Current Strategies for the Management of Painful Diabetic Neuropathy.

The development of painful diabetic neuropathy (PDN) is a common complication of chronic diabetes that can be associated with significant disability and healthcare costs. Prompt symptom identification and aggressive glycemic control is essential in controlling the development of neuropathic complications; however, adequate pain relief remains challenging and there are considerable unmet needs in this patient population. Although guidelines have been established regarding the pharmacological management of PDN, pain control is inadequate or refractory in a high proportion of patients. Pharmacotherapy with anticonvulsants (pregabalin, gabapentin) and antidepressants (duloxetine) are common first-line agents. The use of oral opioids is associated with considerable morbidity and mortality and can also lead to opioid-induced hyperalgesia. Their use is therefore discouraged. There is an emerging role for neuromodulation treatment modalities including intrathecal drug delivery, spinal cord stimulation, and dorsal root ganglion stimulation. Furthermore, consideration of holistic alternative therapies such as yoga and acupuncture may augment a multidisciplinary treatment approach. This aim of this review is to focus on the current management strategies for the treatment of PDN, with a discussion of treatment rationale and practical considerations for their implementation.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Deep Brain Stimulations for Obsessive-Compulsive Disorder: Update of the 2014 Guidelines.

BACKGROUND: In 2020, the Guidelines Task Force conducted another systematic review of the relevant literature on deep brain stimulation (DBS) for obsessive-compulsive disorder (OCD) to update the original 2014 guidelines to ensure timeliness and accuracy for clinical practice. OBJECTIVE: To conduct a systematic review of the literature and update the evidence-based guidelines on DBS for OCD. METHODS: The Guidelines Task Force conducted another systematic review of the relevant literature, using the same search terms and strategies as used to search PubMed and Embase for relevant literature. The updated search included studies published between 1966 and December 2019. The same inclusion/exclusion criteria as the original guideline were also applied. Abstracts were reviewed and relevant full-text articles were retrieved and graded. Of 864 articles, 10 were retrieved for full-text review and analysis. Recommendations were updated according to new evidence yielded by this update. RESULTS: Seven studies were included in the original guideline, reporting the use of bilateral DBS as more effective in improving OCD symptoms than sham treatment. An additional 10 studies were included in this update: 1 class II and 9 class III. CONCLUSION: Based on the data published in the literature, the following recommendations can be made: (1) It is recommended that clinicians utilize bilateral subthalamic nucleus DBS over best medical management for the treatment of patients with medically refractory OCD (level I). (2) Clinicians may use bilateral nucleus accumbens or bed nucleus of stria terminalis DBS for the treatment of patients with medically refractory OCD (level II). There is insufficient evidence to make a recommendation for the identification of the most effective target.The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/deep-brain-stimulation-obsessive-compulsive-disord.

Neuromodulation for Chronic Pelvic Pain: A Single-Institution Experience With a Collaborative Team.

BACKGROUND: Secondary to the complex care, involved specialty providers, and various etiologies, chronic pelvic pain patients do not receive holistic care. OBJECTIVE: To compare our general and neuromodulation cohorts based on referrals, diagnosis, and therapy and describe our neuromodulation patients. METHODS: A multidisciplinary team was established at our center. The intake coordinator assessed demographics and facilitated care of enrolled patients. Outcomes were compared using minimal clinical important difference of current Numerical Rating Scale (NRS) between patients with neuropathic pain who received neuromodulation and those who did not. The neuromodulation cohort completed outcome metrics at baseline and recent follow-up, including NRS score (best, worst, and current), Oswestry Disability Index (ODI), Beck Depression Inventory, and Pain Catastrophizing Scale. RESULTS: Over 7 yr, 233 patients were referred to our consortium and 153 were enrolled. A total of 55 patients had neuropathic pain and 44 of those were managed medically. Eleven underwent neuromodulation. A total of 45.5% patients of the neuromodulation cohort were classified as responders by minimal clinically important difference compared to 26.6% responders in the control cohort at most recent follow-up (median 25 and 33 mo, respectively). Outcome measures revealed improvement in NRS at worst (P = .007) and best (P = .025), ODI (P = .014), and Pain Catastrophizing Scale Rumination (P = .043). CONCLUSION: Eleven percent of patients were offered neuromodulation. There were more responders in the neuromodulation cohort than the conservatively managed neuropathic pain cohort. Neuromodulation patients showed significant improvement at 29 mo in NRS best and worst pain, disability, and rumination. We share our algorithm for patient management.

Craniofacial Peripheral Nerve Stimulation: Analysis of a Single Institution Series.

OBJECTIVE: Objective real-world experience with peripheral nerve stimulation (PNS) is limited. Furthermore, the lack of robust outcome metrics, long-term follow-up and data comparing responders and nonresponders limit the refinement of selection criteria to better identify patients likely to benefit from PNS. MATERIALS AND METHODS: We retrospectively analyzed 22 patients with craniofacial pain treated with PNS, and responders were classified as having ≥50% postoperative improvement in the numeric rating scale (NRS). In a subset of patients (n = 11), detailed prospective outcomes metrics were obtained preoperatively and postoperatively, including NRS, Beck Depression Index (BDI), Pain Catastrophizing Scale (PCS), and McGill Pain Questionnaire (MPQ). RESULTS: About 59.1% (13 of 22) of subjects were classified as responders at a mean follow-up of 37.5 ± 5.27 months. Diagnoses included migraine (n = 6), occipital neuralgia (n = 9), trigeminal neuropathic pain (TNP; n = 6), and central poststroke pain (n = 1). Within the TNP subgroup, responders were more likely to have undergone two or more trigeminal neuralgia procedures prior to PNS (p < 0.05). In the 11 patients with comprehensive preoperative and postoperative outcome data, we noted significant improvement in NRS (p = 0.0005), BDI (p = 0.04), PCS (p = 0.01), as well as components of PCS (helplessness and magnification, p = 0.02) and MPQ (affective, p = 0.02). CONCLUSIONS: The present study adds to the PNS literature by providing long-term data and multiple outcome metrics in a subset of patients. We suggest that BDI, PCS, and MPQ may provide more insight into meaningful response over time. Evaluating functional and quality of life outcomes in patients with craniofacial pain may be more informative than assessing benefit solely based on pain intensity and responder rates.