Spinal cord stimulation in the approach to chronic pelvic pain: A case report and literature review.

RATIONALE: Chronic pelvic pain (CPP) is a pain related to pelvic structures that arise from posttraumatic pain, postsurgical pain, or somatic or visceral pain syndromes. Despite the available treatment options, CPP remains mostly untreated, due to difficulties in covering such a large area. PATIENT CONCERNS: A 46-year-old woman presented chronic low back pain and CPP for more than 1 year and 6 months respectively after multiple pelvic fractures. DIAGNOSIS: Pelvic fractures and a severe lumbar facet arthrosis were revealed through computed tomography and lumbosacral nuclear magnetic resonance imaging. Evidence of a reduced amplitude in the left femoral nerve and a demyelinating neuropathy in the left pudendal nerve were also detected. INTERVENTION: A pharmacologic treatment was prescribed, consisting of celecoxib, fluoxetine, gabapentin, and morphine. Since no pain relief was achieved, spinal cord stimulation was performed using spectra WaveWriter system, placing 2 octopolar linear leads over the bilateral T8 and T9 vertebras with the help of a 3-dimensional neural targeting program. OUTCOMES: Two weeks after the intervention a reduction of 80% of the pain was achieved, which led to the removal of the pharmacologic treatment. Additionally, both EuroQOL-5D and visual analogue scale scores improved after the intervention. LESSON: Through the combination of spinal cord stimulation Spectra Wavewriter and 3D programming technology, both lumbar and leg pain and CPP were successfully relieved, along with an improvement in the quality of life of the patient.

Delphi consensus on strategies in the management of opioid-induced constipation in cancer patients.

BACKGROUND: Opioid-induced constipation (OIC) is a frequent and bothersome adverse event related with opioid therapy in cancer patients. Despite the high prevalence, medical management of OIC is often uncertain. The current project aimed to investigate expert opinion on OIC management and provide practical recommendations to improve the clinical approach of OIC in cancer patient. METHODS: A modified Delphi method was conducted involving 46 different physicians experts in OIC. Using a structured questionnaire of 67 items this project intended to seek consensus on aspects related to diagnosis, treatment, and quality of life of cancer patients suffering with OIC. RESULTS: After two rounds, a consensus was reached in 91% of the items proposed, all in agreement. Agreement was obtained on OIC definition (95.7%). Objective and patient-reported outcomes included in that definition should be assessed routinely in clinical practice. Responsive to symptom changes and easy-to-use assessment tools were recommended (87.2%). Successful diagnosis of OIC requires increase clinicians awareness of OIC and proactivity to discuss symptoms with their patients (100%). Successful management of OIC requires individualization of the treatment (100%), regular revaluation once is established, and keeping it for the duration of opioid treatment (91.5%). Oral Peripherally Acting µ-Opioid Receptor Agonists (PAMORAs), were considered good alternatives for the treatment of OIC in cancer patients (97.9%). This drugs and laxatives can be co-prescribed if OIC coexist with functional constipation. CONCLUSIONS: The panelists, based on their expert clinical practice, presented a set of recommendations for the management of OIC in cancer patients.

Revisión del impacto del tratamiento con acupuntura en el manejo del dolor lumbar inespecífico / Review of the impact of acupuncture treatment on the management of nonspecific low back pain

El dolor lumbar (LBP, por sus siglas en inglés) es un problema común e importante, con una elevada prevalencia en mujeres y ancianos. Es una causa importante de dolor, discapacidad y detrimento económico. En la mayoría de los casos, el dolor se alivia en cuatro a seis semanas y las personas pueden regresar a sus actividades normales. La acupuntura para el tratamiento del dolor lumbar inespecífico sigue siendo un tema bajo investigación. Hemos realizado en este trabajo una revisión de los artículos más importantes publicados en los últimos 7 años (2013-2019), verificando el crecimiento en los últimos años de las terapias alternativas. La acupuntura ha demostrado superioridad en la mejoría del dolor lumbar inespecífico cuando se ha comparado con la opción de ningún tratamiento y, fundamentalmente, cuando se asocia a tratamiento convencional como complemento del mismo

Low back pain (LBP) is a common and important problem, with a high prevalence in women and the elderly. It is an important cause of pain, disability and economic detriment. In most cases, the pain is relieved in four to six weeks and people can return to normal activities. Acupuncture for the treatment of nonspecific low back pain remains a topic under investigation. We have carried out in this work a review of the most important articles published in the last 7 years (2013-2019), verifying the growth in the last years of alternative therapies. Acupuncture has demonstrated superiority in the improvement of non-specific low back pain when compared to the option of no treatment and, fundamentally, when it is associated with conventional treatment as a complement to it

Effect of Dynamic Versus Stylet-Guided Intubation on First-Attempt Success in Difficult Airways Undergoing Glidescope Laryngoscopy: A Randomized Controlled Trial.

BACKGROUND: Tracheal intubation failure in patients with difficult airway is still not uncommon. While videolaryngoscopes such as the Glidescope offer better glottic vision due to an acute-angled blade, this advantage does not always lead to an increased success rate because successful insertion of the tube through the vocal cords may be the limiting factor. We hypothesize that combined use of Glidescope and fiberscope used only as a dynamic guide facilitates tracheal intubation compared to a conventional Glidescope technique with a preshaped nondynamic stylet. METHODS: One hundred sixty adult patients with predicted difficult airway were randomly assigned to a conventional Glidescope (standard Glidescope group) or a combined Glidescope + fiberscope group intubation. In the Glidescope + fiberscope group under direct vision from the Glidescope, tracheal intubation was performed using the fiberscope as a guide without using fiberoptic vision, while in the standard Glidescope group, a conventional stylet-guided intubation technique was performed. We evaluated the rate of tracheal intubation success at first attempt as the primary end point (Fisher exact test). The difference between groups in airway injury, time to successful intubation, and the need for an alternative technique was also evaluated. RESULTS: First-attempt intubation success was higher in the Glidescope + fiberscope group than in the standard Glidescope group (91% vs 67%; P = .0012; fragility index, 8; absolute risk reduction, 24% [95% CI, 12%-36%]). Median time to successful tracheal intubation was shorter in the Glidescope + fiberscope group (50 vs 64 seconds; P = .035). Airway injury rate was lower in the Glidescope + fiberscope group than in the standard Glidescope group (1% vs 11%; P = .035; fragility index, 1; absolute risk reduction, 10% [95% CI, 3%-18%]). Alternative rescue technique requirements to achieve tracheal intubation were higher in the standard Glidescope group (24% vs 4%; P < .001; fragility index, 7). CONCLUSIONS: The use of a dynamic, flexible guide during a Glidescope laryngoscopy in patients with a predicted difficult airway compared to a standard intubation technique improves first-attempt intubation success, decreases the incidence of airway injury and time to successful intubation, as well as the need of an alternative technique to succeed.

Adaptation of an Ultrasound-Guided Technique for Pulsed Radiofrequency on Axillary and Suprascapular Nerves in the Treatment of Shoulder Pain.

BACKGROUND: It has been estimated that 20% of the general population will suffer shoulder pain throughout their lives, with a prevalence that can reach up to 50%. The suprascapular nerve (SSN) provides sensation for the posterior and superior regions of the glenohumeral joint, whereas the anterior and inferior zones and the skin are innervated mostly by the axillary nerve. Pulsed radiofrequency on the SSN has been proposed as a therapeutic option in chronic shoulder pain. Axillary nerve block has been proposed in the context of surgical analgesia as an adjuvant to SSN block. INTERVENTIONS: Ultrasound (US)-guided techniques target the nerve selectively, minimizing patients' and physicians' exposure to harmful radiation while increasing success rates by better needle placement. We perform both US-guided techniques with the patient in a lateral decubitus position with the affected shoulder on the upper side. OBJECTIVE: The aim of this report is to describe the adaptation of a US-guided technique that targets both the suprascapular and axillary nerves for the treatment of painful shoulder syndrome. The simultaneous pulsed radiofrequency on the suprascapular and axillary nerves for the treatment of the chronic condition of shoulder pain has been scarcely studied, with very few references in the literature. CONCLUSIONS: By adapting an approach developed in acute pain management, we can safely deliver pulsed radiofrequency to the suprascapular and axillary nerves for the treatment of shoulder pain.

Interfascial block at the serratus muscle plane versus conventional analgesia in breast surgery: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: In the context of opioid-sparing perioperative management, there is still little evidence from randomized controlled trials regarding the effectiveness of interfascial thoracic blocks. This study hypothesizes that receiving a serratus plane block reduces opioid requirements, pain scores, and rescue medication needs. METHODS: This double-blind, randomized controlled study was conducted on 60 adult females undergoing oncologic breast surgery. After general anesthesia, patients were randomly allocated to either conventional analgesia (control group, n=30) or single-injection serratus block with L-bupivacaine 0.25% 30mL (study group, n=30). First 24-hour total morphine consumption (primary outcome), pain scores at 1, 3, 6, 12, and 24 hours, time-to-first opioid rescue analgesia, and adverse effects were recorded. RESULTS: Median 24 hours' opioid dose was greater in the control group (median difference 9 mg (95% CI 4 to 14.5 mg); p<0.001). Proportional odds model showed that the study group has a lower probability of receiving opioid drugs (OR=0.26 (95% CI 0.10 to 0.68); p<0.001), while mastectomies have a higher probability of receiving them (OR=4.11 (95% CI 1.25 to 13.58); p=0.002). Pain scores in the study group were significantly lower throughout the follow-up period (p<0.001). Control group subjects needed earlier morphine rescue and had a higher risk of rescue dose requirement (p=0.002). CONCLUSIONS: Interfascial serratus plane block reduces opioid requirements and is associated with better pain scores and lower and later rescue analgesia needs in the first 24 hours, compared with conventional intravenous analgesia, in breast surgery. TRIAL REGISTRATION NUMBER: NCT02905149.

Diagnóstico y tratamiento médico del dolor irruptivo / Diagnosis and medical treatment of breakthrough pain

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