The potentiating effect of intravenous dexamethasone upon preemptive pudendal block analgesia for hypospadias surgery in children managed with Snodgrass technique: a randomized controlled study : Dexamethasone for pain management in children.

INTRODUCTION: Evidence regarding the potentiating effects of intravenous dexamethasone on peripheral regional anesthesia in children is sparse. The objective of the current study was to investigate the potentiating effect of intravenous dexamethasone upon pudendal block during surgical correction of hypospadias using Snodgrass technique. METHODS: The study consisted of a monocentric, randomized controlled, double-blinded study. Patients were randomized to receive either intravenous dexamethasone 0.15 mg.kg- 1 (D group) or a control solution (C group). Both groups received standardized anesthesia including a preemptive pudendal block performed after the induction of anesthesia. The primary outcome was the proportion of patients needing rescue analgesia. Secondary outcomes were other pain outcomes over the first 24 postoperative hours. RESULTS: Overall, 70 patients were included in the study. Age were 24 [24; 36] and 26 [24; 38] months in the D and C groups, respectively (p = 0.4). Durations of surgery were similar in both groups (60 [30; 60], p = 1). The proportion of patients requiring rescue analgesia was decreased in the D group (23% versus 49%, in D and C groups respectively, p = 0.02). The first administration of rescue analgesia was significantly delayed in the D group. Postoperative pain was improved in the D group between 6 and 24 h after surgery. Opioid requirements and the incidence of vomiting did not significantly differ between groups. CONCLUSION: Associating intravenous dexamethasone (0.15 mg.kg- 1) to pudendal block during hypospadias surgery improves pain control over the first postoperative day. Further studies are needed in order to confirm these results. GOV IDENTIFIER: NCT03902249. A. WHAT IS ALREADY KNOWN: dexamethasone has been found to potentiate analgesia obtained with regional anesthesia in children. B. WHAT THIS ARTICLE ADDS: intravenous dexamethasone was found to improve analgesia with a preemptive pudendal block during hypospadias surgery. C. IMPLICATIONS FOR TRANSLATION: results of this study indicate that intravenous dexamethasone could be used as an adjunct to pudendal block.

Perioperative pain optimization in the age of the opioid epidemic.

PURPOSE OF REVIEW: The opioid epidemic remains a constant and increasing threat to our society with overdoses and overdose deaths rising significantly during the COVID-19 pandemic. Growing evidence suggests a link between perioperative opioid use, postoperative opioid prescribing, and the development of opioid use disorder (OUD). As a result, strategies to better optimize pain management during the perioperative period are urgently needed. The purpose of this review is to summarize the most recent multimodal analgesia (MMA) recommendations, summarize evidence for efficacy surrounding the increased utilization of Enhanced Recovery After Surgery (ERAS) protocols, and discuss the implications for rising use of buprenorphine for OUD patients who present for surgery. In addition, this review will explore opportunities to expand our treatment of complex patients via transitional pain services. RECENT FINDINGS: There is ample evidence to support the benefits of MMA. However, optimal drug combinations remain understudied, presenting a target area for future research. ERAS protocols provide a more systematic and targeted approach for implementing MMA. ERAS protocols also allow for a more comprehensive approach to perioperative pain management by necessitating the involvement of surgical specialists. Increasingly, OUD patients taking buprenorphine are presenting for surgery. Recent guidance from a multisociety OUD working group recommends that buprenorphine not be routinely discontinued or tapered perioperatively. Lastly, there is emerging evidence to justify the use of transitional pain services for more comprehensive treatment of complex patients, like those with chronic pain, preoperative opioid tolerance, or substance use disorder. SUMMARY: Perioperative physicians must be aware of the impact of the opioid epidemic and explore methods like MMA techniques, ERAS protocols, and transitional pain services to improve the perioperative pain experience and decrease the risks of opioid-related harm.

Challenges of acute pain management in older patients.

Adequate management of acute pain in the older population is crucial. However, it is inherently complex because of multiple physiological changes that significantly impact both the pharmacokinetics and pharmacodynamics of medications. Current guidelines promote paracetamol as the first-line analgesic for acute pain in older adults, whereas opioids are advised cautiously for moderate to severe acute pain. However, opioids come with a significant array of side effects, which can be more pronounced in older individuals. Ketamine administered via intranasal (IN) and nebulised inhalation in the emergency department for managing acute pain in older patients shows promising potential for improving pain management and reducing opioid reliance Kampan, Thong-on, Sri-on (2024, Age Ageing, 53, afad255). Nebulised ketamine appears superior in terms of adverse event incidence. However, the adoption of IN or nebulised ketamine in older adult acute pain management remains unclear because of the lack of definitive conclusions and clear guidelines. Nevertheless, these modalities can be valuable options for patients where opioid analgesics are contraindicated or when intravenous morphine titration is impractical or contraindicated. Here, we review these concepts, the latest evidence and propose avenues for research.

The acute pain crisis in sickle cell disease: What can be done to improve outcomes?

The acute pain crisis (APC) is the commonest complication of sickle cell disease (SCD). Severe episodes may require treatment in hospital with strong opioid analgesic drugs, combined with additional supportive care measures. Guidelines for APC management have been produced over the past two decades gathering evidence from published studies, expert opinion, and patient perspective. Unfortunately, reports from multiple sources indicate that guidelines are often not followed, and that acute care in emergency departments and on acute medical wards is suboptimal. It is important to understand what leads to this breakdown in health care, and to identify evidence-based interventions which could be implemented to improve care. This review focuses on recently published articles as well as information about on-going clinical trials. Aspects of care which could potentially make a difference to patient experience include availability and accessibility of individual care plans agreed between patient and treating specialist, innovative means of delivering initial opioids to reduce time to first analgesia, and availability of a specialist unit away from the ED, where expert care can be delivered in a more compassionate environment. The current evidence of improved outcomes and health economic advantage with these interventions is inadequate, and this is hampering their implementation into health care systems.

Brain network hypersensitivity underlies pain crises in sickle cell disease.

Sickle cell disease (SCD) is a genetic disorder causing painful and unpredictable Vaso-occlusive crises (VOCs) through blood vessel blockages. In this study, we propose explosive synchronization (ES) as a novel approach to comprehend the hypersensitivity and occurrence of VOCs in the SCD brain network. We hypothesized that the accumulated disruptions in the brain network induced by SCD might lead to strengthened ES and hypersensitivity. We explored ES's relationship with patient reported outcome measures (PROMs) as well as VOCs by analyzing EEG data from 25 SCD patients and 18 matched controls. SCD patients exhibited lower alpha frequency than controls. SCD patients showed correlation between frequency disassortativity (FDA), an ES condition, and three important PROMs. Furthermore, stronger FDA was observed in SCD patients with a higher frequency of VOCs and EEG recording near VOC. We also conducted computational modeling on SCD brain network to study FDA's role in network sensitivity. Our model demonstrated that a stronger FDA could be linked to increased sensitivity and frequency of VOCs. This study establishes connections between SCD pain and the universal network mechanism, ES, offering a strong theoretical foundation. This understanding will aid predicting VOCs and refining pain management for SCD patients.

The effect of the simulated intrauterine sound on behavioral and physiological indices of pain during capillary blood sampling for screening preterm infants: a randomized clinical trial study.

INTRODUCTION: Due to medical procedures, preterm infants are at high risk for side effects of pain. In this regard, heel lancing for capillary blood sampling is a common painful procedure. The present study was conducted to assess the effectiveness of a simulated intrauterine sound on behavioral and physiological indices of pain due to heel-prick blood sampling in preterm infants. METHODS: A double­blind randomized clinical trial (RCT) was conducted. The data were collected from September 23 to December 22, 2019. We measured the effect of a simulated intrauterine sound on changes in the behavioral and physiological parameters of pain (heart rate, SPO2) caused by heel lance that was measured 5 min before the intervention, during the sampling, and 5 min after the procedure. We measured behavioral pain by video recording the infants' faces and then the scoring neonatal infant pain scale (NIPS). Heart rate and SPO2 were measured using a pulse oximeter device. The data were analyzed using analysis of variance (ANOVA) and independent t­test in SPSS software version 20.0. RESULTS: Eighty infants were randomized (40 in each group). Mean scores NIPS during and after intervention were in the intervention group (3.55 ± 0.84, 95% CI: 3.30-3.80(, and (1.15 ± 0.84, 95%: 0.95-1.35) and in the control group (5.57 ± 0.95, 95% CI:5.30-5.85) and (3.00 ± 0.98) respectively. There were significant differences in scores of NIPS between the two study groups during (p < 0.001) and five min after heel lancing (p < 0.001). Mean scores of heart rate in the three phases of before, during, and five min after the intervention were respectively in the intervention group (127.57 ± 4.45, 95% CI:126.27-128.99), (131.07 ± 6.54, 95% CI:129.20-133.22), (128.45 ± 5.15, 95% CI:127.02-130.07) and in the control group (128.67 ± 4.57, 95% CI:127.32-130.07), (136.07 ± 7.24, 95% CI:133.90-138.37), and (132.42 ± 6.47, 95% CI:130.37-134.49). There were significant differences in heart rate between the intervention and the control group during (p = 0.002) and five min after the heel lance (p = 0.003). Mean scores of SPO2 in the three phases of baseline, during, and five min after the intervention were respectively in the intervention group (96.72 ± 0.93, 95% CI:96.42-97.00), (91.47 ± 1.46, 95% CI:91.05-91.92), (94.17 ± 1.03, 95% CI:93.22-94.00) and in the control group (96.6 ± 0.84, 95% CI:96.35-96.85), (91.5 ± 1.24, 95% CI:91.12-91.87), and (93.60 ± 1.27, 95% CI:93.85-94.50). CONCLUSION: This study showed that the simulated intrauterine sound reduces the behavioral pain and heart rate in the intervention group during and after heel lance. These results suggest using the method during the painful heel lancing to reduce pain parameters in preterm infants.

Combined rectus sheath block with transverse abdominis plane block by one puncture for analgesia after laparoscopic upper abdominal surgery: a randomized controlled prospective study.

BACKGROUND: Rectus sheath block (RSB) and transversus abdominis plane block (TAPB) have been shown to reduce opioid consumption and decrease postoperative pain scores in abdominal surgeries. However, there are no reports about the one-puncture technique of RSB combined with TAPB for perioperative pain management during laparoscopic upper abdominal surgery. METHODS: A total of 58 patients were randomly assigned to the control group (C), the TAP group (T), and the one-puncture technique of RSB combined with TAPB group (RT). The patients in group C did not receive any regional block. The patients in group T received ultrasound-guided subcostal TAPB with 30 mL of 0.33% ropivacaine on each side. The patients in the RT group received a combination of RSB and TAPB with 15 mL of 0.33% ropivacaine in each plane by one puncture technique. All patients received postoperative patient-controlled intravenous analgesia (PCIA) after surgeries. The range of blocks was recorded 20 min after the completion of the regional block. The postoperative opioid consumption, pain scores, and recovery data were recorded, including the incidence of emergence agitation (EA), the times of first exhaust and off-bed activity, the incidence of postoperative nausea and vomiting, dizziness. RESULTS: The range of the one-puncture technique in group RT covered all areas of surgical incisions. The visual analogue scale (VAS) score of the RT group is significantly lower at rest and during coughing compared to groups T and C at 4, 8, 12, and 24 h after surgery, respectively (P < 0.05). The consumption of sufentanil and the number of postoperative compressions of the analgesic pumps at 24 and 48 h in the RT group are significantly lower than those in groups T and C (P < 0.05). The incidence of EA in the RT group is significantly lower than that in groups T and C (P < 0.05). CONCLUSION: The one-puncture technique of RSB combined with TAPB provides effective postoperative analgesia for laparoscopic upper abdominal surgery, reduces the incidence of EA during PACU, and promotes early recovery. TRIAL REGISTRATION: ChiCTR, ChiCTR2300067271. Registered 3 Jan 2023, http://www.chictr.org.cn .

Association between esketamine interventions and postpartum depression and analgesia following cesarean delivery: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to compare the efficacy and safety of the use of esketamine to reduce the risk for postpartum depression and pain after cesarean delivery. DATA SOURCES: Literature searches were conducted in PubMed, Embase, Cochrane Library, Web of Science, CNKI, and Wan fang from inception to August 2023. STUDY ELIGIBILITY CRITERIA: The eligibility criteria were all randomized controlled trials of people who underwent a cesarean delivery and who were randomized to receive esketamine interventions irrespective of age or ethnicity. The outcomes that were assessed included the incidence of postpartum depression and the Edinburgh Postnatal Depression Scale score within 7 days and at 28 to 42 days after delivery, the pain score (visual analog scale or numerical rating scale, 0-10), the consumption of opioids, and intraoperative and postoperative adverse events. METHODS: The Cochrane collaboration's tool was used for quality appraisal of the included studies. Statistical analysis of the data was performed using Review Manager 5.3 software, and the results were expressed as mean differences with 95% confidence intervals. Assessments were pooled using a random-effects or fixed-effects model. Study heterogeneity was assessed using the standard I2 statistic. RESULTS: Among the 11 included randomized controlled trials that used the Edinburgh Postnatal Depression Scale for postpartum depression assessment, patients in esketamine group had a lower risk for postpartum depression within a week of surgery (risk ratio, 0.45; 95% confidence interval, 0.33-0.62). Intraoperative use of esketamine maintained a lower Edinburgh Postnatal Depression Scale score after surgery (mean difference, -1.64; 95% confidence interval, -2.14 to -1.14). Esketamine was associated with a beneficial effect in terms of the other outcomes, including a significant decline in pain score within 48 hours (mean difference, -0.71; 95% confidence interval, -0.89 to 0.52). Esketamine increased the risk for adverse neurologic and mental events during surgery without harming health, and there was no significant difference after delivery when compared with the control group. CONCLUSION: Esketamine may reduce the risk for postpartum depression among patients who are undergoing cesarean delivery in the short term. In addition, as an adjunct to reduce analgesia, esketamine also effectively assists in pain management. Because of the lack of more high-quality evidence, we need more compelling evidence to confirm the value of esketamine in improving postpartum recovery.

Postural Changes in Spinal Cord Stimulation Thresholds: Current and Voltage Sources.

OBJECTIVE: Spinal cord stimulation (SCS) thresholds are known to change with body position; however, these changes have not been fully characterized for both "constant-voltage" and "constant-current" pulse generators. This study aimed to evaluate and quantify changes in psychophysical thresholds resulting from postural changes that may affect both conventional paresthesia-based SCS and novel paresthesia-free SCS technologies. MATERIALS AND METHODS: We measured perceptual, usage, and discomfort thresholds in four body positions (prone, supine, sitting, standing) in 149 consecutive patients, with temporary lower thoracic percutaneous epidural electrodes placed for treating persistent low back and leg pain. We trialed 119 patients with constant-voltage stimulators and 30 patients with constant-current stimulators. RESULTS: Moving from supine to the sitting, standing, or prone positions caused all three thresholds (perceptual, usage, and discomfort) to increase by 22% to 34% for constant-voltage stimulators and by 44% to 82% for constant-current stimulators. Changing from a seated to a supine position caused stimulation to exceed discomfort threshold significantly more often for constant-current (87%) than for constant-voltage (63%) stimulators (p = 0.01). CONCLUSIONS: Posture-induced changes in SCS thresholds occurred consistently as patients moved from lying (supine or prone) to upright (standing or sitting) positions. These changes were more pronounced for constant-current than for constant-voltage pulse generators and more often led to stimulation-evoked discomfort. These observations are consistent with postural changes in spinal cord position measured in imaging studies, and with computer model predictions of neural recruitment for these different spinal cord positions. These observations have implications for the design, implantation, and clinical application of spinal cord stimulators, not only for conventional paresthesia-based SCS but also for paresthesia-free SCS.

Lidocaine Spray for Acute Postsurgical Pain Control After Posterior Pharyngeal Flap Surgery.

OBJECTIVES: This study evaluated the use of lidocaine spray for acute postsurgical pain control after posterior pharyngeal flap surgery. METHODS: Fifty patients aged 4 to 14 years who were scheduled to undergo elective posterior pharyngeal flap surgery were randomized to receive 2.4% lidocaine spray (Group L) or an identical volume of placebo spray (Group C) on the surgical field at the end of the surgery. The primary outcome was the maximum postoperative pain score in the postanesthesia care unit. RESULTS: The maximum pain score in Group L was significantly lower than that in Group C (p = 0.001). The incidence of moderate-to-severe pain in the postanesthesia care unit was significantly lower in Group L than that in Group C (p < 0.001). In the postanesthesia care unit, more patients in Group C were prescribed rescue analgesics (p < 0.001). The time to the first rescue analgesic was also significantly shorter in Group L (p < 0.001). The incidence and maximum score of emergence agitation were lower in Group L than in Group C. Compared with Group C, Group L showed earlier postoperative fluid intake (p = 0.001). Moreover, the score for parental satisfaction with pain control was higher in Group L than in Group C (p < 0.001). CONCLUSIONS: Our findings indicated that the use of 2.4% lidocaine aerosol spray on the surgical site at the end of the surgery could produce good analgesia for acute postoperative pain, reduce the incidence and severity of EA, and shorten the time to restore fluid intake. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:2438-2443, 2024.

4. Painful diabetic polyneuropathy.

INTRODUCTION: Pain as a symptom of diabetic polyneuropathy (DPN) significantly lowers quality of life, increases mortality and is the main reason for patients with diabetes to seek medical attention. The number of people suffering from painful diabetic polyneuropathy (PDPN) has increased significantly over the past decades. METHODS: The literature on the diagnosis and treatment of diabetic polyneuropathy was retrieved and summarized. RESULTS: The etiology of PDPN is complex, with primary damage to peripheral nociceptors and altered spinal and supra-spinal modulation. To achieve better patient outcomes, the mode of diagnosis and treatment of PDPN evolves toward more precise pain-phenotyping and genotyping based on patient-specific characteristics, new diagnostic tools, and prior response to pharmacological treatments. According to the Toronto Diabetic Neuropathy Expert Group, a presumptive diagnosis of "probable PDPN" is sufficient to initiate treatment. Proper control of plasma glucose levels, and prevention of risk factors are essential in the treatment of PDPN. Mechanism-based pharmacological treatment should be initiated as early as possible. If symptomatic pharmacologic treatment fails, spinal cord stimulation (SCS) should be considered. In isolated cases, where symptomatic pharmacologic treatment and SCS are unsuccessful or cannot be used, sympathetic lumbar chain neurolysis and/or radiofrequency ablation (SLCN/SLCRF), dorsal root ganglion stimulation (DRGs) or posterior tibial nerve stimulation (PTNS) may be considered. However, it is recommended that these treatments be applied only in a study setting in a center of expertise. CONCLUSIONS: The diagnosis of PDPN evolves toward pheno-and genotyping and treatment should be mechanism-based.

Effectiveness of Distal Sodium Channel Block in Managing Lumbosacral Radicular Syndrome: A Pilot Study.

OBJECTIVE: To find the effectiveness of distal sodium channel blocks in managing lumbosacral radicular syndrome. STUDY DESIGN: Open-labelled, non-randomised, single-group, prospective, pilot study. Place and Duration of the Study: Pain Clinic of Armed Forces Institute of Rehabilitation Medicine (AFIRM) Rawalpindi, Pakistan, from January to June 2022. METHODOLOGY: Patients having low back pain radiating to L5/S1/both dermatomes with severity of numerical rating scale (NRS) score of more than 4/10 were included. Straight leg raise (SLR) and NRS score were noted down at baseline and at 30 minutes, 24 hours, 1 week, and 4 weeks post-distal sodium channel block (DSCB). DSCB was performed at beta 1, 2, 3, and 5 portals using 2 ml of 2% injection plain lignocaine + 1 ml (40 mg) injection triamcinolone + 7 ml distilled water. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) 21. RESULTS: Out of 50 patients, 24 (48%) were females and 26 (52%) were males. No serious procedural complications were noted. Post-DSCB, follow-up was done for 4 weeks. A significant fall in NRS and an increase in SLR score were observed at every visit. Results were statistically significant (p<0.001) when mean NRS and SLR scores at every follow-up were compared for pre- and post-DSCBs. CONCLUSION: DSCB reduced pain and improved SLR in patients even at 4 weeks of follow-up. Advantages included immediate pain relief, easy to perform as outdoor procedure, cost-effective and a time buying alternative procedure allowing for the analgesic effect of medicine to kick in. KEY WORDS: Radiculopathy, Low-back pain, Epidural spinal injection, Sciatica, Pain management, Distal sodium channel blocks.

Using Surgicel-wrapped Merocel to reduce pain during the removal of nasal packing.

BACKGROUND: Merocel is a commonly used material for nasal packing; nevertheless, the majority of patients experience pain when the nasal packing is removed.Aims/Objectives: This study aims to introduce a novel technique for nasal packing using Surgicel-wrapped Merocel. MATERIAL AND METHODS: Patients who underwent septoplasty received either Merocel or Surgicel-wrapped Merocel as nasal packing. Clinical complications related to bleeding and subjective symptoms associated with the packing materials were assessed. RESULTS: Between 2018 and 2021, a total of thirty-three patients with a deviated nasal septum underwent septoplasty. Among them, eight patients received Merocel nasal packing, while twenty-five patients were treated with the new nasal packing technique involving Surgicel-wrapped Merocel. We observed a significant reduction in pain during removal in the Surgicel-wrapped Merocel group compared to the Merocel group (p = .008). However, no significant differences were noted in other discomforts related to packing or bleeding after removal between these two groups.Conclusions and Significance:Using Surgicel-wrapped Merocel as nasal packing following septoplasty is an effective method to alleviate pain during removal.

Risk factors for discontinuation of intravenous patient-controlled analgesia after general surgery: a retrospective cohort study.

Identifying patients at risk for developing side effects secondary to intravenous patient-controlled analgesia (IV PCA) and making the necessary adjustments in pain management are crucial. We investigated the risk factors of discontinuing IV PCA due to side effects following general surgery; adult patients who received IV PCA after general surgery (2020-2022) were included. Data on postoperative pain intensity, PCA pain relief, side effects, continuity of PCA use, and PCA pump settings were collected from the records of the acute pain management team. The primary outcome was identifying the risk factors associated with PCA discontinuation due to side effects. Of the 8745 patients included, 94.95% used opioid-containing PCA, and 5.05% used non-steroidal anti-inflammatory drug (NSAID)-only PCA; 600 patients discontinued PCA due to side effects. Female sex (adjusted odds ratio [aOR] 3.31, 95% confidence interval [CI] 2.74-4.01), hepato-pancreatic-biliary surgery (aOR 1.43, 95% CI 1.06-1.94) and background infusion of PCA (aOR 1.42, 95% CI 1.04, 1.94) were associated with an increased likelihood of PCA discontinuation. Preoperative opioid use (aOR 0.49, 95% CI 0.28-0.85) was linked with a decreased likelihood of PCA discontinuation. These findings highlight the importance of individualized pain management, considering patient characteristics and surgical procedures.

The Role of Interventional Pain Management Strategies for Neuropathic Pelvic Pain in Endometriosis.

BACKGROUND: Endometriosis is a chronic common condition affecting 10% of reproductive-aged women globally. It is caused by the growth of endometrial-like tissue outside the uterine cavity and leads to chronic pelvic pain, affecting various aspects of a woman's physical, mental, emotional, and social well-being. This highlights the importance of an understanding of the potential involvement of the nervous system and involved nerves as well as an effective multidisciplinary pain management. OBJECTIVES: Our aim was to assess the current understanding of pain mechanisms in endometriosis and the effectiveness of different interventional pain management strategies. STUDY DESIGN: Literature review. METHODS: A search was conducted using multiple databases, including Google Scholar, MEDLINE (Ovid), PubMed, and Embase. We used keywords such as "endometriosis," "pain," pelvic pain, "management," and "anaesthesia" along with Boolean operators and MeSH terms. The search was limited to English language articles published in the last 15 years. RESULTS: Nerve involvement is a well-established mechanism for pain generation in patients with endometriosis, through direct invasion, irritation, neuroangiogenesis, peripheral and central sensitization, and scar tissue formation. Endometriosis may also affect nerve fibers in the pelvic region, causing chronic pelvic pain, including sciatic neuropathy and compression of other pelvic nerves. Endometriosis can cause sciatica, often misdiagnosed due to atypical symptoms. Interventional pain management techniques such as superior hypogastric plexus block, impar ganglion block, S3 pulsed radiofrequency, myofascial pain trigger point release, peripheral nerve hydrodissection, and neuromodulation have been used to manage persistent and intractable pain with positive patient outcomes and improved quality of life. LIMITATIONS: The complex and diverse clinical presentations of endometriosis make it challenging to compare the effectiveness of different pain management techniques. CONCLUSION: Endometriosis is a complex condition causing various forms of pain including nerve involvement, scar tissue formation, and bowel/bladder symptoms. Interventional pain management techniques are effective for managing endometriosis-related pain. KEY WORDS: Endometriosis, chronic pain, therapeutic interventions, interventional techniques, pain injections, visceral pain, peripheral pain.

Combined cervical and thoracic spinal cord stimulation for chronic pain: A systematic literature review.

OBJECTIVES: Spinal cord stimulation (SCS) is conventionally placed at either cervical or thoracic spinal regions to treat chronic pain. However, for patients with multiarea pain, concomitant cervical and thoracic SCS (ctSCS) may be necessary to provide sufficient coverage. It remains unknown whether ctSCS is effective and safe. Thus, we aimed to survey the existing literature and assess the efficacy and safety of ctSCS. METHODS: A systematic review of the literature was performed according to the 2020 PRISMA guidelines to investigate pain, functional, and safety outcomes related to ctSCS. Articles between 1990 and 2022 available through PubMed, Web of Science, Scopus, and Cochrane Library databases were included if they assessed these outcomes in the context of ctSCS. Data extracted from articles included study type, number of ctSCS implantations, stimulation parameters, indications for implantation, complications, and frequency. The Newcastle-Ottawa scale was used to assess risk of bias. RESULTS: Three primary studies met our inclusion criteria. Overall, ctSCS was effective in providing analgesia. Pain severity was captured with patient-reported pain scales and changes in analgesic requirements. Various metrics were used to quantify quality of life and functional outcomes. Failed back surgery syndrome was the most common indication for ctSCS implantation. Implanted pulse generator pocket pain was the most common postoperative adverse event. CONCLUSIONS: Despite the limited evidence available, ctSCS seems to be effective and generally well tolerated. The dearth of relevant primary literature illustrates a knowledge gap, and future studies are needed to better clarify the efficacy and safety profile of this SCS variant.

Impact of Anesthesia selection on Post-Op Pain Management in Operatively treated Hip Fractures.

OBJECTIVES: To determine if the use of Peripheral Nerve Block (PNB) versus Local Infiltration Analgesia (LIA) for hip fracture patients, affected opioid consumption in the early post-operative period. DESIGN: Retrospective cohort study SETTING: Two level 1 trauma centers PATIENTS/INTERVENTION: 588 patients with surgically treated AO/OTA 31A and 31B fractures between February 2016-October 2017 were included. 415 (70.6%) received general anesthesia (GA) alone, 152 received GA plus perioperative PNB (25.9%), and 21 had GA plus LIA intra-operatively (3.6%). Median age was 82 years; predominantly female (67%) and AO/OTA 31A fractures (55.37%). MAIN OUTCOME MEASURES: Morphine Milligram Equivalents (MME) at 24 and 48 hours postoperatively, length of stay (LOS) and the occurrence of any complication after surgery RESULTS: The PNB cohort was less likely to use any opioid than the GA group at 24 and 48 hours postoperatively (OR: 0.36, 95% CI: 0.22-0.61 and OR: 0.56, 95% CI: 0.35-0.89 respectively). LOS ≥ 10 days had 3.24 times the odds of 24- and 48-hour opioid administration compared to LOS ≤ 10 days (OR: 3.24, 95% CI 1.11-9.42; OR: 2.98, 95% CI 1.38-6.41, respectively). The most common complication was post-operative delirium, with PNB more likely to present with any complication compared to GA (OR= 1.88, 95% CI 1.09-3.26). There was no difference when comparing LIA to general anesthesia. CONCLUSIONS: Our findings suggest PNB for hip fracture can help limit the use of post-operative opioids with adequate pain relief. Regional analgesia does not seem to avoid complications such as delirium.

The Effect of Preoperative Pain Fear on Postoperative Pain, Analgesic Use, and Comfort Level.

BACKGROUND: Preoperative assessment of pain fear could provide essential information for improving perioperative care and could be the first step toward targeted pain management. AIMS: The aim of this study is to determine the effect of preoperative pain fear on postoperative pain, analgesic use, and comfort level. METHOD: This cross-sectional study was conducted with 201 patients in the general surgery service between January 2022 and March 2022. A sociodemographic questionnaire, Visual Analog Scale (VAS), pain fear, and general comfort scales were used for data collection. Correlation analysis was performed to examine the relationship between scales, and p < .05 was considered statistically significant. RESULTS: The mean age of the individuals participating in the study was 51.22±15.89 and 69.2% of them were women. The average score of pain fear was 63.77±21.47, and the average score of the VAS was 7.63±1.82 after the surgery before analgesics and 5.06±1.58 six hours after surgery. The mean comfort level was 132.88±9.26. A significant and positive correlation was detected between the total pain fear and the VAS score, analgesic use, and comfort level (p < .05). CONCLUSIONS: In this research, findings demonstrated that as the patients' pain fear increased, postoperative pain severity and amount of analgesia increased. Providing pain management with analgesics increases comfort in patients, but it may cause secondary problems in patients who use high-dose analgesics. Therefore, reducing pain fear, which is one of the main factors in pain, is essential in pain management.

Patient, operative and pain management factors influencing inpatient compared with surgical day care mastectomy procedures at a community hospital.

BACKGROUND: The COVID-19 pandemic highlighted the importance of maximizing same-day discharge after surgery to mitigate potential patient harms associated with inpatient admission and conserve valuable hospital resources. Adoption of same-day discharge after breast surgery, particularly mastectomy, has been slow despite recent research suggesting the physical and psychological benefits of same-day discharge after surgery. We sought to identify factors associated with inpatient compared with surgical day care mastectomy procedures at a community hospital in Vernon, British Columbia. METHODS: We conducted a retrospective chart review of all patients who underwent a total mastectomy without reconstruction at Vernon Jubilee Hospital, a 196-bed community hospital, between April 2016 and March 2019. Patient characteristics, operative variables and pain management were compared between inpatient and surgical day care mastectomy procedures. We also compared 7-day readmission, reoperation and complications. RESULTS: A total of 187 mastectomy patients were analyzed with 72 (38.5%) surgical day care procedures. Factors associated with inpatient procedures included longer operative time (66.1 min v. 53.5 min, p = 0.001), bilateral mastectomy (91% v. 9%, p = 0.01) and suspected or confirmed obstructive sleep apnea (32% v. 17%, p = 0.04). Preoperative acetaminophen (83% v. 17%, p < 0.001), multilevel intercostal block (83% v. 17%, p < 0.001) and a prescription for acetaminophen plus tramadol (58% v. 42%, p < 0.001) were associated with day care surgeries. There were no significant differences between the inpatient and surgical day care groups with respect to 7-day readmission, reoperation or postoperative complications. CONCLUSION: We found no significant differences in surgical outcomes between inpatients and those with same-day discharge after mastectomy procedures. These findings add to the growing body of evidence that surgical day care mastectomy procedures are safe in the community setting.

Precision Medicine in Neuropathic Pain.

Neuropathic pain is a common chronic pain condition that is caused by a lesion or disease of the somatosensory nervous system. The multitude of sensory negative and positive sensations and associated comorbidities have a major impact on quality of life of affected patients. Current treatment options often only lead to a partial pain relief or are even completely ineffective. In addition, many clinical trials for the development of new drugs have not met the primary endpoint. Therefore, there is still an unmet clinical need in neuropathic pain syndromes. One reason for this therapeutic dilemma could be the heterogeneity of neuropathic pain with a variety of pathophysiological pain mechanisms that are expressed differently in each patient regardless of the underlying disease etiology. Reclassification of neuropathic pain syndromes therefore focuses on the underlying mechanisms of pain development rather than the disease etiology. A priori stratification of patients based on these individual mechanisms could allow the identification of potential treatment responders and thus realize the concept of a mechanism-based treatment. As no biomarkers for pain mechanisms have been discovered yet, one has to rely on surrogate markers that are thought to be closely related to these mechanisms. In this chapter, we present promising predictive biomarkers, focusing in particular on sensory symptoms and signs assessed by patient-reported outcome measures and sensory testing, and discuss how these tools might be used in clinical trials in the future.