality of Social Support on Patients with Chronic Pain.

PURPOSE OF REVIEW: Social support is an important yet often overlooked aspect of chronic pain management. Understanding the impact of social support on patients with chronic pain and determining if a relationship exists between a patient's perceived social support and their perceived quality of life is a crucial component to completely treating a pain patient. We sought to develop an intervention for patients with chronic pain that addresses the different types of social support, barriers to using social support, and ways to improve the quality of their social support. RECENT FINDINGS: A retrospective review of a prospectively collected database was utilized in an Outpatient Chronic Pain Rehabilitation Program with 23 patients with a chronic pain diagnosis who participated in a 3-week comprehensive pain rehabilitation program. Evaluation, intervention, and discharge were evaluated utilizing The American Chronic Pain Association's Quality of Life Scale and The Canadian Occupational Performance Measure (COPM). The intervention phase comprised a 45-min group session. At discharge, the occupational therapist followed up with the patient regarding the results of their social survey. Overall, the results indicated an underutilization of social support among patients with chronic pain. Out of the four questions asked on the social support survey, patients scored their use of tangible support (Q2) as the lowest. No significant positive correlation (0.27) was found between social support and quality of life which can be attributed to the wide variety of patients seen at the PRC. Social support is an essential part of chronic pain treatment and should be addressed throughout all stages of pain management.

Cannabis for the Treatment of Fibromyalgia: A Systematic Review.

Fibromyalgia is a common disease syndrome characterized by chronic pain and fatigue in conjunction with cognitive dysfunction such as memory difficulties. Patients currently face a difficult prognosis with limited treatment options and a diminished quality of life. Given its widespread use and potential efficacy in treating other types of pain, cannabis may prove to be an effective treatment for fibromyalgia. This review aims to examine and discuss current clinical evidence regarding the use of cannabis for the treatment of fibromyalgia. An electronic search was conducted on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus using Medical Subject Heading (MeSH) terms on all literature published up to October 2022. A follow-up manual search included a complete verification of relevant studies. The results of four randomized controlled trials (RCTs) and five observational studies (a total of 564 patients) that investigated the effects of cannabis on fibromyalgia symptoms were included in this review. Of the RCTs, only one demonstrated that cannabinoids did not have a different effect than placebo on pain responses. Overall, this analysis shows low-quality evidence supporting short-term pain reduction in people with fibromyalgia treated with cannabinoid therapeutics. Although current evidence is limited, medical cannabis appears to be a safe alternative for treating fibromyalgia.

The American Society of Pain and Neuroscience (ASPN) Guidelines for Radiofrequency Ablative Procedures in Patients with Implanted Devices.

Radiofrequency ablation (RFA) is a treatment modality used in interventional pain management to treat several conditions including chronic neck or back pain, sacroiliac joint pain, major joint pain, and pain from sites that can be isolated to a sensory nerve amenable to RFA. The goals of such procedures are to reduce pain, improve function, delay need for surgical intervention, and reduce pain medication consumption. As applications for RFA expand through novel techniques and nerve targets, there is concern with how RFA may impact patients with implanted medical devices. Specifically, the electrical currents used in RFA produce electromagnetic interference, which can result in unintentional energy transfer to implanted devices. This may also interfere with device function or cause damage to the device itself. As the number of patients with implanted devices increases, it is imperative to establish guidelines for the management of implanted devices during RFA procedures. This review aims to establish guidelines to assist physicians in the preoperative, intraoperative, and postoperative management of implanted devices in patients undergoing procedures using radiofrequency energy. Here, we provide physicians with background knowledge and a summary of current evidence to allow safe utilization of RFA treatment in patients with implanted devices such as cardiac implantable electronic devices, spinal cord stimulators, intrathecal pumps, and deep brain stimulators. While these guidelines are intended to be comprehensive, each patient should be assessed on an individual basis to optimize outcomes.

Stellate ganglion block as a treatment for vasomotor symptoms: Clinical application.

Vasomotor symptoms, also called hot flashes, hot flushes, and night sweats, are common during the menopause transition. Severe symptoms can substantially decrease quality of life. The authors first review current hormonal and nonhormonal therapies, then review evidence supporting the potential use of stellate ganglion block for managing vasomotor symptoms in perimenopausal and postmenopausal women.

Multispecialty perspective on intradural disc herniation: diagnosis and management - A case report.

BACKGROUND: Intradural disc herniation (IDH) is a very rare and challenging diagnosis, with an estimated incidence of less than 1.5%. The pathogenesis of IDH remains uncertain. Definitive management remains surgical; however, some cases may initially be managed non-surgically. CASE: A middle-aged male with presented with acute right-sided lumbar radiculopathy following heavy lifting. History was significant for prior lumbar disc herniation managed non-surgically. Lumbar MRI demonstrated a large disc herniation. The patient was initially treated non-surgically with epidural steroid injections. At 4-months, he re-injured and follow-up images demonstrated the herniated disc penetrating the dura and the diagnosis of intradural disc herniation. CONCLUSIONS: The present case is rare because the IDH occurred at the L3-4 level and resulted in unilateral radiculopathy without cauda-equina symptoms and occurred in the absence of prior surgery. This patient was initially treated non-surgically with satisfactory relief, however, reinjury led to progression of IDH with new neurological deficits necessitating surgery.

A Comprehensive Review of Alternative Therapies for the Management of Chronic Pain Patients: Acupuncture, Tai Chi, Osteopathic Manipulative Medicine, and Chiropractic Care.

INTRODUCTION: Non-pharmacologic alternative therapies for pain have been around for a long time, some for hundreds of years. They have been used throughout history to treat many issues. RECENT FINDINGS: Currently, alternative medicine is most frequently used to treat musculoskeletal pain, and between 59 and 90% of patients utilizing alternative therapies for chronic pain claimed they were helpful and can serve as an effective adjunctive for the treatment of chronic pain. Some examples of alternative therapies that will be discussed in this review include acupuncture, tai chi, osteopathic manipulation, and chiropractic care. Acupuncture, traditionally a Chinese practice, is becoming more popular across the world to attempt to relieve pain. It involves the placement of thin needles at various points in the body. The efficacy of acupuncture for pain is heavily debated. More research and discussion are necessary to determine the exact role it plays in the treatment of chronic pain. Tai chi is also a traditional Chinese practice that is often used as a form of meditation and for potential health benefits. Tai chi involves a series of complex movements such as squatting combined with deep breathing to achieve relaxation and pain reduction. Osteopathic manipulative treatment (OMT) is a technique used by both osteopathic physicians (DO) as well as other health professionals to manage a wide range of conditions in any given patient. The technique involves utilization and manipulation of the musculoskeletal system to achieve potential health benefits. OMT has been used as therapy for many issues but is commonly used for pain conditions. Alternative therapies may serve as an effective adjunctive treatment modality for the management of chronic pain conditions. There has been a tremendous amount of research dictating the effectiveness of alternative therapies for chronic pain management. The purpose of this review is to provide a comprehensive evidence-based update of alternative therapy used for the management of chronic pain conditions.

Premedication With Gabapentin Significantly Reduces the Risk of Postherpetic Neuralgia in Patients With Neuropathy.

Postherpetic neuralgia (PHN) is the most common complication of varicella zoster virus (VZV) reactivation and a cause of considerable physical and psychosocial morbidity. No known treatment effectively prevents the development of PHN in patients with VZV reactivation. In this study, our objective was to evaluate the efficacy of premedication with gabapentin for reducing the risk of PHN in patients with diabetic and nondiabetic neuropathy. We retrospectively searched the electronic health records of patients with diabetic and nondiabetic neuropathy treated with gabapentin at Mayo Clinic before diagnosis of VZV reactivation. In total, PHN developed in 7 patients with diabetic neuropathy receiving gabapentin (n=62 [11.3%]) compared with 26 not receiving premedication with gabapentin (n=50 [52.0%]) (odds ratio, 0.12; 95% CI, 0.05-0.31; P<.001); PHN developed in 11 patients with nondiabetic neuropathy receiving gabapentin (n=109 [10.1%]) compared with 108 not receiving premedication with gabapentin (n=217 [49.8%]) (odds ratio, 0.11; 95% CI, 0.06-0.22; P<.001). In this cohort of patients with neuropathy, gabapentin administration before the onset of VZV reactivation significantly reduced the risk of PHN.

Parameters associated with efficacy of epidural steroid injections in the management of postherpetic neuralgia: the Mayo Clinic experience.

Purpose: Thirty percent of patients with postherpetic neuralgia (PHN) receiving conservative treatment report unsatisfactory pain relief. Epidural steroid injections (ESIs) are commonly used as a therapeutic intervention in these patients. In this study, we aimed to determine if there are variables that predict the efficacy of ESI in patients with PHN. Patients and methods: We retrospectively identified patients seen at Mayo Clinic who had PHN and received ESI. From their medical records, we abstracted the demographic variables, concurrent medication use, anatomic approach and medication for ESI, and degree of pain relief at 2 and 12 weeks' postintervention. Results: None of the studied variables were significantly associated with efficacy of ESI in patients with PHN. PHN that began <11 months before treatment was predictive of a response to ESI at 12 weeks postintervention (positive predictive value, 55%). Patients who reported poor ESI efficacy 2 weeks after the intervention had a 94% chance of still having pain at 12 weeks. Conclusion: For this cohort of patients with PHN being treated with ESI, no demographic characteristics, concurrently used medications, or type of ESI were associated with ESI treatment efficacy at 2 or 12 weeks after the intervention.

Survey of pain specialists regarding conversion of high-dose intravenous to neuraxial opioids.

The conversion of high-dose intravenous (IV) opioids to an equianalgesic epidural (EP) or intrathecal (IT) dose is a common clinical dilemma for which there is little evidence to guide practice. Expert opinion varies, though a 100 IV:10:EP:1 IT conversion ratio is commonly cited in the literature, especially for morphine. In this study, the authors surveyed 724 pain specialists to elucidate the ratios that respondents apply to convert high-dose IV morphine, hydromorphone, and fentanyl to both EP and IT routes. Eighty-three respondents completed the survey. Conversion ratios were calculated and entered into graphical scatter plots. The data suggest that there is wide variation in how pain specialists convert high-dose IV opioids to EP and IT routes. The 100 IV:10 EP:1 IT ratio was the most common answer of survey respondent, especially for morphine, though also for hydromorphone and fentanyl. Furthermore, more respondents applied a more aggressive conversion strategy for hydromorphone and fentanyl, likely reflecting less spinal selectivity of those opioids compared with morphine. The authors conclude that there is little consensus on this issue and suggest that in the absence of better data, a conservative approach to opioid conversion between IV and neuraxial routes is warranted.

Use of botulinum toxin injections to treat peripheral stimulator induced facial muscle twitching: a case report.

BACKGROUND: Facial pain can be a management challenge. Peripheral nerve/field stimulation may be an effective option for refractory cases, but direct muscle stimulation with facial twitching may result. Botulinum toxin injections have been used for blepharospasm and may be effective when facial stimulation results in unacceptable facial muscle twitching due to peripheral stimulation. CASE PRESENTATION: A 53-year old female suffered with chronic, refractory facial pain and migraines. Her facial pain began after a root canal of a left upper molar. She was trialed and then permanently implanted with a 1 × 8 sub-compact percutaneous stimulator lead, resulting in improved pain control and reduced medication use. However, she experienced blepharospasm whenever the amplitude was above 2.75 A. Therefore, she was treated with botulinum toxin injections into her bilateral cheek, face, temple and occiput. This treatment provided excellent relief of the facial spasms, allowing her to use her stimulator at high amplitudes, and thereby maximizing her pain relief. She received two subsequent treatments of botulinum toxin injections at 5-month intervals with similar results. CONCLUSION: Peripheral nerve/field stimulation is being used for headaches and facial pain. An undesirable side effect of this emerging therapy is direct muscle stimulation. Botulinum toxin injections may be an effective treatment modality when stimulation techniques provide pain relief but also causes muscle twitching.