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We present the unusual case of complex regional pain syndrome (CRPS) of the residual limb in a 54-year-old woman with transtibial lower-limb amputation. Intractable pain developed 14 months after amputation, followed by successful rehabilitation. Anamnesis and clinical findings included sensory symptoms, vasomotor symptoms and signs, and oedema. The Budapest criteria for a diagnosis of CRPS were met. After infusions of bisphosphonates during a 5-week inpatient interdisciplinary rehabilitation programme, the pain decreased. Clinicians should suspect CRPS in case of chronic or recurrent residual limb pain. The Budapest criteria seem applicable even if interpretation of symptoms and findings can be complicated in vascular polymorbid lower-limb amputation. Bisphosphonates, proposed as first-line pharmacological treatment, can be useful.

Chronic hand ischemia causes cold intolerance, intractable pain, and digital ulceration. If ischemic symptoms persist despite pharmacologic treatments, surgical interventions should be considered. This retrospective study evaluated the long-term results after ulnar and radial reconstruction using an interpositional deep inferior epigastric artery (DIEA) graft combined with periarterial sympathectomy. Patients who underwent this surgery from March 2003 to February 2019 were included. To evaluate variables influencing recurrence after the procedure, patients were divided into the recurred and non-recurred groups and their data were compared. Overall, 62 cases involving 47 patients were analyzed (16 and 46 cases in the recurred and non-recurred groups, respectively). The median DIEA graft length was 8.5 cm. The rates of rheumatic disease and female patients were significantly higher in the recurred than in the non-recurred group, without significant between-group differences in postoperative complication rates. In the multivariate analysis, underlying rheumatic disease and graft length had significant effects on recurrence. In Kaplan–Meier analysis, the 5- and 10-year symptom-free rates were 81.3% and 68.0%, respectively, with lower rates for cases with rheumatic disease. Thus, arterial reconstruction using an interpositional DIEA graft provides long-term sustainable vascular supply in patients with chronic hand ischemia, especially in those without rheumatic disease.

Objective : To review the outcomes of various therapeutic modalities that can be offered to patients with chronic orchialgia (CO) after failed conservative treatment. Methods : A literature search was conducted using the PubMed and MEDLINE databases searching for articles exploring different CO treatment modalities. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach was used to report the results of the literature search. Results : A total of 34 studies were included for qualitative analysis. Most of the studies explored microsurgical spermatic cord denervation (MSCD; n = 19). Eight studies involved devices and interventions directed at blocking nerve sensations (pulsed radiofrequency stimulation, n = 5; transcutaneous electrical nerve stimulation, n = 1; cryoablation, n = 1; and mechanical vibratory stimulation, n = 1). Five studies reported on vasectomy reversal as a modality to relieve post-vasectomy pain syndrome (PVPS), while two studies explored the outcomes of orchidectomy on pain relief in patients with CO. Conclusion : Several treatment methods are available in the urologist’s armamentarium for the treatment of CO. MSCD appears to be an appealing treatment modality with encouraging outcomes. Neuropathic pain can be managed with a number of relatively non-invasive modalities. Vasectomy reversal is a sound treatment approach for patients with PVPS and ultimately orchidectomy is a terminal approach that can be discussed with patients suffering from intractable pain.

Background: Hypereosinophilic syndrome is a rare disease that increases the number of circulating eosinophils in the body. It has many complications, including peripheral polyneuropathy. Peripheral polyneuropathy often does not respond well to conventional therapies. Transcutaneous neurostimulatory treatment, also known as scrambler therapy, is an alternative modality for the treatment of chronic retractable pain. Case: A 47-year-old woman presented with complaints of bilateral calf pain. She had been under treatment for peripheral polyneuropathy induced by hypereosinophilic syndrome for 7 years. Pharmacologic treatment did not affect the patient’s symptoms. Conclusions: Transcutaneous neurostimulatory treatment was administered to the patient. It was effective on her symptoms, and the effect of pain alleviation continued for 3 months.

BACKGROUND The spine is the most common location of metastatic diseases. Treating a metastatic spinal tumor depends on many factors, including patients’ overall health and life expectancy. The present study was conducted to investigate prognostic factors and clinical outcomes in patients with vertebral metastases. AIM To investigate prognostic factors and their predictive value in patients with metastatic spinal cancer. METHODS A retrospective analysis of 109 patients with metastatic spinal cancer was conducted between January 2015 and September 2017. The prognoses and survival were analyzed, and the effects of factors such as clinical features, treatment methods, primary lesions and affected spinal segments on the prognosis of patients with metastatic spinal cancer were discussed. The prognostic value of Frankel spinal cord injury functional classification scale, metastatic spinal cord compression (MSCC), spinal instability neoplastic score (SINS) and the revised Tokuhashi score for prediction of prognosis was explored in patients with metastatic spinal tumors. RESULTS Age, comorbidity of metastasis from elsewhere, treatment methods, the number of spinal tumors, patient’s attitude toward tumors and Karnofsky performance scale score have an effect on the prognosis of patients (all P < 0.05). With respect to classification of spinal cord injury, before operation, the proportion of grade B and grade C was higher in the group of patients who died than in the group of patients who survived, and that of grade D and grade E was lower in the group of patients who died than in the group of patients who survived (all P < 0.05). At 1 mo after operation, the proportion of grade A, B and C was higher in the group of patients who died than in the group of patients who survived, and that of grade E was lower in patients in the group of patients who died than in the group of patients who survived (all P < 0.05). MSCC occurred in four (14.3%) patients in the survival group and 17 (21.0%) patients in the death group (P < 0.05). All patients suffered from intractable pain, dysfunction in spinal cord and even paralysis. The proportion of SINS score of 1 to 6 points was lower in the death group than in the survival group, and the proportion of SINS score of 7 to 12 points was higher in the death group than in the survival group (all P < 0.05). The proportion of revised Tokuhashi score of 0 to 8 points and 9 to 11 points were higher in the death group than in the survival group, and the proportion of revised Tokuhashi score of 12 to 15 points was lower in the death group than in the survival group (all P < 0.05). Frankel spinal cord injury functional classification scale, MSCC, SINS and revised Tokuhashi score were important factors influencing the surgical treatment of patients with metastatic spinal cancer (all P < 0.05). CONCLUSION Frankel spinal cord injury functional classification scale, MSCC, SINS and revised Tokuhashi score were helpful in predicting the prognosis of patients with metastatic spinal cancer.

Schwannomas are benign neoplasms that can cause gain‐ and loss‐of‐function neurological phenotypes, including severe, intractable pain. To investigate the molecular mechanisms underlying schwannoma‐associated pain we compared the RNA sequencing profile of painful and non‐painful schwannomas from NF2 patients. Distinct segregation of painful and non‐painful tumors by gene expression patterns was observed. Differential expression analysis showed the upregulation of fibroblast growth factor 7 (FGF7) in painful schwannomas. Behavioral support for this finding was observed using a xenograft human NF2‐schwannoma model in nude mice. In this model, over‐expression of FGF7 in intra‐sciatically implanted NF2 tumor cells generated pain behavior compared with controls.

Background: Complex regional pain syndrome (CRPS) is an intractable pain disease with various symptoms. Here, we investigated the disease status, work life, sleep problems, medical insurance, economic status, psychological problems, and quality of life (QOL) of CRPS patients. Methods: CRPS patients from 37 university hospitals in South Korea were surveyed. The survey questionnaire consisted of 24 questions on the following aspects of CRPS patients: sex, age, occupation, cause of injury, activities of daily living (ADL), pain severity, sleep disturbance, level of education, economic status, therapeutic effect, and suicidal ideation. Additionally, the abbreviated World Health Organization Quality of Life (WHOQOL-BREF) questionnaire, consisting of 26 questions, was used to identify the status of QOL. Results: A total of 251 patients completed the questionnaire. According to the survey, 54.2% patients could not perform ADL on their own. Over the previous week, the mean pain score was 7.15 ± 1.78 (out of a total of 10 points); 92.1% of patients had sleep disorders and 80.5% had suicidal ideation, with most patients suffering from psychological problems. The average for each domain of WHOQOL-BREF was as follows: 21.74 ± 14.77 for physical, 25.22 ± 17.66 for psychological, 32.02 ± 22.36 for social relationship, and 30.69 ± 15.83 for environmental (out of a total of 100 points each). Occupation, ADL, sleep time, therapeutic effect, and suicidal ideation were statistically correlated with multiple domains. Conclusions: Most patients had moderate to severe pain, economic problems, limitations of their ADL, sleep problems, psychological problems, and a low QOL score.

Background With the development of evidence-based guidelines for the diagnosis and antibiotic treatment of patients with pyogenic vertebral osteomyelitis, various nonsurgical and surgical treatment strategies have achieved favorable results. However, sufficient administration of appropriate antibiotics is a prerequisite for treatment success, which cannot be guaranteed in patients with culture-negative pyogenic vertebral osteomyelitis. Unfortunately, previous studies on culture-negative pyogenic vertebral osteomyelitis were limited by small patient groups, short follow-up periods, varied treatment protocols, and inconsistently defined clinical endpoints. Questions/purposes Among patients treated according to our center's treatment protocol for culture-negative pyogenic vertebral osteomyelitis, which included patients treated without surgery, with surgery but without spinal instrumentation, as well as patients treated with instrumented surgery, (1) what proportion of patients in each treatment group experienced recurrence (or persistence) of infection, complications of treatment, and death; and (2) what factors were independently associated with recurrent or persistent infection after treatment under this algorithm? Methods This was a retrospective evaluation of a treatment protocol in use at one center from 2008 to 2020. During that time, we treated 183 patients for culture-negative pyogenic vertebral osteomyelitis. The diagnosis was based on clinical, laboratory, and radiological features excluding disease that presents similar features to pyogenic vertebral osteomyelitis. For those patients, our protocol included three possible approaches: nonsurgical treatment, including the use of empirical antibiotics (nonoperative group, n = 82); spinal decompression without instrumentation (noninstrumented group, n = 41); and spinal decompression with instrumentation (instrumented group, n = 60). The indications for each treatment during the period remained relatively consistent. Nonsurgical treatment including empirical antibiotics was applied to all patients according to the specified antibiotic protocol. Spinal decompression without instrumentation was employed when a patient presented substantial or aggravating neurologic deficits or intractable pain from an abscess. Instrumentation was added in patients with mechanical instability before or after spinal decompression. Minimum follow-up to be included in this study was 1 year, and 91% (252 of 277) of patients were accounted for at that time, with no differential loss to follow-up among the study groups (12, five, and four patients missing from the three groups, respectively, at 1 year). Chart review was performed to ascertain the proportion of patients in each group who experienced recurrence, complications, and death. Factors associated with recurrence were assessed across the entire cohort using a multivariable logistic model. We analyzed 1-year recurrence and mortality rates using the Kaplan-Meier method, and their 95% confidence intervals were calculated using the method by Hosmer and Lemeshow. Results At 1 year, the recurrence-free survival rate was 87% (95% confidence interval 78% to 93%) in the nonoperative group, 87% (95% CI 72% to 94%) in the noninstrumented group, and 91% (95% CI 80% to 96%) in the instrumented group. The proportion of patients who experienced a major medical complication in each group was 12% (10 of 82), 10% (4 of 41), and 8% (5 of 60), respectively. At 1 year, the survival rate with patient death as the endpoint was 95% (95% CI 88% to 98%) in the nonoperative group, 95% (95% CI 82% to 99%) in the noninstrumented group, and 97% (95% CI 87% to 99%) in the instrumented group. After controlling for potentially confounding variables including age, medical comorbidities, and anatomical involvement of infection, the following factors were independently associated with increased odds of infection recurrence or persistence: higher Charlson Comorbidity Index (CCI) score (odds ratio 1.6 per point on the CCI [95% CI 1.2 to 2.1]; p = 0.004) and the presence of a psoas abscess (OR 4.7 [95% CI 1.6 to 13.9]; p = 0.005). Conclusion Among patients with negative initial nonoperative culture results, spinal decompression and abscess drainage can be used in those with substantial or aggravating neurological deficits or intractable pain caused by an abscess, while additional early spinal instrumentation can be applied upon consideration of their medical comorbidities and the presence of a psoas abscess when mechanical instability is present before or after the spinal decompression. Reasonable clinical results can be expected, regardless of the results from subsequent operative cultures. However, our study results should be replicated by other centers, and further studies that consider individual differences such as bone mineral density and include patients with previous spinal instrumentation or recurrent infection should be performed to establish a more comprehensive treatment protocol. Level of evidence Level IV, therapeutic study.

Complex regional pain syndrome is a painful and debilitating syndrome in which the patient presents with disabling pain, edema, and/or vasomotor or sudomotor abnormalities. The mechanism is complex and not well understood. There is no definitive treatment for the condition yet. Pulsed radiofrequency is a minimally invasive, minimal destructive, and safe intervention. It can be used for neuropathic pain. A 40-year-old man with complex regional pain syndrome complained of intractable pain of the lower limb secondary to injury to the saphenous nerve due to a third-degree burn. Conventional medications, epidural block, and sympathetic nerve block provided temporary relief. We performed pulsed radiofrequency of the saphenous nerve for the management of lower limb pain, and the symptoms remained under control at 3 months. To the best of our knowledge, this is the first application of ultrasound-guided pulsed radiofrequency of the saphenous nerve for the management of complex regional pain syndrome.

Background Patients with spinal cord injury (SCI) frequently complain of intractable pain that is resistant to conservative treatments. Here, we report the successful application of 1-kHz high-frequency spinal cord stimulation (SCS) in a patient with refractory neuropathic pain secondary to SCI. Case presentation A 69-year-old male diagnosed with SCI (C4 American Spinal Injury Association Impairment Scale A) presented with severe at-level bilateral upper extremity neuropathic pain. Temporary improvement in his symptoms with a nerve block implied peripheral component involvement. The patient received SCS, and though the tip of the leads could not reach the cervical vertebrae, a 1-kHz frequency stimulus relieved the intractable pain. Conclusions SCI-related symptoms may include peripheral components; SCS may have a considerable effect on intractable pain. Even when the SCS electrode lead cannot be positioned in the target area, 1-kHz high-frequency SCS may still produce positive effects.

Morphine is the first line drug for moderate to severe pain; however, due to side effects it may contribute to discomfort. Dexmedetomidine has both sedative and analgesic actions with a morphine sp...

Fibro-adipose vascular anomaly (FAVA) is a discrete type of vascular anomaly. We describe our experience managing FAVA at a tertiary level paediatric hospital and offer a treatment algorithm. Methods A retrospective review of 27 patients with proven FAVA was undertaken. All patients had undergone MRI and USS evaluation. Patient demographics, presenting concerns, treatment methods, and outcomes were recorded and evaluation with the paediatric outcomes data collection instrument (PODCI) completed a minimum of 12 months after definitive treatment. Results Mean age at presentation was 8.9 years (range: 9 m-17.4 y) and mean post-treatment follow-up was 7.4 y (range: 2 y-11.6 y). Twenty of 27 lesions affected the lower limb. Severe neurogenic-type pain was present in 23 cases and contractures across joints in 11 cases. Sclerotherapy with sodium tetradecyl sulphate was used in 11 cases, with no improvement in symptoms. Cryoablation provided pain relief in 3/4 cases, but contracture subsequently increased in one patient and pain recurred in another. Fourteen cases underwent surgery (four surgical excisions alone, 10 in combination with other procedures). Three patients required four further surgical procedures that include one amputation for intractable pain and poor function. PODCI evaluations suggest overall good function, with surgical management and interventional radiology that provide comparable results. Surgery did correct deformity. Conclusion If conservative measures or cryoablation fail to achieve symptomatic control, surgical excision should be considered, combined with adjunctive procedures, to correct contractures and balance muscle forces. Relief of pain may compensate for the loss of muscle mass and overall improves function. Multidisciplinary team working is essential.

Background Skeletal metastases (SM) in advanced pancreatic ductal adenocarcinoma (PDAC) is an infrequent occurrence that has been previously reported in literature to occur in less than 2.5% of the cases. Complications such as pathological fractures can result in intractable pain, immobilization and a significant deterioration in quality of life. The purpose of this study is to improve the understanding of the increasing incidence of SM and the importance of surveillance and adequate management of SM in these patients. Methods A retrospective analysis was conducted using a clinical database at a single tertiary care institution for cancer patients; this included 207 patients with advanced PDAC diagnosed between December 2004 and March 2017 receiving palliative chemotherapy. SM were identified by computerized tomography (CT)/fluorodeoxyglucose positron emission tomography (FDG-PET)/magnetic resonance imaging (MRI). Information regarding demographics, clinical course and date of last follow-up/death were collected. After a median follow-up of 11 months, an analysis was conducted, including a Kaplan-Meier survival analysis. Results The study included 207 patients; 19 out of 207 patients (9.2%) developed SM; the primary tumor was located in the pancreatic body/tail in 12 out of 19 patients (63.2%). The thoracic and lumbar vertebrae were the most common sites of SM. Other common synchronous sites of metastases included the liver and lung. A majority of the lesions were osteolytic (63.2%). The median time of diagnosis from the initial diagnosis was 2 months (range, 0-60 months). Bone pain was observed as the initial symptom in 7 out of 19 patients (36.8%), 2 out of 19 patients (10.5%) had a pathological fracture and 1 out of 19 patients (5.3%) developed a para-spinal mass causing inferior vena cava compression. The median survival period for patients with SM was 11 months (range, 0-62 months) and for those without SM was 12 months (range, 0-147 months) [hazard ratio (HR) 1.24, 95% confidence interval (CI): 0.66-2.30, P=0.51]. Conclusions There has been a challenge with regards to management of the increasing number of patients with SM. Thoracic and lumbar vertebrae are the most common sites and pathological fractures in these sites can be catastrophic. Careful evaluation of skeletal signs and symptoms, early detection and intervention are essential to prevent morbidity and mortality from complications in patients with PDAC and SM.

Background Postherpetic neuralgia (PHN) is the most common complication of acute herpes zoster. The treatment of PHN remains a challenge for clinical pain management. Despite the effectiveness of anticonvulsants, antidepressants, and lidocaine patches in reducing PHN, many patients still face intractable pain disorders. In this randomized controlled study, we evaluated whether hydromorphone through intravenous patient-controlled analgesia (IV PCA) was effective in relieving PHN. Methods Patients with PHN were randomly divided into two groups, one group received oral pregabalin with IV normal saline, another group received oral pregabalin with additional IV PCA hydromorphone for two weeks. Efficacy was evaluated at 1, 4, and 12 weeks after the end of the treatments. Results Two hundred and one patients were followed up for 12 weeks. After treatment, numerical rating scale (NRS) score of patients in the hydromorphone group was significantly lower than that of the control group, and the difference of NRS scores between the two groups was statistically significant at 4 and 12 weeks after treatment. The frequency of breakthrough pain in the hydromorphone group was significantly lower than that in the control group 1 and 4 weeks after treatment. After treatment, the quality of sleep in the hydromorphone group was significantly improved compared with the control group. The most common adverse reactions in the hydromorphone group were dizziness and nausea, with no significant respiratory depression. Conclusions IV PCA hydromorphone combined with oral pregabalin provides superior pain relief in patients with PHN, which is worthy of clinical application and promotion.

Introduction: Patients with trigeminal neuralgia (TN) are usually treated on an outpatient basis, and symptoms can be controlled using various medical therapeutic options. We present a case of severe TN with an acute on chronic flare, which was now refractory to a wide variety of medical options, had a prolonged inpatient hospitalization, and ultimately required surgery with excellent results.Case: A 54-year-old Hispanic male was admitted with severe left-sided TN. His symptoms gradually became more pronounced and frequent to a point where he was unable to have a meaningful quality of life. A trial of gabapentin, phenytoin, opioids, and NSAIDs had also been unsuccessful before this hospitalization. He had three ER visits before he was finally hospitalized with intractable pain and unfortunately had begun to have suicidal thoughts. Various therapeutic interventions were tried, including escalating doses of opioids and local nerve blocks, but all non-surgical options failed to provide relief. Neurosurgical route was eventually approached, and patient underwent left retro mastoid suboccipital craniectomy. Intraoperatively, the left superior cerebellar artery was found to adhere to the inferior ventral aspect of the left trigeminal nerve root entry zone. Upon decompression patient’s symptoms resolved dramatically. Interestingly this vascular compression was not seen on multiple prior brain imaging.Conclusion: TN can severely affect someone’s quality of life. It often leads to severe anxiety and depression. Our case represents the importance of proceeding towards surgical options sooner rather than later. An early multi-disciplinary approach is warranted.

Background: About 50% of patients that suffer from trigeminal neuralgia do not experience sustained benefit from the use of oral medication. For their adequate management, a few surgical procedures are available. Of these, percutaneous balloon compression (PBC) and microvascular decompression (MD) are two of the most performed worldwide. In this retrospective study, we present the outcomes of these techniques through estimation of initial pain relief and subsequent recurrence rate. Methods: Thirty-seven patients with medically refractory trigeminal pain surgically treated at Hospital Cajuru, Curitiba, Brazil, with PBC, MD or both between 2013 and 2018 were enrolled into this retrospective study. The post-procedural rate for pain relief and recurrence and associations between patient demographics and outcomes were analyzed. Results: MD had an earlier recurrence time than balloon compression. Of the 37 patients, the mean age was 61.6 years, approximately one third were male and most had type I neuralgia. The most affected branch was the maxillary (V2). The time for recurrence after surgery was on average 11.8 months for PBC and 9.0 months for MD. Complications were seen only with microsurgery. Conclusions: MD presented with a more precocious recurrence of pain than PBC in this article. Moreover, it had a higher recurrence rate than described in the literature as well, which is possibly explained by the type of graft (muscle) that was used to separate the neurovascular structures. RESUMO Introdução: Cerca de 50% dos pacientes com neuralgia do trigêmeo não apresenta benefícios a longo prazo com o uso de medicação oral. Para a manutenção do tratamento, algumas opções cirúrgicas estão disponíveis, sendo a compressão percutânea por balão (CPB) e a descompressão microvascular (DM) algumas das modalidades mais realizadas em todo o mundo. Neste estudo retrospectivo, apresentamos os desfechos dessas técnicas por meio de estimativa da melhora inicial da dor e da taxa de recorrência subsequente. Métodos: Trinta e sete pacientes com dor trigeminal refratária ao tratamento medicamentoso tratados cirurgicamente no Hospital Cajuru, Curitiba, Brasil, com CPB, DM ou ambos entre 2013 e 2018 foram incluídos neste estudo retrospectivo. A taxa pós-procedimento para alívio e recorrência da dor e suas associações com a demografia e desfechos dos pacientes foram analisadas. Resultados: A DM foi associada a menor recorrência que a compressão por balão. Entre os 37 pacientes, a idade média foi de 61,6 anos, aproximadamente um terço eram do sexo masculino e a maioria apresentava neuralgia do tipo I. O ramo mais afetado foi o maxilar (V2). O tempo de recorrência após a cirurgia foi em média de 11,8 meses para CPB e 9,0 meses para DM. Foram vistas complicações apenas na microcirurgia. Conclusões: A DM apresentou recidiva mais precoce da dor em comparação à CPB. Além disso, apresentou uma taxa de recorrência mais alta do que a descrita na literatura, o que é possivelmente explicado pelo tipo de enxerto (músculo) usado para separar as estruturas neurovasculares.

Background Post-hemorrhoidectomy pain is common, usually temporary, and responsive to analgesics. However, some patients experience prolonged, intractable anal pain, which is refractory to conventional analgesics and adversely effects quality of life. We aimed to evaluate the efficacy of a combination injection containing local anesthesia and steroids for the treatment of intractable post-hemorrhoidectomy anal pain. Methods This study included five patients with intractable post-hemorrhoidectomy anal pain who presented between July 2015 and November 2018. Milligan-Morgan hemorrhoidectomy (M-M) with a sclerosant injection had been performed in three patients and stapled hemorrhoidectomy (SH) along with external hemorrhoidectomy in two. For the purpose of this study, all patients received local combination injections containing ropivacaine and triamcinolone acetonide. The primary outcome was the visual analogue scale (VAS) score, and secondary outcomes included the Pittsburgh Sleep Quality Index (PSQI) score, adverse reactions, and recurrence. Results Prior to treatment, the VAS score was 8 in one patient and 5-7 in four, and the PSQI score was ≥16 in all patients. The injection was administered once (n=4) or twice (n=1). Rapid pain resolution was achieved on the day of treatment (VAS scores 0-3), and patients reported undisturbed sleep the same night. VAS scores were 0-2 (n=4) and 1-3 (n=1), and the PQSI scores were 0-6 (n=4) and 11-15 (n=1) at the 6-month follow-up. No patient reported significant pain or adverse reaction. Conclusions Intractable post-hemorrhoidectomy anal pain is rare but significantly effects quality of life. While conventional analgesia may be ineffective, the local injection of anti-inflammatory and analgesic drugs may be a useful treatment strategy.

Charles H. Frazier (1870–1936), one of the pioneers of neurosurgery in the US, is known worldwide for devising surgical procedures to relieve trigeminal neuralgia and intractable pain. Less well-known are his substantial contributions to understanding and treating pituitary and parahypophyseal lesions. Along with Bernard Alpers, he defined Rathke’s cleft tumors as a different pathological entity from adenomas and hypophyseal stalk tumors (craniopharyngiomas [CPs]). The surgical challenge posed by CPs piqued Frazier’s interest in these lesions, although he never published a complete account of his CP series. An examination of the Charles Frazier papers at the College of Physicians of Philadelphia allowed the authors to identify 54 CPs that he had treated during his career. In the early 1910s, Frazier developed the subfrontal approach, which would become the primary surgical route to access these lesions, providing better control of the adjacent vital neurovascular structures than the transsphenoidal route hitherto used. Nevertheless, strong adhesions between CPs and the third ventricle floor, the major reason underlying Frazier’s disappointing results, moved him to advocate incomplete tumor removal followed by radiotherapy to reduce both the risk of hypothalamic injury and CP recurrence. This conservative strategy remains a judicious treatment for CPs to this day.

To date, the description of the natural course of concurrent tethered cord syndrome with a low-lying conus medullaris and split cord malformation is lacking in the literature. We report a cohort of adult and pediatric patients with concurrent malformations and long-term follow-up. Patients with concurrent diagnoses of split cord malformation and tethered cord (radiographic evidence supporting clinical symptomatology) were identified between 2000 and 2020. Patients without sufficient documentation or at least 6-month follow-up were excluded. Nine patients were identified with an average of 8.9 years follow-up (range 2–31 years). The most common symptoms were radiating leg pain and lower extremity paresthesias, occurring in 44% of patients; and bladder/bowel dysfunction, worsening scoliosis, and acute motor deterioration were less common. Two patients were successfully treated conservatively for mild leg pain and paresthesias. For those who underwent surgery, all experienced symptomatic relief upon first follow-up. Two had late symptomatic recurrence; one 4 and 8 years after initial surgery; and the other, 11, 26, and 31 years after initial surgery. The rarity of concurrent split cord and tethered cord syndrome with a low-lying conus makes management difficult to formulate. This series supplements our knowledge of the long-term outcomes and lessons learned from the management of these patients. Approximately 25% of patients were managed conservatively and had symptomatic improvement. For surgically managed patients, with intractable pain or worsening neurological function, symptoms can still recur over a decade after intervention. Reoperation, however, can still be beneficial, can provide years of relief, and should be considered.

Calciphylaxis, a rare disease mainly seen in patients with chronic kidney disease, is characterised by ischaemic skin damages and excruciating pain. Calciphylaxis has poor prognosis which often results in amputation and high mortality. Although guidelines for the management of calciphylaxis are not available, sodium thiosulfate has showed efficacy in many clinical reports. We report the case of a 64-year-old advanced calciphylaxis male patient who had two amputations due to intolerable pain manifested as deteriorating ulcer. After he was treated with intravenous sodium thiosulfate (STS), his pain was significantly relieved with a healing trend of the big wound. One more amputation for the remission of intractable pain was avoided. The treatment experience indicates that sodium thiosulfate is of great value in quick pain relief and reducing suffering of calciphylaxis patients. Keywords: Calciphylaxis, Calcific uremic arteriolopathy, Painful skin ulcer, Maintenance haemodialysis, Continuous....

Objectives Targeted Drug Delivery (TDD) is commonly used for the management of patients with intractable pain. Past studies have proven efficacy in pain relief and reduction in opioid use and cost‐effectiveness in long‐term pain management. There are few studies investigating satisfaction among patients with implanted pain pumps that are managed with targeted intrathecal medications. Material and Methods Patients in a single medical practice implanted with pain pumps for relief of intractable pain were identified and extracted from the electronic health record (EHR). Six hundred and ten active TDD patients were identified and an anonymous 18‐question survey was administered to determine satisfaction with TDD therapy. During an 18‐month period from May 2018 to August 2019, patients were invited to take a satisfaction survey. Both primary and secondary outcomes were reported as proportions; P

Background: Postherpetic neuralgia (PHN) is one of the most intractable pain disorders and often does not respond to medication, physical, and interventional procedures. Coblation technology has been demonstrated to have potential for neuralgia, but there are rare reports of the efficacy and security of coblation for PHN. The thoracic segment is the most common predilection part of PHN, so we conducted this long-term study to investigate the results of coblation for the treatment of thoracic PHN. Objectives: The aim of this study was to determine the efficacy and security of computed tomography (CT)-guided coblation of the thoracic nerve root for treatment of PHN. Study Design: Self before-after controlled clinical assessment. Setting: Department of Pain Management, Xuanwu Hospital, Capital Medical University. Methods: Seventy-seven patients with thoracic PHN sustained for at least 6 months and refractory to conservative therapy were identified. Patients underwent CT-guided percutaneous coblation to ablate the thoracic nerve root for thoracic PHN. The therapeutic effects were evaluated using a Visual Analog Scale (VAS), medication doses, and pain-related quality of life (QoL) scale before coblation, and at 1 week, and at 1, 3, and 6 months after the procedure. Patients who achieved more than 50% pain relief were defined as responders. In addition, adverse effects were also recorded to investigate the security of this procedure. Results: The VAS score significantly decreased from 7.22 ± 1.15 before the coblation to 3.51 ± 1.12 (P = 0.01), 3.02 ± 1.21 (P = 0.006), 3.11 ± 2.15 (P = 0.014), and 2.98 ± 2.35 (P = 0.008) at 1 week, and at 1, 3, and 6 months after the procedure, respectively. The number of responders were 56 (77.78%), 54 (75%), 55 (76.39%), and 54 (75%) at 1 week, and at 1, 3, and 6 months after the procedure, respectively. The doses of anticonvulsants and analgesics were decreased significantly at all time points after the procedure compared with before treatment (P < 0.05). Patient responses on the Brief Pain Inventory Short Form indicated mean scores that were significantly lower than baseline across all domains of pain interference with QoL at all evaluations (P = 0.001). Most of the patients had mild numbness and it did not affect the daily activities after the procedure. No other severe adverse events occurred during or after the procedure. Limitations: A single-center study, relatively small number of patients, short duration of review of medical record, and the retrospective study. Conclusions: CT-guided percutaneous thoracic nerve root coblation is an effective and safe method for the treatment of thoracic PHN, and the procedure can also significantly improve the QoL in patients with PHN. Key words: Neuropathic pain, quality of life, radiofrequency ablation, plasma-mediated technology, numbness

Introduction: In our preceding paper, we concluded that Pelvic Girdle Pain (PGP) should be taken seriously. Still, we do not know its causes. Literature reviews on treatment fail to reveal a consistent pattern, and there are patients who do not respond well to treatment. We designated the lack of progress in research and in the clinic as ‘deadlock’, and proposed a ‘deconstruction’ of PGP, that is to say, taking PGP apart into its relevant dimensions. Purpose: We examine the proposition that PGP may emerge as local inflammation. Inflammation would be a new dimension to be taken into account, between biomechanics and psychology. To explore the consequences of this idea, we present four different topics that, so far, have remained out of focus. One: The importance of microtrauma. Two: Ways to counteract chronification. Three: The importance of sickness behaviour when systemic inflammation turns into neuroinflammation of the brain. And Four: The mainly emotional and cognitive nature of chronic pain, and how aberrant neuroinflammation may render chronic pain intractable. For intractable pain, sleep and stress management are promising treatment options. Implications: The authors hope that the present paper helps to stimulate the flexible creativity that is required to deal with the biological and psychological impact of PGP. Measuring inflammatory mediators in PGP should be a research priority. It should be understood that the boundaries between biology and psychology are becoming blurred. Clinicians must frequently monitor pain, disability, and mood, and be ready to switch treatment whenever the patient does not improve.

Background: Chronic pancreatitis has been defined as a continuing inflammatory disease of the pancreas characterized by irreversible morphological changes. These changes typically cause pain and loss of exocrine and endocrine pancreatic function. The most common symptom of chronic pancreatitis is pain, which can be severe and intractable in some patients. Although it is itself benign, chronic pancreatitis can significantly affect quality of life and can cause significant distress with its complications [1]. The initial treatment for pain in most cases is to start of enzyme replacement, control of diabetes with insulin, and administration of oral analgesics. Surgical intervention is required in patients with intractable pain that is resistant to conventional nonsurgical therapy, in patients with associated or suspected malignancy, and in patients who have developed complications such as biliary or duodenal obstruction, pancreatic fistulae, pancreatic ascites/pleural effusion, pseudocyst, or rare hemosuccus pancreaticus [2]. The aetiology of pain in chronic pancreatitis is unclear. Some evidence has suggested that perineural inflammation may be the cause of pain. A dilated pancreatic duct, secondary to obstruction, may cause increased intraductal pressures, resulting in pain [3]. The primary aim of therapy is the achievement of primary pain relief and an improvement in quality of life. This could be achieved by means of endoscopic, open or laparoscopic /robotic lateral pancreaticojejunostomy [4, 13]. Methods: We selected 41 cases of chronic pancreatitis of both genders with moderate to intractable pain hampering routine life. All patients tried conservative treatment for more than 6 months. All selected patients underwent haematological and radiological work up. MRCP of all patients showing dilated pancreatic duct more than 7mm. in size. All of these patients operated for longitudinal pancreaticojejunostomy (Modified Puestow’s). Follow up done for one year to ten years Results: All 41 patients in long term follow up were recovered well from pain and abdominal discomfort. Appetite were improved and weight gain noted in the patients after surgery. Conclusions: Longitudinal pancreaticojejunostomy is still safe, simple and timely approved procedure for pain associated with chronic pancreatitis.

Objectives Nutcracker syndrome is rare, and a proportion of patients with this syndrome continue to have intractable pain and symptoms. Due to the heterogeneity of patients' chief complaints and symptoms, the surgeon's preferred approach may be inherently different but is of paramount importance to the outcome. Materials and methods We present 4 cases in which renal autotransplant with extraction and ligation of previously placed gonadal coils was performed following previously attempted renal vein stenting or combined renal vein transposition followed by renal vein stenting. Results Autotransplant resulted in flank pain resolution with improvement in symptoms associated with pelvic congestion syndrome. Conclusions The approach to such cases requires meticulous and adequate vena cava exposure, with preparation for potential caval reconstruction. No firm inferences can be made from such a small series; however, we believe in renal autotransplant as first-line therapy, and failure after an initial renal vein stent should be salvaged by renal autotransplant over further endovascular attempts.

What is known and objective The botulinum toxin (BoNT) has been widely used for various conditions associated with pain. Case description Here, we report a case where celiac plexus block (CPB) with BoNT relieved intractable chronic pancreatic pain without complications. CPB was performed at the L1 level under fluoroscopic guidance, and 50 IU BoNT was injected on each side. After 15 weeks, pain was decreased to 0/10 on a visual analogue scale, without opioids or tramadol. What is new and conclusion Our case demonstrates the efficacy of CPB with BoNT in intractable pain due to severe chronic pancreatitis.

Introduction Chronic pain in chronic pancreatitis is difficult to manage. The objective of our study is to assess the control of pain that is refractory to medical treatment in patients with an inflammatory mass in the head of the pancreas, as well as to compare the two surgical techniques. Methods A retrospective study included patients treated surgically between 1989 and 2011 who had been refractory to medical treatment with inflammation of the head of the pancreas. An analysis of the short and long-term results was done to compare patients who had undergone pancreaticoduodenectomy (PD) and/or resection of the head of the pancreas with duodenal preservation (RHPDP). Results 22 PD and 12 RHPDP were performed. Postoperative complications were observed in 14% of patients, the most frequent being delayed gastric emptying (14.7%) and pancreatic fistula (11.7%). No statistically significant differences were found in terms of surgical technique. Pain control was satisfactory in 85% of patients, 43% presented de novo diabetes mellitus, and 88% returned to their work activities. Fourteen patients died during follow-up, 7 due to malignancies, and some were related to tobacco use and alcohol consumption. The overall 5 and 10 year survival rates were 88% and 75% respectively. Conclusion Cephalic resection in patients with intractable pain in chronic pancreatitis is an effective therapy that provides good long-term results in terms of pain control, with no significant differences between the two surgical techniques. Patients with chronic pancreatitis have a high mortality rate associated with de novo malignancies.

Introduction Symptomatic postoperative hematoma after spine surgery is a rare but serious complication. The objective of this study was to investigate the incidence and clinical features of symptomatic postoperative hematoma after spine surgery. Methods We retrospectively identified 10,680 patients who underwent spine surgery between 2002 and 2012 in nine hospitals. We reviewed the incidence of postoperative hematoma and its clinical features, including time before onset, main symptoms, and neurological outcomes. Results The overall incidence of symptomatic postoperative hematoma after spine surgery was 0.4% (45/10,680). Postoperative hematoma was more frequent after thoracic spine surgery than after cervical or lumbar surgery. The onset of postoperative hematoma occurred at an average of 2.6 days (range 0-14 days) postoperatively. The chief symptoms caused by postoperative hematoma after spine surgery were tetra/paraplegia in 30 patients, hemiplegia in eight patients, intractable pain in five patients, and airway dysfunction in two patients. Surgical evacuation of the spinal epidural hematoma resulted in improvement of at least one grade in 35 patients, while four patients had complete motor paralysis even after evacuation surgery. Conclusions We report the clinical details of 45 patients with postoperative hematoma after spine surgery. This information could assist surgeons to make a prompt diagnosis and perform early evacuation surgery for postoperative hematoma following spine surgery.

Purpose To report the characteristic clinical and imaging findings in a series of patients with thrombosed orbital venolymphatic malformations. Methods Patients affected by acute thrombosis of an orbital venolymphatic malformation were reviewed. Clinical findings including symptoms and signs of presentation, characteristic imaging features, and clinical course are presented. Results Ten patients were identified. The mean age at presentation was 56 years. All patients presented with acute pain or pressure sensation, with the most common additional presenting symptoms being proptosis (6/10) and diplopia (5/10). CT imaging typically demonstrated a nonspecific orbital mass. Nine patients underwent MRI which revealed a soft tissue mass with peripheral rim enhancement and a central, typically T2 hypointense, core. Seven out of 10 patients were observed and had improvement in symptoms and signs without surgical intervention. Two patients underwent surgical intervention for intractable pain. Conclusion Patients with thrombosis of a venolymphatic malformation often present with acute pain, proptosis, and diplopia. Characteristic MRI findings of a peripheral rim enhancing mass with a T2 hypointense core can be noted. Careful observation is a reasonable management option for cases without visual compromise or intractable pain.

Pancreatic cancer is the seventh leading cause of cancer deaths worldwide and is associated with a poor survival rate. The vast majority of pancreatic cancers are inoperable at the time of diagnosis. In the absence of metastatic disease, operability depends on the extent of local disease; in particular, the presence or absence of vascular and lymph node involvement. Adequate staging is vital in deciding an appropriate treatment plan. Cross sectional imaging including CT, MRI and PET-CT are commonly used for staging. However, EUS is a useful adjunct for accurate loco-regional staging in addition to allowing diagnostic tissue samples to be obtained. Emerging EUS-guided therapeutic techniques have opened up new horizons in the management of pancreatic malignancy. EUS guidance can be used for coeliac plexus neurolysis in patients with intractable pain and fiducial placement in directing stereotactic radiotherapy. The majority of patients with cancer of the pancreatic head present with biliary obstruction. ERCP can be used to drain the obstructed biliary system with plastic or metal stents and offers an opportunity to confirm the diagnosis by obtaining brush cytology and forceps biopsy specimens. EUS-guided choledocho-duodenostomy or hepatico-gastrostomy is increasingly being employed for draining the biliary system if ERCP is unsuccessful.

Hip joint osteoarthritis, a widespread disabling disease with no known cause, produces considerable bouts of intractable pain as a result of multiple disease associated problems. This paper examines some sources of osteoarthritic hip joint pain, a poorly understood topic at best. Presented in three parts are data retrieved from several sources, including animal models. It is concluded that to improve the effectiveness of treatments designed to minimize hip osteoarthritis pain, a better understanding of the diverse origins of hip joint pain, and hip joint neurology, may permit the development of more precise as well as targeted pain strategies.

This study aimed to analyze the clinical safety and effectiveness of endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) in alleviating intractable abdominal pain caused by advanced pancreatic cancer. A total of 58 patients with inoperable pancreatic cancer who underwent EUS-CPN from May 2015 to December 2017 were enrolled. Pain levels before and after EUS-CPN were assessed and compared using the Visual Analogue Scale. The preoperative Visual Analogue Scale score was 8.2±2.3, which decreased significantly to 3.6±1.5 at 2 days after EUS-CPN and to 2.2±0.8 after 1 month. The response rate was 79.3%. No patient experienced serious complications; 14 patients experienced mild, transient side effects (self-limiting diarrhea, reflex hypotension, and worsening of abdominal pain) that resolved within 48 hours. For pancreatic cancer patients, EUS-CPN can effectively control pain with minimal adverse effects.

Surgical management of spinal burst fractures has progressed to include minimally invasive techniques as preferred modalities of treatment. Burst fractures with indications for surgical treatment either through instability or intractable pain classically have required pedicle screw fixation, which requires extensive dissection resulting in postoperative pain and significant recovery time, and also requires longer operative times with more potential blood loss. Balloon kyphoplasty is an established percutaneous technique that can provide quick pain relief for patients with intractable pain following compression and burst fractures, and vertebral body height can also be restored. In the present case, a female patient was seen in the emergency room with intractable pain and a dehiscent thoracolumbar incision after recently undergoing surgery with placement of a Hartshill rectangle and sublaminar wires at another institution for a T12 burst fracture (AO classification [AO] A4 and thoracolumbar injury classification and severity score [TLICS] 4) caused by a motor vehicle accident. Imaging identified an acute unhealed fracture at T12 and other vertebrae with questionable lesions. She underwent surgery to remove the Hartshill construct, stabilize the fracture, biopsy lesions (T7, T10, L2, and L4), and debride and close the wound. Following hardware removal, kyphoplasty was then performed through the open exposure at T12, which could have otherwise been done percutaneously. The patient experienced immediate and complete resolution of her pain associated with the fracture and had no neurological deficits. Modern minimally invasive techniques including kyphoplasty should be favored when indicated as alternative treatment options over more invasive treatment modalities, as they lead to quicker resolution of pain and recovery when compared to techniques requiring a large exposure.

Bone is the third most common site involved by cancer metastases, and skeleton-related events such as intractable pain due to direct osseous tumor involvement, pathologic fracture, and neurologic deficits as a consequence of nerve or spinal cord compression often affect patients' functional independence and quality of life unfavorably. The annual medical-economic burden related to bone metastases is a substantial component of the total direct medical cost estimated by the National Institutes of Health. There have been substantial recent advances in percutaneous image-guided minimally invasive musculoskeletal oncologic interventions for the management of patients with osseous metastatic disease. These advances include thermal ablation, cementation with or without osseous reinforcement with implants, osteosynthesis, thermal and chemical neurolyses, and palliative injections, which are progressively incorporated into the management paradigm for such patients. These interventions are performed in conjunction with or are supplemented by adjuvant radiation therapy, systemic therapy, surgery, or analgesic agents to achieve durable pain palliation, local tumor control, or cure, and they provide a robust armamentarium for interventional radiologists to achieve safe and effective treatment in a multidisciplinary setting. In addition, these procedures are shifting the patient management paradigm in modern-era practice. The authors detail the state of the art in minimally invasive percutaneous image-guided musculoskeletal oncologic interventions and the role of radiologists in managing patients with skeletal metastases. ©RSNA, 2021.

ObjectivePain in chronic pancreatitis is subdivided in a continuous or intermittent pattern, each thought to represent a different entity, requiring specific treatment. Because evidence is missing, we studied pain patterns in a prospective longitudinal nationwide study.Design1131 patients with chronic pancreatitis (fulfilling M-ANNHEIM criteria) were included between 2011 and 2018 in 30 Dutch hospitals. Patients with continuous or intermittent pain were compared for demographics, pain characteristics, quality of life (Short-Form 36), imaging findings, disease duration and treatment. Alternation of pain pattern and associated variables were longitudinally assessed using a multivariable multinomial logistic regression model.ResultsAt inclusion, 589 patients (52%) had continuous pain, 231 patients (20%) had intermittent pain and 311 patients (28%) had no pain. Patients with continuous pain had more severe pain, used more opioids and neuropathic pain medication, and had a lower quality of life. There were no differences between pain patterns for morphological findings on imaging, disease duration and treatment. During a median follow-up of 47 months, 552 of 905 patients (61%) alternated at least once between pain patterns. All alternations were associated with the Visual Analogue Scale pain intensity score and surgery was only associated with the change from pain to no pain.ConclusionContinuous and intermittent pain patterns in chronic pancreatitis do not seem to be the result of distinctly different pathophysiological entities. The subjectively reported character of pain is not related to imaging findings or disease duration. Pain patterns often change over time and are merely a feature of how severity of pain is experienced.

Bioelectrical signals analogous to pain arise in a bioengineered tissue model of peripheral nerve connected to spinal cord., Debilitating chronic pain resulting from genetic predisposition, injury, or acquired neuropathy is becoming increasingly pervasive. Opioid analgesics remain the gold standard for intractable pain, but overprescription of increasingly powerful and addictive opioids has contributed to the current prescription drug abuse epidemic. There is a pressing need to screen experimental compounds more efficiently for analgesic potential that remains unmet by conventional research models. The spinal cord dorsal horn is a common target for analgesic intervention, where peripheral nociceptive signals are relayed to the central nervous system through synaptic transmission. Here, we demonstrate that coculturing peripheral and dorsal spinal cord nerve cells in a novel bioengineered microphysiological system facilitates self-directed emergence of native nerve tissue macrostructure and concerted synaptic function. The mechanistically distinct analgesics—morphine, lidocaine, and clonidine—differentially and predictably modulate this microphysiological synaptic transmission. Screening drug candidates for similar microphysiological profiles will efficiently identify therapeutics with analgesic potential.

Background: Primary and secondary malignant tumors of the spine are relatively uncommon in the pediatric population but are associated with high morbidity and significantly decreased quality of life due to pain. Local management of these tumors is often challenging due to the importance of maintaining vertebral mechanical integrity as well as the spinal growth potential. Typically, surgery and/or radiation therapy have been used in the primary management of these tumors. However, treatment options become more limited when there is relapse or refractory disease, with re-resection or additional radiotherapy often not being viable therapies. The purpose of this study was to assess the feasibility of percutaneous vertebroplasty as a palliative treatment for intractable pain secondary to malignant tumors affecting the spine. Procedure: A retrospective review of all cases of vertebroplasty performed at a single institution between 2003 and 2020. Results: A total of 11 vertebral levels were treated in 3 children with relapsed cancers (two with alveolar rhabdomyosarcoma, and one with Wilms tumor). All three had clinical benefit with sustained significant improvement in their pain. Conclusions: Vertebroplasty is a currently underutilized modality that might provide excellent pain palliation in cases of relapsed cancer in the spine. Future prospective studies of its use in pediatric oncology are needed.

Emphysematous osteomyelitis (EO) is a rare condition characterized by the appearance of gas locules within the bone on imaging, usually as a result of anaerobic bacterial infection. We present the case of a 46-year-old known intravenous (IV) drug user who was admitted to the emergency department with intractable pain in the right groin. He was febrile with elevated white cell count and C-reactive protein. He underwent an X-ray and CT of the pelvis which demonstrated intraosseous gas in the proximal right femur. A diagnosis of EO was made radiologically, allowing for prompt antibiotic treatment and a plan for surgical debridement. There are only a handful of published cases of EO in the literature, only one of which has described IV drug use as the underlying factor.

Background: Epithelioid hemangioendothelioma (EHE) patients can experience severe pain. Nonsteroidal anti-inflammatory drugs, including ketorolac tromethamine, can effectively treat cancer-related ...

Background: Lumbar disc herniation (LDH)/radiculopathy is the most frequent cause of lost workdays in people under 50 years of age. Although there is consensus about how to assess these patients, the optimal management strategy is still debated. Methods: An online survey was sent to spine surgeons who are members of the Iberian-Latin American Spine Society to assess how they treat LDH with radiculopathy. Results: There were 718 surgeons who answered the survey; 66% reported that 76–100% of their monthly clinic work was due to spine issues. The most frequently used conservative treatment modalities included non-opioid analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) (90.5%), followed by physical therapy (55.2%) and pregabalin (41.4%). Notably, 40% of surgeons in the public sector believed that conservative treatment failed if symptoms persisted beyond 6–12 weeks, while 39% of private surgeons deemed conservative management insufficient if it had failed to provide symptomatic relief with 3–6 weeks. Of interest, 78% utilized epidural steroid injections (ESI); 51.7% preferred the transforaminal, 27.2% the interlaminar, and 7.5% the caudal approaches. The most frequent indications for surgery included: cauda equina syndrome, progressive neurological deficits, and intractable pain. Traditional microdiscectomy was the most common technique (68.5%) utilized, followed by 7.5% advocating endoscopic disc resection, and just 6.4% favoring the tubular discectomy. Conclusion: There is considerable heterogeneity among Iberian and Latin American spine surgeons in the treatment of LDH/radiculopathy. Although most begin with the utilization of NSAIDs and non-opioid analgesics, followed by ESI (88%), surgery was recommended for persistent symptoms/signs for those failing between 3 and 6 weeks (private sector) versus 6–12 weeks (public sector) of conservative therapy.

For patients undergoing evaluation and treatment of cancers, symptom management is a critical component of their treatment plan. For some patients, symptoms may become intractable or refractory to common therapies. Here, we review treatment options for these severe symptom conditions. Medication options and regimens have improved to treat refractory symptoms. Medications can be tailored to treat chemotherapy-induced nausea and vomiting based on current guidelines. Interventions such as venting gastrostomy can mitigate symptoms associated with malignant bowel obstruction, when life expectancy is long enough to realize this benefit. Opiates can reduce refractory dyspnea, consistent with guidelines from the American Thoracic Society. Interventional therapies for intractable pain, such as neurolytic blocks and intrathecal pumps, have shown promise in managing symptoms when traditional therapies have been ineffective. Refractory symptoms can be managed in cancer care. The use of multimodal therapies delivered by interdisciplinary teams appears to be the most effective way to approach these clinical situations.

Referred orofacial pain as the first symptom of an otherwise silent distant, nonmetastatic cancer has been reported, but there is sparse literature on the subject. Referred pain may not be considered in the orofacial pain differential diagnosis because of its rarity; however, this may delay a cancer diagnosis. The authors present a case report and a review of the English literature. Peer-reviewed publications were identified through a systematic search of MEDLINE, Embase, and Cochrane CENTRAL. Historic cases were reviewed, and available data regarding demographics, pain characteristics, treatment, cancer diagnosis, and outcome were extracted. Thirty-seven cases were identified. All cancers were intrathoracic. The average age was 54.1 years with a slight female predominance (3:2). Common pain characteristics were (1) diffuse location affecting the ear (76%), jaw (46%), and temple (30%); (2) constant duration (65%); (3) aching quality (74%); (4) severe intensity (94%); and (5) associated systemic symptoms (68%) such as weight loss and digital clubbing. The average time from the onset of facial pain to seeking medical attention was 9 months, and the average time from seeking medication attention to cancer diagnosis was 8 months. Orofacial pain was often attributed to odontogenic (35%) or neuropathic (25%) causes, and treatments for these conditions were also common. The impact of referred orofacial pain on the cancer prognosis was not possible because of the nature of the reviewed studies (case reports with no comparison group). Cancer-associated referred orofacial pain as a first symptom is rare but should be considered in cases with intractable pain and associated systemic symptoms.

Context: Total pancreatectomy (TP) with islet-cell auto transplantation (IAT) is an option for pain management for patients with chronic pancreatitis (CP). IAT allows the preservation of beta cell function to reduce or prevent long-term diabetes. Objective: We performed a follow-up study up to 12 years after TPIAT surgery with an off-site isolation laboratory, to determine the efficacy and durability of the procedure. Methods: Data (August 2008 to August 2020) were obtained from a TPIAT database which included information from medical records, clinic visits, questionnaires, and follow-up telephone calls. Patient demographics were collected. Additionally, each patient was assessed with a 4-hour mixed meal tolerance test for metabolic measurements, serial glycosylated hemoglobin (HbA1c), and insulin requirements prior to surgery and during their most recent follow-up appointment. Results: Seventy-seven patients with a median age of 45.0 years underwent TP-IAT for CP due to different etiologies. At a median follow-up time of 422.5 days 12 patients were insulin independent and 65 patients were on at least one insulin injection a day. Post-operative C-peptide area under the curve (AUC) measurements (P=0.008) were a better indicator of procedure success compared to the number of islet cells transplanted (P=0.225). Patients who were insulin-dependent post-surgery demonstrated increased insulin resistance prior to surgery, by their median pre-surgery insulin AUC; insulin-independent, 626 (241, 3803); insulin-dependent, 1591 (325, 4803), HOMA-IR values 9.02. Conclusions: TPIAT improves intractable pain for patients with CP. IAT decrease insulin requirement and improve blood glucose control after TP. Insulin resistance prior to surgery may be a predictor for insulin-dependence. Intervention studies using insulin sensitizer prior surgery may be considered in evaluating long-term outcomes for these patients. Disclosure S. U. Lad: None. K. F. Ali: None. P. C. Johnston: None. V. San martin: None. Y. Lin: None. R. Bottino: None. M. Walsh: None. T. Stevens: Speaker’s Bureau; Self; AbbVie Inc. B. Hatipoglu: None.

Neurolysis of the celiac plexus has been found to be an effective way of palliating chronic pain due to non-pelvic intra-abdominal organ pathologies such as upper abdominal malignancies and chronic pancreatitis. We assessed the effectiveness of celiac plexus block (CPB) for pain due to chronic pancreatitis in pediatric age group. Eleven children between the age group of 3–10 years suffering from abdominal pain due to chronic pancreatitis underwent CPB through transaortic approach. Assessment of pain relief compared to pre-procedure status was done using Wong-Baker Faces Pain Rating Scale. Ten out of 11 children had symptomatic relief post-procedure and on 6 months follow-up. One child had relapse of pain after 3 months of CPB. We conclude that CPB is a promising solution for tackling intractable pain due to chronic pancreatitis in pediatric age group.

Primary benign neurogenic neoplasms of the pleura are exceedingly rare. Neurofibromas rarely involve the pleura. A review of the literarture reveals only a single reported case of isolated pleural neurofibroma. Herein the authors describe another case of isolated primary pleural neurofibroma. A 39-year-old nonsmoker woman presented to the emergency room with complaints of progressively worsening chest pain of one month duration. A computed tomography of the chest revealed a crescent shaped, pleural based mass suspicious for a neurogenic tumor such as an intercostal schwannoma. A PET-CT skull base to midthigh failed to reveal any other masses or abnormalities. A surgical excision of the mass was performed due to the patient’s intractable pain. The resected specimen consisted of an ovoid fragment of soft tissue with pale yellow, smooth and glistening cut surface. Microscopic examination revealed the tumor to be composed of spindle cells with wavy nuclei arranged haphazardly in loose collagenous and pale myxoid stroma with rare interspersed mast cells. The spindle cells were diffusely positive for S100 protein and SOX-10, and focally positive for neurofilament. In the absence of any other masses in the patient and no pertinent history, a diagnosis of primary pleural neurofibroma was made. This case emphasizes the need to consider neurofibroma in any spindle cell neoplasm of the pleura irrespective of age or singularity.

Chronic pain is a common condition that affects the physical, emotional, and mental well‐being of patients and can significantly diminish their quality of life. Due to growing concerns about the substantial risks of long‐term opioid use, both governmental agencies and professional societies have recommended prioritizing the use of nonpharmacologic treatments, when suitable, in order to reduce or eliminate the need for opioid use. The use of 10 kHz spinal cord stimulation (10 kHz SCS) is one such nonpharmacologic alternative for the treatment of chronic, intractable pain of the trunk and limbs. This review examines published clinical data regarding the efficacy of 10 kHz SCS for decreasing chronic pain in patients and its potential to reduce or eliminate opioid usage. Multiple prospective and retrospective studies in patients with intractable pain demonstrated that 10 kHz SCS treatment provided ≥50% pain relief in >70% patients after at least 1 year of treatment. Pain relief with 10 kHz SCS therapy ranged from 54% to 87% in the studies. More importantly, the mean daily dose of opioids required by patients in these studies was reduced after 10 kHz SCS treatment, and on average over 60% patients in studies either reduced or eliminated opioids at the last follow‐up., The use of 10 kHz spinal cord stimulation (10 kHz SCS) is a nonpharmacologic alternative for the treatment of chronic, intractable pain of the trunk and limbs. This review examines published clinical data regarding the efficacy of 10 kHz SCS for decreasing chronic pain in patients and its potential to reduce or eliminate opioid usage.

Background: Head and facial pain is a common and often difficult to treat disorder. Routine treatments sometimes fail to provide acceptable relief, leaving the patient searching for something else, including narcotics and surgery. Recently, neuromodulation has been expanding to provide another option. Secondary to its potentially temporary nature and relatively manageable risk profile, several reviews have suggested trialing neuromodulation prior to starting narcotics or invasive permanent surgeries. There is evidence that neuromodulation can make a difference in those patients with intractable severe craniofacial pain. Objectives: To provide a basic overview of the anatomy, epidemiology, pathophysiology and common treatments of several common head and facial disorders. Furthermore, to demonstrate the suggested mechanisms of neuromodulation and the evidence currently existing for the use of neuromodulation. Methods: A comprehensive review was performed regarding the available literature through targeting articles reporting on the use of neuromodulation to treat pain of the head and face. Results: We compiled and discuss the current evidence available in treating head and facial pain. The strongest evidence currently for neuromodulation is for occipital nerve stimulation for migraine, transcutaneous vagal nerve stimulation for migraine and cluster headache, sphenopalatine ganglion microstimulation for cluster headache, and transcutaneous supraorbital and supratrochlear nerve stimulation for migraine. In addition, there is moderate evidence for occipital nerve stimulation in treating occipital neuralgia. Limitations: Neuromodulation has been trialed and is promising in several craniofacial pain disorders; however, there remains a need for large-scale, randomized, placebo-controlled clinical trials to further evaluate the efficacy and safety of most treatments. Much of the current data relies on case reports without randomization or placebo controls. Conclusions: With advancing techniques and technology, neuromodulation can be promising in treating intractable pain of the head and face. Although more randomized controlled trials are warranted, the current literature supports the use of neuromodulation in intractable craniofacial pain. Key words: Neuromodulation, headache, facial pain, craniofacial pain, migraine, cluster headache, trigeminal neuralgia, occipital neuralgia, peripheral nerve stimulator, high cervical spinal cord stimulator, peripheral nerve field stimulator

Background Sympathetic block is commonly performed in clinical practice for management of intractable pain conditions. However, stellate ganglion block (SGB) alone often does not achieve sufficient sympatholysis of the upper extremity. The paravertebral space continues up to the cervical sympathetic chain and includes the stellate ganglion. We compared the sympatholytic and analgesic effect of paravertebral block performed at the T2 level (T2 PVB) with that of SGB in patients with complex regional pain syndrome (CRPS) of the upper extremity. Objectives The aim of this study was to compare the sympatholytic property of T2 PVB with that of the conventional SGB in patients with CRPS of the upper extremity. Study design Prospective, randomized cross-over trial. Setting University hospital pain center in Korea. Methods Fifteen patients with upper extremity CRPS were randomly assigned to 1 of 2 intervention methods (SGB or T2 PVB). After effects of the first block receded, the patients were crossed over to the second procedure. A difference in temperature increase between the treated side and the opposite side (DeltaT) DeltaT greater than or equal to1.5°C was considered as a successful primary outcome. Rate of successful primary outcome, degree of pain reduction, duration of effect, and patient satisfaction scores were compared between the 2 intervention methods. Results Rate of successful primary outcome (DeltaT greater than or equal to 1.5°C) was significantly higher in the T2 PVB cases than in the SGB cases (80.0% vs. 20.0%; P = 0.003). Numeric Rating Scale scores after the procedure were significantly lower in the T2 PVB group. Patient satisfaction scores were significantly higher, and the duration of the block was significantly longer in the T2 PVB cases than in the SGB cases. Limitations The relatively small sample size from a single center, and the lack of standardization of the injected volume of T2 PVB and SGB were limitations. Conclusions T2 PVB showed superior sympatholytic effect than SGB; other clinical outcomes were also better with T2 PVB than with SGB. T2 PVB can be a useful option for producing sympatholytic and analgesic effect in patients with CRPS of the upper extremity. Key words Sympathetic block, Complex Regional Pain Syndrome, paravertebral block, stellate ganglion block.

Introducción: La distrofia simpática refleja, también es conocida como algoneurodistrofia, causalgia, fibromialgia, atrofia de Sudeck o síndrome del dolor regional complejo tipo I (SDRCT1). Relato de caso: Paciente de sexo femenino, 22 años, con reporte de caída de altura con trauma en la extensión del miembro superior derecho. Evolucionó después del evento con dolor y parestesias difusas en el miembro superior derecho. Electroneuromiografía de los miembros superiores no evidenció alteraciones relevantes. A pesar del uso de diversos medicamentos cursó con dolor intratable, impidiendo la realización de fisioterapia adecuadamente. Fue elegido la simpatectomía del ganglio cervical inferior a cielo abierto. En el postoperatorio evolucionó con el síndrome de Horner ipsilateral, como se esperaba, con moderado control del dolor. Discusión: En el SDRCT1 nótese que lesiones leves a moderadas de las extremidades o en áreas distantes de la zona de distrofia pueden preceder el surgimiento de los síntomas. No se verifica lesión de un nervio específico en los estudios electrofisiológicos y el cuadro clínico se caracteriza por una gama de síntomas sensorios motores y disautonómicos. En cuanto a los medicamentos no existe unanimidad, siendo aún posible el uso de bloqueos del ganglio estrellado y la simpatectomía de este. Conclusión: La simpatectomía del ganglio cervicotorácico (ganglio estrellado) puede ser una opción de tratamiento del SDRCT1 cuandolas modalidades del tratamiento conservador no promueven un resultado satisfactorio.