Single-bolus injection of local anesthetic, with or without continuous infusion, for interscalene brachial plexus block in the setting of multimodal analgesia: a randomized controlled unblinded trial.

INTRODUCTION: Previous trials favored a continuous interscalene brachial plexus block over a single injection for major shoulder surgery. However, these trials did not administer a multimodal analgesic regimen. This randomized, controlled unblinded trial tested the hypothesis that a continuous infusion of local anesthetic for an interscalene brachial plexus block still provides superior analgesia after major shoulder surgery when compared with a single injection in the setting of multimodal analgesia, inclusive of intravenous dexamethasone, magnesium, acetaminophen and ketorolac. METHODS: Sixty patients undergoing shoulder arthroplasty or arthroscopic rotator cuff repair were randomized to receive a bolus of ropivacaine 0.5%, 20 mL, with or without a continuous infusion of ropivacaine 0.2% 4-8 mL/hour, for an interscalene brachial plexus block. Patients were provided with intravenous morphine patient-controlled analgesia. The primary outcome was cumulative intravenous morphine consumption at 24 hours postoperatively. Secondary outcomes included pain scores at rest and on movement, and functional outcomes, measured over 48 hours after surgery. RESULTS: Median (IQR) cumulative intravenous morphine consumption at 24 hours postoperatively was 10 mg (4-24) in the continuous infusion group and 14 mg (8-26) in the single injection group (p=0.74). No significant between-group differences were found for any of the secondary outcomes. CONCLUSIONS: A continuous infusion of local anesthetic for an interscalene brachial plexus block does not provide superior analgesia after major shoulder surgery when compared with a single injection in the setting of multimodal analgesia, inclusive of intravenous dexamethasone, magnesium, acetaminophen and ketorolac. The findings of this study are limited by performance and detection biases. TRIAL REGISTRATION NUMBER: NCT04394130.

Cryoneurolysis of alveolar nerves for chronic dental pain: A new technique and a case series.

BACKGROUND: Chronic neuropathic dental pain has a poor prognosis with a low chance of significant spontaneous improvement. Local or oral therapies may be efficient, however short in terms of duration with potential side effects. Cryoneurolysis has been described to prevent acute postoperative pain or to treat some chronic pain conditions; however, application to dental orofacial pain has not been reported so far. CASE SERIES: Following a positive diagnostic block on the corresponding alveolar nerve, neuroablation was performed using a cryoprobe on three patients suffering from persistent pain after a dental extraction and 1 after multiple tooth surgeries. The effect of treatment was assessed using a Pain Numeric Rating Scale (NRS) and determined by changes in medication dosage and quality of life at day 7 and 3 months. Two patients experienced more than 50% of pain relief at 3 months, 2 by 50%. One patient was able to wean off pregabalin medication, one decreased amitriptyline by 50%, and one decreased tapentadol by 50%. No direct complications were reported. All of them mentioned improvement in sleep and quality of life. CONCLUSION: Cryoneurolysis on alveolar nerves is a safe and easy-to-use technique allowing prolonged neuropathic pain relief after dental surgery.

[Intrathecal drug delivery for chronic pain management]. / Traitement de la douleur chronique par administration continue de médicaments par voie intrathécale.

Intrathecal drug delivery appeared in the early eighties and allows to administer high concentrate analgesic medications in the cerebrospinal fluid with higher efficacy and a limited incidence of systemic side effects. Opioids are still the first line treatment with high-quality evidence for chronic cancer pain, and limited evidence for chronic non-cancer pain, being often considered as a last resort therapy. Device implantation requires a strict patient's selection with a close follow-up in order to adapt therapy, refill the reservoir and detect and prevent potential severe complications.

La thérapie intrathécale, apparue au début des années 80, a pour but d'administrer dans le liquide céphalo-rachidien, au moyen d'une pompe implantée, des médicaments antalgiques hautement concentrés tout en limitant leurs effets secondaires systémiques. Les opioïdes restent le traitement de première ligne, avec une évidence d'efficacité claire lors de douleurs cancéreuses. En revanche, son efficacité reste limitée lors de pathologies non cancéreuses, dans lesquelles elle est plutôt considérée comme un traitement de dernier recours. L'implantation de ce dispositif nécessite une sélection adéquate des patients ainsi qu'un suivi régulier, dans le but d'adapter le traitement, de procéder au remplissage du réservoir et d'éviter les éventuelles complications.

[Cryotherapy for pain treatment: An overview]. / Cryothérapie dans le traitement de la douleur : tour d'horizon et nouveau.

The role of cryotherapy in the treatment of pain has been known since the Egyptians. For fifty years, techniques initially dedicated to the whole body have evolved into more specific approaches by targeting nerve structures. Several indications for the treatment of acute and chronic pain have emerged and are supported by scientific evidence. A reduction in pain for up to several months, a decrease of opioid consumption and an improvement in the physical activity are among the main results reported in the literature. Cryotherapy appears to be an efficient treatment in pain management correlated with a relatively few numbers of side effects.

Le rôle de la cryothérapie dans le traitement des douleurs est connu depuis l'époque des Égyptiens. Au cours des 50 dernières années, les techniques d'application systémique du froid ont évolué vers des approches plus ciblées visant les structures nerveuses. De nombreuses indications pour le traitement des douleurs aiguës et chroniques ont vu le jour et sont soutenues par des évidences scientifiques. Une diminution des douleurs jusqu'à parfois plusieurs mois, une baisse de la consommation d'opiacés ainsi qu'un gain fonctionnel sont parmi les résultats retrouvés dans la littérature. La cryothérapie est une option thérapeutique antalgique efficace comportant relativement peu d'effets secondaires.

[Interventional pain management for knee pain.] / Traitement des gonalgies en antalgie interventionnelle.

Arthritis is the main cause of knee pain among adults over 50 years old. Prosthetic surgery is the ultimate treatment, however percutaneous interventional pain management is a good alternative treatment for patients who are not eligible for an operation or for those who experiment persistent pain after surgery. Intra-articular corticosteroids or hyaluronic acid injections have a mild effect which is limited in time. Nerve ablation treatment using radiofrequency or cryotherapy may have longer lasting analgesic effects superior than 6 months. Finally, regenerative medicine, meaning platelet-rich plasma or mesenchymal stem cells, seems a very promising treatment by improving pain and mobility for a longer period.

La principale cause des gonalgies chez l'adulte de plus de 50 ans est l'arthrose. Si la chirurgie prothétique est le traitement définitif, l'antalgie interventionnelle percutanée est une alternative intéressante et peu risquée pour les patients non candidats à une chirurgie ou qui présentent des douleurs persistantes après une intervention. Les injections intra-articulaires de corticostéroïdes ou d'acide hyaluronique ont un bénéfice modéré à court terme. Les traitements de neurolyse par radiofréquence ou cryothérapie peuvent avoir des effets antalgiques de plus de 6 mois. Enfin, la médecine régénérative, soit l'injection intra-articulaire de plasma riche en plaquettes ou de cellules souches mésenchymateuses, semble très prometteuse dans l'amélioration des douleurs et de la mobilité dans le temps.

[Medical cannabinoids and their indications in chronic pain]. / Les cannabinoïdes et leurs indications en antalgie chronique.

Democratization of the cannabis consumption and its derivatives incite patients to ask ever more for medical cannabinoid prescriptions, especially in the context of chronic pain. Its use is only validated in certain limited cases, in particular spasticity linked to multiple sclerosis and refractory epilepsies. All other prescriptions require a special request to the OFSP. Moreover, cannabinoid intake may produce several dose-dependent side effects that require a close monitoring with a slow and gradual initiation of its dosage. In the absence of clear medical evidence, many other mechanisms of action need to be investigated with ongoing and future studies to clarify their indication.

La démocratisation de la consommation de cannabis et de ses dérivés pousse les patients à être de plus en plus demandeurs de prescriptions de cannabis à usage médical, d'autant plus dans le cadre de douleurs chroniques. Il convient alors de rappeler que son utilisation n'est validée que dans certains cas restreints, notamment dans la spasticité liée à la sclérose en plaques et les épilepsies réfractaires. Toute autre prescription nécessite une demande spéciale à l'Office fédéral de la santé publique. Par ailleurs, la prise de cannabinoïdes étant liée à nombre d'effets secondaires dose-dépendants, son administration nécessite une surveillance rapprochée et une initiation lente et progressive. En l'absence d'évidence médicale claire, il reste de nombreuses pistes encore à développer pour cibler leur indication.

Pain Intensity in the First 96 Hours After Abdominal Surgery: A Prospective Cohort Study.

OBJECTIVE: Multimodal pain management strategies aim to improve postoperative pain control. The purpose of this study was to analyze pain scores and risk factors for acute postoperative pain after various abdominal surgery procedures. METHODS: Data on 11 different abdominal surgery procedures were prospectively recorded. Pain intensity (rest, mobilization) and patient satisfaction at discharge were assessed using a visual analog scale (VAS; 0-10), and analgesic consumption was recorded until 96 hours postoperation. Demographic, surgery-related, and pain management-related univariate risk factors for insufficient pain control (VAS ≥ 4) were entered in a multivariate logistic regression model. RESULTS: A total of 1,278 patients were included. Overall, mean VAS scores were <3 at all time points, and scores at mobilization were consistently higher than at rest (P < 0.05). Thirty percent of patients presented a prolonged VAS score ≥4 at mobilization at 24 hours, significantly higher than at rest (14%, P < 0.05). High pain scores correlated with high opioid consumption, whereas a variability of pain scores was observed in patients with low opioid consumption. The only independent risk factor for moderate and severe pain (VAS ≥ 4) was younger age (<70 years, P = 0.001). The mean satisfaction score was 8.18 ± 1.29. CONCLUSIONS: Among 1,278 patients, pain was controlled adequately during the first four postoperative days, resulting in high levels of patient satisfaction. Pain levels were higher at mobilization. Younger age was the only independent risk factor for insufficient pain control. Preventive treatment in patients <70 years old and before mobilization could be evaluated for potential improvement.

Pain perception after colorectal surgery: A propensity score matched prospective cohort study.

The purpose of this prospective cohort study was to compare multimodal pain management and pain perception after open vs. laparoscopic colorectal surgery within enhanced recovery care. Pain scores at rest and at mobilization were prospectively assessed in consecutive patients using Visual Analog Scales (VAS 0-10) and consumption of different analgesics was recorded daily until 96 hours postoperatively. Uni- and multivariate risk factors for pain peaks (≥ 4/10) were identified by logistic regression and compared between two propensity score matched groups (open vs. laparoscopic). 156 open and 176 laparoscopic procedures were included. Mean VAS scores were consistently < 3 until 96 hours at rest and at mobilization. Patients operated by laparoscopy experienced more pain peaks (≥ 4) within 24 hours (p < 0.05), while patients operated by open approach experienced more pain peaks (≥ 4) during mobilization at 72 hours (p < 0.05). Independent risk factors for insufficient pain control (≥ 4) within 24 hours from surgery were duration of the procedure (OR 3.37, 95%CI 2.03-5.59), emergency surgery (OR 3.01, 95%CI 1.72-5.31), wound infiltration (OR 3.23, 95%CI 0.97-10.70), age < 70 years (OR 2.03, 95% CI 1.18-3.48) and ASA I-II score (OR 2.06, 95% CI 1.19-3.56). The perioperative adding of lidocaine ± ketamine to opioids did not improve postoperative pain perception nor decrease morphine equivalents. In conclusion, overall pain scores were low after colorectal surgery. However, pain peaks remained a concern early after minimally invasive surgery and after epidural removal for open surgery. Multimodal strategies were not superior to opioids alone.

Is standardized care feasible in the emergency setting? A case matched analysis of patients undergoing laparoscopic cholecystectomy.

BACKGROUND: Immediate laparoscopic cholecystectomy is the accepted standard for the treatment of acute cholecystitis. The aim of the present study was to evaluate the feasibility of a standardized approach with tailored care maps for pre- and postoperative care by comparing pain, nausea and patient satisfaction after elective and emergent laparoscopic cholecystectomy. METHODS: From January 2014 until April 2015, data on pain and nausea management were prospectively recorded for all elective and emergency procedures in the department of visceral surgery. This prospective observational study compared consecutive laparoscopic elective vs. emergency cholecystectomies. Visual analogue scales (VAS) were used to measure pain, nausea, and satisfaction from recovery room until 96 hours postoperatively. RESULTS: Final analysis included 168 (79%) elective cholecystectomies and 44 (21%) emergent procedures. Demographics (Age, gender, BMI and ASA-scores) were comparable between the 2 groups. In the emergency group, patients did not receive anxiolytic medication (0% vs.13%, p = 0.009) and less postoperative nausea and vomiting (PONV) prophylaxis (77% vs. 97% p = <0.001). Perioperative pain management was similar in terms of opioid consumption (median amount of fentanyl 450ug [IQR 350-500] vs. 450ug [375-550], p = 0.456) and wound infiltration rates (24% vs. 25%, p = 0.799). Postoperative consumption of paracetamol, metamizole and opiod medications were similar between the 2 groups. VAS scores for pain (p = 0.191) and nausea (p = 0.392) were low for both groups. Patient satisfaction was equally high in both clinical settings (VAS 8.5 ± 1.1 vs. 8.6 ± 1.1, p = 0.68). CONCLUSIONS: A standardized pathway allows equally successful control of pain and nausea after both elective and emergency laparoscopic cholecystectomy. This study was retrospectively registered by March 01, 2016 in the following trial register: www.researchregistry.com (UIN researchregistry993).

[Chronic postoperative pain]. / Douleur chronique postopératoire.

Chronic postoperative pain remains a frequent pathology whose global impact approximates 20 and 30% and accounts for 20% of the consultations in a pain center. Risk factors consider firstly each patient's feature and comorbidity and also different surgical procedures with their technical approach. Neuropathic pain compared to nociceptive pain is a great component in the postoperative period and needs to be recognized by specific tests (DN4). Pain prevention involves risk factors' detection, appropriate anesthetic support and effective postoperative pain management. Treatment is based on the type of pain and includes a multimodal analgesia with interventional pain therapy.

[PIPAC--Pressurized intraperitoneal aerosol chemotherapy. A novel treatment for peritoneal carcinomatosis]. / PIPAC--Chimiothérapie intrapéritonéale vaporisée. Un traitement innovateur de la carcinose péritonéale.

Peritoneal carcinomatosis remains a diagnostic challenge with sparse treatment options. The effect of systemic chemotherapy remains limited inside the peritoneum due to low penetration and a relative resistance of peritoneal nodules. Heated IntraPeritoneal Chemotherapy (HIPEC) improves survival in selected patients but entails a high incidence of complications. Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) allows to disperse the active agents inside the peritoneal cavity by laparoscopy. Distribution and tissue penetration of chemotherapy by PIPAC are superior to HIPEC and systemic chemotherapy despite of lower doses. Systemic side effects are uncommon and surgical trauma is limited. Histological and clinical response rates in platinum-resistant patients approach 70% and survival data appear to be favorable compared with standard therapy.

Dysregulation of voltage-gated sodium channels by ubiquitin ligase NEDD4-2 in neuropathic pain.

Peripheral neuropathic pain is a disabling condition resulting from nerve injury. It is characterized by the dysregulation of voltage-gated sodium channels (Navs) expressed in dorsal root ganglion (DRG) sensory neurons. The mechanisms underlying the altered expression of Na(v)s remain unknown. This study investigated the role of the E3 ubiquitin ligase NEDD4-2, which is known to ubiquitylate Navs, in the pathogenesis of neuropathic pain in mice. The spared nerve injury (SNI) model of traumatic nerve injury-induced neuropathic pain was used, and an Na(v)1.7-specific inhibitor, ProTxII, allowed the isolation of Na(v)1.7-mediated currents. SNI decreased NEDD4-2 expression in DRG cells and increased the amplitude of Na(v)1.7 and Na(v)1.8 currents. The redistribution of Na(v)1.7 channels toward peripheral axons was also observed. Similar changes were observed in the nociceptive DRG neurons of Nedd4L knockout mice (SNS-Nedd4L(-/-)). SNS-Nedd4L(-/-) mice exhibited thermal hypersensitivity and an enhanced second pain phase after formalin injection. Restoration of NEDD4-2 expression in DRG neurons using recombinant adenoassociated virus (rAAV2/6) not only reduced Na(v)1.7 and Na(v)1.8 current amplitudes, but also alleviated SNI-induced mechanical allodynia. These findings demonstrate that NEDD4-2 is a potent posttranslational regulator of Na(v)s and that downregulation of NEDD4-2 leads to the hyperexcitability of DRG neurons and contributes to the genesis of pathological pain.